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The Office of the Chief Medical Examiner of Maryland recorded a total of 149 drug abuse deaths of teenagers aged 13-19 years between 1991 and 2006. Of these deaths, 96 (64.4%) were caused by the use of narcotic drugs only, 29 (19.5%) by both narcotics and cocaine, four (2.7%) by both narcotics and methylenedioxymethamphetamine, six (4.0%) by cocaine only, and 14 (9.4%) by volatile substances (e.g., butane, Freon, nitrous oxide, and propane). The annual death rate from drug abuse for teenagers increased from 1.4 deaths per 100,000 population in 1991 to 2.7 deaths per 100,000 population in 2006 (chi-square test for time trend, p<0.01). The increase in teenager drug abuse deaths occurred in 1999 and since has remained at a higher rate. Further analysis revealed that the increase in drug abuse deaths was attributable to a large degree to narcotic drugs, particularly heroin/morphine and methadone, and was confined to teenagers residing in the suburban and rural areas., (© 2011 American Academy of Forensic Sciences.)

Introduction: Freons generally have a low order of toxicity, but exposure to relatively high concentrations (>100 ppm) may produce adverse effects on health. Currently, intoxication reports are unintentional inhalation of CFCs. We report an unintentional ingestion of a mixture of CFCs and the results of a rat study., Case Report: A 43-year-old man was admitted to the Emergency Department with a chief complaint of acute abdominal pain that developed minutes after he ingested a clear liquid in a water glass, which contained a mixture of Freon and water. Subsequent surgical evaluation revealed perforation of the stomach and necrosis of the stomach wall. He developed a transient rise in his hepatic transaminases, which resolved spontaneously, and fully recovered from his surgery., Methods: A murine model of the injury was created to evaluate threshold concentration and effect of time on injury grade., Results: Injury grade increased with delay to histologic analysis from 8 to 24 hours after exposure to Freon. Increasing amounts of Freon also increased the lesion grade score., Conclusions: Patients ingesting Freon need to be closely evaluated for risk of gastric damage and perforation.

A case of accidental Freon 22 (monochlorodifluoromethane) poisoning in a fishing vessel is reported. Forensic autopsy revealed severe pulmonary edema and congestion (left lung; 576 g, right lung; 740 g). GC-MS analysis clearly showed that the deceased inhaled Freon 22 gas prior to his death. Freon 22 concentration was 169+/-7.0 microg/ml in the heart blood. The distribution pattern of Freon 22 in tissue samples was similar to that in previously reported cases. The brain had the highest concentration of Freon 22 followed by the spleen, liver, kidney and lung, respectively. Histopathologically, Oil red O staining of the liver showed many small, positive red areas in the cytosol, which have been reported in other cases of Freon 22 poisoning. However, Schmorl staining revealed that most areas of Oil red O positivity were lipofuscin granules. Lipofuscin in the liver, which closely relates to aging and other cell stresses, could have a relevance to Freon 22 exposure, but further experimental studies are needed to confirm it.

We report 43 cases of chlorodifluoromethane (Freon-22) intoxication that occurred on August 5, 2003 when a freezer in a seafood factory exploded. In this accident, 80 workers were exposed to Freon-22 gas and 43 workers developed symptoms and were transferred to six hospitals. Neurological symptoms including dizziness, headache, and nausea were most frequently observed (40 of 43 patients). One patient was comatose but recovered within 1 h with oxygen inhalation. Airway and respiratory symptoms including dysesthesia of the tongue, pharyngitis, and shortness of breath were also frequently observed (26 of 43 patients). These symptoms disappeared within a few days in all patients. There were no fatalities. Although Freon-22 has been considered to be a chlorofluorocarbon of relatively low toxicity, this incident suggests that potentially significant toxic effects may occur following large exposures.

