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Postmortem Chemistry
  (Medicolegal Significance)


   Mamdouh K. Zaki
–
 Postmortem biochemistry is usually performed by the hospital
  autopsy pathologist, but it can be useful in a forensic setting.


 The pathologist should be aware of the value and limitations of
  postmortem biochemistry because he will inevitably encounter
  a number of cases that require investigation into the
  decedent’s metabolic state.


 Most of the previous studies were performed by comparing
  premortem and postmortem fluids to show which components
  remain relatively constant, which undergo predictable change,
  and which are too altered to be of diagnostic use.
 Carbohydrates and Related Metabolites.


 Electrolytes and Trace Elements.


 Nitrogenous Compounds.


 Cholesterol and Other Lipids.


 Proteins.


 Bile Pigments and Other Indicators of Hepatic Function.


 Hormones.
 Carbohydrate
   s and
   Related
   Metabolites.

 Electrolytes
                   1.Glucose.
   and Trace
   Elements.

 Nitrogenous      2.Ketones.
   Compounds.

 Cholesterol
   and Other
   Lipids.
                   3.Lactic Acid.
 Proteins.

 Bile Pigments
   and Other
   Indicators of
   Hepatic
   Function.

 Hormones.
 Carbohydrate     1.Glucose.
   s and
   Related           Hypoglycemia: (it is a normal postmortem event)
   Metabolites.

 Electrolytes
                       Postmortem Decrease & Possible Value:
   and Trace
   Elements.
                           1. Due to continuous consumption of glucose by surviving
 Nitrogenous                 cells postmortem, blood glucose levels decrease rapidly.
   Compounds.
                           2. Its level can decrease to ZERO after few hours.
 Cholesterol
   and Other
                           3. A low glucose level in blood from the right atrium and a
   Lipids.
                              positive test for ketones MAY support starvation in the
 Proteins.
                              setting of abuse or neglect.
 Bile Pigments
   and Other
   Indicators of
   Hepatic
   Function.

 Hormones.
 Carbohydrate     1.Glucose.
   s and
   Related           Hyperglycemia: (a level more than 200 mg/dL)
   Metabolites.

 Electrolytes
   and Trace
                       Limitations concerning sampling & Interpretation:
   Elements.
                          1. Sampling of vitreous fluid from the centre of both eyes.
 Nitrogenous
   Compounds.             2. It is preferred to be sampled as soon as possible after arrival

 Cholesterol                at the morgue (loss of vitreous humor with low temp.).
   and Other
   Lipids.
                          3. Immediate bedside analysis using a blood gas instrument.

 Proteins.               4. Standardized sampling containers must be used.

 Bile Pigments
                          5. This level only indicates that the decedent had uncontrolled
   and Other
   Indicators of
                             diabetes.
   Hepatic
   Function.

 Hormones.
 Carbohydrate     1.Glucose.
   s and
   Related           Hyperglycemia: (a level more than 200 mg/dL)
   Metabolites.

 Electrolytes
   and Trace
                     Difficult interpretation & False Positive Results:
   Elements.
                        1. Death from asphyxia, cerebral hemorrhage, congestive heart
 Nitrogenous              failure, electrocution, or terminal cardiopulmonary resuscitation
   Compounds.
                           may increase postmortem peripheral vascular glucose.
 Cholesterol
                           So, other causes of violence must be excluded by autopsy.
   and Other
   Lipids.
                        2. Other investigations must be done as well: (i) glycosuria,
 Proteins.                (ii) ketonuria, or (iii) elevated serum acetone level,
 Bile Pigments            and (iv) blood level of glycosylated hemoglobin and
   and Other
                           (v) glycosylated fructosamine to confirm diabetic ketoacidosis.
   Indicators of
   Hepatic
   Function.

 Hormones.
 Carbohydrate     2. Ketones & Lactic Acid.
   s and
   Related          Total ketone bodies (acetone, acetoacetate, and b-
   Metabolites.     hydroxybutyrate): can be measured in PM blood, vitreous,
                    pericardial fluid, and urine
 Electrolytes
   and Trace
                    interpretation of Results:
   Elements.

