Criminal Clozapine Poisoning

Objective: For recent years criminal poisoning with clozapine in Moscow has come top, replacing clonidine which prevailed before. Hence, the objective of this study was to investigate clinical symptoms and treatment of criminal poisoning with clozapine. Methods: The study included 611 patients with criminal clozapine poisoning aged from 16 to 55 years. They had consumed various drinks with persons little known to them and within 5-15 minutes developed a sudden weakness with loss of consciousness. All of them were robbed. The time from toxic substance exposure to hospital admission varied from 1.5 to 3 hours. Forensic chemical and organ morphology investigations were made in 22 men aged 30-35 years who died at a pre-hospital stage from criminal clozapine poisoning. Clozapine was identified in the urine and in the organs of the dead, ethanol was found in the blood and urine in concentrations corresponding to intoxication of moderate to severe degree. Results: On patients' admission the level of consciousness scored 7.9 plus or minus 0.6 on the Glasgow Coma Scale with periods of non-pronounced psy-chomotor agitation similar to neuroleptic syndrome. Patients also showed marked dysarthria, decrease in muscle tone, prolonged miosis for 4-6 hours and skin pallor. In 60% of cases we observed moderately pronounced hypersalivation. Tachycardia with normal arterial blood pressure was a typical symptom. Nine patients (1.5%) showed severe respiratory impairment that required mechanical lung ventilation for 3-8 hours. Clozapine urine concentration averaged 4.7 plus or minus 3.1 mcg/ml, and ethanol blood and urine concentrations 2.2 plus or minus 1.4 g/l and 3.0 plus or minus 1.5 g/l respectively. Consciousness was restored within 8-16 hours. The process was accompanied by psy-chomotor agitation and consequent transition to asthenia persisting for 14-22 hours. Detoxification therapy included forced diuresis, gastric lavage followed by activated charcoal and laxatives. 2-3 mg intravenous aminostigmine or galantamine (Nivalin) were used as antidotes and were followed by rapid (within 15-20 minutes) restoration of consciousness. In 21% of cases a repeated administration of antidote was required. The length of hospital stay was 36 plus or minus 4.3 hours. All patients recovered. The most prominent postmortem organ abnormalities were found in the liver as predominant droplet, both focal and diffuse, fatty hepatocytes degeneration. Conclusion: Criminal clozapine poisoning has