What to do from the Emergency Room in Case of Suspected Chemical Submission

Chemical submission is a crime where criminals use substances to impose their will on victims. A 44-year-old woman comes to the Health Center disoriented in the temporal sphere, stating that “she does not remember what happened.” Her brother, the companion who brings her to the health center, says that he has found her in a place he does not usually frequent. The patient missed a bag she was carrying and could not locate her mobile phone. The patient and companion suspect that she may have been “drugged” in order to rob them. Given the suspicion that the patient may have been a victim of chemical submission, the Emergency Service is called to inform that the victim is going to be referred. The detection of biological samples of the substances used for submission is of vital importance.

In recent years, an increase in cases of Chemical Submission (CS) has been observed. This consists of the administration of chemical substances with psychoactive effects to a person, without their knowledge or consent for criminal purposes [1]. Chemical substances are administered to modify the state of consciousness, and their behavior or override their will. In recent years, the phenomenon of chemical submission has acquired notable relevance due to the increase in cases and its important health and social impact. Crimes against sexual freedom are the most frequent. Most of the victims are young women. The person under chemical submission can be a victim of any type of crime. In 2022, the Ministry of Justice developed and published the Guide to Good Practices for Forensic Action before the victim of a crime facilitated by psychoactive substances [2].

The substances used in Chemical Submission have a series of characteristics that are shown in Table 1.

More than 30 substances implicated in cases of chemical submission have been described, some of which appear in Table 2.

In the case of providing out-of-hospital health care (Table 3)

to a person likely to have suffered chemical submission, they must be referred without delay to the Emergency Service of the reference Hospital, and it is preferable to notify the Emergency Service of the patient’s referral. The person will be referred by their own means or with medical transport appropriate to their clinical status [3].

Table 4 summarizes the history to be taken and the symptoms of a person who declares or is suspected to have been a victim of possible chemical submission and who is treated in the Emergency Department.

If CS is suspected, the first thing that will be done will be to collect samples for toxins (after signing the informed consent) given that they are time-dependent.

Subsequently, a history is taken (Table 5) aimed at searching for symptoms associated with or suspicious of chemical submission (Table 6).

Furthermore, the physical examination must be carried out systematically and by means of devices in the presence of witnesses; at least one person will be a healthcare professional, conveniently of the same sex as the patient, and if desired, there will also be a person they trust.

An injury report will be made that must describe all the injuries found. It is recommended that they be drawn in a sketch of the body, detailing its size, location, and appearance. In the case of hematomas, it is possible to tell the evolution time based on their characteristics. The medical personnel responsible for the care must complete the injury report with the diagnosis of suspected poisoning by substances involved in a probable chemical submission, recording whether biological samples have been collected, whether contact has been established with forensic medicine, and whether there was possible aggression of a physical or sexual nature.

If sexual assault is suspected (Table 7), a physical examination directed at the urogenital or gynecological area is required with sample collection in the presence of a forensic doctor, especially in the first 72 hours. The Gynecology service, and the forensic doctor, will be contacted on guard and the State Security Forces will be informed.

The victim must be informed of the need to formalize a complaint and the need for it to continue with the judicial process. In the event that the person decides to report, the competent Security Forces and Bodies will be contacted from the emergency room. Obtaining informed consent is a fundamental part of the action. It is recommended to explain to the victim what the toxicological test consists of, the non-guarantee that the tests will reveal psychoactive substances to facilitate the crime. The tests may reveal other substances that the victim may have voluntarily ingested. Written informed consent will be requested from the person and/or legal representative, giving a copy to the interested person and keeping the original together with the biological samples collected and another copy in their medical record for digitalization [4].

If Chemical Submission is suspected, it will be collected systematically and as soon as possible as they are time-dependent substances [5-7]:

Urine: Urine is the sample of choice in most crimes facilitated by psychoactive substances. It is a usually abundant sample that reports relatively recent consumption, and that offers detection windows superior to blood. Collection will be made when no more than 5 days have passed since the alleged crime. All that can be collected will be sent in a 50 ml safety bottle.

Blood: Blood is a biological sample that informs about the recent consumption of a substance and also allows for establishing the correlation between the concentration and the clinical effect. The main disadvantage is the rapid elimination of substances from this medium; if there is a delay in collection, it is likely that the administered substance has disappeared from the blood. It must be obtained within the first 48 hours after the alleged event. The sample will be taken without using alcohol or another volatile substance as a disinfectant. Peripheral venous blood will be sent in four 5 ml tubes, preferably two with sodium fluoride as a preservative and potassium oxalate as an anticoagulant (gray stopper tube) and another two with whole blood anticoagulated with EDTA – edetic acid – to avoid the in vitro formation of glycohemoglobin. (lilac stopper tube).

Hair: Its collection is not common in the alleged victim’s first healthcare visit. The hair sample is the appropriate matrix to confirm consumption or repeated administration over a period of time. Hair is of forensic interest when it is necessary to rule out chronic consumption of some psychoactive substance by the victim. In cases in which the report has been delayed (more than 5 days), or it is estimated that the elimination of the toxin in the blood and urine has occurred, the victim can be summoned 4-6 weeks after the event, indicating that During this time, it is advisable to not cut their hair or carry out cosmetic treatments (dye bleaching). Tufts of hair cut from the occipital area and very close to the scalp - cut flush - will be collected, with a minimum thickness of 7 mm in diameter. It will be placed on a piece of paper fixed with adhesive tape, indicating the end close to the root (proximal zone) and the end of the tip (distal zone).

The emergency nursing staff will be in charge of taking the samples and storing them in the refrigerator located in the Emergency area. To guarantee the chain of custody of the samples, the chain of custody form must be completed, which must include the signatures of the doctor responsible and the nurse responsible for the extraction.

Chemical submission is a crime that has increased in recent years in Spain. Criminals use substances to impose their will on victims. The detection of biological samples of the substances used for submission is of vital importance. Health professionals who care for these victims must know the peculiarities of the biological samples that will be used to determine the possible existence of a chemical substance.

1. Folgar MI, Boubeta AR. Drugs that facilitate sexual assault and chemical submission. Health and Addictions. 2015; 15(2):137-150.
2. General Técnica/Good practice guide for forensic action before the victim of a crime facilitated by psychoactive substances: intervention in the event of suspected chemical submission. Ministry of Justice. Technical General Secretariat 2022.
3. Protocol for comprehensive, health and judicial care for victims of sexual assault in the Valencian Community. Generalidad Valenciana, 2019.
4. García MG, Pérez-Cárceles MD, Osuna E, Legaz I. Drug-facilitated sexual assault and other crimes: A systematic review by countries. J Forensic Leg Med. 2021 Apr;79:102151. doi: 10.1016/j.jflm.2021.102151. Epub 2021 Mar 12. PMID: 33773270.
5. Papadodima SA, Athanaselis SA, Spiliopoulou C. Toxicological investigation of drug-facilitated sexual assaults. Int J Clin Pract. 2007 Feb;61(2):259-64. doi: 10.1111/j.1742-1241.2006.01123.x. PMID: 17263712.
6. Sonone SS, Jadhav S, Sankhla MS. A forensic aspect on drug facilitated sexual assault. Forensic Res Criminal Int J. 2021; 9(2): 59-63.
7. Alonso CF, Jorge OQ, Serrano BB, Rodríguez EGM, Ferrer MEF, Armengol JJG, Santiago-Sáez AE. The importance of the time factor in the toxicological analysis of cases of suspected chemical submission in a hospital emergency department. Emergencias. 2019; 31(1).