Carbon monoxide – the silent killer

Tarnished jewellery and skin - a subtle external marker indicating exposure to hydrogen sulfide

A 39-year-old woman was found lying in the rear of a car at her home address. A smell of rotten eggs was noted and bottles of brick, tile and paver cleaner and lime sulfur were found in the rear of the vehicle. Suicide notes were found in the house. At autopsy there was no evidence of significant trauma with black tarnishing of a silver-coloured ring and a silver-coloured necklace noted with staining of the underlying skin, in keeping with a chemical reaction between hydrogen sulfide and silver. Internally the most significant finding was unusual greenish discolouration of the gray matter of the external and cut surfaces of the cerebral hemispheres, cerebellum and brain stem. No other organs had this discoloration. Death was attributed to hydrogen sulfide poisoning. Skin discoloration from silver jewellery may represent a subtle external marker for lethal or non-lethal hydrogen sulfide exposure.

Recent trends in an uncommon method of carbon monoxide suicide

PURPOSE

The most prevalent method of carbon monoxide (CO) suicide is inhalation of vehicle exhaust (VE). However, a new method of CO suicide has recently emerged involving charcoal burning (CB) in a confined space to produce fatal CO levels. This method has been reported from countries in Asia, associated with economic instability and media reporting of high-profile celebrity cases. The current study was undertaken to analyze rates and characteristics of CB suicides in South Australia (SA) for comparison with respect to their characteristics and scene, autopsy and toxicology findings.

METHODS

A search was undertaken for all intentional fatal carbon monoxide poisonings in SA between 2000 and 2019. Collected variables included age, sex, cause of death, location of death, decedent histories, scene, autopsy and toxicology findings and manner of death. Statistical analyses were performed using R (version 4.2.3).

RESULTS

There was a significant decrease in VE suicides (p < 0.05) and a significant increase in CB suicides (p < 0.001) over the 20-year period. Those who used CB were found to be, on average, between 1.5 and 15.8 years younger than those who used VE (p = 0.017). The risk factors for CB suicide included psychological/psychiatric conditions and financial problems, while VE suicides were associated with a history of physical problems and contact with the legal system. External and internal autopsy findings were consistent with the literature.

CONCLUSION

CB suicide is perceived to be widely accessible and painless and is therefore becoming a popular suicide method. Monitoring future trends will be important to determine whether intervention is required.

Carbon monoxide related deaths: A Verona case series. When cooperation becomes compulsory

INTRODUCTION

Carbon monoxide (CO) poisoning is a significant concern in forensic medicine, as it often presents unique challenges in terms of diagnosis, investigation, and determination of the cause of death. CO is a colourless, odourless, and tasteless gas that can be lethal when inhaled in high concentrations. It binds strongly to haemoglobin, forming carboxyhaemoglobin (COHb), which reduces the oxygen-carrying capacity of the blood, leading to tissue hypoxia and ultimately death.

MATERIALS AND METHODS

Circumstantial data, medical history information, autopsy findings, and toxicological analysis results related to 24 CO poisoning cases at the Institute of Legal Medicine in Verona were collected and analysed. The data were examined in an integrated manner to identify correlations and common patterns. A comparison was also made with the data available in the literature.

RESULTS

The male gender was confirmed to be the most frequently involved. COHb levels were found to be less than 50% in 6 cases. Three individuals had concurrent cardiovascular pathologies, while 11 subjects tested positive for various substances, including alcohol, benzodiazepines, and morphine. In most cases, the manner of fatal intoxication was accidental, although 6 suicides and 1 homicide are reported.

CONCLUSIONS

The Verona case series demonstrates that deaths due to CO poisoning require a multidisciplinary approach. The integration of diverse expertise is essential for assessing the manner of death. This approach enables a comprehensive evaluation of the available data, aids in distinguishing between accidental, suicidal, and homicidal deaths, and ensures accurate and reliable forensic conclusions.

The spectrum of presentations of unintentional carbon monoxide poisoning

Carbon monoxide (CO) is an odourless and tasteless gas which can be produced by the incomplete combustion of carbon-containing fuels. Compared to vehicular CO suicides, unintentional cases (excluding those related to fires) are much less common. Increased education surrounding the risks associated with the accumulation of CO in enclosed spaces has contributed to a reduced incidence of unintentional CO poisonings. However, such cases may remain undetected, particularly in domestic and recreational settings where scene findings are often non-specific. The current study of unintentional CO poisonings in South Australia and the Northern Territory, each with a unique climate (Mediterranean and tropical respectively), demonstrated differences in the circumstances of death. Several cases where individuals used carbon-producing fuel sources for heat, both in domestic and vehicular settings and without adequate ventilation, resulted in fatal outcomes. Less common scenarios involved faults in equipment (e.g. a hot water heater), vehicle faults resulting in the accumulation of fatal levels of CO in enclosed spaces, and inadvertent introduction of CO into a diving oxygen supply in a recreational aquatic setting. In ascertaining the cause of death, other considerations include the potential role of underlying chronic cardiovascular and respiratory disease and age which may increase an individual's susceptibility to CO toxicity. Understanding the wide variety of presentations and contributing factors in cases of fatal CO poisoning including consideration of climate-specific differences in domestic and extra-domestic settings may enable improved detection at autopsy.

