- Email: [email protected]
Influence of cause of death and blood ethanol concentration on the coagulability of cadaveric blood
Legal Medicine 11 (2009) S226–S227
Contents lists available at ScienceDirect
Legal Medicine journal homepage: www.elsevier.com/locate/legalmed
Influence of cause of death and blood ethanol concentration on the coagulability of cadaveric blood Shirushi Takahashi *, Jun Sakai, Masaki Hashiyada, Masato Funayama Division of Forensic Medicine, Department of Public Health and Forensic Medicine, Tohoku University Graduate School of Medicine, 2-1 Seiryo-machi, Aoba-ku, Sendai 980-8575, Japan
a r t i c l e
i n f o
Article history: Received 6 December 2008 Accepted 14 January 2009 Available online 6 March 2009 Keywords: Coagulability of cadaveric blood Ethanol
a b s t r a c t It is well-known that cadaveric blood tends to retain their fluidity in acute deaths. However, our experience indicated that blood clots are occasionally seen in such cases, especially with antemortem consumption of ethanol. We reviewed autopsy reports from 2001 to 2006 in our division retrospectively. We made evaluations of blood coagulability based on the descriptions in the autopsy reports, and classified them into three categories; ‘‘none”, ‘‘some amount of clot”, and ‘‘large amount of clot”. Out of 782 cases except for putrefactive or charred bodies, 202 cases showed coagulation of heart bloods. Among them, large amount of clots were observed in 140 cases, in which the cause of death included so-called slow deaths such as hypothermia, infections and in-hospital deaths. Additionally, some reputed acute deaths exhibited large amount of clots; fire death (18 cases), drowning (17 cases), other types of asphyxia (5 cases) and cardiac deaths (9 cases). We adopted 0.1 mg/ml of blood ethanol concentration (BEC) as a cut off value, and a correlation of blood coagulability and BEC was tested with chi-square test. With exclusion of slow deaths, the number of cases with blood clot was significantly higher in cases with positive BEC (180 cases) than those with negative BEC (367 cases) (p = 0.000085). However, after raising cut off value of BEC (>1.0 mg/ml), the p value was elevated (p = 0.00066). Based on this study, we considered that postmortem blood coagulability was influenced not only by simple pharmacodynamic actions of ethanol but also by other factors including coexisting pathological conditions. Ó 2009 Elsevier Ireland Ltd. All rights reserved.
1. Introduction Cadaveric blood is known to retain fluidity in acute deaths, in part because of an activation of the fibrinolysis pathway including tissue plasminogen activator (t-PA) in the agonal stage. However, our experience indicates that blood clots are occasionally seen in such cases, especially with antemortem consumption of ethanol. In this study, we analyzed the relationship between causes of death and blood ethanol concentration on the coagulability of cadaveric blood. 2. Materials and methods Out of 1211 autopsy cases in our institute from 2001 to 2006, severely decomposed or charred cases were excluded. We evaluated blood coagulability on 782 subjects (507 males and 275 females, age: 48.61 ± 25.03 years old, with a maximum of 98 years old and a minimum of 0 years old) based on the descriptions in the autopsy reports. Cases were classified into
* Corresponding author. Tel.: +81 22 717 8110; fax: +81 22 717 8112. E-mail address: [email protected] (S. Takahashi). 1344-6223/$ - see front matter Ó 2009 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.legalmed.2009.01.067
three categories; ‘‘none”, ‘‘some amount of clot”, and ‘‘a large amount of clot”. Additionally, we analyzed blood ethanol concentration (BEC), using a head-space gas chromatograph (Shimadzu GC-14B). We adopted 0.1 mg/ml of BEC as the cut off value. The correlation of blood coagulability and BEC was tested by chi-square test. A p value <0.05 was considered statistically significant. 3. Results Annual transition of subjects is shown in Table 1. Among them, large amount of clots were observed in 140 cases (Table 2), and causes of death included so-called slow deaths such as hypothermia (24 cases), infections (6 cases) and in-hospital deaths (19 cases). On the other hand, some reputed acute deaths exhibited large amounts of clots (Table 3); fire deaths (18 cases), drowning (17 cases), other types of asphyxia (5 cases) and cardiovascular diseases (9 cases). As to correlation of blood coagulability and BEC, there was a greater tendency of clotting in cases with more than 0.1 mg/ml of BEC (p = 0.000085; Table 4a). However, after raising BEC cutoff value to 1.0 mg/ml, the p value was elevated, though the significance was maintained (p = 0.00066; Table 4b).