Although the neurological and cardiovascular effects of Freons have been extensively described, the respiratory effects have been less well documented. We report four cases of occupational asthma following accidental exposure to bromochlorodifluoromethane (Halon 1211) due to release of the contents of a fire extinguisher. All subjects developed an irritative reaction of the upper airways and lower respiratory symptoms immediately after exposure. Non-specific bronchial hyperreactivity was present for at least two months in all subjects and was still present more than two years after exposure in one case. The diagnosis of reactive airways dysfunction syndrome can be adopted in at least three of these four cases.

A gas chromatographic method with mass spectrometry has been developed for the determination of bromochlorodifluoromethane (Halon 1211) in biological material (whole blood, organ samples). After incubation of the sample (temp. 65 degrees C, 15 min), 10 microliters of the headspace is analysed using a capillary column DB-5 ms (30 m x 0.25 mm x 0.25 micron). Quantitative analysis was made with the use of a single ion monitoring option--m/z 85 and m/z 87. This developed method was used to determine the concentration of bromochlorodifluoromethane in biological material collected from the body of the man whose death was due to intoxication of Halon 1211--fire-extinguisher contents.

The authors analyze 62 expert conclusions on deaths from acute and chronic poisoning with various toxic substances used by toxicomaniacs. Forensic medical examination of corpses and forensic chemical analysis identified drugs, toluene, freon, organophosphorus compounds, and other toxins.

Two cases of lethal poisoning due to chlorodifluoromethane (Freon 22) inhalation are described. The fluorocarbon was determined in biological tissues by headspace gas chromatography/mass spectrometry. Ions monitored were m/z 67, 86 and 51, the latter being used for quantification. Blood concentrations were 26.0 and 37.1 microliters/ml. In both cases, the drug was also identified in urine, vitreous humor and bile, but in much lower concentrations.

Phosgene is a highly toxic gas to which some workers may be occupationally exposed. This case report demonstrates the possibility of refrigeration workers suffering phosgene poisoning after heating certain chlorinated fluorocarbons ('freons'). The need to suspect phosgene exposure and observe such patients is emphasized, especially in view of the delay in clinical deterioration observed in some patients who subsequently develop adult respiratory distress syndrome.

A case of lethal poisoning due to trichlorofluoromethane (FC11) inhalation is described. The fluorocarbon was determined in biological tissues by headspace gas chromatography-mass spectrometry. FC11 was detected in all the examined tissues, with decreasing levels in heart, lung, brain, liver, blood, kidney, and spleen. The highest concentration measured in heart could be related to the mode of toxic action of fluorocarbons postulated by many authors, characterized by the sensitization of the myocardium to the catecholamines producing arrhythmia and cardiac arrest. Nevertheless the aspecific picture of the anatomo-pathological and histological findings does not exclude that the described accidental fatality may have been caused by the combination of direct from toxicity with hypoxemic asphyxiation, due to the saturation of the atmosphere by FC11 in the closed environment in which the intoxication occurred.

Two cases of atrial fibrillation and one case of sudden death occurred in workers exposed to trifluorotrichloroethane (CFC 113) as a solvent/degreasing agent. This agent and related halogenated hydrocarbons are widely used in industry as solvents and degreasing agents, and have been previously linked to ventricular arrhythmias and cardiac sudden death when inhaled in excessive concentrations. We suggest that occupational overexposure to halogenated hydrocarbons should be considered a potential precipitant for atrial as well as ventricular arrhythmias.

Presented is a case of successful resuscitation of cardiopulmonary arrest following inhalation of a fluorinated hydrocarbon. Fluorinated hydrocarbons have a direct cardiotoxic effect. We found no previous reports describing resuscitation with good neurologic outcome of a patient in cardiopulmonary arrest subsequent to inhalation of a fluorinated hydrocarbon. Early bystander cardiopulmonary resuscitation and ACLS provider intervention help to contribute to improved patient survival. We present a case illustrating the utility of basic life support and early advanced life support, followed by a review of the pertinent literature.