Selective Detection of CO Using Proton-Conducting Graphene Oxide Membranes with Pt-Doped SnO2 Electrocatalysts: Mechanistic Study by Operando DRIFTS

To reduce the risk of carbon monoxide (CO) poisoning, there is a strong need for small, compact gas sensors to detect and monitor CO at ppm concentrations. In this study, we focused on detecting CO with electrochemical sensors based on proton-conducting graphene oxide (GO) nanosheets at room temperature. We found that a Ce-doped GO nanosheet membrane fitted with the sensing electrode composed of Pt (10 wt %)-doped SnO2 nanocrystals exhibits an excellent sensor response to CO at 25 °C. Pt doping of SnO2 nanocrystals has made it possible to detect CO more selectively than H2 and ethanol. The CO detection mechanism is analyzed by operando diffuse reflectance infrared Fourier transform spectroscopy (DRIFTS), Fourier transform infrared gas cell measurements, and comprehensive density functional theory-based calculations. The results revealed that adsorption of CO occurs predominantly on Pt sites, and the adsorbed CO is anodically oxidized at the interface between the sensing electrode and proton-conducting membrane, generating the selective sensor response. The strong adsorption of CO was realized with Pt (10 wt %)-doped SnO2 nanocrystals, as revealed by the DRIFTS analysis and temperature-programed desorption technique.

The relationship between chronic disease and drugs/toxins-how important is negative disease-drug synergy?

The interaction of diseases with drugs and toxins may result in significantly worse outcomes in a forensic context when i) chronic diseases cause toxicity by increasing drug levels due to reduced renal clearance or slowed hepatic breakdown, and ii) drugs exacerbate underlying lethal mechanisms. In other words, 'negative disease-drug synergy' may result in increased drug toxicity and/or greater organ dysfunction despite the use of standard dosages. This is yet another confounding factor to be considered in the interpretation of postmortem toxicological results, as underlying illness and disease states may significantly alter drug availability and physiological responses.

An overview of suicides related to motor vehicles

Although vehicles may be used in a wide variety of suicides, this has not been a focus in the forensic literature. Thus, an analysis of coronial autopsy reports at Forensic Science SA, Adelaide, South Australia over a 16-year period from January 2005 to December 2020 was undertaken to provide an overview of cases in which it was considered that a vehicle had been integral to the successful completion of a suicide. De-identified details were collected from all cases in which a vehicle had facilitated or been used as a method of suicide. A number of different types of vehicle-related suicide methods were identified, including cases where vehicles had been used as secure places for suicide or where the vehicle had been used to cause significant blunt force trauma or to enter a lethal environment such as water. Specific examples were taken from the following categories: (1) inhalation of gas, (2) drug toxicity, (3) hanging or ligature strangulation, (4) self-immolation, (5) drowning, (6) vehicle collision, (7) driving off a cliff, (8) jumping or lying in front of a vehicle and (9) the use of more than one method (i.e. complex). This report is not intended to provide an epidemiological analysis of car-related suicides. Instead, the details of selected cases have been used to illustrate the spectrum of methods that may be used in vehicle-assisted suicides.

Hyperbaric oxygen therapy in carbon monoxide poisoning in Moroccan patients

Describe the epidemiological, clinical characteristics of acute carbon monoxide poisoning (COP), and the therapeutic effect of hyperbaric oxygen therapy on patient's clinical outcome. This is the first study in this field in Morocco. It studies retrospectively 309 victims of acute COP with major neurological signs. All patients have been treated with hyperbaric oxygen therapy, and have been admitted by the emergency department of the Mohammed V military training hospital in Rabat, between January 2015 and December 2018. All poisonings were accidental and occurred especially in winter (50%), with a predominance in urban areas (93%). The poisoning was often caused by a non-compliant water heater (91%), multi-causality was in half of the cases, and affected adults and women (mean age: 21 ± 17 years, gender (male:female) 1:1.5. The average admission time to the hyperbaric chamber lasted 9 h 04 min (± 12 h 32 min). Clinical signs were mainly unconsciousness (151 cases), headache (85 cases), vomiting (63 cases), nausea (53 cases), and dizziness (51 cases). All the patients benefitted from hyperbaric oxygen therapy sessions. The clinical outcome was positive in the majority of cases, but 23% of the cases presented minor or major sequelae. Patients with sequelae had a longer length of admission than those who had not. COP is a major public health problem in Morocco. Through this study, we suggest the interest of hyperbaric oxygen therapy, especially when it is administered timely without delay.

