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(sorry for the caps, that's how it came to me)
DR KELLER. I HAVE BEEN READING YOUR INFORMATION REGARDING COCAINE AND OVERDOSE. I TOO HAVE A QUESTION..ANY HELP WOULD BE SINCERLY APPRECIATED...
25 YEAR OLD MALE GOT INTO A FIGHT..
RECIEVED A STAB WOUND TO CHEST.
WOUND WAS 1.8 -BY 0.5 IN WOUND.
PENETRATES THE PERICARDIUM AND THEN THE HEART, NEAR APEX INTO THE RIGHT VENTRICLE. WOUND OF HEART IS 1.3 CENT ACROSS. WOUND DOES COMMUNICATE WITH THE VENTRICLE CHAMBER. ASSOCIATED WITH WOUND WAS A 300 MILLITER HEMOPERICARDIUM.
ONE LUNG IS 420 AND THE OTHER IS 380.GRAMS
HEART 350 GRAMS.
STOMACH CONTAINED 800 MILLI OF FOOD AND NOTED WAS A MALTED BEVERAGE ODOR.
TOX REPORTS STATES
PERIPHERAL BLOOD ETHYL ALCOHOL 0.068 G/100ML
BENZODIAZEPINES POSTIVE
CANNABINOIDS POSTIVE
COCAINE/METABOLITES POSTIIVE
TRICYCLIC ANTIDEPRESSANT POSTIVE
CARISOPRODOL POSTIVE
OPIATES POSTIVE
MARIHUANA [THC] 0.004 MG/L
MARIHUANA METABOLITE [THC-COOH] 0.005 MG/L
COCAINE 0.059MG/L
COCAINE METABOLITE [BENZOYLECGONINE 0.958MG/L
MEPROBAMATE 0.869MG/L
HYDROCODONE 0.035MG/L
HGB ALC 5.6%
AFTER HE WAS INJURIED HE WENT BACK INTO THE HOUSE AND DID MORE COCAINE.. THEN CALLED FOR 911. HE WAS ON THE 911 TAPE SNORING AND THEN PASSED OUT. YOU CAN HEAR WHAT SEEMS LIKE BUBBLING SOUNDS IN THE BREATHING.THE AUTPOSY REPORT SHOWED GASTRIC CONTENTS IN THE BRONCOHOLS. HE WAS REPORTED SHALLOW BREATHING AND PULSE RATE OF 46. ON THE WAY TO THE HOSPITAL HE DIED. WHAT IS THE POSSIBILTY THAT HE SUFFOCATED ON THE GASTRIC CONTENTS OR OVERDOSED ON THE DRUGS?? THE 300 MIL BLOOD IN THE PERICARDIUM SAC BEING DELAYED [ CONTINUING AFTER DEATH]
TIME SPAN WOULD HAVE BEEN APPOX 10MIN AFTER EMS ARRIVED BP DROPPED.
ARRIVED AT HOSP 15 MIN LATER UNDER TOTAL CPR. TOTAL TIME APPOX 28-30 MIN.
MY QUESTION IS COCAINE / DRUG OVERDOSE CONSISTANT WITH THE GASTRIC ASPIRATION. AND WOULD THE DEATH HAVE OCCURED BY THIS BEFORE THE INJURY CREATED THE 300 MILL.
BLOOD IN THE SAC??
THEY DID ALSO ADMISTER EPINEPHRINE 3X AND ATROPINE 3X .
PLEASE HELP SHINE SOME LIGHT. THANK YOU
My reply:
It would seem most likely that he died of the stab wound. The wound into the ventricle will send blood into the pericardial sac. As the pericardium fills, blood return to the heart stops with tamponade and continued filling stops. In addition, as the heart stops beating no more blood flows into the pericardium, because of the loss of pressure in the ventricle.
The aspiration of stomach contents may have occurred just before death, but is just as likely with resuscitative efforts in this case.
Certainly the cocaine didn’t help him, but was likely more a confounder in this case than anything. Cocaine (with his Soma and hydocodone) may have contributed some, but vomiting due to them at these levels would be somewhat unusual.
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4 comments:
Dr.Keller,
Thanks for the information regarding the unsual death.
One thing i forgot to mention was
that the victim was unconscious
and and not responding. Found by the police and ems shallow breathing and unconscious.Pulse at that time was 46. Testimony was given that it was not a fatle wound.That it was just a scratch on the right ventricle..
Ems did not state he aspirated.They only gave oxygen when they first arrived.
Stopped the bleeding and during transport his bp dropped.
I have read numerous reports reguarding cocaine overdose/ and the mix of the two.
How people unconscious aspirate due to the gagg reflex don't work when your unconscious.
Is there any evidence that if a person aspirates while unconscious that should show up in the report? This whole ordeal has been awfull and hurtfull. I thank you so very much for your time.
Sincerly
Ps. Sorry for the caps last time. This is all new to me.
I am sure it was awful (don’t worry about the caps, it communicates the mood).
For blood to collect in the pericardium, as in this case, the heart was penetrated (not scratched) or a significant coronary vessel was cut when stabbed (and would have been visible at autopsy).
CPR was most likely done at some point and that is likely when the aspiration occurred (although there is the possibility it happened before death, but then that should have been noted in the initial EMS assessment). Either the compressions or attempts at intubating can cause regurgitating of stomach contents, even in an unconscious individual. That should have been documented by EMS or ER staff. (From your brief description I do wonder about the EMS care being adequate.)
The heart injury is a lethal injury and unless immediate and appropriate care is available, after the correct diagnosis is made, the final result is however unchangeable.
As you are solving tragic mysteries, perhaps you could look this over:
Yesterday I got an admission- a transfer from ICU. Comfort measures. 24y/o self-inflicted gunshot wound to the head. They had extubated him in ICU, but he didn't die immediately. The bullet went in the right side then out the left side, causing a subarachnoid hemhorrage and brainstem injury. I talked to one of his doctors and she said that the EEG confirmed that he was not completely brain dead. As far as I could assess, he was completely unresponsive, though breathing on his own with stable vs. I changed the head dressing- there was hardly anything to see. Must have been a 9 or 22mm. They had to put in a chricotracheotomy when he arrived to ED. So here is my question: what do you make of this man's copious amounts of clear oral and nasal secretions in the absence of IV fluids and in the presence of a scopolamine patch? Initially I thought it was just regular mucous membrane secretions that had to come out of his mouth and nose because the trach cuff prevented the secretions from draining into his throat. But another nurse there said, "I wonder if it's brain matter." Is there anything in the brain that might look like mucous that might drain through to the oropharynx if punctured by a bullet? It was only very slighly bloody, and I think that was from dry nose irritation.
Laura
It would seem highly likely that this individual has a cerebrospinal fluid leak (possibly mixing with nasopharyngeal mucous if it is mucoid). These develop not infrequently when you punch a hole into the CSF containing spaces surrounding the brain (and spinal cord) and will often not heal as long as there is flow of fluid (they need to get patched). With this, it is likely that the CSF will get infected and may contribute to his death.
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