eISSN: 1689-1716
ISSN: 0324-8267
Archiwum Medycyny Sądowej i Kryminologii/Archives of Forensic Medicine and Criminology
Current issue Archive Manuscripts accepted About the journal Supplements Editorial board Reviewers Abstracting and indexing Subscription Contact Instructions for authors Ethical standards and procedures
SCImago Journal & Country Rank
4/2017
vol. 67
 
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abstract:
Case report

Patient’s death as a result of mistakenly injection of pancuronium

Rafał Skowronek
1
,
Małgorzata Korczyńska
1
,
Joanna Kulikowska
1
,
Joanna Nowicka
1
,
Stanisława Kabiesz-Neniczka
1

  1. Chair and Department of Forensic Medicine and Forensic Toxicology, School of Medicine in Katowice, Medical University of Silesia in Katowice, Poland
Arch Med Sadowej Kryminol 2017; 67 (4): 254–263
Online publish date: 2018/04/16
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Pancuronium is a typical non-depolarizing, curare-mimetic, very potent muscle relaxant. Besides application in anesthesiology and intensive care, it is used in execution as a part of lethal injection. In medico-legal practice, there are cases of using this substance in order to commit suicide or to deprive other people of their lives. Accidental pancuronium intoxications are very rare. The authors present such case ended in sudden death of hospitalized woman after mistakenly injection of the drug. 57-year-old female alcoholic was admitted to the Acute Poisoning Centre after ethylene glycol ingestion. During the fifth day of treatment the nurse by mistake, instead of furosemide, intravenously administered her pancuronium. Sudden respiratory and circulatory arrest occurred, so she was intubated and resuscitation with artificial ventilation were undertaken, however within 1 hour and 45 minutes the patient died. Due to the vague background of a sudden deterioration in the patient’s condition, the case was brought for prosecution. The autopsy and histopathological studies did not reveal the cause of death, but undertaken chemico-toxicological examinations identified the presence of pancuronium in blood, liver and kidney (190 ng/ml, 70 ng/g and 125 ng/g, respectively). Chemico-toxicological analysis proved that the cause of death of the 57-year-old hospitalized woman was pancuronium intoxication due to evident medical error during drug administration. In our case the concentration of pancuronium in blood was in therapeutic range (200–600 ng/ml). However, even a therapeutic pancuronium dose administered to patient the breath of whom is not supported and monitored can be a threat to his life.
keywords:

medical error, lethal poisoning, non-depolarizing muscle relaxants

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