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FSC401 II Flashcards

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1
Q

What is the greek and latin words for poison (2)

A

Greek - toxikon

Latin - toxicum

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2
Q

What is toxicology (1)

A

The study of harmful or adverse effects of chemicals on living systems

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3
Q

What is forensic toxicology (1)

A

Study and practice of the application of toxicology to the purposes of the law

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4
Q

What does forensic toxicology accomplish (2)

A

Identification and quantification of drug, poison or substance in human tissue
Interpretation of results in context of death investigation

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5
Q

3 uses of forensic toxicology

A

Workplace drug testing
Performance toxicology
Postmortem toxicology

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6
Q

4 steps of pharmacokinetics

A

Absorption
Distribution
Metabolism
Excretion

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7
Q

What is pharmacodynamics (1)

A

The impact of the drug on the physiologic and biochemical processes in the body

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8
Q

What is pharmacokinetics (1)

A

Biochemical fate of the drug in the body and the biochemical processes affecting that fate (movement of drugs)

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9
Q

What is absorption (1)

A

How drugs are brought into the blood and cells

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10
Q

What is distribution (1)

A

How drugs are moved through the body and taken up into organs/tissues

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11
Q

What is metabolism (1)

A

How drugs are biochemically altered or broken down

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12
Q

What is elimination (1)

A

How drugs are removed from the body

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13
Q

What is a central factor or transit mechanism for drugs to reach target tissues (1)

A

Blood

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14
Q

4 methods for chemicals to gain access to blood

A

Ingestion
Injection
Inhalation
Transdermal and across mucosal membranes

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15
Q

4 methods for chemicals to gain access to cells from blood

A

Passive transport
Active transport
Facilitated transport
Endocytosis

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16
Q

Passive transport occurs via what (1)

A

Concentration gradient

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17
Q

Active transport occurs by what (1)

A

Receptor mediated usually with use of ATP

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18
Q

Facilitated transport occurs how (1)

A

Glycoprotein binding and protein mediated route into cell

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19
Q

4 factors affecting rate of absorption

A

Drug itself
Delivery mechanism
Degree of blood perfusion
Tissues acting as barrier to absorption

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20
Q

How does the drug itself affect the rate of absorption (2)

A

pH of drug

Protective coating/capsule

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21
Q

What are 6 different delivery methods of drugs

A 
Pill/tablet
Oral liquid
IV/IA/IM/SC injection
Intrathecal pump/injection
Inhalation
Transdermal
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22
Q

What does blood perfusion refer to (2)

A

Heart rate and blood pressure

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23
Q

3 means of tissues acting as barrier to absorption

A

Gastrointestinal tract
Respiratory tract
Integumentary system

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24
Q

How can the gastrointestinal tract act as a barrier to absorption (1)

