Kala M., Lechowicz W., Madej K., Stanaszek R.

Institute of Forensic Research, Westerplatte 9, 31-033 Krakow, Poland

At the last TIAFT Meeting (1996, Interlaken, Switzerland), toxicologists from France presented two fatalities due to intravenous self-administration of the neuromuscular blocking agent atracurium. In this paper we described two other cases which are interesting from the clinical and forensic toxicology point of view.
In the first case a 52-year-old anesthetist was found dead in her car parked not far from her place of work. A syringe was found in her hand. Two other syringes and 5 empty ampoules and another original medicines were found among her paraphernalia. Autopsy was performed 17 hours after finding the body. It revealed a needle mark on the inside part of the left thigh. The direct cause of death was acute circulatory failure.
The second case was a 5-year-old child who was anesthetized with Tracrium, methohexital and atropine under assisted ventilation. The child was undergoing on operation for strabismus on her right eye.
All empty syringes and ampoules found in the first case were analysed. The residues were identified by GC/MS. Laudanosine (degradation product of atracurium) was detected only in the syringe by GC/MS-EI, GC/MS-CI, TLC and HPLC-DAD.
In both cases, systematic toxicological analyses on stomach and liver tissues were performed. Laudanosine was detected in stomach and liver in case 1 and in liver in case 2. Additionally, in case 1 dibenzepin (0.8 mg/l), mianserin, diazepam and pethidine were found. Laudanosine was then quantified by means of the specific HPLC-DAD methods. The laudanosine concentrations were 028 mg/l, 0.38 mg/kg and 0.70 mg/l respectively in blood, liver and urine in case 1, and 0.46 mg/l in blood and 0.64 mg/kg in liver of the child.
These values are in the same range as therapeutic levels measured in surgical patients under assisted ventilation, but almost every injected dose of atracurium might be fatal without the assistance of ventilation.