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TOXICOLOGY
It is a branch of medical science which deals with
the nature, character and source of poisons,
their fatal dose, fatal period,
the signs and symptoms they produce,
method of their detection and
the treatment in case of poisoning.
Toxicos : arrow poison
DEFINITIONS
FORENSIC TOXICOLOGY :
It is the branch of Forensic Medicine which deals
with the medical & legal aspect of the harmful
effects of the poisonous substances on human
bodies.
CLINICAL TOXICOLOGY :
Branch of toxicology which deals with
signs and symptoms produced by poisons and
their method of treatment.
TOXINOLOGY:
branch of toxicology which deals with the
toxic substances produced by living organism
in the human body and their effects.
DEFINITIONS
DRUG
Any substance natural or synthetic which produces
physiological or psychological changes on the living &
used for treatment/diagnosis of disease ,
producing beneficial effects with minimum il effects.
Teratogenicity :
Toxic effect, either structural damage or functional deficit that occurs in
fetus due to exposure of the mother to an agent, beneficial to her during
pregnancy.
DEFINITION OF POISON
Any substance ? solid, liquid or gas ?
which when enters the living body either by ingestion, injection,
inhalation or through natural orifices (i.e. Urethra, anus, ear or
vagina) or when applied on the body surface
causes ill-health, disease or death by its local or remote action.
Poison : (Potio : Drink )
(Any substance in any form, entering into a living body through
any route or coming in contact with the body surface, produces
disease, ill health or death by its local or remote action.)
DEFINITION OF POISON (AS PER STATUTE OF LAW) :
any substance, Irrespective of its quality or quantity, when
given with an intention to endanger, injure or kill a person, will
be cal ed poison.
Acts related to POISON
The Narcotic & Psychotropic SubstancesAct-1984 (NDPS)
The Drug & Magic Remedies Act-1954
The Drug Control Act-1950
The Pharmacy Act- 1948
The Drug & Cosmetic Rules-1945
The Drug & Cosmetic Act-1940
The Drug Act-1940
The Poison Act-1919
LAWS OF POISON
IPC's :176,193,201,202, 270, 278, 284, 299,
300,304A, 306, 307, 309, 324, 326, 328, 329.
The Cr PC : 39, 40, 175
The IEA : 32, Clause I
Deals with poison
LAWS OF POISON : IPCs
IPC
176
Dr must report al cases of homicidal poisoning to IO, if not Reported :
punishable
193
Dr is Punishable for giving False Information
201
Destroying the evidences
202
Dr must divulge information about poisoning case to IO, Dr is Punishable
for concealing fact from IO, about A case of poisoning.
284
Penalty for causing harm by rash & negligent act
299
Culpable Homicide by any method (including poisoning)
300
Murder by any Method
304A
Rash & Negligent ? Homicide by method including Poisoning
324, 326 Causing Hurt by dangerous weapon
328
Causing Hurt by Poison (10 yr Imprisonment)
Cr PC s :
39 : Public Bound To Give Information Regarding any
crime occurred
40 : officer bound to give information of certain
offences
175 : If summoned by IO must go & give information
IEA 32 CL-1 : Recording dying Declaration
?if pt is on the verge of death - cal magistrate. Or
record yourself,
Certify compose mentis
Acts :
The Narcotic & Psychotropic Substance Act -1985
(NDPS)
The act consolidates & amends the act relating to narcotic drug (The opium
act 1878, 1957 : the dangerous drug act 1930) 1989,& 2001.
Drug of abuse
Penalties for drug trafficking
Control over psychotropic substances
Narcotic Drugs : opiates, cannabis, cocaine
Psychotropic Substances : mind altering drugs : LSD,
phencyclidine, amphetamine, barbiturates, methacolon,
benzodiazepine, mescaline, psilocybin, Designer drugs : MDPA,
DMT
Narcotic drugs : opiates, cannabis & cocaine
Psychotropic Substances : mind altering drugs :
LSD, phencyclidine, amphetamine, barbiturates,
methacolon, benzodiazapine,
Prohibition on cultivation, manufacture, sale,
purchase, use, transport, of both except for
medicinal/ scientific purpose.
Minimum punishment -10 yr imprisonment &1
lakh fine.
Maxi : 20 yr rigorous imprisonment & 2 lakh fine
Repeated offence : imposition of even death
penalty,
To constitute offence first time minimum qty
sized should be
250 mg heroin,
5 gm hashish, charas, opium,
125 mg cocain,
500mg ganja.
