Forensic Toxicology and Drug Analysis

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What is a medical use of fentanyl?

Short term anesthesia

Which substance can increase CNS depression when combined with opioids?

Benzodiazepines

What is the purpose of naloxone in relation to opioid overdose?

To reverse a coma caused by high opioid doses

When were fentanyl and its analogues developed and increasingly used?

1960s Signup and view all the answers

What is the primary focus of forensic toxicology?

Investigating cause and manner of death in postmortem cases Signup and view all the answers

In what types of cases does forensic toxicology play a role?

Impaired driving, workplace drug testing, and homicides Signup and view all the answers

What distinguishes an expert witness in court from a regular witness?

An expert witness provides opinion evidence based on education, training, experience Signup and view all the answers

What type of testing is typically done in clinical forensic toxicology?

(GC/MS(/MS) LC/MS(/MS) Signup and view all the answers

Which system conducts death investigation in Alberta, Manitoba, Nova Scotia, and Newfoundland?

Medical Examiner system Signup and view all the answers

Who determines the cause and manner of death in the Medical Examiner system?

Forensic pathologist Signup and view all the answers

Which sample is most consistently available for postmortem toxicology?

Blood Signup and view all the answers

Which sample is useful for alcohol analysis and some drugs?

Vitreous humor Signup and view all the answers

Which sample can provide a large amount of specimen for drug analysis?

Liver Signup and view all the answers

Which statement about interpreting stomach contents in postmortem toxicology is correct?

$g(x) = -4(x - 3)^2 + 2$ Signup and view all the answers

Which type of fatalities may not show specific signs at autopsy and require postmortem toxicology?

Drug or poison-related fatalities Signup and view all the answers

What is the role of postmortem toxicology in determining the cause of death?

It can identify contributory factors. Signup and view all the answers

Which forensic laboratories in Canada focus on criminal cases?

RCMP labs in Vancouver, Edmonton, and Ottawa Signup and view all the answers

What is the myth about drug overdoses that postmortem toxicology can rule out?

All drug overdoses leave evidence in the stomach. Signup and view all the answers

Why should blood not be interpreted in isolation for postmortem toxicology?

Blood can show fluctuating drug concentrations after death. Signup and view all the answers

What is the main purpose of postmortem toxicology?

To determine the presence of drugs or toxins after death Signup and view all the answers

Which of the following is a specimen commonly analyzed in postmortem toxicology?

CSF Signup and view all the answers

Why is chain of custody crucial in postmortem toxicology?

To track exhibits from collection to disposal and ensure the integrity of analysis Signup and view all the answers

How can carbon monoxide cause deaths?

Through its strong binding to hemoglobin Signup and view all the answers

Why is postmortem blood on its own unreliable for assessing alcohol presence at the time of death?

Due to fermentation, which can lead to false high BAC levels Signup and view all the answers

What factors contribute to postmortem redistribution of drugs?

Cells die, pH changes, and protein binding weakens Signup and view all the answers

Why can delayed deaths involving depressants or alcohol result in low or near-absent drug levels?

Due to redistribution of drugs in the body after death Signup and view all the answers

What makes postmortem THC analysis complex?

Redistribution, concentration in muscle tissue, and fat solubility in postmortem blood Signup and view all the answers

Why can postmortem THC concentrations be significantly higher than antemortem concentrations?

Due to redistribution and concentration in specific tissues after death Signup and view all the answers

What do postmortem toxicology case examples illustrate?

The complexities of interpreting postmortem blood concentrations of THC in different scenarios Signup and view all the answers

Why are postmortem blood samples not always reliable for toxicology analysis?

Due to factors such as contamination and the fat solubility of THC Signup and view all the answers

What type of samples are primarily used for forensic toxicology testing?

Whole blood and tissue Signup and view all the answers

Which method is commonly used to minimize interference and concentrate the analyte in forensic testing?

Sample processing and extraction Signup and view all the answers

What are ELISA plates optimized for in forensic work?

Diluted whole blood Signup and view all the answers

Which extraction methods are common for GC-based assays in forensic testing?

Liquid-liquid and solid-phase extractions Signup and view all the answers

What is the aim of the extraction process in forensic testing?

To make the analyte more soluble in a solvent than the aqueous specimen Signup and view all the answers

Which factors influence the extraction process in forensic testing?

The specimen type, available instrumentation, robustness, precision of the assay, and purpose of the test Signup and view all the answers

What do chromatography methods such as GC and LC differ in?