A

Can delay gastric emptying time if food or other is present

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25
How can the respiratory tract act as a barrier to absorption (1)
Actually more efficient due to high surface area and rapid blood perfusion
26
What is significant about the integumentary system acting as a barrier to absorption (2)
Least effect absorption | Good for controlled rate of absorption
27
2 processes of distribution
Passive, diffusion based | Active, receptor mediated
28
What is passive distribution initially based upon (1)
Blood flow
29
Active, receptor meditation distribution depends on what 2 things
Affinity of specific drug for particular issue | Ability of tissue to internalize drug via specific uptake mechanisms
30
What is post mortem redistribution (1)
Phenomenon of the movement of drugs after death from region in which they were concentrated in life
31
Loss of what 2 things cell related contributes to PMR
Loss of cell membrane charge | Loss of membrane continuity
32
Loss of cell membrane charge and loss of membrane continuity allows drugs to do what based on what (2)
Allows drugs to diffuse out of tissues that they could not diffuse out of during life Gradient based diffusion allows drugs to increase in blood from tissues that concentrated drugs in life like liver, heart, lungs, stomach, fat
33
Where is preferable to take blood samples and tissue samples from (2)
Peripheral blood as opposed to central blood | Liver from deep right lobe as it is away from GI tract where pills might be
34
What is metabolism (1)
Chemical modification of drugs prior to their eventual elimination
35
Why are drugs metabolized (2)
Usually to decrease toxicity of compound | Enhance aqueous solubility of compound and shorten its residence time in the body
36
Metabolism occurs almost exclusively as a function of what (1)
Enzymatic reactions
37
What are the two broad categories of metabolism
Phase I and Phase II
38
What do phase I reactions do (1)
Enhance or increase reactivity of molecule
39
What do phase II reactions do (1)
Conjugation of drugs with water-soluble molecules leading to filtration and elimination in the kidney
40
Reactions what fall under phase I (5)
``` Hydroxylation Oxidation Reduction Hydrolysis Dehydrogenation ```
41
Enzymes used in phase I reactions (3)
Cytochrome P450s Flavin- containing mono-oxygenases Cytosolic enzymes
42
Reactions that fall under phase II (7)
``` Glucuronidation Sulphation Methylation Acetylation Amino acids Glutathione Mercapturic acids ```
43
What is the primary route of elimination (1)
Urine
44
Why is urine the primary route of elimination (2)
End result of metabolism is usually to make more polar molecule with greater water solubility than original compound
45
What are the two elimination kinetics (2)
Zero order | First order
46
What is a zero order kinetic (1)
The rate of elimination of the drug is independent of drug concentration (same amount of drug eliminated per unit time)
47
What is a first order kinetic (1)
Rate of elimination is a function of the concentration of the drug
48
What is half life (1)
Time required for concentration of a drug to be reduced by half
49
2 general challenges with interpreting toxicology findings
PMR | Decomposition
50
Why can decomposition make toxicology findings challenging to interpret (2)
Specimens may be limited and only have decomposition fluid and tissue Microbial production of ethanol via bacterial fermentation of native sugars
51
What two things ate produced by bacteria postmortem that indicate that ethanol found in the body may be due to putrefaction? How are they recognized? (3)
N-propanol Aldehydes Gas chromatography
52
During the scene and circumstances portion of forensic pathology methodology, what things pertaining to drug paraphernalia are looked for (8)
``` Spoons Lighters Syringes Needles Glass pipes or bongs Tourniquet Prescription meds Illicit drugs ```
53
What two ancillary tests are important when the cause of death is a suspected drug overdose
Toxicology | Microscopy
54
External examination of the body in a drug or toxin related death includes what (4)
Injection sites (recent or remote) Presence of drugs Stigmata of chronic drug use Evidence of overdose by froth from nose/mouth
55
How does cocaine use leading to perforated septum? (2)
Cocaine is vasoconstrictor | Blood vessels close too often that the cartilage tissue begins to die
56
Internal examination of individuals believed to have died from a toxin or drug related death includes examining what (1) what two things cab signify an opioid overdose?(2)
Stomach contents and anything along the GI tract Pulmonary edema Cerebral edema
57
Histology of drug use cab be denoted by what two anatomical areas (2)
Skin at injection sites | Lungs
58
How can skin at injection sites reveal info on the histology of drug use (4)
Acute hemorrhage Chronic fibrosis Sclerosed vessels Foreign body granuloma
59
How can the lungs denote histology of drug use (3)
Polarizable, refractile foreign material Foreign body granuloma Peribronchial macrophages with coarse carbonaceous pigment
60
What are 8 samples that forensic pathologists collect for ancillary testing
``` Blood Urine Vitreous fluid Cerebrospinal fluid Bile Tissue samples Stomach contents Maggots ```
61
4 types of blood samples collected
Femoral Subclavian Heart Body cavity
62
5 types of tissue samples collected
``` Liver Kidney Striated muscle Heart muscle Brain ```
63
How does forensic toxicology differ from clinical laboratory (hospital) testing (3)
Accreditation by documentation of calibrators and controls Accreditation by specific instrument operating conditions Chain of custody of the sample
64
How do hospital labs and forensic labs differ in toxicology instruments (2)
Hospital- automatic analyzers with enzymatic based method | Forensic- chromatography
65
How do hospital labs and forensic labs differ in toxicology controls (2)
Hospital- run periodically eg. Daily/twice daily | Forensic- Batch- specific controls prepared contemporaneously with samples
66
How do hospital labs and forensic labs differ in toxicology calibration of instruments (2)
Hospital -Specific timetable or on as-needed basis | forensic- calibrated with each sample batch
67
How do hospital labs and forensic labs differ in toxicology samples (2)
Hospital - prepared and analyzed individually or batched (as necessary based upon patient need) Forensic- discrete batches with multiple samples
68
How do hospital labs and forensic labs differ in toxicology accreditation (2)
Hospital- ISO 15189 | Forensic- ISO 17020 and 17025
69
Steps for collection of samples (5)
Sterile needle and syringe Glass tube with preservative Appropriate labelling with tamper proof seal Maintenance of chain of custody Store appropriately in secure, cool location
70
What 4 things need to be noted about the tamper proof seal
Seal number corresponds to individual decedent and sample Date and time of collection Source/site of sample Who placed the seal
71
2 screening methods for drugs in drug related deaths
GC, GC/MS | Immunoassay
72
2 targeted methods for drugs in drug related deaths
GC, GC/MS | LC, LC/MS
73
What is chromatography (2)
Method used to isolate compounds based on different interactions with mobile phase and stationary phase as compounds travel through support medium
