Two Fatal Intoxications Due to Tramadol Alone: Autopsy Case Reports and Review of the Literature

Since tramadol was marketed, it has been widely prescribed as a pain killer because of its relatively safe profile among opioids. Nevertheless, intoxication can occur: overdose can lead to fatal outcomes mostly in association with other drugs, via the potential interaction with serotonergic antidepressant medications, as well as the potential for increased central nervous system (CNS) depression. Fatal outcomes only attributable to tramadol are a rare entity. In this case report, 2 fatal cases are described due to tramadol stand-alone intoxication with peculiar characteristics. In case 1, gas chromatography - mass spectrometry analysis detected tramadol in all specimens (32 \u3bcg/mL in the heart blood, 23.9 \u3bcg/mL in the femoral blood, 3.3 \u3bcg/mL in the bile, and 1.4 \u3bcg/mL in the urine). No other CNS depressants were detected by toxicological analysis. In case 2, gas chromatography - mass spectrometry analysis detected tramadol in all specimens (7.5 \u3bcg/mL in the heart blood, 5.8 \u3bcg/mL in the femoral blood, and 18 \u3bcg/mL in the urine). No other CNS depressants were detected by toxicological analysis. Review of the literature was performed to clarify the actual knowledge on this topic

Fatal Clostridium perfringens Septicemia After Colonoscopic Polypectomy, Without Bowel Perforation

Since its introduction, colonoscopy has played an important role as a diagnostic, therapeutic, and screening tool. In general, colonoscopy is regarded as a safe procedure, but complications may occur. The most dreaded of these complications is colonic perforation. Bacteremia postprocedure may occur, and although it is not uncommon, it rarely results in clinically significant complications. Patients with IBD (inflammatory bowel disease) are a high-risk population for bacteremia, which may leads to bowel wall overstepping by the bacteria. With regard to that, we report a fatal case of gas gangrene complicating colonoscopy polypectomy without bowel perforation in a healthy adult. To the best of our knowledge, only two other cases of retroperitoneal gas gangrene associated with colonoscopy polypectomy without bowel perforation have been described in international literature, but none of which was completed by a molecular biology analysis

A case of bilateral extracranial internal carotid artery dissection due to the helmet strap after motorcycle crash

The authors report a case of a man who developed stroke symptoms a few days after a road accident on his motorcycle. Radio-graphic examinations revealed the presence of bilateral dissection of the extracranial internal carotid arteries with signs of involvement of the brain parenchyma. The location, timing, and presentation lead to the conclusion that the carotid lesions were secondary to the motorcycle collision; in particular, we suppose that it is due to the pressure exerted by the helmet strap worn. Although helmets have undoubtedly prevented serious injuries, this report highlights that the helmets themselves may cause injuries, especially to cervical soft tissues and vessels

Deaths by gas sniffing in prison: Responsibility of the psychiatrist

In the prison environment, suicide and self-injury are almost a structural feature, making prevention a primary target. The Prison Administration has issued a wide range of measures on suicide prevention. The present survey examines the measure adopted in some Prison to evaluate the prisoners authorized to use gas instruments with monitoring of pipelines by the psychiatrists

An enigmatic death in farm chopping machine: Is this the perfect murder?

Forensic autopsy, like the other sectors in medicine, has benefited from the technological progress and the creation of multidisciplinary teams to unveil more and more finely planned criminal intents. Forensic pathologists, however, can sometimes deal with very enigmatic cases, meeting so with the limits of their own knowledge. Therefore, in these cases, they must not allow themselves to be pressured by inquiring agencies, remaining instead always faithful to empiric observations. With regard to that, we present a peculiar case of death by shredding inside a grinding machinery. The magistrature consequently opened a dossier for willful murder. Lots of figures were appointed to solve the case and among them is the forensic pathologist. However, a great number of obstacles were put in the investigators' inquiries. Was it a perfect murder

A fatal case of acute butane-propane poisoning in a prisoner under psychiatric treatment: Do these 2 factors have an arrhythmogenic interaction, thus increasing the cardiovascular risk profile?