 Nitrogenous          1. Serum lactic acid increases rapidly after death, and antemortem
   Compounds.
                           levels are increased 20 times and 50 to 70 times at 1 and 24
 Cholesterol              hours, respectively.
   and Other
   Lipids.             2. Vitreous humor lactic acid increases from its initial values of 80

 Proteins.                to 160 mg/dL to 210 to 260 mg/dL 20 hours after death.

 Bile Pigments        3. Its value allow a quick determination of Possible ketoacidosis.
   and Other
   Indicators of
   Hepatic
   Function.

 Hormones.
 Carbohydrate
   s and
   Related         1.Sodium, Chloride, and Potassium.
   Metabolites.

 Electrolytes
                   2. Carbon Dioxide Content.
   and Trace
   Elements.

 Nitrogenous
                   3. Calcium, Magnesium, Phosphorus,
   Compounds.

 Cholesterol
                     and Sulfur.
   and Other
   Lipids.
                   4. Trace Elements.
 Proteins.

 Bile Pigments
   and Other
   Indicators of
   Hepatic
   Function.

 Hormones.
 Carbohydrate
   s and
                   1.Sodium, Chloride, and Potassium.
   Related
                   Their PM blood concentration do not accurately reflect AM levels
   Metabolites.
                              because of variable instability after death.
 Electrolytes
   and Trace
   Elements.
                    interpretation of Results:
 Nitrogenous
   Compounds.          1. Vitreous sodium (150 – 190 mEq/L) concentration remain
 Cholesterol              relatively stable in the early postmortem period.
   and Other
   Lipids.             2. Vitreous chloride (114 mEq/L) concentration remain almost
                           constant during the early 18 hours.
 Proteins.

 Bile Pigments
   and Other
   Indicators of
   Hepatic
   Function.

 Hormones.
 Carbohydrate
   s and
                   1.Sodium, Chloride, and Potassium.
   Related
                    interpretation of Results:
   Metabolites.
                       3.   The blood potassium level rises extremely rapidly after death as cell
 Electrolytes
                            membranes lose integrity. In vitreous, PM K+ levels rise gradually (stable
   and Trace
   Elements.                correlation phase), however, the margin of error in these calculations is
                            HIGH and vitreous K+ levels should not be used to estimate time of death,
 Nitrogenous
                            due to many factors:
   Compounds.
                             a.   Possible AM electrolytes’ imbalance.
 Cholesterol
                             b.   Metabolic diseases.
   and Other
   Lipids.                   c.   Environmental temperature (inappropriate conservation - lower in
                                  cold weather).
 Proteins.
                             d.   The K+ rise is faster in infants> adults.
 Bile Pigments              e.   Inappropriate sampling (near retinal lining)  false results.
   and Other
                             f.   Further clinical researches and case-studies are in process.
   Indicators of
   Hepatic
   Function.

 Hormones.
 Carbohydrate     2. Carbon Dioxide.
   s and
   Related           ML Significance:
   Metabolites.        Postmortem vitreous carbon dioxide content averages
                        15 mEq/L (range 4 to 27 mEq/L) and remains relatively stable for at
 Electrolytes
                        least 15 hours after death.
   and Trace
   Elements.

 Nitrogenous      3. Calcium, Magnesium, Phosphorus, and Sulfur.
   Compounds.

 Cholesterol
                    ML significance: of little use
   and Other            The serum Ca++ remains briefly stable and then rises slowly. Initial
   Lipids.
                         vitreous calcium levels range from 6 to 8 mg/dL (1.5 to 2 mmol/L),
                         and the values rise very slowly until decomposition ensues.
 Proteins.             Mg++in vitreous humor rise slowly but erratically after death.
                        Inorganic and organic phosphorus levels increase quickly after
 Bile Pigments          death.
   and Other            Sulfate levels are stable during the initial PM period.
   Indicators of
   Hepatic
   Function.

 Hormones.
 Carbohydrate
   s and
   Related
   Metabolites.

 Electrolytes
   and Trace
                   1. Urea Nitrogen and Creatinine.
   Elements.

 Nitrogenous
   Compounds.
                   2. Other Nitrogenous Compounds.
 Cholesterol
   and Other
   Lipids.