Improving Household Safety via a Dynamic Air Terminal Device in Order to Decrease Carbon Monoxide Migration from a Gas Furnace

The airtightness of buildings is continuing to grow and impact the indoor environment. Its aim is to conserve energy, but this may influence the indoor air quality and increase contaminant accumulation by limiting the amount of fresh air that infiltrates the building. The goal of this study was to quantify how the contaminants from a faulty gas furnace in a household could impact the occupants. The gas furnace was located in an attached garage and leaked carbon monoxide (CO). Multizone and CFD simulations were caried out to determine if an air terminal device (ATD) with a changing geometry could improve the air quality. The goal of the ATD was to maintain a steady air throw in the garage, while the air flow in the ventilation system would change. A steady air throw should help to remove the carbon monoxide generated from the furnace and prevent infiltration into the household. The results show that with the use of the new ATD, it was possible to maintain a steady air throw and the infiltration of CO was lowered.

Comparison of CFD and Multizone Modeling from Contaminant Migration from a Household Gas Furnace

In Central and Eastern Europe, a growing popularity of gas heaters as the main source of heat and domestic hot water can be observed. This is the result of new laws and strategies for funding that have been put in place to encourage households to stop using coal and replace it with cleaner energy sources. However, there is a growing concern that gas furnaces are prone to malfunction and can be a threat to occupants through CO (carbon monoxide) generation. To see how a faulty gas furnace with a clogged exhaust may affect a household, a series of multizone and computational fluid dynamics (CFD) simulations were carried out using the CONTAM software and CFD0 editor created by the National Institute of Standards and Technology (NIST). The simulations presented different placements of the furnace and ventilation outlet in an attached garage. The results showed how the placement influenced contaminant migration and occupant exposure to CO. It changed the amount of CO that infiltrated to the attached house and influenced occupant exposure. The results may be used by future users to minimize the risk of CO poisoning by using the proper natural ventilation methods together with optimal placement of the header in the household.

Mapping Carbon Monoxide Pollution of Residential Areas in a Polish City

Road traffic is among the main sources of atmospheric pollution in cities. Maps of pollutants are based on geostatistical models using a digital model of the city along with traffic parameters allowing for ongoing analyses and prediction of the condition of the environment. The aim of the work was to determine the size of areas at risk of carbon monoxide pollution derived from road traffic along with determining the number of inhabitants exposed to excessive CO levels using geostatistical modeling on the example of the city of Bydgoszcz, a city in the northern part of Poland. The COPERT STREET LEVEL program was used to calculate CO emissions. Next, based on geostatistical modelling, a prediction map of CO pollution (kg/year) was generated, along with determining the level of CO concentration (mg/m3/year). The studies accounted for the variability of road sources as well as the spatial structure of the terrain. The results are presented for the city as well as divided into individual housing estates. The level of total carbon monoxide concentration for the city was 5.18 mg/m3/year, indicating good air quality. Detailed calculation analyses showed that the level of air pollution with CO varies in the individual housing estates, ranging from 0.08 to 35.70 mg/m3/year. Out of the 51 studied residential estates, the limit value was exceeded in 10, with 45% of the population at risk of poor air quality. The obtained results indicate that only detailed monitoring of the level of pollution can provide us with reliable information on air quality. The results also show in what way geostatistical tools can be used to map the spatial variability of air pollution in a city. The obtained spatial details can be used to improve estimated concentration based on interpolation between direct observation and prediction models.

Carbon monoxide poisoning

Carbon monoxide (CO) is the leading cause of poisoning deaths in many countries, including Japan. Annually, CO poisoning claims about 2000-5000 lives in Japan, which is over half of the total number of poisoning deaths. This paper discusses the physicochemical properties of CO and the toxicological evaluation of CO poisoning.

Suicide by Inhalation of Carbon Monoxide of Car Exhausts Fumes

BACKGROUND

Carbon monoxide (CO) is a major and ubiquitous component of fire atmospheres produced when organic matter is burned in an inadequate supply of oxygen. Accidental poisoning by CO is common in cold climates where fireplaces, a gas, electric or kerosene heaters or grills are used inside ill-ventilated buildings. In the Brazilian Amazon, with its hot and humid climate, there is no need for the use of heaters and accidents may occur in cases of residential fires or burning of the forests for land use in agriculture.

OBJECTIVE

We present a case of CO suicide of twenty-six-year-old men.

METHODS

A forensic autopsy was performed to evaluate the circumstances, cause and medio-legal death etiology.

RESULTS

Autopsy evidenced the typical but also not commonly published cherry-red color of the hypostasis, lungs and other organs, and the very fluid cherry-red blood. The cause of death was due to a massive CO inhalation.

CONCLUSION

While these poisonings are well recognized, and a vast number of publications on CO toxicity exist, both in an environmental and industrial context, suicide is infrequently encountered in forensic practice and the typical signs are rarely seen in the literature.