Opium year -1/10 to 30/09.
Acts:
Opium Act-1857 : Empowers the central Govt. to
cultivate poppy plant & manufacture opium.
Opium Act-1878 : Prohibited the import, export,
transport, possession, and sale of opium,
The act was further amended in 1957.
BOMBAY Poison act : control sale of certain
drugs in Bombay
Poisons Act :
The Drug & Magic Remedies act-
1954
OBJECTS
To ban advertisement which offends decency or morality
To prevent self medication and treatment which cause
harmful effect.
**Advertisement of magic remedies for
procuring abortion or prevention of conception,
increase the sexual potency,
correction of menstrual disorder and
treatment of venereal disease is completely prohibited.
The Drug Control Act, 1950
CONTROL : sale, supply and distribution of drug.
: the issue of cash memo for sale.
: the existing list of price and stock.
GIVES POWER to fix the maximum price of drug,
which may be charged by dealer or producer
The Pharmacy Act, 1948
REGULATE :
the profession of pharmacy & to constitute
-Central Council of Pharmacy
-State Council of Pharmacy
OBJECTS : To al ow only registered pharmacist to
compound, prepare, mix or dispense any
medicine on prescription of medical
practitioner.
The Drug and Cosmetics Act,
1940
REGULATE: Import, manufacture, distribution and
sale of al kind of drugs.
CONTROL: Quality, purity and strength of drugs
Any patent or proprietary medicine should be
displayed on label or container.
Drugs and Cosmetics Act, 1945:
(amended in 1964)
1. to regulate importation of drugs.
2. functioning of Central Drug Laboratory.
3. appointment of licensing authorities and for
manufacture, distribution and sale of drugs.
4. Drugs are classified into different schedules.
Drugs are classified into different schedules
as fol ows :
1. Schedule C --- Biological and special products.
2. Schedule E - -List of poisons including substances under
ayurvedic, siddha and unani system.
3. Schedule F -- Vaccines and sera.
4. Schedule G -- Hormone, anti-histamines, anticancer drugs.
5. Schedule H - Drugs / poisons to be sold only on prescription of
a RMP.
i.e.. Barbiturates. Amphetamines, Reserpine, Ergot
& some of sulfonamide
6. Schedule J - List of the diseases like appendicitis, blindness,
Cancer, cataract, epilepsy, Hydrocele etc. for the cure and
prevention of which no drug should be advertised
7. schedule L- antibiotics, Anti-histaminics and other recent
chemotherapeutic agents.
INSPECTION OF DRUG
Procedures to be fol owed by the Drug inspector while col ecting and
sending a sample of drug or cosmetic for analysis :
1. He is required to pay fair price of the drug.
2. He will have to divide the sample in 4 portions and will
utilize it as fol ows :
(a) One part is to be restored to the vendor.
(b) 2nd part is to be sent to the Government analyst for
examination.
(c) 3rd part is to be retained for production in the court.
(d) 4th part is to be sent to the warrantor ? if he supplied it or
if has undergone any change since its supply.
Offences are tried in the Court of Judicial Magistrate.
epidemiology
v
According to WHO 3 million cases of acute
poisoning occurs with 2,20,000 deaths
occurring annual y in world.
v
90% cases occurs in developing country.
History
2700 B.C.- Chinese journals : various plant
poisons & fish poisons are described
1900-1200 B.C. : Egyptian documents states
directions for collection, preparation, and
administration of more than 800 medicinal and
poisonous recipes.
800 B.C. India ? Ayurveda includes notes on
poisons and antidotes.
50-100 A.D. - Greek physicians classified over 600
plant, animal, and mineral poisons.
50- 400 A.D. - Romans used poisons for execution
& assassination. Eg. The philosopher, Socrates,
was executed using hemlock for teaching his
ideas to youths.
1200 A.D. - Spanish rabbi Maimonides Wrote first-
aid book for poisonings, "Poisons and Their
Antidotes"
physician Paracelsus (1493-1541)
Scredited with
"The father of modern toxicology."
"Al substances are poisons: There is none
which is not a poison. The right dose
differentiates a poison and a remedy."
Spanish physician Orfila (1815)
Founder of modern toxicology
established toxicology as a distinct scientific
discipline.
Poison Information Center
AIIMS, New Delhi.
Occupational Health Centre , Ahmadabad
AIMS (Amrita Inst of Med Sciences), Trivandrum.