74
The mobile phase of chromatography can be what two states
Gas or liquid
75
In chromatography, what can retention time determine (1)
Compound’s identity
76
In chromatography, the concentration of the compound can be derived by what 2 things
Integration of peak area | Method of internal standardization
77
What are the 5 different separation techniques used in LC
``` Adsorption Partition Ion exchange Affinity Size exclusion ```
78
Adsorption separation for LC involves what two states
Liquid- Solid
79
What two states is partition LC based, what are the two types of partition LC and how are they different (6)
``` Liquid-Liquid Normal phase (polar liquid stationary phase) Reverse phase (non-polar liquid stationary phase) ```
80
Ion exchange LC is based in what (1)
Column packing material has charge-bearing functional groups
81
Affinity LC is based on what (1)
Immobilized biochemical ligands as stationary phase
82
Size exclusion LC is based on what (1)
Support material has certain range of pore sizes, small molecules in solute enter pores and larger ones cannot so larger molecules elute first
83
What is mass spectrometry and what is it used for (3)
Fragmentation and ionization of molecules with a source of energy Resultant fragment masses and their relative abundance yield characteristic mass spectrum of parent compound Detection and quantification
84
3 steps to mass spectrometry
Convert parent molecule into stream of ions (usually single charged positive ions) Separate ions by mass/charge ratio Count number of ions of each type or measure current produced when ions strike transducer
85
What is immunoassay and why can false positives develop? (3)
Detects compound based upon its ability to act as an antigen Detected using an antibody specific to the drug False positives with drugs that cross react
86
What are the 7 different toxins, drugs, and drug classes
``` Alcohols Opiates and opioids Non-opiate sedative/hypnotic drugs Sympathomimetic amines Hallucinogens, psychedelics, and cannabinoids Cholinergic and anticholinergic toxins Metals ```
87
What are four different alcohols found in drug related deaths
Ethanol Methanol Isopropanol Ethylene glycol
88
What are 5 different opiates and opioids found in drug related deaths
``` Heroin Codeine Oxycodone Methandone Fentanyl ```
89
What are 4 non-opiate sedative/hypnotic drugs found in drug related deaths
Barbiturates Benzodiazepines Tricyclic antidepressants Antipsychotics
90
What are 5 different sympathomimetic amines found in drug deaths
``` Amphetamine Methamphetamine MDA MDMA Cocaine ```
91
What is ethyl alcohol (1), its prevalence (2), and 3 various scenarios its used (3)
``` Ethanol, drinking alcohol, or grain alcohol Most common legal drug Commonly encountered in postmortem cases Drunk driving Binge drinking Sequelae of alcohol use ```
92
What is sequela (1)
A condition which is the consequence of a pervious disease or injury
93
Absorption of ethyl alcohol (4)
Following oral ingestion, rapid absorption in stomach and intestinal mucosa Up to 20% absorbed through stomach wall Most absorption in small intestine Rate of absorption function of alcohol concentration maxing out at 25% alcohol
94
Distribution of ethyl alcohol (2)
Ethanol small enough to cross aquaporin channel proteins | Rapid distribution throughout all body water and equilibrates in all aqueous spaces
95
3 aqueous spaces ethyl alcohol can distribute to
Blood CSF vitreous fluid
96
Metabolism of ethyl alcohol (3)
90% ingested alcohol is metabolized Remainder excreted via urine, exhaled, and transdermal volatiles Metabolism occurs via 2 oxidation steps
97
What are the 2 oxidation steps for the metabolism of ethyl alcohol
Etoh via alcohol dehydrogenase turns into acetaldehyde, which then turns into acetyl-CoA via aldehyde dehydrogenase
98
What is alcohol dehydrogenase (2)
Inducible enzyme associated with tolerance that also has a genetic component
99
2 routes of elimination of alcohol
Urine and breath
100
True or false: urine levels are reflective of blood alcohol levels
False, they are not
101
Effects of alcohol above 30 (1)
Impairment of complex skills such as driving
102
Effects of blood alcohol 30-50 (1)
Definite deterioration in driving ability
103
Effects of alcohol 50-100 (4)
Loquaciousness (chattiness) Loss of inhibitions Laughter Sensory disturbance
104
Effects of alcohol 100-150 (3)
Slurred speech Unsteadiness Possible nausea
105
Effects of alcohol 150-200 (3)
Obvious drunkenness Nausea Staggering gait
106
Effects of alcohol 200-300 (3)
Stupor Vomiting Possibly coma
107
Effects of alcohol 300-350 (3)
Stupor Coma Aspiration of vomit
108
Effects of alcohol over 350 (1)
Progressive danger of death from respiratory centre paralysis
109
6 external signs of chronic ethanol use
``` Jaundice Bruising Scleral icterus Gynecomastia Caput medusae Testicular atrophy ```
110
What is jaundice (1)
skin and whites of the eyes become yellow and urine is dark yellow
111
What is scleral icterus (1)
The manifestation of juandice
112
What is gynecomastia (1)
Enlargement of the male breast gland because of a hormonal imbalance
113
What is caput medusae (1)
the appearance of distended and engorged superficial epigastric veins, which are seen radiating from the umbilicus across the abdomen
114
Testicular atrophy (1)
the male reproductive organs (the testes, which in humans are located in the scrotum) diminish in size and may be accompanied by loss of function
115
Internal pathology of the head regarding alcohol (4)
Subdural hemorrhage Mammillary body hemorrhage/atrophy Superior cerebral atrophy central pontine myelinolysis
116
Cardiovascular and respiratory system internal pathology regarding alcohol (2)
``` Dilated cardiomyopathy Aspiration pneumonia (gram negative enteric bacteria) ```
117
Gastrointestinal system internal pathology regarding alcohol (4)
Oral/esophageal carcinoma Esophageal varices Mallory-Weiss tear Gastric erosions/ulcers
118
Hepatobiliary and pancreas internal pathology regarding alcohol (4)
Steatosis Cirrhosis Hepatocellular carcinoma Pancreatitis
119
What is methanol (1), where is it often found (4), and how it can be found in drinking solutions (1)
``` Colourless liquid Window washing fluid Antifreeze Solvents Methylated spirits Inadvertent containment in home brew whiskey ```
120
Where does absorption of methanol occur (3)
GI tract Skin Lungs
121
Distribution of methanol (1)
Within body water
122
Metabolism of methanol (2)
Slowly metabolized in liver by alcohol dehydrogenase to yield formaldehyde and then formic acid
123
Elimination of methanol (1)
Longer elimination rate than ethanol
124
Clinical effects of methanol use (4)
Toxic effects from formaldehyde and formate (CNS depressants) and metabolic acidosis Irreversible damage to retina and optic nerve Often present with similar symptoms as ethanol intoxication Treat with ethanol administration or fomepizole (alcohol dehydrogenase inhibitor), hemodialysis, correct acidosis
125
Pathology regarding methanol (3)
No gross features Focal white matter necrosis in brain Basal ganglia damage: putamen in brain
126
What is ethylene glycol (4) and where is it found (2)
``` Viscous Sweet Colourless Odorless liquid Antifreeze Industrial chemical ```
127