 Proteins.

 Bile Pigments
   and Other
   Indicators of
   Hepatic
   Function.

 Hormones.
 Carbohydrate     1. Urea Nitrogen & Creatinine.
   s and
   Related          ML significance:
   Metabolites.        Postmortem Urea nitrogen & creatinine are perhaps the most stable
                       blood constituent following death as it approximates premortem
 Electrolytes
                       levels, even after moderate decomposition.
   and Trace
   Elements.

 Nitrogenous
   Compounds.

 Cholesterol
   and Other
   Lipids.

 Proteins.
                     These patterns can indicate child neglect, homicide, septicemia,
 Bile Pigments
                      SIDS, alcoholism, or prolonged diuretic therapy.
   and Other
                     Creatinine is a valid postmortem marker of nitrogen retention and
   Indicators of      renal function.
   Hepatic
   Function.

 Hormones.
 Carbohydrate     2. Other Nitrogenous Compounds.
   s and
                            concentrations of ammonia, amino acids, glutamine,
   Related
                      creatine, and oxypurines (uric acid, xanthine, and hypoxanthine)
   Metabolites.

 Electrolytes
   and Trace        ML Significance:
   Elements.
                      All these compounds increase after death.
 Nitrogenous
                      PM ammonia levels in vitreous humor increase linearly – during the
   Compounds.
                        first 24 hours.
 Cholesterol
                      Although relatively stable after death, uric acid levels are higher in
   and Other
   Lipids.              blood samples from the right side of the heart than from left heart or
                        periphery. Postmortem hyperuricemia may also be elevated after
 Proteins.
                        death caused by asphyxiation or drowning, but further studies of this
 Bile Pigments
   and Other
                        finding are required.
   Indicators of
   Hepatic
   Function.

 Hormones.
 Carbohydrate
   s and
                    ML Significance:
   Related
   Metabolites.
                      Postmortem serum total cholesterol  used to identify familial
 Electrolytes
                        hypercholesterolemia.
   and Trace
   Elements.
                      Correlation of PM serum lipid levels with AM state is difficult:
                             1. The decedent may not have been in a fasting state at the
 Nitrogenous
   Compounds.                    time of death.
                             2. Familial hyperlipoproteinemias have been identified from
 Cholesterol
   and Other                     postmortem studies.
   Lipids.                   3. Elevated levels of postmortem lipids in serum and other
 Proteins.                      fluids have been associated with the presence of coronary

 Bile Pigments                  heart disease and sudden cardiac death.
   and Other
   Indicators of
   Hepatic
   Function.

 Hormones.
 ML Significance:
 Carbohydrate
   s and
   Related             Albumin/Globulin ratio: PM studies show that the values for total
   Metabolites.          proteins and ratio are similar to those of AM specimens.
 Electrolytes
   and Trace               1. Provided that there is minimal hemolysis, serum
   Elements.                  electrophoresis has been useful in the postmortem diagnosis
 Nitrogenous                 of agammaglobulinemia, monoclonal gammopathy, and
   Compounds.
                              hemoglobinopathies .
 Cholesterol
   and Other               2. Total immunoglobulin E (IgE) is elevated in some cases of
   Lipids.                    fatal asthma.
 Proteins.
                           3. Specific IgE antibodies in postmortem serum may help
 Bile Pigments
   and Other
                              corroborate the diagnosis of anaphylaxis following insect
   Indicators of              stings or ingestion of allergenic food.
   Hepatic
   Function.

 Hormones.
 ML Significance:
 Carbohydrate
   s and
   Related
   Metabolites.        C-reactive protein: PM Postmortem measurement of in the blood or
 Electrolytes           liver (if blood is not available):
   and Trace
                           1. If marked elevation and in case of doubt of minimal injury: it
   Elements.
                               may indicate a natural mode of death in decedents.
 Nitrogenous
                           2. In those with obvious trauma, it suggests a vital reaction.
   Compounds.

 Cholesterol
                       CRP levels were independent of the post-mortem interval.
   and Other
   Lipids.             CRP is stable for 1 month PM (easy, viable, inexpensive).

