An unusual fatality secondary to oxycodone in a child is reported. A 2-year-old female child was conveyed to a local hospital after exhibiting signs of rubbing of the mouth and staggering. A hospital toxicological immunoassay screen for drugs of abuse and tricyclic antidepressants was performed on a urine sample and reported as negative. She was discharged and found unresponsive the next morning. She was conveyed to a second hospital in full cardiopulmonary arrest and despite resuscitative efforts, was pronounced dead upon arrival. An autopsy was performed and postmortem specimens were submitted and screened for drugs using mainly chromatographic techniques. Quantitation was achieved by gas chromatography with nitrogen phosphorus detection. Confirmation was performed by gas chromatography/mass spectrometry. Oxycodone was the only drug detected in the following concentrations: heart blood, 1.36 mg/L; gastric contents, 7.33 mg in 33 mL (222.34 mg/L); liver, 0.2 mg/kg; and urine, 47.23 mg/L (47,230 ng/mL). In addition, immunoassay testing of the urine was positive for the opiate class of drugs. This case report demonstrates an unusual cause of death in a young child with emphasis on potential limitation in hospital urine screening tests and the importance of complete forensic toxicological testing in all child deaths.
An enzyme multiplied immunoassay technique (EMIT) was used to test for opiates (morphine, hydromorphone, and codeine) in extracts of blood, bile, and tissue homogenates. All immunoassay opiate positive specimens were then tested by a reversed-phase liquid chromatographic procedure using electrochemical detection (LCEC). Blood specimens were then quantitated by LCEC. The sensitivity of the immunoassay (as morphine) was 0.020 mg/L, 0.200 mg/L, and 0.100 mg/kg for blood, bile, and tissue homogenates, respectively, with 2% intrarun and 7% interrun precision. The LCEC method was linear from 0.005 to 0.300 mg/L for morphine, hydromorphone, and codeine (nalorphine internal standard) with detection limits of 0.005 mg/L for each analyte. Intrarun and interrun precision varied from 1 to 2% and 6 to 11%, respectively. Recoveries, using a double extraction technique, ranged from 70 to 95%. These two methods, applied to 495 post mortem cases, demonstrated a 6% incidence of opiates, with no false positives.
Basic drugs were extracted from 1 mL of serum, urine, or other biological fluids under alkaline conditions into hexane:isoamyl alcohol (98:2). The drugs were back-extracted into acid and re-extracted into 50 microL of chloroform:isoamyl alcohol (95:5) after the acid had been alkalinized. An aliquot of the chloroform:isoamyl alcohol was injected onto a temperature programmed gas chromatograph equipped with two nitrogen phosphorus detectors and two fused silica capillary columns fitted into a single injector. Results obtained from 388 serum samples (from suspected overdose patients) tested using this procedure are presented. The same extraction applied to a variety of body fluids proved reliable for quantitations of several of the basic drugs when a packed column was used.
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