Pharmacokinetics of ethylene glycol (4)
Absorption via GI tract Distribution through body water Metabolized to oxalic acid Elimination via oxidation and in urine
128
Clinical effects of ethylene glycol (3)
Toxic effects by parent compound and metabolites with CNS depression Metabolic acidosis Treat with ethanol administration, hemodialysis, correct acidosis
129
Pathology regarding ethylene glycol (1)
Oxalate binds with calcium to form insoluble calcium oxalate crystals
130
What are opiates (2)
Group of structurally related, narcotic/analgesic and euphorogenic conpounds, typified by morphine, derived from opium
131
What are opioids (1)
Synthetic drugs that act on opioid receptors and are used as analgesics
132
What term now commonly refers to both opiates and opioids (1)
Opioid
133
What is morphine (1)
Derived from poppy plant
134
What is codeine (1)
Drug on its own; metabolizes to morphine
135
What are oxycodone, hydrocodone, and hydromorphone (1)
Semi- synthetics (derived from codeine or thebaine/paramorphine) with high addictive potential
136
What is methadone (2)
Synthetic | Used in maintenance therapy for prior substance abuse (long half life, daily dosing)
137
What is krokodil (desomorphine) (2)
Illegally manufactured using codeine | Sever side effects including gangrene
138
What is gangrene (1)
Necrosis of limbs
139
What is fentanyl (2)
Synthetic opioid with potency 60-100 that of morphine | An analogue is carfentanil
140
What is buprenorphine (1)
Semisynthetic used as analgesic and for treatment of opioid addiction
141
What is W-18 (1)
Synthetic that is reported to be 10000x more potent than morphine
142
What is heroin (1)
Metabolizes to morphine and 6-monoacetyl morphine which is specific to heroin
143
Absorption/distribution of opioids (2)
Injection and inhalation | Bypass first metabolism in lover which would effectively inactivate 40-50% of an oral dose
144
Metabolism of opioids (1)
Substrate for phase II metabolism via conjugation with glucuronic acid
145
Elimination of opioids (2)
90% via urine | Alternate route across hepatocyte:biliary membrane -> bile -> feces
146
Clinical effects of opiates and opioids (9)
``` Act on opiate receptors (GPCR IN CNS and GI tract) Mu, delta, kappa receptors Analgesia Euphoria Respiratory and CNS depression Decrease intestinal motility CVS effects: bradycardia and hypotension Miosis Cough suppression ```
147
Treatment of opiates and opioids (2)
Opiate antagonists naloxone (Narcan) with short half life and Naltrexone (Trexan) with longer half life
148
What is a sedative (1)
Aka tranquilizer | Substance with calming effect reducing excitement or activity level
149
What is a hypnotic (1)
Substance that induces sleep
150
What do non-opiate sedative/hypnotic drugs act as (2)
GABA receptor agonists or | Allosteric activators
151
What risk do barbiturates and benzodiazepines have (1)
Overdose risk with ethanol- CNS depression
152
What do tricyclic antidepressants act as (1)
Sodium and calcium channel blockers at high concentrations -> cardiotoxic
153
What are sympathomimetic amines (2)
Stimulants | Physical and cognitive performance enhancers
154
What kind of psychotropic effects arise from sympathomimetic amines (4)
Euphoria Mental focus Self esteem Confidence
155
Antemortem Symptoms of amphetamine overdose (10)
``` Psychotic symptoms Nausea Tachypnea Fever Tremors Lethal seizures Hyperthermia Rhabdomyolysis Hypertension Cardiac arrhythmia ```
156
Antemortem symptoms of methamphetamine overdose (4)
Seizures Arrhythmia Stroke Hyperthermia
157
Antemortem symptoms of MDA and MDMA overdose (6)
``` Hypertension Tachycardia Hyperthermia Seizures Coma Death ```
158
What are cathinones (bath salts), their chemical name, and 2 effecrs
Stimulant and psychotrope Methylenedioxypyrovalerone Tachycardia Hyperthermia
159
What is cocaine (3)
Highly addictive Psychotropic Produces euphoria and anesthesia
160
Metabolic path of cocaine (3)
Benzoylecgonine (predominant) Ecgonine methyl estrr Both hydrolyzed to ecgonine
161
How long after cocaine use can benzoylecgonine bet detected in urine (1)
3 days
162
What is cocaethylene (3)
Product formed with both cocaine and ethanol are present in liver Potent psychotropic No tolerance can be developed
163
What is a cannabinoid (4)
Delta 9 tetrahydrocannabinol Psychotropic active compound derived from cannabis Lipophilic Cant kill you on its own
164
What are synthetic cannabinoids (4)
Herbal incense, K2, Spice Synthetic analogues of THC New analogues constantly being manufactured and challenging to detect (different mass spectra) Can kill you on its own
165
How is the interpretation of toxicology results done (3)
COD- is it at a lethal level? Contributing factor - recreational level or presence of drug detected but another cause of death? Or is there no role in COD
166
What is asphyxia (1)
Inadequate oxygenation of tissue
167
What are the two types of asphyxia
Hypoxia | Anoxia
168
What are the two mechanisms of hypoxia
Cant take in oxygen | Cant use available oxygen
169
What is anoxia (1)
Total depletion of oxygen
170
Organ damage via anoxia occurs primarily where (4)
Brain Kidneys Heart Tissues
171
Oxygen access (breathing) deaths (4)
Suffocation Strangulation Drowning Chemical asphyxia
172
Oxygen utilization (cellular respiration) deaths (2)
Chemical asphyxia | Biochemical processes
173
What is suffocation (1)
Failure of oxygen to reach blood
174
What are the 5 types of suffocation
``` Environmental suffocation Smothering Choking Mechanical Drowning ```
175
What is mechanism of death for suffocation (7)
``` Loss of oxygen to tissues Cellular respiration ceases No energy available to perform routine cellular tasks Cells cease functioning Cell death Organ failure Organism failure ```
176
What is environmental suffocation (1)
Inadequate atmospheric oxygen
177
What are the two kinds of environmental suffocation
Closed chamber | Oxygen replacement
178
How can closed chamber environmental suffocation occur (1)
Children hiding in discarded refrigerators
179
oxygen replacement environmental suffocation replaces oxygen with what commonly (3)
Carbon dioxide Carbon monoxide Nitrogen
180
Manner of deaths of environmental suffocation (3)
Accident/suicide | Rarely homicide
181
Autopsy findings for environmental suffocation (2)
No specific findings | No petichiae
182
What are petechiae (3)
Small circular non raised patch of blood Bleeding under the skin Often a sign of increased hemostatic pressure
183
What is smothering? (1)
Mechanical obstruction of the nose and mouth
184
What are three most common forms of smothering
Face wedged into an object Head wrapped in plastic Deliberate occlusion or gagging
185
What are four ways to deliberately occlude or gag someone or yourself
Hand covering mouth and nose Hands covering mouth and pinching nose Duct tape Object covering face like pillow
186
What are the manners of death for smothering from most common to least (3)
Accident Suicide Homicide
187
What autopsy findings are found in smothering cases (4)
Where decedent may have resisted (adult): bruising on face and scratches No petechiae No diagnose without info on surroundings and how body was found (things over face)
188
What is choking (1)
Blockage of internal airways
189
What are 3 ways you can choke
