Download MBBS Cocaine Poisoning Lecture PPT

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It is an alkaloid obtained from the leaves of coca
tree, (Erythroxylon coca) and is a powerful
addictive stimulant that directly affects the brain.
It is typical y sold to users as a fine, white,
crystalline powder. It is a colourless, odourless,

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with a bitter/numbing taste, slightly volatile,
melting point 96 degree Celsius and should be
protected from heat and sunlight.
It dissolves easily in alcohol but slightly soluble in
water. Once taken oral y, it causes numbness of

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the tongue and mucous membrane of mouth.

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Forms:
Hydrochloride Salt
Freebase
Crack

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Hydrochloride Salt: It is the powdered form of
cocaine, dissolves in water and when abused, can
be taken I/V or snorted.
Freebase: Compound that has not been neutralized
by an acid to make hydrochloride salt. It can be

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smoked.
Crack: it is produced when the hydrochloride
molecule is removed by ether extraction, which
frees the basic cocaine molecule (freebase). The
term CRACK describes the cracking sound heard

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when cocaine freebase is smoked.

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COCAINE HYDROCHLORIDE

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FREEBASE

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SMOKING-CRACK

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PRINCIPLE ROUTES OF ABUSE

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Intravenous
Snorting (application to nasal mucous membrane)
Smoking/inhalation(free basing)
Ingestion/chewing: both cocaine and leaves of coca
plants

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Cocaine may be inhaled through a straw or
rol ed in paper currency, or a coke spoon
containing 5-20 mg of the drug of the drug is
used to snort.

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SNORTING

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INTRAVENOUS
SMOKING
INHALATION
INGESTION --LEAVES

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Cocaine has been classified as a

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Schedule II drug by the United States.
Cocaine is extracted and refined from
the Coca plant.
Now a days, cocaine can be
synthetically made. An ester of

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benzoic acid and a base containing
nitrogen is synthetic cocaine.

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GEOGRAPHICAL DISTRIBUTION
This plant original y grew in South America
but now is cultivated in India, Sri Lanka

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and Java. Nowadays, grows throughout
the tropical regions, whole of Latin
American Countries such as Columbia,
Mexico, Ecuador, and other countries
such as Chile, Peru, India, Indonesia, Sri

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Lanka, etc.
Bolivia-leading producer-80% world total
cocaine producer.

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HIGH RISK GEOGRAPHICAL AREAS
Bolivia

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Peru
Brazil ? Amazon region
Ecuador
Columbia
Chile

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ERYTHROXYLON COCA

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FEATURES
Plant is 8-12 feet tall.
Category: Shrubs
Fruits: Red oval shaped, 1 cm size and

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produces only one seed.
Seeds: Brownish oval
Stem diameter: 16cms

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LEAVES
Green, smooth, glossy, opaque, oval, tapering

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at extremities, 2-3 cm wide and 3-11 cm long.
Leaves when chewed have pleasant, pungent
taste.
Poisonous parts: Leaves
Toxins: Methylbenzoylecgonine is one of at

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least 12 alkaloids extracted from the leaves of
E. coca. Al have ecgonine as common
constituent.
Some
other

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alkaloid
are:
cinnamylcocaine,
hygrine,
tropococaine,

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truxil ines, isotropylcocaine, cocaicine.

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COCA FRUITS
COCA FLOWER
COCA LEAVES
COCA LEAVES, FLOWERS

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COMMON NAMES FOR COCAINE
CRACK
PASTA
BAZOOKA
SPEEDBALL (Mixture of cocaine and heroin.

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Taken I/V)
SNUFF
SNOW
COKE
CADILLAC

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TORNADO
WHITE LADY

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CRACK
PASTA
BAZOOKA

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SNOW
SPEEDBALL
SNUFF
COKE
CADILLAC

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TORNADO
WHITE LADY

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ACTION
Cocaine produces a hyper adrenergic state.
It increase the synaptic concentrations of the

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monoamine neurotransmitters, norepinephrine and
serotonin by binding to transporter proteins in
presynaptic neurons and blocking uptake.
It is also a local anesthetic as it blocks initiation and
conduction of nerve impulse, desensitizes the

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terminal nerves and causes vasoconstriction by
decreasing axonal membrane permeability to
sodium ions.
When taken I/V or inhaled, stimulates the cerebral
cortex for a short time, fol owed by depression.