 Proteins.

 Bile Pigments
   and Other
   Indicators of
   Hepatic
   Function.

 Hormones.
 ML Significance:
 Carbohydrate
   s and
   Related
                     Enzymes:
   Metabolites.
                       1. Elevated levels of creatine kinase, lactic dehydrogenase, and
 Electrolytes
                          their isozymes in pericardial fluid and serum have been
                          correlated with myocardial injury related to trauma or the
   and Trace
                          early stages of myocardial infarcts.
   Elements.

 Nitrogenous          2. Myosin concentration was a better indicator of widespread
   Compounds.             cardiac muscle damage.

 Cholesterol          3. Postmortem pericardial levels of cardiac troponin I greater
   and Other              than 40 ng/mL (better combined with troponin T) correlated
   Lipids.                closely with pericardial concentrations of myoglobin, with
                          elevated troponin levels supporting a diagnosis of cardiac
 Proteins.               injury (the highest level was in acute MI).
 Bile Pigments
   and Other
   Indicators of
   Hepatic
   Function.

 Hormones.
 ML Significance:
 Carbohydrate
   s and
   Related
                       Enzymes:
   Metabolites.
                        4. Mast cell tryptase (combined assay for a- and b-tryptase) has
 Electrolytes
                           been used to detect anaphylactic reactions (NOT-specific 
   and Trace
                           elevated in other conditions, including coronary artery
   Elements.               thrombosis, heroin injection, sudden infant death syndrome,
                           amniotic fluid embolism, and asphyxia).
 Nitrogenous
   Compounds.
                        To increase accuracy, MAY be combined with:
 Cholesterol
                            (1) accurate medical history (particularly atopic disposition of
                                 the decedent and temporal relationship of possible allergen
   and Other
                                 exposure and death).
   Lipids.
                            (2) findings at autopsy, total IgE levels, and,
 Proteins.
                            (3) if possible, analysis of relevant IgE antibodies.
                            (4) A peripheral blood is better (heart blood contains more
 Bile Pigments                  elevated levels of tryptases).
   and Other
   Indicators of
   Hepatic
   Function.

 Hormones.
 ML Significance:
 Carbohydrate
   s and
                       Serum Bilirubin : increase slowly after death but allow determination
   Related
                        of the extent of antemortem jaundice; however, minimal elevations
   Metabolites.         of postmortem bilirubin are difficult to interpret.
 Electrolytes         Urobilinogen remains stable in the urine but diffuses from blood to
   and Trace            CSF whenever the blood level is high.
   Elements.
                      MILD liver dysfunction cannot be readily assessed using
 Nitrogenous          postmortem chemical analysis because the enzymes used to
   Compounds.
                       assess liver function become elevated after death, BUT, total
                       cholesterol + low serum protein levels with inversion of the
 Cholesterol          albumin/globulin ratio + high serum bilirubin level + and the
   and Other           presence of abnormal levels of bile and urobilinogen in the urine
   Lipids.
                       CONFIRM SEVERE liver damage.
                      Elevation of glutamine level in the postmortem CSF samples
 Proteins.
                       CORRELATES with Hepatic Coma.
 Bile Pigments
   and Other
   Indicators of
   Hepatic
   Function.

 Hormones.
 ML significance:
 Carbohydrate
   s and                Serum cortisol, parathormone, chorionic gonadotropin, thyroid-
   Related               stimulating hormone, and luteinizing hormone concentrations remain
   Metabolites.          stable in the early postmortem period.
                        Insulin Poisoning (suicide and homicide): Serum insulin is extremely
 Electrolytes           difficult to measure accurately because it degrades rapidly at room
   and Trace             temperature.
   Elements.                 Diagnosis can be made as follows:
                              1.   Peripheral blood samples should be collected in tubes containing
 Nitrogenous
                                   sodium fluoride or ethylenediaminetetraacetic acid (EDTA).
   Compounds.
                              2.   Serum should be separated from red blood cells as soon as possible
 Cholesterol
                              3.   Samples should be refrigerated or, preferably, frozen.
   and Other
                              4.   Elevated PM blood INSULIN.
   Lipids.
                              5.   Low blood C Peptide (a diagnosis of exogenous insulin overdose).
 Proteins.                   6.   In postmortem blood, C peptide is more stable than insulin, although

 Bile Pigments                    collections still require special handling: collection in heparinized
   and Other                       tubes, separation of plasma, and, without delay, storage of the
   Indicators of                   serum sample in a freezer.
   Hepatic
   Function.