Sudden death due to inhalation of aliphatic hydrocarbons such as butane and propane is well described in the literature. The main mechanism involved is the induction of a fatal cardiac arrhythmia. This phenomenon is frequently associated with prisoners who accidentally die while sniffing these volatile substances with an abuse purpose. Furthermore, such prisoners are often under psychiatric treatment; specific drugs belonging to this pharmacological class lead to a drug-related QT interval prolongation, setting the stage for torsade de pointes. In this article, we present the case of a prisoner died after sniffing a butane-propane gas mixture from a prefilled camping stove gas canister. The man was under psychiatric drugs due to mental disorders. He was constantly subjected to electrocardiogram to monitor the QTc (corrected QT interval), which was 460 milliseconds long. Toxicological analysis on cadaveric samples was performed by means of gas chromatography (head space) and revealed the presence of butane and propane at low levels. The aim of this article was to discuss a possible arrhythmogenic interaction of QT interval prolongation induced by psychiatric drugs and butane-propane inhalations, increasing the cardiovascular risk profile. In other words, evidence may suggest that prisoners, under these circumstances, are more likely to experience cardiovascular adverse effects. We believe that this study underlines the need to take this hypothesis into account to reduce death risk in prison and any medical-related responsibilities. Further studies are needed to validate the hypothesis

An unusual autopsy case of incomplete decapitation of a motorcyclist with herniation of thoracic organs through a helmet-related neck wound

The authors report an unusual autopsy case of a motorcyclist who wore a full-face type helmet and had incomplete decapitation and herniation of the heart and a portion of the right lung through an extensive lacerate wound on the front of the neck after his motorcycle crashed. The authors identified 2 main offensive dynamics that occurred simultaneously: First, partial decapitation with a extensive gaping wound on the neck caused by the chin strap after a violent angular movement of the head; second, the translocation of the abdominal organs into the thorax and the herniation of the thoracic organs through the neck wound generated by a compressive trauma of the thorax and abdomen. This singular case, like few others in forensic literature, shows the possibility of helmet chin strap-related traumas and highlights the limitations of modern protective helmets. If the postulated mechanism is confirmed despite the massive benefits derived from the compulsory use of protective helmets, the properties of the helmet chin strap would need to be reassessed to improve the protection of the soft tissue and bones in the neck. \ua9 2013 by Lippincott Williams & Wilkins

An unusual case of unintentional firearm death of a 3-year-old child

The authors report the case of an accidental death of a 3-year-old child who unintentionally shot himself while he was handling his father's handgun.The peculiarity of the observed injury makes the case particularly interesting, along with the fact that, in Italy, unintentional firearm-related deaths are rather uncommon among children and adolescents.Because of the presence of only 1 bullet hole on the parietal-occipital region, radiological cranial examinations were performed before proceeding with the autopsy.Computed tomographic scans were useful to confirm the entrance site of the bullet and, especially, to establish the trajectory with the whole spectrum of fractures.The case shows that the unusual entrance site of the bullet through the nose led to a fatal cranial injury, as a result of curiosity of a 3-year-old child in the presence of an unsupervised handgun

Instantaneous death due to transorbital reverse penetration of a screw in an accidental fall. Unusual autopsy case report and review of the literature

We present a peculiar autopsy case of a transorbital penetrating head injury, in a male worker, after an accidental fall onto a screw not completely stuck into a wooden board.A 13-cm screw entered the cranium 9.5 cm deep, penetrating with the flat end, a condition defined in literature as "reverse penetration." The death was instantaneous and caused by a neurogenic shock due to injuries to the brain stem and the right cerebellar hemisphere.These injuries, enabled by the length of the screw, are generally described in literature as due to nontransorbital penetrations, frequently associated with posterior entry and a large intracranial injury.The ocular globe has been, furthermore, perfectly preserved thanks to its mobility in the orbit.Even the dynamic of the incident is peculiar because of the stationary nature of the penetrating object, which the victim actively fell on by accident.To the best of our knowledge, the matter is therefore a very peculiar mortal case of transorbital intracranial penetration, whose verified injuries and dynamics are absolutely atypical.The case is now under discussion, and a review of pertinent literature is performed. Copyright \ua9 2014 Lippincott Williams & Wilkins