S227
S. Takahashi et al. / Legal Medicine 11 (2009) S226–S227 Table 3 Reputed acute death exhibiting large amount of clots.
Table 1 Annual transition of subjects. 2001
2002
2003
2004
2005
2006
Total
With fluid blood With some amount of coagulated blood With coagulated blood
66 7
79 11
91 9
100 10
119 6
125 19
580 62
26
26
21
25
22
20
140
Total
99
116
121
135
147
164
782
4. Discussion There are some epidemiological studies about an association between blood coagulability and ethanol. In a study of 759 autopsy cases in Japan, Mizutani et al. reported that coagulated cadaveric blood was more common in cases dying of strangulation and head injury, and that it required a BEC cutoff value of more than 3.0 mg/ ml to show a significant difference for coagulability in a study of 759 autopsy cases in Japan [1]. A study of 138 autopsy cases in Germany also showed that cases with more than 1.0 mg/ml of BEC were likely to have coagulated blood [2]. However, precise pharmacological action of ethanol on blood coagulation remains to be undetermined. Our study showed that coagulability of cadaveric blood was not associated with the concentration of blood ethanol, but with its presence or absence. Thus, we considered that postmortem blood coagulability was influenced not only by the simple pharmacodynamic actions of ethanol but also by other factors including coexisting pathological conditions. Conflict of interest There are no conflicts of interest including any financial, personal or other relationships with other people or organizations that could inappropriately influence this study.
Age
Sex
Death scene
Autopsy findings
BEC (mg/ ml)
Drowning 50’s M 50’s M 20’s F
In a canal In a pond Under a stock way
<0.1 3.0 <0.1
40’s
M
In a canal
70’s
M
In a river
Emphysema aquosum Emphysema aquosum Pulmonary edema TriageÒ: BZO(+) Emphysema aquosum Heart weighed 500 g Emphysema aquosum Heart weighed 490 g
Other types of asphyxia 50’s M In a canal 50’s
F
In her house
20’s
M
Found strangled with rope
Fire deaths 40’s M
In his car
50’s
F
In her house
50’s
F
In her house
20’s
M
In a car
40’s
M
In his house
Cardiac deaths 40’s M Found collapsed, died in hospital 60’s M In his house 40’s M On a sidewalk
30’s
M
In his house Had complained of chest pain
2.4 1.6
Large amount of mud in the air passage Large amount of vomit in the air passage Fractures of the hyoid bone and surrounding bleedings
1.6
Soot in the air passage CO–Hb saturation <10% Soot in the air passage CO–Hb saturation <10% Soot in the air passage 71% of CO–Hb saturation Soot in the air passage 19% of CO–Hb saturation Soot in the air passage 48% of CO–Hb saturation Heart weighed 500 g
1.5
Heart weighed 480 g
<0.1
Heart weighed 340 g Heart weighed 450 g Severe stenoses in all branches of the coronary artery Heart weighed 400 g Thrombi in the left anterior branch
0.3 1.4
<0.1 1.5
<0.1 <0.1 1.0 0.7
<0.1
Table 2 Causes of death in cases with large amount of coagulated blood. Cause of death Hypothermia Hypothermia with ketoacidosis Ketoacidosis due to other causes Intracranial injury Other mechanical injury Acute intoxication*
Number 24 3 2
Percentage to total number of each cause (%) (70.6) (60)
Table 4 Correlation of blood coagulability and BEC with a BEC cutoff value of (a) more than 0.1 mg/ml and (b) more than 1.0 mg/ml.
(40)
With coagulated blood
With fluid blood
Total
a* 15 5 5
(25.4) (6) (18.5)
BEC =0.1 mg/ml BEC <0.1 mg/ml Total
59 64 123
121 303 424
180 367 547
Reputed acute deaths Fire death
18
(9.8)
Asphyxia Drowning Other types of asphyxia Cardiovascular diseases
b** BEC =1.0 mg/ml BEC <1.0 mg/ml Total
32 91 123
56 368 424
180 367 547
17 5 9
(12.6) (7.6) (17.0)
Respiratory infection Other types of natural death** Hypoxic encephalopathy
4 12 3
(50.0) (42.9) (25.0)
Others, complicated or unspecified
18
Total *
140
Causative drugs were methamphetamine, toluene, salicylic acid, 5-Meo-AMT, acetoaminophen (1 case each). ** Diseases were peptic ulcer (3 cases), intracerebral hematoma (2), and renal abscess, retroperitoneal abscess, alcoholic liver disease, liver cirrhosis, tumor embolism, angioedema, and Wilms’ tumor (1 case each).
* **
Statistically significant (chi-square test, p = 0.000085). Statistically significant (chi-square test, p = 0.00066).
References [1] Mizutani Y. Acute alcoholic intoxication and blood coagulability. J Aichi Medical Univ Assoc 1989;17:717–31 [in Japanese]. [2] Fracasso T, Brinkmann B, Beike J, Pfeiffer H. Clotted blood as sign of alcohol intoxication: a retrospective study. Int J Legal Med 2008;122: 157–61.
