Thread by @NaturesPoisons

Dropping a bit of knowledge for a Toxicology Thursday.
Did you know that your lungs - you likely have two of them (I hope) -don't weigh the same? Your right one weighs more than the left. Mean masses (R/L) are 450/500g in males and 350/300g in females. How come, you ask?

Why? It's your heart. As a kid we're told our heart is on the left side, then we learn that it's really in the center. Then someone like me says, "you know what, it really is a little bit to the left." This takes up a bit of space from the left lung, hence the weight difference.

They even have different numbers of lobes. The right lung has 3 lobes, and the left lobe has 2. You're probably wondering why a toxicologist even cares about this, aren't you? Well, it has to do with opiate deaths. Lingering opiate deaths to be specific.

A lot of postmortem toxicology is easy and routine. Cocaine, heroin, fentanyl...pretty cut and dry. But it's the 5% of cases that make things interesting. For example: If we have an oxycodone of 800 ng/mL in blood, we're pretty sure that's likely the cause of death (COD).

But what if you have an oxycodone of 80 ng/mL, and nothing else? Not that impressive, even if they aren't prescribed it. It's important to remember though, that drug deaths aren't always fast, like in the movies. You can lay around for a while...lingering, as we say.

So someone may be unconscious - often we hear they are "on the couch, snoring loudly." That's a red flag the size of Cincinnati. That whole time they are still metabolizing whatever drugs are in them. What was once a high oxycodone concentration, is slowly decreasing.

So once they die and we analyze the blood - from what we are assured is an overdose - and find 80 ng/mL of oxycodone, we're thinking, "Hmmm, this doesn't look like an overdose, how can this be rationally explained?"

**** And with that I have to take a break for our lab Holiday party ****

Whre was I? Ahhh, lingering deaths. So if a toxicology report doesn't scream "DRUG DEATH!", it doesn't necessarily mean that it wasn't. There are signs from the autopsy that are indicative of as drug overdose.

Common signs of an opiate OD are: foam cones an the mouth and nose (or purge), pulmonary edema (fluid in the lungs), and an early pneumonia. People may have all, or just one of these signs. But what do these things affect? Lung weights!

Lung weights from decedents of an opioid overdose are significantly and statistically higher (p <0.0001) than those that did not die of an overdose. Right lung weights for males and females are about +300g and + 260g higer than "normal," respectively.

So when the tox doesn't scream at me, questions I ask are "What were the lungs like? Was there pulmonary edema? Any pneumonia?"

These answers help us (me and the pathologist) paint the picture of the death.

My former boss always says "Toxicology doesn't exist in a vacuum." And she's right. We often need more information, either from the pathology side or from the investigation - and usually both. In short, the good toxicologists ask questions.

Numbers anfd drugs on a piece of paper often won't - or can't - tell the whole story. It's why I made and present this "Triangle of Death" at death investigation symposiums: it takes pathology, toxicology, and investigations to complete a medico-legal death investigation.

Some articles:
Increased lung weights in drug deaths: ncbi.nlm.nih.gov/pubmed/28317115
Lingering opiate deaths (from my friends in Cuyahoga county): ncbi.nlm.nih.gov/pubmed/23869071

The end.