 Hormones.
Interpretation of biochemical results must be done with great caution
                & on an individual case by case basis.

High selection of suspected and criminal cases is a necessity, rather
 than wasting efforts, time and costs in revealing cause of death in
                        normal natural deaths.

    Re-evaluation and unifying toxicological and histopathological
investigations through providing experienced professionals in these
  fields, extensive scientific cooperation including immunostaning
studies for histopathology and sharing thoughts and plans for better
                achievement with these departments.


     Group meeting and workshops are needed with the related
laboratories to study further cooperation, feasibility studies, and cost
effectiveness of these sophisticated investigations in specific kinds of
                          medicolegal cases.
Thank You

Mamdouh K. Zaki

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Postmortem chemistry

  • 1. Postmortem Chemistry (Medicolegal Significance) Mamdouh K. Zaki
  • 2.
  • 3.  Postmortem biochemistry is usually performed by the hospital autopsy pathologist, but it can be useful in a forensic setting.  The pathologist should be aware of the value and limitations of postmortem biochemistry because he will inevitably encounter a number of cases that require investigation into the decedent’s metabolic state.  Most of the previous studies were performed by comparing premortem and postmortem fluids to show which components remain relatively constant, which undergo predictable change, and which are too altered to be of diagnostic use.
  • 4.  Carbohydrates and Related Metabolites.  Electrolytes and Trace Elements.  Nitrogenous Compounds.  Cholesterol and Other Lipids.  Proteins.  Bile Pigments and Other Indicators of Hepatic Function.  Hormones.
  • 5.  Carbohydrate s and Related Metabolites.  Electrolytes 1.Glucose. and Trace Elements.  Nitrogenous 2.Ketones. Compounds.  Cholesterol and Other Lipids. 3.Lactic Acid.  Proteins.  Bile Pigments and Other Indicators of Hepatic Function.  Hormones.
  • 6.  Carbohydrate 1.Glucose. s and Related  Hypoglycemia: (it is a normal postmortem event) Metabolites.  Electrolytes  Postmortem Decrease & Possible Value: and Trace Elements. 1. Due to continuous consumption of glucose by surviving  Nitrogenous cells postmortem, blood glucose levels decrease rapidly. Compounds. 2. Its level can decrease to ZERO after few hours.  Cholesterol and Other 3. A low glucose level in blood from the right atrium and a Lipids. positive test for ketones MAY support starvation in the  Proteins. setting of abuse or neglect.  Bile Pigments and Other Indicators of Hepatic Function.  Hormones.
  • 7.  Carbohydrate 1.Glucose. s and Related  Hyperglycemia: (a level more than 200 mg/dL) Metabolites.  Electrolytes and Trace  Limitations concerning sampling & Interpretation: Elements. 1. Sampling of vitreous fluid from the centre of both eyes.  Nitrogenous Compounds. 2. It is preferred to be sampled as soon as possible after arrival  Cholesterol at the morgue (loss of vitreous humor with low temp.). and Other Lipids. 3. Immediate bedside analysis using a blood gas instrument.  Proteins. 4. Standardized sampling containers must be used.  Bile Pigments 5. This level only indicates that the decedent had uncontrolled and Other Indicators of diabetes. Hepatic Function.  Hormones.
  • 8.  Carbohydrate 1.Glucose. s and Related  Hyperglycemia: (a level more than 200 mg/dL) Metabolites.  Electrolytes and Trace  Difficult interpretation & False Positive Results: Elements. 1. Death from asphyxia, cerebral hemorrhage, congestive heart  Nitrogenous failure, electrocution, or terminal cardiopulmonary resuscitation Compounds. may increase postmortem peripheral vascular glucose.  Cholesterol So, other causes of violence must be excluded by autopsy. and Other Lipids. 2. Other investigations must be done as well: (i) glycosuria,  Proteins. (ii) ketonuria, or (iii) elevated serum acetone level,  Bile Pigments and (iv) blood level of glycosylated hemoglobin and and Other (v) glycosylated fructosamine to confirm diabetic ketoacidosis. Indicators of Hepatic Function.  Hormones.