Object in pharynx, larynx, trachea, bronchi Choke hold Infection by epiglottis or pneumonia
190
What is a choke hold (1)
Deliberate block of airway to subdue individual
191
What are the manners of death for choking from most common to least (3)
Accident Homicide Natural
192
What are the 3 autopsy findings in choking
Obstruction in airway No typical findings No petichiae
193
What is mechanical suffocation (3)
Traumatic asphyxia Pressure on thorax or abdomen restricts respiratory movement Decreases inspiration
194
What is overlay and an example (2)
Mechanical asphyxiation + smothering | Sleeping parent rolling onto sleeping infant
195
What is positional suffocation (1)
Trapped in a position where respiration becomes inadequate
196
What are the two types of mechanical suffocation
Overlay | Positional
197
What are the two manners of death of mechanical suffocation from most common to least
Accidental | Homicide
198
Autopsy findings for mechanical suffocation (4)
May be no internal injuries Face and neck are deep red/purple Conjuctival and scleral petichiae (secondary to congestion) Confluent scleral hemorrhage
199
What is hog tying (1) when does it occur usually (1) and what does it involve (1) and what has research shown is not a factor in most hogtying situation (1)
Positional/restraint asphyxia In custody Individual prone, pressure on back/thorax while hands and feet are restrained and tied to each other Hypoxia
200
What is strangulation (2)
Occlusion of blood vessels in the neck | Secondary to external pressure
201
3 means of strangulation
Hanging Ligature Manual
202
Mechanism of death for strangulation (2)
Cerebral hypoxia | Secondary to obstruction of arteries supplying brain
203
What is the cardiac arrest hypothesis in regards to strangulation (2)
Cardiac arrest causes carotid body and sinus stimulation leading to death in strangulation Not scientifically supported
204
What is hanging (6) and mechanism of death (1)
Noose around neck Tightened/pressure increased by body weight May or may not be completely suspended Head weight sufficient to occlude carotid arteries Compresses carotid, jugular, and vertebral veins Secondary venous sinuses still drain Cerebral hypoxia
205
Manners of death for hanging from most common to least (3)
Suicide Accident (autoerotic asphyxiation) Homicide (v rare)
206
Common autopsy findings from hanging (5)
``` Pale face as blood can still drain Usually no petichiae coz blood can drain (no hydrostatic rupture of vessels) Protruding and dried out tongue Mucous drips from nose Furrow in skin ```
207
Aspects about furrows in skin from hanging (6)
``` Usually above larynx Patterned abrasions consistent with noose material Inverted V-shape Apex at point of suspension Pale yellow drying to brown Edges congested (swollen) ```
208
Uncommon autopsy findings in hangings (5)
Scleral/conjuctival hemorrhage (25%) Hyoid or thyroid cartilage fractures (12%) Strap muscle hemorrhage (20%) Cervical spine fracture only with high drop suspension Pooling of blood in lower extremities and Tardieu spots in complete suspension
209
Autopsy findings of hanging via autoerotic asphyxiation (4)
Transient cerebral hypoxia to enhance masturbatory pleasure (10-15s to loss of consciousness) (poor timing = death) Decedent usually male Often found with erotic literature/paraphernalia near body Padded noose - no abrasions
210
What is strangulation via ligature (2) and mechanism of death (1)
Pressure on neck applied by ligature (tightening by forces other than body weight) Occlusion of carotid arteries and jugular veins (vertebral arteries usually not affected) Cerebral hypoxia
211
Manner of death for strangulation via ligature from most common to least (3)
Homicide (against women and during rape is common) Suicide (rare, possible to strangle self to death before loss of consciousness) Accident (rare, clothing around neck caught in machinery)
212
Autopsy findings from strangulation via ligature (5)
Face congested (vertebral arteries still open) Petichiae of sclerae and conjuctivae, face, and periorbital skin (vertebral arteries still open) Ligature marks (parchment yellow drying to brown, varies with nature of ligature (soft ligature - poorly defined mark vs wire - deep and well defined) horizontal, overlies or is inferior to larynx) Internal injuries present 33% (hemorrhage 20%, hyoid or thyroid cartilage fracture 12.5%) External injuries (defense wounds, scratch marks around ligature)
213
What findings at autopsy can be ruled out of playing a role in strangulation by ligature (2)
Pale crease marks between rolls of neck skin as its normal in elderly and infants
214
What is manual strangulation (2) and mechanism of death for it (1)
Pressure on neck applied by hands, arms, other limb Occludes vessels of the neck Death by cerebral hypoxia or aggravation of severe underlying disease
215
Mechanism of death by manual strangulation is NOT due to what (5)
``` Vasovagal reflex Stimulation of carotid sinus Bradycardia Vasodilation Hypotension Cardiac arrest ```
216
Manner of death from manual strangulation from most common to least (3)
Homicide (almost exclusively) Accident (possibly) Suicide (impossible)
217
Autopsy findings from manual strangulation (6)
Facial congestion Petichiae (scleral and conjuctival, periorbital and cheek) Abrasions and contusions (skin of underside of jaw and neck) Fingernail marks (semicircular on skin) Hemorrhage of neck muscles + hyoid/thyroid cartilage fracture (no hemorrhage = postmortem fracture, most male decedents and age related, occurs in 50% of female decedents) No external or internal injuries (rare but possible as decedent unconscious during neck occlusion)
218
What is a neck hold and what are the two kinds (3)
Used by military/police agencies to subdue individuals Bar arm (choke) hold Carotid sleeper hold
219
What is the bar arm (choke) hold (4)
Forearm across the neck Compresses airway Moves tongue back to occlude hypopharynx Can fracture hyoid/ossified thyroid/cricoid cartilages
220
What is the carotid sleeper hold (3)
Forearm across neck, elbow bend at the larynx Compresses neck vessels Spares airway
221
What is drowning (1)
Water enters airway
222
How does drowning in freshwater cause death (7)
``` Hypotonic, passes more quickly through alveoli Increase blood volume Hemolysis Denatures surfactant Collapses alveoli Hinders re-inflation Worsens hypoxia ```
223
How does drowning in saltwater cause death (3)
Hypertonic, draws water into alveoli from blood Decrease in blood volume Washes away surfactant
224
What is the mechanism of death for drowning (3)
Hypoxia Cerebral anoxia Death
225
Why are men more likely to drown than women? (3)
Access to aquatic sites High risk behaviour Alcohol consumption at sites
226
How does drowning in cold water affect death (3)
Diving reflex Bradycardia Vasoconstriction shunting blood to brain and heart
227
How does drowning in warm water affect death (1)
Irreversible cerebral anoxia within 3-10 mins
228
How does drowning in heated water affect death (4)
Hot tub, whirlpool deaths Often accompanied by alcohol, other intoxication Cerebral anoxia more rapid Hypotension leads to fainting, slipping underwater (often unwitnessed)
229
What is near drowning deaths (1)
Survival after almost drowning for at least 24 hours post rescue
230
Autopsy findings for near drowning deaths (8)