Contents lists available at ScienceDirect
Legal Medicine journal homepage: www.elsevier.com/locate/legalmed
Influence of cause of death and blood ethanol concentration on the coagulability of cadaveric blood Shirushi Takahashi *, Jun Sakai, Masaki Hashiyada, Masato Funayama Division of Forensic Medicine, Department of Public Health and Forensic Medicine, Tohoku University Graduate School of Medicine, 2-1 Seiryo-machi, Aoba-ku, Sendai 980-8575, Japan
a r t i c l e
i n f o
Article history: Received 6 December 2008 Accepted 14 January 2009 Available online 6 March 2009 Keywords: Coagulability of cadaveric blood Ethanol
a b s t r a c t It is well-known that cadaveric blood tends to retain their fluidity in acute deaths. However, our experience indicated that blood clots are occasionally seen in such cases, especially with antemortem consumption of ethanol. We reviewed autopsy reports from 2001 to 2006 in our division retrospectively. We made evaluations of blood coagulability based on the descriptions in the autopsy reports, and classified them into three categories; ‘‘none”, ‘‘some amount of clot”, and ‘‘large amount of clot”. Out of 782 cases except for putrefactive or charred bodies, 202 cases showed coagulation of heart bloods. Among them, large amount of clots were observed in 140 cases, in which the cause of death included so-called slow deaths such as hypothermia, infections and in-hospital deaths. Additionally, some reputed acute deaths exhibited large amount of clots; fire death (18 cases), drowning (17 cases), other types of asphyxia (5 cases) and cardiac deaths (9 cases). We adopted 0.1 mg/ml of blood ethanol concentration (BEC) as a cut off value, and a correlation of blood coagulability and BEC was tested with chi-square test. With exclusion of slow deaths, the number of cases with blood clot was significantly higher in cases with positive BEC (180 cases) than those with negative BEC (367 cases) (p = 0.000085). However, after raising cut off value of BEC (>1.0 mg/ml), the p value was elevated (p = 0.00066). Based on this study, we considered that postmortem blood coagulability was influenced not only by simple pharmacodynamic actions of ethanol but also by other factors including coexisting pathological conditions. Ó 2009 Elsevier Ireland Ltd. All rights reserved.
1. Introduction Cadaveric blood is known to retain fluidity in acute deaths, in part because of an activation of the fibrinolysis pathway including tissue plasminogen activator (t-PA) in the agonal stage. However, our experience indicates that blood clots are occasionally seen in such cases, especially with antemortem consumption of ethanol. In this study, we analyzed the relationship between causes of death and blood ethanol concentration on the coagulability of cadaveric blood. 2. Materials and methods Out of 1211 autopsy cases in our institute from 2001 to 2006, severely decomposed or charred cases were excluded. We evaluated blood coagulability on 782 subjects (507 males and 275 females, age: 48.61 ± 25.03 years old, with a maximum of 98 years old and a minimum of 0 years old) based on the descriptions in the autopsy reports. Cases were classified into
* Corresponding author. Tel.: +81 22 717 8110; fax: +81 22 717 8112. E-mail address: [email protected] (S. Takahashi). 1344-6223/$ - see front matter Ó 2009 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.legalmed.2009.01.067
three categories; ‘‘none”, ‘‘some amount of clot”, and ‘‘a large amount of clot”. Additionally, we analyzed blood ethanol concentration (BEC), using a head-space gas chromatograph (Shimadzu GC-14B). We adopted 0.1 mg/ml of BEC as the cut off value. The correlation of blood coagulability and BEC was tested by chi-square test. A p value <0.05 was considered statistically significant. 3. Results Annual transition of subjects is shown in Table 1. Among them, large amount of clots were observed in 140 cases (Table 2), and causes of death included so-called slow deaths such as hypothermia (24 cases), infections (6 cases) and in-hospital deaths (19 cases). On the other hand, some reputed acute deaths exhibited large amounts of clots (Table 3); fire deaths (18 cases), drowning (17 cases), other types of asphyxia (5 cases) and cardiovascular diseases (9 cases). As to correlation of blood coagulability and BEC, there was a greater tendency of clotting in cases with more than 0.1 mg/ml of BEC (p = 0.000085; Table 4a). However, after raising BEC cutoff value to 1.0 mg/ml, the p value was elevated, though the significance was maintained (p = 0.00066; Table 4b).