  • 9.  Carbohydrate 2. Ketones & Lactic Acid. s and Related Total ketone bodies (acetone, acetoacetate, and b- Metabolites. hydroxybutyrate): can be measured in PM blood, vitreous, pericardial fluid, and urine  Electrolytes and Trace  interpretation of Results: Elements.  Nitrogenous 1. Serum lactic acid increases rapidly after death, and antemortem Compounds. levels are increased 20 times and 50 to 70 times at 1 and 24  Cholesterol hours, respectively. and Other Lipids. 2. Vitreous humor lactic acid increases from its initial values of 80  Proteins. to 160 mg/dL to 210 to 260 mg/dL 20 hours after death.  Bile Pigments 3. Its value allow a quick determination of Possible ketoacidosis. and Other Indicators of Hepatic Function.  Hormones.
  • 10.  Carbohydrate s and Related 1.Sodium, Chloride, and Potassium. Metabolites.  Electrolytes 2. Carbon Dioxide Content. and Trace Elements.  Nitrogenous 3. Calcium, Magnesium, Phosphorus, Compounds.  Cholesterol and Sulfur. and Other Lipids. 4. Trace Elements.  Proteins.  Bile Pigments and Other Indicators of Hepatic Function.  Hormones.
  • 11.  Carbohydrate s and 1.Sodium, Chloride, and Potassium. Related Their PM blood concentration do not accurately reflect AM levels Metabolites. because of variable instability after death.  Electrolytes and Trace Elements.  interpretation of Results:  Nitrogenous Compounds. 1. Vitreous sodium (150 – 190 mEq/L) concentration remain  Cholesterol relatively stable in the early postmortem period. and Other Lipids. 2. Vitreous chloride (114 mEq/L) concentration remain almost constant during the early 18 hours.  Proteins.  Bile Pigments and Other Indicators of Hepatic Function.  Hormones.
  • 12.  Carbohydrate s and 1.Sodium, Chloride, and Potassium. Related  interpretation of Results: Metabolites. 3. The blood potassium level rises extremely rapidly after death as cell  Electrolytes membranes lose integrity. In vitreous, PM K+ levels rise gradually (stable and Trace Elements. correlation phase), however, the margin of error in these calculations is HIGH and vitreous K+ levels should not be used to estimate time of death,  Nitrogenous due to many factors: Compounds. a. Possible AM electrolytes’ imbalance.  Cholesterol b. Metabolic diseases. and Other Lipids. c. Environmental temperature (inappropriate conservation - lower in cold weather).  Proteins. d. The K+ rise is faster in infants> adults.  Bile Pigments e. Inappropriate sampling (near retinal lining)  false results. and Other f. Further clinical researches and case-studies are in process. Indicators of Hepatic Function.  Hormones.
  • 13.  Carbohydrate 2. Carbon Dioxide. s and Related  ML Significance: Metabolites.  Postmortem vitreous carbon dioxide content averages 15 mEq/L (range 4 to 27 mEq/L) and remains relatively stable for at  Electrolytes least 15 hours after death. and Trace Elements.  Nitrogenous 3. Calcium, Magnesium, Phosphorus, and Sulfur. Compounds.  Cholesterol  ML significance: of little use and Other  The serum Ca++ remains briefly stable and then rises slowly. Initial Lipids. vitreous calcium levels range from 6 to 8 mg/dL (1.5 to 2 mmol/L), and the values rise very slowly until decomposition ensues.  Proteins.  Mg++in vitreous humor rise slowly but erratically after death.  Inorganic and organic phosphorus levels increase quickly after  Bile Pigments death. and Other  Sulfate levels are stable during the initial PM period. Indicators of Hepatic Function.  Hormones.
  • 14.  Carbohydrate s and Related Metabolites.  Electrolytes and Trace 1. Urea Nitrogen and Creatinine. Elements.  Nitrogenous Compounds. 2. Other Nitrogenous Compounds.  Cholesterol and Other Lipids.  Proteins.  Bile Pigments and Other Indicators of Hepatic Function.  Hormones.