Reports on fatalities of chlorofluorocarbons usually involve chlorotrifluoroethane, trichlorofluoromethane, dichlorodifluoromethane or chlorodifluoromethane, where analysis was done using packed column gas chromatography. In this case a death was caused by an azeotropic mixture of chlorodifluoromethane and chloropentafluoroethane, a combination that has not previously been reported in the forensic literature. This report details the analysis using mass selective detection employing capillary gas chromatography columns currently used in many toxicology laboratories. Postmortem toxicology revealed blood concentrations of chlorodifluoromethane and chloropentafluoroethane of 71 mg/L and 0.30 mg/L, respectively. Brain, liver, and lung concentrations of chlorodifluoromethane were (mg/kg) 2.8, 4.4, and 1.6, respectively. Brain, liver, and lung concentrations of chloropentafluoroethane were (mg/kg) 0.80, 0.80, and 0.11, respectively. The victim's blood contained 5.5 mg/L caffeine. Lidocaine, used in resuscitation attempts, was also present in the victim's blood. No other alkali-extractable drugs or volatile alcohols were detected in the victim's blood. The cause of death was acute respiratory arrest due to chlorofluorocarbon inhalation.

An accidental discharge of a Halon 1301 system is reported. Thirty-one workers were assessed, 22 who were present at the time of the discharge, and 9 who worked the next shift. The incident was complicated by a small Freon-22 leak several hours later. Throat, eye, and nasal irritation and lightheadedness were reported by the majority of workers. Workers present during the halon discharge reported significantly more lightheadedness, headache, voice change, cough, and a fast heartbeat than did those who worked the later shift. These differences were significant even after correcting for confounding factors such as age, sex, and sense of anxiety at the time of the incident. The possible causes for the irritant symptoms include breakdown products of Halon 1301 and Freon-22 or contaminants from the halon discharge system. Although these irritant effects may not be an effect of Halon 1301 alone, they may occur in these discharge situations, and workers should be advised of this possibility. The possible cardiac and central nervous system effects also should be considered. The importance of a clear-cut protocol to deal with such incidents as well as worker education are discussed.

Bromochlorodifluoromethane (Halon 1211) is a widely used fire extinguishing agent. Several cases of sudden death in teenagers associated with BCF abuse have been reported. BCF is used as a fire extinguisher in battle tanks. Two young previously healthy male soldiers were accidentally exposed to BCF in a battle tank. The tank driver died, but the gunner survived the event with no medial complications. It is concluded that BCF should be used in confined chambers only after the evacuation of all personnel.

Fatalities due to accidental exposure to chlorinated hydrocarbon in an industrial setting have been infrequently reported. The deaths in these cases have occurred within poorly ventilated, enclosed compartments or areas. A case is presented of a 16-year-old male who died as a result of exposure to trichlorotrifluoroethane while working in an open pit. Chromatographic results and tissue concentrations are presented.

We studied trifluoromethane as a potential gaseous indicator in nuclear magnetic resonance measurements of cerebral blood flow. We considered the effects of trifluoromethane on cerebral blood flow in 17 cats and on the electroencephalogram and electrocardiogram in nine cats and compared these with the effects of the more toxic compound chlorodifluoromethane in five cats. Inhaled at 60%, trifluoromethane had no effect on cerebral blood flow, the cerebral metabolic rate for oxygen, or oxyhemoglobin content. At 70%, trifluoromethane sensitized the cats' hearts to epinephrine, but to a much lesser degree than 40% chlorodifluoromethane, and produced only moderate changes in cerebral electrical activity as measured by the electroencephalogram. We found trifluoromethane to be suitable for use in animals, but its toxicity needs to be studied further before it can be used in humans for the measurement of cerebral blood flow.

Accidental ingestion of trichlorofluoromethane (Freon 11) by a healthy adult male resulted in necrosis and multiple perforations of the stomach. The patient recovered after surgical intervention, the excision of necrotic tissue and the reestablishment of gastrointestinal continuity. The freezing action of Freon 11 is postulated as the cause of tissue necrosis.