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ABSORPTION/METABOLISM AND EXCRETION
Cocaine is rapidly absorbed from the mucous
membranes and subcutaneous tissues.
About 30-50% of cocaine is metabolised by hepatic
esterases and plasma pseudo cholinesterase,

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resulting in the formation of ecgonine methyl ester.
Spontaneous nonenzymatic hydrolysis of another
30-40% results in benzoylecgonine.
Only 1-5% of cocaine is excreted unaltered through
th kidneys within 6 hours of use.

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Half Life: 30-90 min.
A metabolite of cocaine, COCAETHYLENE has
been found in blood and urine of patients who abuse
both alcohol and cocaine

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DETECTION

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Metabolites can be detected for varying lengths of time in
urine depending upon the dose consumed and sensitivity of
the assay.
Metabolites in urine is generally detected in urine for 24-72
Hrs. even after brief consumption.

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Metabolites also detectable in blood, saliva, hair and sweat.
With chronic use it is deposited in body in fats/CNS. and is
slowly released. Hence, can be detected in urine for even
couple of weeks.
Blood and saliva: Provide accurate conc. of the drug

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consumed.
Urine: Provides longer window of opportunity for detection.

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SIGNS AND SYMPTOMS
Signs
and

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symptoms
of
acute
poisoning include elevated pulse,
blood

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pressure,
respiration
and
temperature. Onset occurs within 7
seconds after inhalation, 15 seconds

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after taking I/V, 3 minutes after nasal
insufflations and 10 minutes after oral
ingestion.

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SIGNS AND SYMPTOMS
Cocaine can be taken into the body by

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insufflations , (snorting or sniffing), by
smoking, ingestion and by intravenous
route.
There are three stages in acute
poisoning:

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SIGNS AND SYMPTOMS
Stage I: It is the stage of early
stimulation.
There is sense of well being, euphoria,
excitement, and talkativeness. Dryness

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of mouth and throat is seen.
Tachycardia, hypertension and
hyperthermia are seen. Vertigo and
nausea may be there. There is
numbness in mouth.

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SIGNS AND SYMPTOMS
Stage II: It is a stage of advanced
stimulation in which hallucinations are
seen. Vomiting, muscle twitching,
hyperthermia,

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(cocaine
fever),
dyspnea, and convulsion may be seen.
Circulatory and respiratory systems
start failing.

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SIGNS AND SYMPTOMS
Stage III: It is a stage of depression
where paralysis of muscles, loss of
reflexes, and coma are seen. Death
may occur.

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STAGE OF EXCITEMENT
SYSTEM
SIGNS AND SYMPTOMS
Local
Feeling of numbness or tingling at the places of

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application
Face
Flushed
Skin
Pale

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GIT
Bitter taste, dryness of mouth, vomiting, diarrhea,
hyperactive bowel sounds
CNS
Feeling of well being, euphoria, restlessness, excitement,

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talkativeness, delirium, maniacal, hal ucination, tremors
(i.e. twitching of small muscles, especially facial and
finger) and tonic-clonic seizures. Reflexes are
exaggerated
RS

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Tachypnea, dyspnea, cyanosis
CVS
Tachycardia, hypertension, ventricular arrhythmias
Temperature Hyperthermia
Ocular

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Pupils are dilated resulting in blurred vision

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LOCAL
FEELING OF NUMBNESS OR TINGLING AT THE PLACES OF
APPLICATION

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FACE

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FLUSHED FACE

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SKIN
PALE SKIN

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GIT
VOMITING

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BITTER TASTE
DRYNESS OF MOUTH
DIARRHOEA
HYPERACTIVE BOWEL SOUNDS

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CENTRAL NERVOUS SYSTEM

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FEELING OF WELL BEING
Euphoria
RESTLESSNESS
EXCITEMENT
TALKATIVENESS

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DELIRIUM

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CENTRAL NERVOUS SYSTEM
MANIACAL
HALLUCINATION
REFLEXES ARE EXAGGERATED

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TREMORS
TONIC-CLONIC SEIZURES

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RESPIRATORY SYSTEMS

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CADIO -VASCULAR SYSTEM

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TEMPERATURE

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TEMPERATURE-HYPERTHERMIA

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OCULAR---PUPILS ARE DILATED RESULTING IN BLURRED VISION

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STAGE OF DEPRESSION
After an hour, respiration
becomes slow, there is profuse

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sweating, and patient becomes
calm and dul .

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STAGE OF DEPRESSION
SYSTEM
SIGNS AND SYMPTOMS

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CNS
Coma, areflexia, pupils fixed and dilated, flaccid paralysis
and loss of vital support functions.
RS
Cheyne-stroke respirations, apnea, pulmonary odema,

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cyanosis, respiratory failure
CVS
Ventricular dysrhythmias results in weak, rapid, irregular
pulse and hypotension, circulatory failure and cardiac
arrest.