  • 15.  Carbohydrate 1. Urea Nitrogen & Creatinine. s and Related  ML significance: Metabolites. Postmortem Urea nitrogen & creatinine are perhaps the most stable blood constituent following death as it approximates premortem  Electrolytes levels, even after moderate decomposition. and Trace Elements.  Nitrogenous Compounds.  Cholesterol and Other Lipids.  Proteins.  These patterns can indicate child neglect, homicide, septicemia,  Bile Pigments SIDS, alcoholism, or prolonged diuretic therapy. and Other  Creatinine is a valid postmortem marker of nitrogen retention and Indicators of renal function. Hepatic Function.  Hormones.
  • 16.  Carbohydrate 2. Other Nitrogenous Compounds. s and concentrations of ammonia, amino acids, glutamine, Related creatine, and oxypurines (uric acid, xanthine, and hypoxanthine) Metabolites.  Electrolytes and Trace  ML Significance: Elements.  All these compounds increase after death.  Nitrogenous  PM ammonia levels in vitreous humor increase linearly – during the Compounds. first 24 hours.  Cholesterol  Although relatively stable after death, uric acid levels are higher in and Other Lipids. blood samples from the right side of the heart than from left heart or periphery. Postmortem hyperuricemia may also be elevated after  Proteins. death caused by asphyxiation or drowning, but further studies of this  Bile Pigments and Other finding are required. Indicators of Hepatic Function.  Hormones.
  • 17.  Carbohydrate s and  ML Significance: Related Metabolites.  Postmortem serum total cholesterol  used to identify familial  Electrolytes hypercholesterolemia. and Trace Elements.  Correlation of PM serum lipid levels with AM state is difficult: 1. The decedent may not have been in a fasting state at the  Nitrogenous Compounds. time of death. 2. Familial hyperlipoproteinemias have been identified from  Cholesterol and Other postmortem studies. Lipids. 3. Elevated levels of postmortem lipids in serum and other  Proteins. fluids have been associated with the presence of coronary  Bile Pigments heart disease and sudden cardiac death. and Other Indicators of Hepatic Function.  Hormones.
  • 18.  ML Significance:  Carbohydrate s and Related  Albumin/Globulin ratio: PM studies show that the values for total Metabolites. proteins and ratio are similar to those of AM specimens.  Electrolytes and Trace 1. Provided that there is minimal hemolysis, serum Elements. electrophoresis has been useful in the postmortem diagnosis  Nitrogenous of agammaglobulinemia, monoclonal gammopathy, and Compounds. hemoglobinopathies .  Cholesterol and Other 2. Total immunoglobulin E (IgE) is elevated in some cases of Lipids. fatal asthma.  Proteins. 3. Specific IgE antibodies in postmortem serum may help  Bile Pigments and Other corroborate the diagnosis of anaphylaxis following insect Indicators of stings or ingestion of allergenic food. Hepatic Function.  Hormones.
  • 19.  ML Significance:  Carbohydrate s and Related Metabolites.  C-reactive protein: PM Postmortem measurement of in the blood or  Electrolytes liver (if blood is not available): and Trace 1. If marked elevation and in case of doubt of minimal injury: it Elements. may indicate a natural mode of death in decedents.  Nitrogenous 2. In those with obvious trauma, it suggests a vital reaction. Compounds.  Cholesterol  CRP levels were independent of the post-mortem interval. and Other Lipids.  CRP is stable for 1 month PM (easy, viable, inexpensive).  Proteins.  Bile Pigments and Other Indicators of Hepatic Function.  Hormones.
  • 20.  ML Significance:  Carbohydrate s and Related  Enzymes: Metabolites. 1. Elevated levels of creatine kinase, lactic dehydrogenase, and  Electrolytes their isozymes in pericardial fluid and serum have been correlated with myocardial injury related to trauma or the and Trace early stages of myocardial infarcts. Elements.  Nitrogenous 2. Myosin concentration was a better indicator of widespread Compounds. cardiac muscle damage.  Cholesterol 3. Postmortem pericardial levels of cardiac troponin I greater and Other than 40 ng/mL (better combined with troponin T) correlated Lipids. closely with pericardial concentrations of myoglobin, with elevated troponin levels supporting a diagnosis of cardiac  Proteins. injury (the highest level was in acute MI).  Bile Pigments and Other Indicators of Hepatic Function.  Hormones.
