Acute Exposure Guideline Levels
CH 2 CH-CHO
2. HUMAN TOXICITY DATA
4.3. Issues Related to Postmortem CO Determination in Humans 1. Potential Factors Influencing COHb Levels
4.3. Issues Related to Postmortem CO Determination in Humans
hotel fire on December 31, 1986. The samples remained refrigerated until being mailed frozen to a second laboratory for testing (received March 26, 1987). The samples were frozen upon arrival and were thawed and refrozen several times during the next 3 months for experimental purposes. After sonication and filtra- tion, the samples were analyzed on a CO-oximeter IL-282 (sensitivity not given). The authors concluded that aging of blood samples and methods of stor- age could affect accuracy of analytic results. This result was supported by an- other study, which determined that the contact of the sample with air could de- crease the percent of COHb saturation (Chace et al. 1986). That result is in contrast to reports that CO would be stable for months to years in stored samples (vacutainer tubes, especially heparin-anticoagulated tubes) (Kunsman et al.
2000; Hampson 2008). Proper storage of samples would prevent loss of CO (Nelson 2006b).
4.3.2. Influence on Collection Site on Measured COHb Concentrations Reductions in the percent of COHb saturation are also associated with dif- ferences between COHb measurements derived from heart blood and from pe- ripheral blood specimens. Levine et al. (2002) studied data from 42 CO poison- ing cases. The Office of the Chief Medical Examiner in the state of Maryland provided the data. Blood samples from the heart and the subclavian veins were analyzed in a CO oximeter. The specific heart site for blood collection was not reported. Also, the report did not indicate whether the deceased individuals with decreased COHb were given oxygen therapy. Blood samples with COHb satura- tion levels greater than 12% were confirmed and quantitated by gas chromatog- raphy. The latter analysis measured both CO content and CO capacity and did not measure hemoglobin concentration, which tends to vary in postmortem specimens (Levine et al. 2002). Samples were normalized for hemoglobin, en- suring that differences between the heart blood and peripheral blood were not caused by significant differences in hemoglobin between the two blood samples.
The average heart blood COHb level was 42% (range = 11-79; SD = 19.95; me- dian = 38), and the average peripheral blood COHb level was 39% (range = 4.2- 71; SD = 17.07; median = 37). The average heart blood to peripheral blood (H:P) ratio was 1.09. Sixty-two percent of the cases (26 of 42) had an H:P ratio of 0.9 to 1.1, whereas 74% of the cases (31 of 42) had an H:P ratio of 0.8 to 1.2.
Statistical analysis showed no statistically significant differences in COHb lev- els between heart and peripheral blood samples (Levine et al. 2002). The report acknowledged that there might be instances (e.g., cardiopulmonary resuscita- tion) where differences between heart blood and peripheral blood COHb levels might occur in isolated cases, but in general, there were no significant differ- ences between the two blood sources.
Dalpe-Scott et al. (1995) calculated the H:P ratio of drug concentrations in postmortem blood samples for 113 drugs representing 320 cases. Thirty-five CO
poisoning cases were examined. The average H:P ratio was 1.0 (range 0.9- 1.5).
The specific COHb levels were not provided. Data from Dalpe-Scott et al.
(1995) confirmed those findings in Levine et al. (2002).
Differences among COHb levels in the heart blood when compared with those found in the periphery (e.g., femoral vein) have been reported in cases that received cardiopulmonary resuscitation. Rice (1976) found wide variation in COHb levels in 300 consecutive fatal cases of CO poisoning. Source of CO poi- soning, such as fire and gas heaters, was not identified in most of the 300 cases;
four case studies identified the source in the paper. The author hypothesized that levels below 50% COHb were probably low due to the dissociation of COHb after death when oxygen therapy was given in an attempt to resuscitate the per- son. A summary of the case findings is given below.
Case 1: A child (14 months) was found apparently dead in a smoldering room fire. Artificial respiration was given on the way to the hospital and contin- ued for about an hour before death was pronounced. Subclavian blood showed COHb levels of 15%. The report did not indicate if it was collected from the subclavian artery or vein. Blood from the femoral vein reported a 31% COHb, or a 2-fold difference between sites. The ratio of subclavian blood to femoral blood was 0.48.
Case 2: A man of 57 yrs died of CO poisoning. The CO source was a dis- connected coal gas supply pipe. The emergency personnel found him cold but gave him artificial respiration on the way to the hospital where he was pro- nounced dead. Subclavian blood showed COHb levels of 32%. The report did not indicate if it was collected from the subclavian artery or vein. Blood from the femoral vein reported a COHb of 52%, or a 1.6-fold difference between sites. The ratio of subclavian blood to femoral blood was 0.62.
Case 3: A woman of 43 yearrs was exposed to CO during a fire. Fire per- sonnel recovered her and attempted resuscitation using artificial respiration and pure oxygen. Subclavian blood showed a COHb of 42%. The report did not in- dicate if it was collected from the subclavian artery or vein. The common iliac vein showed a COHb of 45%. Blood from the femoral vein reported a COHb of 59%, or a 1.2-fold difference when compared with the subclavian vein. The ratio of subclavian blood to femoral blood was 0.71, and the ratio of subclavian blood to iliac blood was 0.93.
Case 4: An infant of 5 months died in a room fire. Artificial respiration was performed on the infant. Femoral samples were not provided. Blood drain- ing the blood cavity was taken and a COHb of 48% was reported, whereas the subclavian blood was reported to have a COHb of 34%. The report did not indi- cate if it was collected from the subclavian artery or vein. The ratio of sub- clavian blood to peripheral blood was 0.71.
Rice (1976) explained the results by pointing out that blood with high concentrations of COHb does not coagulate, and artificial respiration would
have pushed blood to move into and out of the lungs. Thus, oxygen therapy would have increased the dissociation of COHb in the blood, and the amount of the dissociation would have depended on the vigor and the duration of the artifi- cial respiration. The disassociation would be higher in the blood from the lungs, the heart, and the blood vessels in close proximity to the lungs and heart.
Currently, the standard forensic practice is to collect blood from suitably isolated peripheral sites (e.g., femoral vein), which are less likely to be subject to postmortem chemical redistribution (Flanagan et al. 2005; Drummer 2007).
The common practice of procuring blood samples from live persons has been venipuncture of the antecubital area of the arm (Ernst 2005).
Gas chromatography is considered the most precise and accurate tech- nique to measure COHb concentrations, but other techniques, such as spectro- photometric analyses, worked well (Lee et al. 1975; Mahonoey et al. 1993; R.
Coburn, personal commun., April 8, 2008).
4.4. Other Relevant Information