``` Sequelae of anoxia Pulmonary edema Blood in urine (hemolysis) Swollen ling tissue (pneumonitis) Cardiac arrhythmia Fever Sepsis Cerebral edema leading to death ```
231
Manner of death by drowning from most common to least (3)
Accident Homicide Suicide
232
Autopsy findings from drowning (4)
Highly variable (Dependent on circumstances, water type, body condition at discovery) Diagnosis of exclusion if body recovered quickly, (bloody froth mix of air, water, mucous, blood, surfactant throughout airway, and has washerwoman hands and feet) Over time (body sinks, hangs near bottom, scrapes, cuts associated with contact, scavenging by fish, decomposition causes it to float with rate depending on water temp, clothing, adipose tissue)
233
Ancillary findings from drowning (2)
Blood/tissue from closed organ system like liver or kidney | Diatoms matched to water source (if in closed system, means they ingested them while they were alive)
234
Final reports for drownings must address what (2)
Was decedent alive or dead when they entered the water | Are wounds perimortem or postmortem artifacts
235
How do chemical asphyxiants cause death (3)
Oxygen is replaced by gas Cannot enter tissues Cannot be utilized by cells in respiration
236
What are three common gases that can be chemical asphyxiants
Carbon monoxide Hydrogen cyanide Hydrogen sulfide
237
How is carbon monoxide taken in and how does it cause death (3)
Inhaled Binds to hemoglobin more tightly than oxygen Inhibits cellular respiration in mitochondria
238
Manner of death of carbon monoxide from most common to least common (2)
Accident | Suicide
239
External autopsy findings for chemical asphyxiants (2)
Cherry red skin | Cutaneous bullae
240
Internal autopsy findings from carbon monoxide (3)
Cherry red tissues Pulmonary and cerebral edema Necrosis and cavitation of brain structures
241
How is hydrogen cyanide taken in and cause death (2)
Inhaled as a burned gas or ingested as a powder or pill | Inhibits cellular respiration
242
Manner of death by hydrogen cyanide from most common to least (2)
Suicide | Accidental
243
External autopsy findings from hydrogen cyanide (2)
Cherry red skin | Bitter almond skin
244
Internal autopsy findings from hydrogen cyanide (2)
Stomach mucosa cherry red colour | Pulmonary edema
245
How is hydrogen sulfide taken in and cause death(2)
Inhaled or ingested | Inhibits cellular respiration
246
Manner of death for hydrogen sulfide (1)
Accidental (~100%) from people working in sewer plants/cesspools
247
Autopsy findings from hydrogen cyanide (3)
Rotten egg odour Signs of general hypoxia Greenish-purple colour in blood and viscera
248
What is ohms law and what does each variable stand for (4)
V=I/R V is voltage or electromotive force I is current or the flow of electric charge R is resistance or the opposition to the flow of charge
249
Manner of death of electrocution from most common to least (3)
Accident (ground fault circuit interrupters GFCIs, detect abnormality in the circuit and interrupt the current) Suicide Homicide (judicial electrocution)
250
4 ways someone can accidentally electrocute themselves
Live wire handling Damaged electrical appliance Work related (may be forensically significant, poor grounding in electrical areas, poor training near electrical equipment) Third rail
251
Why is suicidal electrocution difficult and who usually attempts this and how (3)
Difficult because of GCFIs Electrical engineers or electricians Can be elaborate or as simple as an appliance in body of water (does not need to be turned on)
252
Factors that affect the severity/mechanism of electrocution (7)
``` Nature of current (frequency of AC) Voltage Amount of current Path through the body Time of exposure Condition of the circuit (wet, dry, grounded to earth) Resistance of the body ```
253
What are the two current types, which is more dangerous to humans, and what is the condition the currents must be in to cause harm (4)
Direct current (unidirectional) Alternating current (changes direction) Humans more sensitive to AC Circuit must be closed
254
What is the lethal frequency of AC and the typical frequency in households (2)
39-150Hz | ~60Hz
255
What path does current follow? (1)
Shortest path, not of least resistance
256
Current path through the body varies by what 2 things
Current entry | Exit site
257
Fatal paths of current usually cross what two things
Brain or heart
258
How much current is sufficient to cause cardiac arrest (1)
2 amperes
259
What is considered voltage, standard voltages in North America and Europe, and how must it interact with humans to cause damage (4)
Under 1000V is low 120V in NA 240V in residential Europe Must be direct contact
260
Mechanism of death via low voltage (2)
Ventricular fibrulation | Muscle paralysis with secondary asphyxia (low voltage over long time)
261
Autopsy findings from low voltage (2)
Inconclusive (burns in 50%, contact necessary (burns at site), diffused contact (burns may not occur) Scene info crucial
262
What is considered high voltage and what are 3 sources of high voltage
Greater than 1000V Power lines (2300-100000v) Electrical arc Lightning strike
263
Mechanism of death by high voltage (2)
``` Respiratory arrest Electrothermal injury (irreversible) ```
264
Autopsy findings from high voltage (4)
Burns in most cases Severe tissue charring (metal from object may imbed in skin) Arc burns or flash burns may occur Dissection and histology of charring, embedding, and streaming)
265
What are arc burns (1)
Small burns over an area
266
What are flash burns (1)
Burns over a large area of skin
267
What kinds of surfaces are better conductors (1)
Wet
268
What are different types of surfaces that can be wet and make for better conductors (3)
Skin Earth Surrounding conditions
269
Resistance to electrocution can come from what two things
Skin (dry has higher resistance) | Clothing (rubber boots/gloves may be insulating and break the circuit)
270
When was judicial execution abolished in Canada (1) and how was it performed (2)
July 1974 Hanging Firing squad for military executions
271
When was the electric chair first used, what states allow it still and what other country uses it (6)
``` 1881 in Buffalo NY Virginia Tennessee South Carolina Arkansas Phillipines ```
272
How are deaths in custody handled in Ontario (5)
Autopsies by forensic pathologist Documentation via photographs, video, ancillary tests Automatically triggers a coroner’s inquest
273
Manners of death in prisons from most common to least (4)
Accidental (head injuries from intoxication) Suicidal Homicidal (prisoner v prisoner) Natural (age, chronic disease)
274
Manners of death in jails from most common to least (2)
Accidental | Suicidal
275
Aspects of delirium (5)
``` Disorientation Disorganized thinking Reality vs hallucination Speech disturbance Inability to recognize people ```
276
Aspects of excited delirium syndrome (7)
``` Rapid onset Delirium Violent behaviour Restraint Cardiac death Attempts to resuscitate Underlying conditions ```
277
Eds deaths occur when and at what percent (3)
Scene of arrest (48%) In transport (29%) On arrival of hospital or jail (16%)
278
Mechanism of death for EDS syndrome (2)
Excitation by sympathetic nervous system acting on damaged vessels or myocardium to produce arrhythmia or on stimulant intoxication