  • 21.  ML Significance:  Carbohydrate s and Related  Enzymes: Metabolites. 4. Mast cell tryptase (combined assay for a- and b-tryptase) has  Electrolytes been used to detect anaphylactic reactions (NOT-specific  and Trace elevated in other conditions, including coronary artery Elements. thrombosis, heroin injection, sudden infant death syndrome, amniotic fluid embolism, and asphyxia).  Nitrogenous Compounds. To increase accuracy, MAY be combined with:  Cholesterol (1) accurate medical history (particularly atopic disposition of the decedent and temporal relationship of possible allergen and Other exposure and death). Lipids. (2) findings at autopsy, total IgE levels, and,  Proteins. (3) if possible, analysis of relevant IgE antibodies. (4) A peripheral blood is better (heart blood contains more  Bile Pigments elevated levels of tryptases). and Other Indicators of Hepatic Function.  Hormones.
  • 22.  ML Significance:  Carbohydrate s and  Serum Bilirubin : increase slowly after death but allow determination Related of the extent of antemortem jaundice; however, minimal elevations Metabolites. of postmortem bilirubin are difficult to interpret.  Electrolytes  Urobilinogen remains stable in the urine but diffuses from blood to and Trace CSF whenever the blood level is high. Elements.  MILD liver dysfunction cannot be readily assessed using  Nitrogenous postmortem chemical analysis because the enzymes used to Compounds. assess liver function become elevated after death, BUT, total cholesterol + low serum protein levels with inversion of the  Cholesterol albumin/globulin ratio + high serum bilirubin level + and the and Other presence of abnormal levels of bile and urobilinogen in the urine Lipids. CONFIRM SEVERE liver damage.  Elevation of glutamine level in the postmortem CSF samples  Proteins. CORRELATES with Hepatic Coma.  Bile Pigments and Other Indicators of Hepatic Function.  Hormones.
  • 23.  ML significance:  Carbohydrate s and  Serum cortisol, parathormone, chorionic gonadotropin, thyroid- Related stimulating hormone, and luteinizing hormone concentrations remain Metabolites. stable in the early postmortem period.  Insulin Poisoning (suicide and homicide): Serum insulin is extremely  Electrolytes difficult to measure accurately because it degrades rapidly at room and Trace temperature. Elements.  Diagnosis can be made as follows: 1. Peripheral blood samples should be collected in tubes containing  Nitrogenous sodium fluoride or ethylenediaminetetraacetic acid (EDTA). Compounds. 2. Serum should be separated from red blood cells as soon as possible  Cholesterol 3. Samples should be refrigerated or, preferably, frozen. and Other 4. Elevated PM blood INSULIN. Lipids. 5. Low blood C Peptide (a diagnosis of exogenous insulin overdose).  Proteins. 6. In postmortem blood, C peptide is more stable than insulin, although  Bile Pigments collections still require special handling: collection in heparinized and Other tubes, separation of plasma, and, without delay, storage of the Indicators of serum sample in a freezer. Hepatic Function.  Hormones.
  • 24. Interpretation of biochemical results must be done with great caution & on an individual case by case basis. High selection of suspected and criminal cases is a necessity, rather than wasting efforts, time and costs in revealing cause of death in normal natural deaths. Re-evaluation and unifying toxicological and histopathological investigations through providing experienced professionals in these fields, extensive scientific cooperation including immunostaning studies for histopathology and sharing thoughts and plans for better achievement with these departments. Group meeting and workshops are needed with the related laboratories to study further cooperation, feasibility studies, and cost effectiveness of these sophisticated investigations in specific kinds of medicolegal cases.