Their sample preparation requirements and effects on the analyte and matrix. Signup and view all the answers

What is increasingly used for LC-MS in forensic testing?

'Crash' extracts Signup and view all the answers

What techniques are employed to prepare samples for specific analytical methods in forensic testing?

Dilution, headspace analysis, and protein 'crash' Signup and view all the answers

What does the process of extraction involve in whole blood samples?

Denaturing proteins and peptides in whole blood to form a clear supernatant after centrifugation. Signup and view all the answers

What influences the extraction scheme used in forensic testing?

Robustness, precision of assay, purpose of test only. Signup and view all the answers

What are synthetic cannabinoids also known as?

K2 Signup and view all the answers

Which receptors do synthetic cannabinoids interact with?

Cannabinoid receptors Signup and view all the answers

What is a common adverse effect of synthetic cannabinoids?

Psychiatric issues Signup and view all the answers

Why can analyzing synthetic cannabinoids be challenging?

Extensive metabolism and over 200 possible structures Signup and view all the answers

What is a risk associated with the use of synthetic cannabinoids?

Unpredictable toxicity and long-term effects Signup and view all the answers

What does opioid tolerance allow individuals to do?

Withstand increasing doses with static or decreasing side effects Signup and view all the answers

What is naloxone's function in relation to opioid overdose?

Competitively binds to mu-receptors, displacing opioids without activating the receptors Signup and view all the answers

What is the half-life range of naloxone?

30 to 80 minutes Signup and view all the answers

Why may fentanyl and certain opioids be tolerant to naloxone?

Making overdose reversal more challenging Signup and view all the answers

In what ways can medical administration of naloxone be done?

Intravenous, intramuscular, or intra-nasal Signup and view all the answers

What is the primary focus of the PADIS Team?

Providing clinical pharmacology and toxicology services Signup and view all the answers

What are the initial vital signs of the 30-year-old unknown male in Case #1?

T 40C, HR 149, BP 160/110, RR 30, Sats 95% RA Signup and view all the answers

What are the presenting symptoms of the 25-year-old female in Case #2?

GCS 3 (nonresponsive), pinpoint pupils, respirations 6 breaths / minute, O2 85% on RA Signup and view all the answers

Who staffs the PADIS Team?

Specially trained and certified healthcare professionals Signup and view all the answers

What is the primary management approach for the 'Hot & Bothered' DDX?

Aggressively cool the patient using various methods such as body bag with ice/water, fanning and misting, and cooled IV fluids Signup and view all the answers

What is the recommended approach for managing hyperthermia in the 'H & B' case?

Chemical sedation followed by aggressive cooling methods such as body bag with ice/water, fanning and misting, and cooled IV fluids Signup and view all the answers

What is the main difference between 'Fever' and 'Hyperthermia'?

'Fever' is regulated by the body's thermostat while 'Hyperthermia' is not Signup and view all the answers

What should be done about the elevated temperature in the 'H & B' management?

Aggressively cool the patient using methods such as body bag with ice/water, fanning and misting, and cooled IV fluids Signup and view all the answers

Which residency programs in Canada are entry points for the Clinical Pharmacology & Toxicology Training (CPT)?

Emergency Medicine, Internal Medicine, Anesthesia, and Pediatrics Signup and view all the answers

What is a key aspect of PADIS roles?

Toxicovigilance involving identifying and evaluating toxic risks in the community Signup and view all the answers

What does the toxicologic exam involve?

Assessing head, eyes, ears, nose, throat, skin, central nervous system, gastrointestinal system, and cardiovascular system Signup and view all the answers

What may be included in the toxicologic workup?

'Tox panel,' urine tox screens, electrolytes, creatinine, urea, VBG/ABG, serum osmols Signup and view all the answers

What does the urine drugs of abuse screen test for?

Various substances but its results may not directly correlate with the patient's signs and symptoms Signup and view all the answers

What are the ABCs of toxicology?

Airway protection, breathing assessment, circulation Signup and view all the answers

What is the primary focus of the PADIS Team?

Assessing and managing common toxicology cases Signup and view all the answers

What is the aim of the extraction process in forensic testing?

To separate compounds for analysis Signup and view all the answers

What are the presenting symptoms of the 25-year-old female in Case #2?

GCS 3, pinpoint pupils, and low respiration rate Signup and view all the answers

What factors contribute to postmortem redistribution of drugs?

