Fatal halothane poisoning during anesthesia with other agents

A patient was inadvertently overdosed with halothane during the nitrous oxide phase of anesthesia induction. During the subsequent 2 1/2-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.