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CENTRAL NERVOUS SYSTEM
COMA
AREFLEXIA
PUPILS FIXED AND DILATED
FLACCID PARALYSIS

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LOSS OF VITAL SUPPORT FUNCTIONS

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RESPIRATORY SYSTEM

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RESPIRATORY SYSTEM

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CARDIO VASCULAR SYSTEM
VENTRICULAR DYSRHYTHMIAS

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CIRCULATORY FAILURE
CARDIAC ARREST

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Tea
coloured
urine may

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indicate
rhabdomyolysis and potential renal
failure. In fatal cases, the onset and
progression are
accelerated,

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with
convulsion
and
death
frequently

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occurring in 2-3 minutes.
Fatal dose :-20 mg I/V; 500mg to 1.4 gms
orally.
Fatal period:- few minutes to 1-2 hours.

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LONG-TERM EFFECTS

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It is powerful addictive drug.
Once having tried, an individual may
have difficulty in predicting the extent
to which he wil continue to use the
drug.

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Abusers are of upper class society
peoples to enhance self image or
improve professional performance.

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REASON FOR ADDICTION?
Its stimulant and addictive effects are

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thought to be primarily a result of its
ability to inhibit the re-absorption of
dopamine by nerve cel s.
Note: Dopamine is directly or indirectly
involved in addictive properties of

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every major drug of abuse

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COCAINE IN BRAIN
In normal communication process, dopamine is
released by neuron into the synapse, where it can
bind with dopamine receptors on neighboring

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neurons.
Normally dopamine is then recycled back into the
transmitting neuron by a dopamine transporter.
If cocaine is present, it attaches to the dopamine
transporter and blocks the normal recycling

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process, resulting in a building up of dopamine in
the synapse which contributes to the pleasurable
effects of cocaine.

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CRACK BABIES
? "Crack baby" is a term for a child born to a mother

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who used crack cocaine during her pregnancy.
Cocaine use during pregnancy can affect a
pregnant woman and her unborn baby in many
ways. During the early months of pregnancy, it may
increase the risk of miscarriage. Later in pregnancy,

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it can trigger preterm labor (labor that occurs
before37 weeks of pregnancy) or cause the baby to
grow poorly. As a result, cocaine-exposed babies
are more likely than unexposed babies to be born
with low birth weight (less than 5.5 lb/2.5 kg).

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? ...............................cont..........................

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CRACK BABIES
? Low-birth weight babies are 20 times more likely to
die in their first month of life than normal-weight
babies, and face an increased risk of lifelong

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disabilities such as mental retardation and cerebral
palsy. Cocaine-exposed babies also tend to have
smaller heads, which generally reflect smaller
brains. Some studies suggest that cocaine-exposed
babies are at increased risk of birth defects,

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including urinary-tract defects and, possibly, heart
defects. Cocaine also may cause an unborn baby to
have a stroke, irreversible brain damage, or a heart
attack.

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CRACK BABIES

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CRACK LUNG
This may occur within 1-48 hours
after cocaine smoking. It is a
hypersensitivity
pneumonitis

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wherein there is chest pain,
cough,
hemoptysis,
dyspnea,
bronchospasm, pruritus, fever,

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diffuse alveolar infiltrates without
effusion, and pulmonary and
systemic eosinophilia.

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CRACK LUNG

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CRACK DANCING

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It refers to the extra pyramidal phenomena
and other movement disorders that are
sometimes associated with cocaine
abuse. One of the side effects of cocaine
is a phenomenon which is informally

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cal ed "crack dancing" - involuntary
movements,
jerks,
and twitches
accompanied by obsessive thinking,

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which can continue to persist long after
the use of the drug is halted.

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CRACK DANCING

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COCAINISM
(COCAINOMANIA/COCAINOPHAGIA)

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Abusers can tolerate upto 1ogms/day. SIGNS AND SYMPTOMS
Emaciation
Anorexia
Digestive disturbance
Significant loss of libido

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Impotence
Gynecomastia
Galctorrhea
Major derangements in menstrual cycle in women--amenorrhea
and infertility

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Face is pale, shifty gaze, sunken eyes, dilated pupils. Tongue and
teeth are black, and ulceration of nasal septum.
Degeneration of CNS with hallucinations, convulsions and
delirium may occur.

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COCAINE BUGS

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PHENOMENON/MAGNAN`S SYNDROME
This is seen in cocaine addicts. Grains of sand are
lying under skin or some small insects are
creeping on the skin giving rise to itching
sensation ? a form of tactile sensation/

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hallucination (Formication). This may cause:-
Loss of libido
Impotence
Gynecomastia
Irregular menstrual cycle

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Infertility
Amenorrhea
................ cont................