CLASSIFICATION AS PER MEDICOLEGAL USE
Common Intentions/Causes of poisoning
1. Criminal ?
Homicidal,
Suicidal,
Stupefaction,
Cattle poisoning,
Abortion.
Adulteration of food and drink or causing annoyance or injury to a person.
2. Accidental ?
Wrong medication,
over medication,
consumption of poison as medicine,
Consumption of contaminated food or drink,
bite by venomous animals,
poisoning at commercial industrial or agricultural field.
(1) Ideal Homicidal Poison:
1.
It must be cheap, & easily available.
2.
Colourless, odour-less, tasteless. SO can be easily
administered with food, drinks or medicine without
arousal of any suspicion.
3.
highly toxic and wil be certain in action.
4.
Signs and symptoms should appear late giving the
culprit the scope to escape and
5.
Signs and symptoms wil simulate a disease process :
without arousing any suspicion.
6.
no specific postmortem findings.
7.
appropriate antidote wil not be available.
8.
No proper chemical or biological tests for easy
detection and wil be destroyed in the body quickly.
(1) Ideal Homicidal Poison:
Aconite. Arsenic. Mercury, Nux Vomica. Opium. Powdered
glass. Combination of two or more. Organic compounds of
fluorine. Thal ium satisfy many of the criteria.
However. aconite can be regarded as the best, because of its
sweetish taste, signs and symptoms simulating disease and
difficulty in detection.
Heavy metals including arsenic satisfies most of the criteria's
of ideal homicidal poison, but can easily be detected long
after death- even from the hair- nail, bones.
(2) Ideal suicidal poison: :
1.
It must be easily & readily available,
2.
cheap.
3.
either tasteless or with agreeable taste.
4.
can easily be consumed with food/drinks.
5.
highly toxic and will be certain in action.
6.
and will cause painless death.
Organophosphorus compounds. Opium,
scopalamine, Barbiturate Oleander. Oxalic acid.
Copper sulphate. Combination of two or more.
(3) Accidental Poisoning
IGNORENCE : in Medicine : Dose , way to take
CARELESSNESS : in storing poisons
MISBELIEF : Love filter, Aphrodisiac, Fare Complexion
INDUSTRIAL : in Manufacturing ,Storing
FOOD/DRINKING Poisons due to :
CONTAMINATION
PESTICIDE IN AGRICULTURE
WRONG MEDICATION
SNAKE BITE : INSECT BITE
COOKING GAS POISONING
SPURIOUS / LOW QUALITY COSMETICS
OXALIC ACID, POISONOUS SNAKE OR INSECT BITE.
(4) lnfanticidal :
Opium, Organophosphorus compound
(5) Abortifacient :
Ergot, Madar, Oleander, Marking nut.
(6) Stupefying agents: Substances given in
sub-lethal dose mixed with chapati. chutney.
curry. tea. coffee. liquor or sherbet or in
cigarette or bidi causing lethargy, deep sleep,
Or somnolence or making the victim idiot or
imbecile. e.g.
Dhatura, Cannabis, Chloroform.
7) Cattle poisoning : (To kill cattle to procure
hide) Arsenic. Abrus precatorius, Oleander.
Organophosphorus compounds.
(8) Aphrodisiac / Love Philter :
The drugs which increase and enhance sexual passion
but it can do so only when it is given in a very big
dose which is likely to cause toxic symptoms.
(9) Arrow poisons : Abrus precatorius, aconite,
croton oil. Calotropis, snake venom, strychnine.
(10) Rarely : Bacteria. Insulin.
Factors which modifies the
actions of poisons
(1) Quantity
(2) Form
(3) Mode of administration;
(4) Condition of the body.
(1) Quantity :
Usual y with increase in dose-
death occurs rapidly with few exceptions.
very Large dose may initiate / induce profuse vomiting. Thus
effect is lessened (e.g.. copper sulphate).
while some poisons in large dose without producing usual effects
may lead to death by shock : fulminating
(e.g.. Arsenic may lead to death by shock without producing any irritant
effect.
Oxalic acid - may cause death instantaneously by shock by local
corrosive action without producing any remote action fol owing
absorption).
On the other hand.
repeated smal er sublethal doses, due to cumulative effect,
may lead to chronic poisoning.
(2) Form :
It may be considered under the fol owing headings
(a) Physical state;
(b) Mechanical combination;
(c) Chemical combination.
(a) Physical state ?
Gaseous form : act earlier than in other physical states.
Solution act : rapidly than the powdered form.
Poisons in solid state or when coated by some inert substance will
show their effect late.