Postmortem interval and sampling site Signup and view all the answers

What is the primary difference between 'Fever' and 'Hyperthermia' according to the given text?

Fever is a regulated increase in body temperature, while hyperthermia is an unregulated increase in body temperature. Signup and view all the answers

What should be done to manage hyperthermia in the 'H & B' case according to the given text?

Aggressively cool the patient using methods such as body bag with ice/water, fanning and misting, and cooled IV fluids. Signup and view all the answers

What are the primary effects of sympathetic stimulation on the body according to the given text?

Mydriasis, increased heart rate, and dilated airways Signup and view all the answers

What should be considered for management in the 'H & B' case when sedation is needed according to the given text?

Benzodiazepines for sedation and potential intubation with paralysis Signup and view all the answers

What is the primary focus of the PADIS Team?

Providing bedside consults and toxic risk assessment Signup and view all the answers

What is the aim of the toxicologic exam?

Evaluating the patient's clinical status and toxin specifics Signup and view all the answers

Which process involves evaluating the patient's airway protection, breathing assessment, and circulation?

$ABCD$ of toxicology Signup and view all the answers

What may be included in the toxicologic workup?

$Tox$ panel and urine tox screens Signup and view all the answers

What is the purpose of the ABCs of toxicology?

Finding and initiating specific therapies for toxicity Signup and view all the answers

What is toxicovigilance primarily focused on?

Providing bedside consults and toxic risk assessment Signup and view all the answers

Which method is commonly used for decontamination in managing toxicology cases?

SDAC (single-dose activated charcoal) Signup and view all the answers

What does the urine drugs of abuse screen test for?

Qualitative presence of various substances Signup and view all the answers

Which residency programs in Canada are entry points for Clinical Pharmacology & Toxicology Training (CPT)?

FRCPC Emergency Medicine only Signup and view all the answers

What is involved in the PADIS elective for residents from any specialty?

Bedside consults and information specialist training Signup and view all the answers

Study Notes

Forensic Laboratory Testing Overview

Forensic labs use extraction and chromatography methods for whole blood and tissue testing, as opposed to clinical labs.
Forensic testing covers a wide range of substances, including drugs, poisons, and chemicals at varying concentrations.
Most forensic toxicology testing is done on whole blood or tissue, which presents more difficulty and interference compared to serum or plasma.
Sample processing and extraction are crucial in forensic testing to minimize interference and concentrate the analyte for improved sensitivity.
Immunoassay designs vary for forensic and clinical testing, with ELISA plates being optimized for diluted whole blood in forensic work.
Chromatography methods such as GC and LC differ in their sample preparation requirements and effects on the analyte and matrix.
Specific extraction methods like liquid-liquid or solid-phase extractions are common for GC-based assays, while protein 'crash' extracts are increasingly used for LC-MS.
Techniques like dilution, headspace analysis, and protein 'crash' are employed to prepare samples for specific analytical methods.
The process of extraction involves denaturing proteins and peptides in whole blood, forming a clear supernatant for analysis after centrifugation.
The extraction process aims to make the analyte more soluble in a solvent than the aqueous specimen, often involving the adjustment of pH.
The extraction scheme used depends on the specimen type, available instrumentation, robustness, precision of the assay, and the purpose of the test.
Factors like amphoteric and zwitterion functions in analytes, as well as the presence of specific substances, influence the extraction process.

Synthetic Cannabinoids and Opioids: Key Facts and Risks

Synthetic cannabinoids, also known as "Spice" or "K2", are chemicals impregnated into dried plant materials and may or may not closely relate to the structure of delta-9-THC.
These synthetic cannabinoids interact with cannabinoid receptors, causing effects such as relaxation, euphoria, anxiety, paranoia, increased heart rate, and impaired motor skills.
Adverse effects of synthetic cannabinoids include psychiatric issues, cardiovascular problems, neurological impacts, gastrointestinal discomfort, and other health concerns.
Analyzing synthetic cannabinoids can be challenging due to low blood concentrations, extensive metabolism, and over 200 possible structures, requiring high-end methods for confirmation.
Users face risks as the composition and potency of synthetic cannabinoids can vary from batch to batch, leading to unpredictable toxicity and long-term effects.
Canada and the USA have different approaches to controlling synthetic drugs, with Canada focusing on federal drug laws and the USA having federal rules but also allowing individual states to make drugs illegal.
Opioids refer to any chemical that activates mu-receptors, while opiates are naturally occurring or semi-synthetic derivatives of the opium poppy, and synthetic opioids are not structurally related to morphine.
Opioid tolerance allows individuals to withstand increasing doses with static or decreasing side effects, which can be dangerous due to the potential for overdose.
Naloxone is a common reversing agent for opioid overdose, as it competitively binds to mu-receptors, displacing opioids without activating the receptors.
Naloxone's half-life ranges from 30 to 80 minutes, while fentanyl's half-life is 3-12 hours, necessitating repeat naloxone injections and close monitoring.
Fentanyl and certain opioids may be tolerant to naloxone, making overdose reversal more challenging.
Medical administration of naloxone can be intravenous, intramuscular, or intra-nasal, with minimal toxicity if opioids are not present.