279
How does hogtying, choke holds, and EDS relate to asphyxia deaths
Research shows EDS is the mechanism of death brought on by hogtying or chokeholds
280
What are tasers and how do they work (3)
High voltage, low current (162mA), 5s burst Electromuscular disruption Incapacitation
281
Deaths with tasers are associated with what (1)
EDS
282
Taser deaths are often associated with what kind of drug use (1)
Stimulant use
283
Autopsy findings for taser deaths (2)
Non specific | Two prong burn may be present (direct skin contact)
284
Suicides in custody typically occur when (1)
Often within 48 hours of arrival
285
Suicides in custody typically occur how (2)
Hanging asphyxia from clothing or bedding | Incomplete suspension and often mistaken for homicide by family
286
What types of scenarios mandate an inquest (5)
Death occurs on the job at a construction site, mine, pit, or quarry Death occurs while a person is in custody or being detained Death occurs due to an injury sustained or other event that occurred in custody or when the use of force of a police officer, special constable, auxiliary member of a police force or first nations constable is the cause of death Death of a child is a result of a criminal act of a person who has custody of the child if certain circumstances are met Death of a person occurs while being physically restrained and detained in a psychiatric facility, hospital, or secure treatment program
287
Discretionary inquests may be held when one of what three things happen (3)
Coroner determines that enough info is known from death investigation to support an inquest Coroner decides that it is desirable for the public to have an open and full hearing of the circumstance of a death Coroner believes a jury could make useful recommendations to prevent further deaths
288
5 questions a coroners inquest aims to answer
Who was the deceased Where did the death occur When did the death occur How did the death occur (medical cause and mechanism) By what means did the death occur (classification or manner of death: natural, suicide, accident, homicide or undetermined)
289
5 broad social determinants of health
Factors influence individuals health and their risk of disease Social, economic, political and policy factors Not individual biological/genetic factors Factors are not discreet - considerable overlap Factor distribution is influenced by public policy
290
What are the social determinants of health in canada (14)
``` Income/income distribution Level of education Job security and unemployment Employment and working conditions Early childhood development and experience Food security/insecurity Social exclusion/inclusion Housing Social safety network Health service access Aboriginal status Gender Race Disability ```
291
6 social determinants of health that arent recognized by Canada
``` War/peace time Access to clean water Transportation access Addiction Sexuality Sex work ```
292
Income/income distribution is an overarching factor that affects access to what (7)
``` Food Healthcare Transportation (public or private) Education Employment resources such as networking groups Technology Job/interview appropriate clothing ```
293
Higher education is inversely correlated with what and directly correlated with what (2)
Unemployment | Higher income
294
Higher income increases access to what (1)
Higher education
295
Children of wealth families have access to what (4)
Private tutoring Writing help (applications) Extracurricular activities Time to study (versus aiding household, supporting selves)
296
How many people smokers are there worldwide and how many are from developing countries (2)
900 million smokers | 70% from developing world
297
Alcohol related disease affects how much of the world population annually (1)
5-10%
298
Families spent on what (3) negatively affect budgets food and is disproportionately true for poorer families
Cigarettes Alcohol Other drugs
299
Poverty and addiction increase risk of what 5 thins
``` Malnutrition Malnutrition related disease Cancers Communicable diseases Early death in adults (primary income earners) ```
300
Adverse childhood experiences (11)
``` Physical abuse Sexual abuse Emotional abuse Physical neglect Emotional neglect Intimate partner violence Mother treated violently Substance misuse within household Household mental illness Parental separation or divorce Incarcerated household member ```
301
Correlations exist between adverse childhood experiences and what 4 things
Cognitive outcomes (learning impairments) Mental health (depression, high risk behaviour) Morbidity (disability, heart disease and stroke) Mortality (early death)
302
Bio geographical affiliations and adverse childhood experiences in canada (3)
First nations communities experience adverse childhood experiences related outcomes at higher rates than non-indigenous peoples 3-5x more likely to develop type 2 diabetes 80% of suicide attempts in childhood linked to ACEs
303
World health organization routinely recommends and promotes public health that what (2)
Take poverty into account as a risk factor (pro-poor health approach) Promote systems of universality of access (health care including mental health care, education, and income distribution)
304
What is a public policy on universal basic income (1)
Policy where each individual in a community receives a guaranteed income provided by the government
305
Universal basic income in namibia (3)
Experiment from othjivero-omitara region 2008-2009 Increase in number of individuals able to travel to receive HIV medication Decrease in number of children considered overweight (42-10%)
306
Universal basic income in Canada (2)
Experiment in Dauphin MB 1967-1974 (Mincome) | Decrease in hospitalizations for accidents, injuries. And relating to mental health
307
Universal basic income in Finland (2)
Currently running a series of UBI experiments 2017-2019 | Trying models of partial UBI, needs based UBI, non-needs based UBI
308
Universal pharmacare in Canada (1)
29% British Columbia households reported they did not take medicines as directed because of cost
309
Universal pharmacare in USA (3)
2015: diabetes was listed as cause of death on 252,806 death certificates in 2015 Between 2012-2018 insulin prices have doubled US Census data indicates 27.3 million people have no insurance for drugs or healthcare
310
Universal pharmacare in UK (2)
Has universal pharmacare | Individual costs for insulin about 500USD/year
311
Gun control laws set laws and policies the restrict what 6 things by civilian individuals
``` Manufacture Sale Ownership Transfer Possession And use of firearms ```
312
In non-war zones, rates of gun violence are proportional to what (1)
Civilian gun ownership
313
Vaccinations date back to when (3)
Date back to 1700s Snake venom ingestion, variolation in China 1798 - first smallpox vaccine (variola virus)
314
How do vaccinations work (1) and what is their goal (1)
Introduction of an antigen that produces antibodies (live attenuated virus, killed virus) Goal is widespread vaccination (95%) - “herd immunity”
315
Vaccination programs have led to directly to drops in what (4)
Infection Disease Morbidity Mortality rates
316
Vaccinations in canada (2)