Powder Form or Stone Form
(b) Mechanical combination ?
When used in combination with some inert substances, action will be
altered
e.g. concentrated mineral acids largely diluted with water:
heavy poisonous powder mixed with water - the powder settles down at
the bottom due to gravity and therefore sediment escapes swal owing).
(c) Chemical combination -- The action of the poisons
in combination will depend upon the solubility or insolubility
of the combination .
(e.g. Silver nitrate and Hydrochloric acid are both poisonous
separately but in combination the salt silver chloride will be
produced which is insoluble;
on the other hand Lead carbonate or Copper arsenite are
insoluble in water but in combination with gastric acid
secretion become soluble and will be readily absorbed).
(3) Mode of administration :
Rapidity of action of a poison depends upon the mode of administration.
The fol owings are the routes in order of rapidity of onset of action of a
poison.
(a)
Inhalation.
(b)
Intravenous injection.
(c)
Intramuscular injection.
(d)
Subcutaneous injection.
(e)
Ingestion -- Absorption will be more rapid through stomach
than rectum (exception Paraldehyde - readily absorbs through
rectal route).
(f)
Application on open wounds.
(g)
Application on serous surface, cel ular tissue & mucous membrane
(h)
Application on unbroken intact skin.
Poisons which are readily absorbed
through unbroken intact skin.
(a)
Phenol;
(b)
Alcohol;
(c)
Organophosphorus compounds:
(d)
Mercury;
(e)
Hydrocyanic acid;
(f)
Nicotine;
(g)
Methyl salicylate;
(h)
Mustard gas;
(i)
Local anaesthetics.
ratio between medicinal dose and lethal dose of a
substance is 1 : 10.
(4) Condition of the body :
The fol owing conditions are taken into account -
(a) Age
(b) Al ergy;
(c) idiosyncrasy
(d) Habit / Tolerance / Drug dependence;
(e) Synergism / Drug interaction / Drug potentiation ;
(f) Cumulative effect;
(g) Sleep and intoxication;
(h) State of health.
(a) Age:
Poisons have greater effect on extremes of age
(exception -- Mercury and Bel adonna are wel -tolerated by
children. however, even a smal er dose of Opium cannot
be tolerated by them).
(b) Al ergy/Hypersensitivity :
It is the hypersensitive reaction to a particular substance.
Penicillin, Aspirin, Opium, Bel adonna etc. are the common
examples.
This may be the result of previous administration of the
agent.
(c) idiosyncrasy :
It is the abnormal reaction of a person to a particular substance.
This may be due to inherent personal hypersensitivity (Inborn
peculiarity). Iodides, bromides, sulphur salts , opium, egg, shel
fish. prawn. pulses, mushrooms etc.
(d) Habit :
By long continued use of some substances tolerance increases.
To get the same desired effect larger dose is required.
Repeated and long continued use may also lead to addiction and
drug-dependence.
Eg. Opium, alcohol, tobacco, cocaine. arsenic
(e) Synergism : The effect of a poison may be increased
by the action of another. The substances each in nontoxic
doses, when given together, may produce much more toxic
effects than the sum of their effects. Eg : Sedatives,
tranquillizers, antihistamines, barbiturates when given
together with alcohol will cause synergistic effects.
(f) Cumulative effects : Repeated administration in a
smal dose at short intervals may produce the effect of
poisoning like that of large single dose due to accumulation of
it in the body when the rate of elimination is less than the rate
of administration. Eg. Digitalis poisoning .
(g) Sleep and intoxication :
Unconsciousness, sleep, intoxication retards the
effect of poison due to slow absorption at the lower
metabolic level.
(h) State of health :
Some disease conditions alters the effect of the
poison on the body .
Diseases of kidney and liver increase the effect of
most of the poisons.
On the other hand, in acute fever, the effect may
seem to be less because of the lower rate of
absorption.
Common Sources/
Circumstances of poisoning
1. Domestic source -
(a) Cosmetic : Nail polish removers, Body powder, hair wave
lotion, depilators etc.
(b) Kitchen articles : Safety match, detergents. cleaning
agents. baking agents etc.
(c) Poisons : Rodenticides, insecticides etc.
(d) Sanitary : Disinfectants. deodorants etc.
(e) Miscel aneous : lnk remover, paint remover, shoe polish,
furniture polish etc.
2. Agricultural and horticultural ?
? Insecticides, pesticides , weed killers etc.
3. Industrial source
- Where poisons are dealt with or produced as byproduct.