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LOSS OF LIBIDO
IMPOTENCE

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GYNECOMASTIA
IRREGULAR
MENSTRUAL CYCLE
INFERTILITY
AMENORRHEA

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COCAINE BUGS
PHENOMENON/MAGNAN`S SYNDROME
The tongue and teeth may be jet black.
Chronic complication of nasal
insufflations in the form of rhinitis, nasal

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erosions or perforation or sinusitis may
be seen. Chronic cough or bronchitis may
be seen due to smoking. Due to chronic
use through intravenous route, the
person may have infection and

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thrombosis of vein. Since cocaine users
share needles too, they may have high
risk of AIDS infection.

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FORMICATION

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DIFFERENTIAL DIAGNOSIS

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Cocaine over dose may resemble
Lithium toxicity
Antidepressants
Neuroleptic malignant syndrome
Thyroid storm

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Hyper adrenergic states

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DIAGNOSTIC CRITERIA FOR
NEUROLEPTIC SYNDROME
THYROID STORM
HYPER ADRENERGIC STATES

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TREATMENT
If injected, apply tourniquet above the part;
if applied to nose or throat, wash-out with
warm water or saline. If swallowed, gastric
lavage should be done withKMnO4 and /or

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activated charcoal.
To control seizures: diazepam in doses
upto 0.5mg/kg I/V may be given over an
period of 8 hour period. Physical restraint
should be avoided due to the risk of

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rhabdomyolysis and hyperthermia.

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TREATMENT
Dysrhythmias should be treated according to
standard protocol. Ventricular arrhythmia
is

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managed by giving 0.5-1 mg of propranolol I/V.
Short acting, direct vasodilators (esomolol) and
short acting beta-blockers are indicated for
tachycardia and hypertension.
Thiamine 100mg I/V

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Intensive supportive therapy is needed in case of
acute intoxication.
Airways are kept clean, artificial respiration and
oxygen inhalation as required.

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MEDICO-LEGAL SIGNIFICANCE

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Cocaine is widely used as drug of abuse.
Accidental deaths have been reported with overdoses.
Homicidal poisoning is rare.
Sometimes, it is smuggled across countries by individuals by
swallowing several small plastic bags or balloons or condoms

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fil ed with cocaine and then they take flight to other countries.
Once reaching the destination, they take purgative to pass
these bags through stool. Sometimes, smal packets are kept
in rectum or vagina. Once these packets are retrieved, they
are cleaned and sold at very high prices. This process is called

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Body packer syndrome or Body
stuffing. Sometimes, these packets rupture inside
stomach or rectum and a large dose of cocaine is released.
The
person

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may
die
because
of
such

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dose.
..........................cont..............

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MEDICO-LEGAL SIGNIFICANCE
Such persons are sometimes caught at airport and may
be brought for medical examination. X-ray and

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ultrasound can be done to see bags and purgative or
enema is given to retrieve such bags.
It is believed to increase the libidinal drive and increase
the duration of sexual act by paralyzing the sensory
nerves of glans penis.

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Sometimes, prostitutes inject a solution of cocaine into
vagina. This gives the individual who is having sex with
them a sense of local constriction and hence more
pleasure. But the person can get intoxicated as cocaine
gets absorbed.

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It causes lowering of moral values, loss of decency and
self-respect.

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AUTOPSY FINDINGS
Non- specific findings
Patients may have linear excoriations, crack pipe` burns of

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the fingers or thumbs, thermal burns of the face and upper
airways
Track marks in the usual sites such as the antecubital fossae,
and at unusual sites such as the tongue and on the feet may
be seen

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Intense asphyxia signs and cardiac dilatation may be seen
Injection marks
Atrophy, inflammation of nasal mucosa
Endocarditis due to aseptic I/V infusion of drug
Pulmonary granulomatosis due to infusion of adulterated

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particles viz. starch, talc, etc.
Note:- blood should be preserved by adding fluoride

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CRACK PIPE` BURNS
TRACK MARKS
THERMAL BURNS OF THE FACE

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INJECTION MARKS

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INTENSE ASPHYXIA SIGNS
CARDIAC DILATATION
ATROPHY, INFLAMMATION OF NASAL MUCOSA
ENDOCARDITIS

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PULMONARY GRANULOMATOSIS DUE TO INFUSION OF
ADULTERATED PARTICLES VIZ. STARCH, TALC, ETC.

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