Measles: 1960-2009 | From 3000- fewer than 300 cases post vaccine introduction
317
Vaccinations in Europe (3)
Smallpox study from 1950-1960 95% of vaccinated do not develop disease 52% of unvaccinated die of smallpox
318
Vaccine hesitancy/refusal has led to what (1)
Increased rates of previously controlled diseases like measles
319
Measles in the US (5)
2019 as of march 21 - 268 cases reported in the US NY/NJ primarily Orthodox Jewish community Very low community vaccination rate Travellers to israel exposed Currently a large measles outreach in israel
320
Trends in public policy (4)
Policies aimed at universality of access result in overall increased health and life expectancy Mitigate negative effects of social determinants of health Level the playing field Protect vulnerable populations
321
Ncbi definition of vulnerable populations
Vulnerable populations include patients who are racial or ethnic minorities, children, elderly, socioeconomically disadvantaged, uninsured or those with certain medical conditions. Members of vulnerable populations often have health conditions that are exacerbated by unnecessarily inadequate healthcare
322
World health organization definition of vulnerable populations
Vulnerability is the degree to which a population, individual or organization is unable to anticipate, cope with, resist and recover from the impacts of disasters
323
World bank definition of vulnerable populations
A vulnerable group is a population that has some specific characteristics that make is at higher risk of falling into poverty than others living in areas targeted by a project
324
CMAJ has chosen four areas of focus. What are they?
Sepsis Health services Mental health Vulnerable populations
325
Vulnerable populations (19)
``` Women (pregnant women) Children Elderly Travellers Immigrants Undocumented border crosses Refugees Ppl with compromised health status (HIV +) Inmates or in police custody Individuals in poverty/low SES status Racialized individuals Religious groups Food secure individuals Sex workers People with addictions People with disabilities Institutionalized person Non-binary gender identities Non heterosexuals ```
326
Manner of death of elderly from most common to least (4)
Natural Suicide Homicide Accident
327
Natural deaths in elderly (2)
Age and disease related | Imminent or reasonably expected
328
Suicides in elderly (2)
High depression rate among elderly | Exacerbated by illness, lack of social support, underlying mental illness
329
Homicide in elderly (2)
Direct abuse - staff personnel, visitors | Negligence (home or in care facilities)
330
Accidents in elderly (1)
Bed rail entrapment
331
Autopsy findings in neglected elderly (5)
``` Decubitus (pressure) ulcers Malnutrition Dehydration Contractures Poor hygiene ```
332
Stage 1 of decubitus (1)
Compression of the skin with reddening
333
Stage 2 of decubitus ulcers (1)
Partial thickness including epidermis and/or dermis, blisters or ulcers
334
Stage 3 of decubitus ulcers (1)
Full thickness - epidermis, dermis, subcutaneous fat, fascia
335
Stage 4 of decubitus ulcers (1)
Through fascia to muscle and/or bone; risk of osteomyelitis and sepsis
336
Types of elder abuse (6)
``` Physical Neglect Verbal/mental (psychological) Financial Sexual Violation ```
337
What phase of life is the most critical for infanticide or neonaticide and why (2)
1st year of life: deaths due to craniocerebral injuries | 2nd year of life: deaths due to traumatic abdominal injuries
338
Homicides of children over 2 years include what kinds of deaths (3)
Battered children Impulse homicide Gentle homicide
339
Injuries due to battered child syndrome (5)
Often multiple, various stages of healing, patterned (belt buckle impression etc) or not Fractures in ribs and extremities due to kicks or squeezing (CPR rarely breaks ribs in children) Delay between fractures and appearance at hospital Head injuries prevalent with or without signs of trauma (hemorrhage with or without skull fractures) Abdominal injury frequently no outside signs (child may present with non-specific symptoms like vomiting, lethargic, unwell, flu-like symptoms)
340
Neglect in children can lead to what 4 things
Inclusion in battered child syndrome Severe malnutrition - skeletal appearance (natural disease must be ruled out) Severe dehydration Contracture
341
Impulse homicide in children can include what 3 things
Acute injuries Not necessarily battered child syndrome Punishment injuries (scalding with typical pattern, blow from caregiver)
342
Gentle homicide in children can include what 3 things
Smothering as COD, asphyxia as mechanism Non specific findings - full autopsy required Homicide often judged based on parental pattern (sudden infant death syndrome)
343
Women are globally at higher risk of what (3) and during what time do they increase (1)
Homicide Intimate partner violence Sexual violence Increased rates in war time
344
Rape homicide of women can include what (4)
Body position (on back, legs spread, clothing fully or partially removed/pushed up or away) Bite marks Abrasions, contusions, lacerations visible - inner legs, genitalia, perineum, anus Often accompanied by blunt force trauma in other areas, stabbing, or strangulation, rarely firearm injuries
345
Natural deaths of pregnant women now rare because of what 3 public health measures and improved medical practice (decrease in overall maternal mortality)
Improved prenatal care Improved sensitivity of diagnosis Scope of available therapies
346
Pregnant women deaths most frequently are due to (4)
Hemorrhage Embolism Pregnancy induced hypertensive complications Infection
347
Outcomes of pregnant women worsen with what 3 things
Poor SES poor education Racialization
348
Black women experience higher infant and maternal mortality in North America, but this is normalized for what 3 things
SES Overall health Education
349
Firsthand interviews of black pregnant women show what 3 things
Disbelief regarding pain or other symptoms by medical staff Disregard of concerns Increased wait times for care
350
Where abortion is legal, available, and safe, complications and deaths are rare, but deaths occur mainly due to what 4 things. Future fertility is affected how?
``` Hemorrhage Infection Emboli Anesthetic complications Is unaffected ```
351
Illegal abortion safety is increasing and deaths occur mainly due to what 3 things
Hemorrhage Sepsis (including endometritis) Air emboli
352
In developing countries, lack of access to abortions increases what (1)
Maternal mortality by illegal abortion practices
353
Lack of access to abortion affects maternal and child health outcomes how (5)
Increases SES disparity Unequal access to healthcare Decreased rates of maternal higher education Increased food insecurity Increased childhood trauma and adverse childhood experience related outcomes
354
Availability of healthcare for immigrant populations is limited due to what 6 things
``` Legal status Job security (benefits, ability to pay) Language Gender Age Cultural differences in health behaviour ```
355
Refugee populations have difficulty accessing basic needs such as what (4)
Nutrition Clean water Health access (treatment, reproductive health, communicable disease prevention) Mental health access

UTM (2 decks)

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