Common Sources/
Circumstances of poisoning
4. Commercial source - Where poisonous substances
are stored, distributed or sold.
5. Therapeutic source - Self medication, overmedication
medication or abuse of drugs.
6. Through food and drinks - Accidental contamination
or intentional adding of colouring or odouring agents.
7. Other: - Sewer gas, pol uted atmosphere, Bite by animals,
insects etc.
Presentation of a case of poisoning
The patient in a case of poisoning is brought to the
physician in the fol owing forms :
1.
Fulminating - Poisoned with massive dose where
death is eminent with sudden col apse even without any
preceding symptoms.
2.
Acute - Poisoned with a single dose or with some
doses taken at short interval with sudden onset of
symptoms.
3.
Subacute - with features of both acute and chronic
poisoning.
4.
Chronic - with gradual onset of symptoms due to
intake of smal dose for a long period.
Features suggestive of poisoning
? GIT : Sudden onset of Abdominal pain,
Nausea, Vomiting & Col apse,
? CNS : Sudden onset of Coma with
constriction of pupil, OR
? Delirium with dilated pupils,
? Paralysis special y of lower motor neuron type
? Sudden onset of Convulsions,
? HEPATIC : Jaundice & Hepatic failure,
? KIDNEY : Oliguria with proteinuria & haematuria,
Persistent cyanosis.
Symptoms of Chronic Poisoning
? Symptoms exaggerated after administration of
suspected food , fluid or medicine .
? Malaise, Cachexia, Depression & Deterioration of
General condition,
? Repeated attacks of diarrhoea, vomiting.
? Traces of poison may be found in the urine, stool
or vomit,
? When the patient is removed from his usual
surroundings, symptoms disappears.
And is presented with the fol owing
common non specific symptoms :
1. Dehydration;
2. Respiratory distress;
3. Cardiovascular depression;
4. Hypothermia:
5. Convulsions;
6. Blurring of consciousness;
7. Cardiac arrhythmias.
Fate of the poison in the body
? Greater part thrown out of the body as a result of
vomiting and purging.
? Portion absorbed is mainly deposited in the liver
which metabolizes or completely destroys.
? Unaltered poison enters in circulation and acts on
particular organs unless excreted by kidney or
made harmless by the metabolism.
? Certain poisons like Arsenic & Antimony retain in
tissues like nails ,Hair, Bones etc.
? Some poison like Chloroform, Phosphorus etc.
disappear by evapourization or get oxidized.
CLASSIFICATION
Classification of Poisons
[A] According to Site & Mode of Action
[B] According to Nature of Use
Continue-
I. Corrosives:
I.
Strong acids:
a. Mineral/inorganic acids : Sulphuric, Nitric, HCL
b. Organic acid: Carbolic, Oxalic, Acetic, Salicylic
I .
Strong alkalis: Hydrate and Carbonate of
sodium, potassium and ammonia.
I I. Metal ic salts: Zinc chloride, Ferric chloride,
copper sulphate, Silver nitrate, Potassium
cyanite, chromate and bichromate.
I .
Irritant:
1)
Inorganic:
a.
Non-metal ic: phosphorus, chlorine, bromine, iodine,
carbon tetrachloride
b.
Metal ic: arsenic, antimony, copper, lead, mercury, silver,
zinc
c.
Mechanical: Powdered glass, diamond dust, hair etc.
2)
Organic
a.
Vegetable: abrus precatorious, castor, croton, calotropis,
aloes.
b.
Animal: snake and insect venom, cantharides, ptomaine
3)
agriculture
i i. Systemic:
1. Cerebral:
1.
CNS stimulant: Cyclic antidepressant, amphetamine,
caffeine, methyl phenidate.
2.
CNS depressant: alcohol, general anesthetics,
analgesics, hypnotic, sedative
3.
Deliriant: Datura, bel adonna, cannabis, cocaine,
hyocyamus.
2. Spinal : Nux-vomica, gelsemium
3. Peripheral : Conium, curare.
4. Cardiovascular : Aconite, quinine, oleander, tobacco, hydrocyanic
acid.
5. Asphyxiants : CO, CO2, hydrogen sulphide.
IV. Miscel aneous: food poisoning, botulism
Treatment of poisoning
1. Immediate resuscitative measure
2. Removal of unabsorbed poison from body
3. Administration of antidotes
4. Elimination of poison by excretion
5. Symptomatic treatment
Immediate resuscitative measure :
ABCD
A.