Four cases of cutaneous rash, clinically more or less similar to erythema multiforme have been observed in patient who either stayed in a room with an accidentally high content of fluorocarbons, or had a skin contact with butane or phenyl-azo-beta-naphthol. The cutaneous lesions appear to be secondary to absorption of the toxic product, and probably induced by inhalation rather than by percutaneous penetration. Arguments for the responsibility of the substances rely on anamnestic data.

During the course of dockside ship maintenance, a compartment was partially flooded with tricholotrifluoroethane gas. One sailor entered the compartment, collapsed, and was then rescued by two other men. All three victims then climbed a 11-m (36-ft) ladder and collapsed. They all experienced a rapid development of cardiac arrest. We report on the pathologic, toxicologic, and pathophysiologic aspects of the incident.

Two cases of abuse of bromochlorodifluoromethane (BCF - a fire-extinguishing agent) by inhalation are reported. In the first case, a 15-year-old youth presented in ventricular fibrillation; the second youth was dead on arrival at hospital. Port-mortem toxicological investigations confirmed BCF inhalation in the latter patient. Management of the surviving patient included cardioversion, controlled mandatory hyperventilation, intravenous infusions of mannitol, and barbiturate protection against cerebral ischaemia. He had completely recovered after eight days. Community agencies report that BCF inhalation occurs frequently on the Gold Coast, Queensland. This behaviour can be associated with sudden death from ventricular arrhythmias after cardiac sensitization to endogenous adrenaline. The "lone sniffer" is at greatest risk, and identification of such individuals may prevent a fatal outcome.

This case documents postmortem tissue concentrations of fluorocarbons in an individual whose inhalation of cooking spray vapors was well documented. The data presented here should contribute to the information base which will assist the pathologist in determining the cause of death in cases related to inhalation of these fluorocarbons.

With the removal from the general marketplace of volatile hydrocarbons which have been previously abused by "thrill-seekers", new and often unlikely products are now being exploited by those who whish to escape reality. Many of these products have proven harmful. An example of such an unusual product is reported in this case of a sixteen-year-old male who inhaled Arrid Extra-Dry aerosol deodorant and subsequently died following ventricular fibrillation. The only findings at autopsy were cerebral edema, pulmonary edema and generalized visceral congestion.

A report of two autopsies which is thought to be the first case of its kind in Japan is presented here. The cause of death was concluded to be oxygen deficiency from the filling of a compartment by Freon gas escaping from a cylinder. However, the authors suspect that Freon per se is not a non-toxic substance as had been believed but has some toxicity because of the existence of fat droplets in hepatocytes of mice exposed to reon gas and because of the behavioral findings on them during experiments.

This study reports two occupational deaths resulting from exposure to fluorocarbon-113 (1,1,2-trichloro-1,2,2-trifluoroethane; FC-113) in enclosed and confined spaces. One incident involved a worker who was exposed to FC-113 after entering a small degreasing tank to clean it. The second case involved a significant spill of FC-113 onboard a marine vessel. The incidents are compared to other fatal exposures.

An accidental discharge of a total flooding Halon 1301 fire extinguishing system is described. The release of the Halon was accompanied by a sudden very loud noise, considerable air turbulence and a dense fog, resulting in worker anxiety and loss of visibility. The workers in the area at the time of the discharge reported higher frequencies of lightheadedness, headache, nasal complaints and disorientation than those entering the area later. Halon 1301 usually is regarded as having a low toxicity, although at concentrations above those used in occupied spaces, effects on consciousness and cardiac rhythm have been reported. In the present report no significant illness or injury due to the Halon exposure was found. A fine oily deposit found on horizontal surfaces in the area subsequent to the discharge consisted of mineral oil and iron, suggesting that this material was scoured out of the piping as the Halon discharged. The disorientation and anxiety produced by an accidental discharge can be minimized through education programs designed to ensure that personnel know what to expect and how to abort the discharge if it results from a false alarm. Situations leading to triggering of fire detectors by events other than fires should be investigated and reduced.