Clinical Toxicology Fellowship Training Program Overview

Clinical toxicology fellowship training is a 2-year program in the US, typically pursued after a 3-5 year Emergency Medicine residency.
In Canada, the Clinical Pharmacology & Toxicology Training (CPT) is a 2-year Royal College Fellowship, and entry residency programs include FRCPC Emergency Medicine, Internal Medicine, Anesthesia, and Pediatrics.
The PADIS (Poison and Drug Information Service) elective is open to residents from any specialty and involves bedside consults, information specialist training, and exposure to drugs, chemicals, or toxins via various routes.
PADIS roles include day-to-day activities such as patient care, telephone and bedside consultation, education, research, surveillance, and prevention.
Toxicovigilance is a key aspect of PADIS roles, involving the active process of identifying and evaluating toxic risks in the community.
The PADIS team assesses risks of public health concern, including poisoning outbreaks due to contamination, new drugs, mass chemical exposures, or unusual patterns.
The telephone risk assessment by PADIS involves evaluating the patient's clinical status, history, physical exam, initial investigations, and toxin specifics.
The toxicologic exam includes assessing head, eyes, ears, nose, throat, skin, central nervous system, gastrointestinal system, and cardiovascular system, along with a complete set of vitals.
The toxicologic workup may include a "tox panel," urine tox screens, electrolytes, creatinine, urea, VBG/ABG, serum osmols, LFTs, transaminases, and ECG.
Urine drugs of abuse screen is a qualitative test for various substances, and its results may not directly correlate with the patient's signs and symptoms.
The ABCs of toxicology involve airway protection, breathing assessment, circulation, decontamination, enhanced elimination, and finding and initiating specific therapies.
Decontamination and enhanced elimination are key processes in managing toxicology cases, including methods such as SDAC, hemodialysis, and intra-lipid (IV fat emulsion).

Clinical Toxicology Fellowship Training Program Overview

Clinical toxicology fellowship training is a 2-year program in the US, typically pursued after a 3-5 year Emergency Medicine residency.
In Canada, the Clinical Pharmacology & Toxicology Training (CPT) is a 2-year Royal College Fellowship, and entry residency programs include FRCPC Emergency Medicine, Internal Medicine, Anesthesia, and Pediatrics.
The PADIS (Poison and Drug Information Service) elective is open to residents from any specialty and involves bedside consults, information specialist training, and exposure to drugs, chemicals, or toxins via various routes.
PADIS roles include day-to-day activities such as patient care, telephone and bedside consultation, education, research, surveillance, and prevention.
Toxicovigilance is a key aspect of PADIS roles, involving the active process of identifying and evaluating toxic risks in the community.
The PADIS team assesses risks of public health concern, including poisoning outbreaks due to contamination, new drugs, mass chemical exposures, or unusual patterns.
The telephone risk assessment by PADIS involves evaluating the patient's clinical status, history, physical exam, initial investigations, and toxin specifics.
The toxicologic exam includes assessing head, eyes, ears, nose, throat, skin, central nervous system, gastrointestinal system, and cardiovascular system, along with a complete set of vitals.
The toxicologic workup may include a "tox panel," urine tox screens, electrolytes, creatinine, urea, VBG/ABG, serum osmols, LFTs, transaminases, and ECG.
Urine drugs of abuse screen is a qualitative test for various substances, and its results may not directly correlate with the patient's signs and symptoms.
The ABCs of toxicology involve airway protection, breathing assessment, circulation, decontamination, enhanced elimination, and finding and initiating specific therapies.
Decontamination and enhanced elimination are key processes in managing toxicology cases, including methods such as SDAC, hemodialysis, and intra-lipid (IV fat emulsion).

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