Airway : opening up and cleaning up airway of
secretion, vomiting and other foreign body,
protect and secure airway by endotracheal tube.
B.
Breathing : if arterial blood gas can not be
maintained, administer oxygen via ventimask or
through ET tube.
C.
Circulation : IV fluid administration
D.
Depression of CNS should be corrected.
The general line of treatment of
cases of poisoning
Treatment is based on the fol owing principles :
(1) Removal of the unabsorbed poison
(2) Neutralization of effects of poison by antidotes.
(3) Elimination of the poison already absorbed in the
system.
(4) Symptomatic treatment.
(1)
Removal of unabsorbed
poison
(a). When applied local y :
Removed immediately : Contaminated clothes &
articles
Wash : thoroughly with water/sp antidote over
intact skin, ulcerated area, eyes / introduced
into the natural orifices like rectum, vagina
Eye should be irrigated with normal saline every
15 minutes.
If acids or alkalis : washing for 15 to 20 minutes
and no chemical antidote should be used.
(because it wil liberate heat, causing more damage)
(b) When injected or bitten :
If injected subcutaneously from a bite or injection,
A tight ligature should be applied immediately above
the wound, which must be loosened for 1 minute after
every 10 minutes to prevent gangrene.
Wound should be excised , poison sucked out and
neutralized by suitable substance or Multiple incisions
are given for al owing bleeding, through which a portion
of unabsorbed poison wil be removed. .
Local vasoconstriction by adrenaline.
Immersion of extremity in water at 10 `C
Then suitable antidote is to be applied over the area
(c) When inhaled :
Remove Pt from place of occurrence to fresh air.
Artificial respiration by oxygen mask or nasal
catheter at the rate of 6-8 liter per minute.
Airway should be kept free of mucous
discharge by postural drainage.
Nikethamide 2 ml i.v. if necessary
Aminophyline 250 to 500 mg if bronchospasm
Diuretics if pulmonary oedema
(d) When ingested :
unabsorbed poison can be removed by
Stomach wash or
Induction of vomiting or
Catharsis.
But in most of the cases dilution of the
poison can be induced by giving water,
milk etc. as an immediate measure.
STOMACH WASH
STOMACH WASH
It is the best method of removal of the
unabsorbed ingested poison even in
unconscious patients if proper care is taken
upto 2 to 5 hours of ingestion.
Stomach wash is done with the help of
stomach tube in adult and with Ryle`s tube
or French rubber catheter (of 8 to 12 size) in
children.
Stomach tube.
It is a flexible, non-col apsible rubber tube 5' (1 & ? meter )
in length, 1/2" (I2.5 mm) in external diameter with a rubber
funnel at the upper end and the other end is rounded with
more than one opening at the sides just proximal to the tip.
One suction bulb is provided at the mid part to suck fluid or
push air when required.
The tube is provided with a marking at 20" (50.5 cm) from
the lower end. [The distance between mouth to cardiac end
of stomach is approx. I8" (45 cms).]
When the marking reaches the mouth after introduction of
the tube the lower end will be within the stomach.
Procedure of stomach wash
Position : lie in prone or on the Lt lat sides with head at
the lower level than hips. Mouth is to be kept open by
mouth gag and tongue is to be kept depressed by
spatula (If artificial denture is there, it is removed earlier).
Stomach tube is lubricated with olive oil / glycerine/
liquid paraffin/any sweet oil. It is to be introduced in the
mouth through central hole of the mouth gag, then to be
gradual y pushed into the stomach.
Sudden aphonia or induction of cough or any resistance
during pushing means false passage into the larynx.
In such cases no force should be applied and the tube is
to be withdrawn partial y and again introduced with
caution.
Tests :
The tube has reached the stomach can be tested in the
fol owing ways :
(a) No cough reflex.
(b) No breath sounds will be heard through the tube.
(c) If entered into stomach initial y air bubbles comes out, but if
it entered larynx air bubbles comes out continuously.
(d)No air bubble will be seen if the funnel end of the tube is
dipped in water.
(e) if air is pushed through the tube bubbling sound
can be auscultated through the abdomen.
Procedure :
Stomach contents are removed by mechanical suction.
First about 250 ml of plain water or suitable solution
(according to the type of suspected poison) is passed through
the tube keeping the funnel end high up above the level of
the head.
When the funnel is almost empty, stomach contents are
emptied by syphonic action.
The first stomach wash should be done with plain water & the
material should be preserved for sending to the Chemical
Examiner.