S227
S. Takahashi et al. / Legal Medicine 11 (2009) S226–S227 Table 3 Reputed acute death exhibiting large amount of clots.
Table 1 Annual transition of subjects. 2001
2002
2003
2004
2005
2006
Total
With fluid blood With some amount of coagulated blood With coagulated blood
66 7
79 11
91 9
100 10
119 6
125 19
580 62
26
26
21
25
22
20
140
Total
99
116
121
135
147
164
782
4. Discussion There are some epidemiological studies about an association between blood coagulability and ethanol. In a study of 759 autopsy cases in Japan, Mizutani et al. reported that coagulated cadaveric blood was more common in cases dying of strangulation and head injury, and that it required a BEC cutoff value of more than 3.0 mg/ ml to show a significant difference for coagulability in a study of 759 autopsy cases in Japan [1]. A study of 138 autopsy cases in Germany also showed that cases with more than 1.0 mg/ml of BEC were likely to have coagulated blood [2]. However, precise pharmacological action of ethanol on blood coagulation remains to be undetermined. Our study showed that coagulability of cadaveric blood was not associated with the concentration of blood ethanol, but with its presence or absence. Thus, we considered that postmortem blood coagulability was influenced not only by the simple pharmacodynamic actions of ethanol but also by other factors including coexisting pathological conditions. Conflict of interest There are no conflicts of interest including any financial, personal or other relationships with other people or organizations that could inappropriately influence this study.
Age
Sex
Death scene
Autopsy findings
BEC (mg/ ml)
Drowning 50’s M 50’s M 20’s F
In a canal In a pond Under a stock way
<0.1 3.0 <0.1
40’s
M
In a canal
70’s
M
In a river
Emphysema aquosum Emphysema aquosum Pulmonary edema TriageÒ: BZO(+) Emphysema aquosum Heart weighed 500 g Emphysema aquosum Heart weighed 490 g
Other types of asphyxia 50’s M In a canal 50’s
F
In her house
20’s
M
Found strangled with rope
Fire deaths 40’s M
In his car
50’s
F
In her house
50’s
F
In her house
20’s
M
In a car
40’s
M
In his house
Cardiac deaths 40’s M Found collapsed, died in hospital 60’s M In his house 40’s M On a sidewalk
30’s
M
In his house Had complained of chest pain
2.4 1.6
Large amount of mud in the air passage Large amount of vomit in the air passage Fractures of the hyoid bone and surrounding bleedings
1.6
Soot in the air passage CO–Hb saturation <10% Soot in the air passage CO–Hb saturation <10% Soot in the air passage 71% of CO–Hb saturation Soot in the air passage 19% of CO–Hb saturation Soot in the air passage 48% of CO–Hb saturation Heart weighed 500 g
1.5
Heart weighed 480 g
<0.1
Heart weighed 340 g Heart weighed 450 g Severe stenoses in all branches of the coronary artery Heart weighed 400 g Thrombi in the left anterior branch
0.3 1.4
<0.1 1.5
<0.1 <0.1 1.0 0.7
<0.1
Table 2 Causes of death in cases with large amount of coagulated blood. Cause of death Hypothermia Hypothermia with ketoacidosis Ketoacidosis due to other causes Intracranial injury Other mechanical injury Acute intoxication*
Number 24 3 2
Percentage to total number of each cause (%) (70.6) (60)
Table 4 Correlation of blood coagulability and BEC with a BEC cutoff value of (a) more than 0.1 mg/ml and (b) more than 1.0 mg/ml.
(40)
With coagulated blood
With fluid blood
Total
a* 15 5 5
(25.4) (6) (18.5)
BEC =0.1 mg/ml BEC <0.1 mg/ml Total
59 64 123
121 303 424
180 367 547
Reputed acute deaths Fire death
18
(9.8)
Asphyxia Drowning Other types of asphyxia Cardiovascular diseases
b** BEC =1.0 mg/ml BEC <1.0 mg/ml Total
32 91 123
56 368 424
180 367 547
17 5 9
(12.6) (7.6) (17.0)
Respiratory infection Other types of natural death** Hypoxic encephalopathy
4 12 3
(50.0) (42.9) (25.0)
Others, complicated or unspecified
18
Total *
140
Causative drugs were methamphetamine, toluene, salicylic acid, 5-Meo-AMT, acetoaminophen (1 case each). ** Diseases were peptic ulcer (3 cases), intracerebral hematoma (2), and renal abscess, retroperitoneal abscess, alcoholic liver disease, liver cirrhosis, tumor embolism, angioedema, and Wilms’ tumor (1 case each).
* **
Statistically significant (chi-square test, p = 0.000085). Statistically significant (chi-square test, p = 0.00066).
References [1] Mizutani Y. Acute alcoholic intoxication and blood coagulability. J Aichi Medical Univ Assoc 1989;17:717–31 [in Japanese]. [2] Fracasso T, Brinkmann B, Beike J, Pfeiffer H. Clotted blood as sign of alcohol intoxication: a retrospective study. Int J Legal Med 2008;122: 157–61.