How clinical toxicology service can contribute in forensic cases?

Abstract

To present the contribution of clinical toxicology service in forensic cases investigations. Poisons control centers (PCC) are medical units that works mainly with clinical toxicology. They exist to provide advice to the public, physicians and others on the toxicity of and management of poisoning, caused by medicaments, drugs of abuse, chemicals, commercial products and venoms. Other attributions to the PCC include clinical and laboratory diagnosis, notification of intoxication cases, control and distribution of antidotes. The service should be available 24 hours a day, 365 days a year, and be staffed by multiprofessional team which guarantee coverage in clinical and laboratory support. A clinical toxicologist plays an important role in multiple areas of clinical medicine. By providing consultative services, clinical toxicologists facilitate the best treatment plan for patients present at the emergency department for the treatment of an acute toxic exposure of accidental or intentional nature. In many cases the causative agent is unknown, thus an analytical toxicology laboratory service is crucial to the operation of a clinical toxicology center. The tasks may cover besides support for diagnosis and prognosis of poisonings, help for indication for (invasive) treatment, monitoring of the efficiency of detoxication and support in differential diagnostic exclusion of poisonings. Furthermore, patients addicted to alcohol, medicaments or drugs of abuse have to be monitored. For the other hand, but not so distant, forensic toxicology pertains to the practice of toxicology in the medicolegal realm including investigation of causes of death, driving under the influence of drugs, child protection services, drug-facilitated crime, doping control, bioterrorism, and environmental exposures. This presentation was based on the management of clinical cases of Campinas Poison Control Center (Campinas, Brazil), with outcome in forensic investigation. In most of clinical toxicology cases, the end-user is physician using the emergency toxicology laboratory findings to treat and care for an intoxicated or poisoned patient, while in forensic toxicology, the end-user can be a physician or a non-medical professional such as a lawyer, or law enforcement agent using the results to interpret a cause of death or the forensic event. Nevertheless, some circumstances of clinical intoxication cases such as suicide and homicide attempt, drug abuse, drug-facilitated sexual assault, child abuse, chemical disasters, bioterrorism and chemical warfare agents will develop into a forensic investigation. Therefore when a forensic case was previously assisted by a PCC some advantages can be listed in benefit of fulfilled the investigation, such as: (a) fully data of case, especially signs and symptoms, story, exposed dose, applied treatment (antidote) and clinical laboratory exams; (b) collection of biological samples during the “peak of effects” (blood: Cmax; urine: few hours after exposure); (c) confirmation of diagnosis of intoxication/poisoning. In fatal cases of intoxication (caused by pesticides, NPS, chemicals and animal venoms) previously assisted by PCC, patient's normally remain hospitalized more than 1 week, resulting in false-negative detection in postmortem samples analysis, thus the confirmation of diagnosis by a PCC laboratory, medical data report and hospital samples will be an important tool to contribute in forensic intoxication cases. While clinical toxicology professionals interact with medical and clinical laboratory professionals who most commonly practice in a hospital-based setting, forensic toxicology professionals interact with, coroner's law enforcement officers, and the judicial system. The analytical aspects of both clinical and forensic toxicology practice are convergent and involve similar workflow approaches thus the partnership between them toxicology will result in increase of the success of the investigations.