Procedure : continued until the original colour of the stomach
wash fluid returns or the smel of poison passes off.
Some antidote solution or Sodi. Bicarb.. or Mag. SuIph. or
activated charcoal should be left in the stomach Before taking
out the tube,
Stomach Tube
Body Position
Solutions commonly used for
stomach wash.
(a)
Saline or water - Commonly used in most of the poisoning:
(particularly in unknown poisoning).
(b)
Potassium permanganate (KMNO4 : 1 in 5000/1 in1000 dil.) - For
alkaloids. salicylate etc. For oxidizable poisons
(c)
Castor oil and warm water (I in 2 dil.) ? In carbolic acid.
(d)
Calcium gluconate - For oxalates.
(e)
Sodium thiosulphate (25%) - ln cyanide.
(f)
Desferrioxamine (2 gm in 1 litre of water)? iron poison
(g)
5% sodium bicarbonate
(h)
4% tannic acid
(i)
1% potassium or sodium iodide
(j)
1-3% calcium lactate
(k)
Saturated lime water or starch solution
? 0.9% saline
Contraindication of Stomach Wash
(1 ) Corrosives - acid or alkali poisoning - To avoid perforation.
(2) Poisoning with volatile poisons - To avoid pneumonia.
(3) Strychnine poisoning -- To avoid induction of convulsion.
(4) Deeply unconscious or comatose patient ? To avoid
asphyxia, aspiration pneumonia.
(5) In ful stomach to avoid asphyxia, aspiration pneumonia
[For 3. 4 & 5. stomach wash can be given when proper
assistance of an anaesthetist is available.)
(6) Upper alimentary disease: esophageal varices.
? In marked hypothermia and heamorrhagic diastasis
Demulcent :
?
protective coating on gastric mucous membrane
?
milk, starch, egg white, mineral oil, milk of
magnesia, aluminum hydroxide
?
fat and oil should not be used for oil soluble like
kerosene, phosphorus, DDT, organo-phosphorus,
phenol, aniline, turpentine, acetone, carbon
tetrachloride.
Bulky food :
mechanical antidote to glass powder
EMETICS
? Should be used only in difficulty in obtaining or
using stomach tube.
? Vomiting can be induced only if medul ary centre
are responsive.
? Due to risk of aspiration vomiting is induced only in
conscious patient lying in bed with head
dependent.
? EMETICS:
House hold emetics :
?Mustard powder and common salt are not
effective and can lead to complication.
?Apomorphine
?Copper sulphate
?Tarter emetic
?Zinc sulphate
Emesis
(1) Tickling the throat by a feather, with blunt
end of a spoon or with finger.
(2) 5 mg (1/10 gr) of apomorphine
hydrochloride can be given hypodermal y. or
(3) Oral administration of some amount of
(1) plain warm water or
(2) 1 tablespoonful of ground mustard /
(3) two table-spoonful of common salt in a glass
of warm water not much effective and can
lead to complications.
Oral administration of
4.
1.5 gm zinc sulphate in a glass of warm water.
5.
2 to 3 gm of ipecacuanha powder or
6.
15 ml of ipecacuanha syrup.(in children 1/2 to 2 tsf )
(But fluid extract instead of syrup must not be given as that may lead
to fatality).
? 1 to 2 gm of ammonium carbonate in waterIpecacuanha
powder 1 to 2 g.
? 30 ml of ipecac syrup for adult, 15 ml from 1 to 12 year,
10ml from 9 to 12 month, 5 ml 6 to 9 month fol owed by
several glasses of water.
? Syrup of ipcac contain cephaeline and emetine.
Contraindications of emesis
(1)
corrosive poisoning ? To avoid the risk of perforation
of the stomach.
(2)
volatile substance like kerosene oil etc. poisoning - to
avoid aspiration pneumonia precipitating fatality.
(3)
strychnine poisoning - To avoid the risk of induction of
convulsion.
(4)
After ingestion of CNS stimulant, because further
stimulant cause convulsion with vomiting.
(5)
deep unconsciousness or comatose patient - To avoid
the risk of obstruction of air-passage by aspirated vomitus.
(6)
advanced state of pregnancy.
(7)
advanced stage of heart or lung diseases.
Disadvantages of use of emetics
Only 20% of ingested poison comes out by emesis.
On the other hand, there remains the danger of pushing of
poison to the lower bowel (smal intestine) from the
stomach facilitating absorption.
