(Received 12 January 1981; accepted 10 June 1981)
Published Online: January
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A patient was inadvertently overdosed with halothane during the nitrous oxide phase of anesthesia induction. During the subsequent 2$#00BD;-h resuscitation attempt, the oxygen via the anesthesia machine continued to be contaminated with 5% halothane. Brain death was pronounced when the patient may have been only very deeply anesthetized. The vaporizer had accidentally been left on the full ON position prior to the procedure. Poor design of vaporizer controls.and operator neglect combined to allow protracted patient exposure to the toxic concentration of halothane. The medical examiner has a critical role in the adequate management of anesthesia/surgery related deaths.
Toxicologist, Office of the Chief Medical Examiner, Chapel Hill, NC
Associate in pathology, University of Iowa, Iowa City, IA
Stock #: JFS11472J