(2)
Neutralization of the effects of a
poison by an antidote
Antidote:
Any substance which counteracts or neutralize
the effects of a poison.
types of antidote
(a) Mechanical:
(b) Chemical;
(c) Physiological.
Universal Antidotes
Antidotes
Work on :
1.
Inert complex formn : & excreted, eg , chelating
agents, Prusian blue+ thal ium, dicobalt edta
+cyanide, digoxin + sp AB fragment
2.
Accelerated detoxification : thiosulfate converts
conversion of cyanide to nontoxic thiocynate
3.
Reduced toxic conversion : ethanol for methanol
4.
Receptor site competition : nalaxon for nicotine
5.
Receptors site blockage : ace for OP
6.
Toxic effect bypass : 100 % O2 in cyanide poisoning
A) MECHANICAL
They either neutralize the poison by mechanical action
or prevent their absorption. e.g.
Activated charcoal : 4 to 8 gm acts mechanical y by
adsorbing and retaining within its pores of some
organic and mineral poisons and thus delays their
absorption from the stomach. (1gm :1000 sq m)
Demulcent drinks ? forms a protective coating on the
gastric mucosa and thus prevent the poison from
causing damage.
Eg. like milk. white of egg. milk of magnesia etc.
Bulky food - acts mechanical y by imprisoning the
poison within its meshes, thus preventing damage as
in the case of poisoning by powdered glass, diamond
dust etc.
Activated charcoal
It is fine, black, odourless, tasteless powder prepared by burning
wood, coconut shel , rice starch. Bone or sucrose and then treated
with activating agents like steam or O2 etc. at high temperature.
These particles are extremely smal and has a very large surface area.
1 gm of powder has about 3000 metre square surface area.
Now-a-days super activated charcoal having double of the absorbing
surface area with the same quantity, is also available. It acts by
adsorbing the poisons on its surface.
thus prevents absorption of the poison in the system.
1 gm of activated charcoal adsorbs
300 mg of barbiturate.
300 mg of alcohol. 400 mg of carbolic acid.
700 mg of nicotine. I000 mg of strychnine.
35 mg of potassium cyanide.
Dose : 1 gm/kg of body weight.
i.e.. 50 to 100 gms in adult and 10 to 30 gms in child.
to be given oral y after gastric lavage or emesis. in the form of
suspension by mixing it with 4 to 8 times of water.
Disadvantages :
(1) Unpleasant taste.
(2) Induction of vomiting.
(3) Pulmonary aspiration.
(4) Constipation or diarrhoea.
(5) Intestinal obstruction.
contraindications :
(1) In case of smal bowel obstruction or in absence of peristaltic sounds;
(2) Poisoning with petroleum distil ates.
(B) CHEMICAL ANTIDOTE
They counteract the action of poison - either by
oxidizing them or
by forming a harmless or insoluble compounds. e.g.
acid neutralizes alkali.
albumen precipitates mercuric chloride.
Dialyzed iron neutralizes arsenic.
copper sulphate precipitates phosphorus etc.
chemical antidote
Counteract the action of poison by forming harmless or
insoluble compound or oxidizing poison.
1.
Common salt reacts with silver nitrate by forming
insoluble silver chloride
2.
Albumen precipitates mercury chloride
3.
Dialyzed iron is used to neutralize arsenic
4.
Copper sulphate is used to precipitate phosphorus
5.
Potassium permanganate has oxidizing properties.
1:5000 solution used in opium, strychnine,
phosphorus, HCN, barbiturate. Wash until pink
color of KMnO4 comes out as it was introduced.
6.
A solution of tincture iodine or lugol's iodine 15 drops
to half glass of warm water precipitates most alkaloid,
lead, mercury, silver, quinine, strychnine
7.
Tannic acid 4 % or tannin in form of strong tea or one
teaspoonful in glass of water precipitate
apomorphine, cinchona, strychnine, nicotine, cocaine,
aconite, pilocarpine, lead, silver, cobalt, aluminium,
copper, mercury, zinc.
8.
Alkali neutralize acid by direct action. Weak alkali of
magnesia, ammonia is safer. Bicarbonate should not
be used as possible risk of rupture of stomach by
liberation of co2.
9.
Acid neutralize alkali by direct action. Vinegar, lemon
juice, canned fruit juice can also be used.
(C) PHYSIOLOGICAL ANTIDOTE :
Produces signs and symptoms exactly opposite to
those caused by the poison
Counteract al the evil effects of poison.
But known physiological antidotes are partial in their
action & in higher doses they may be dangerous to
life
Atropine & physostigmine are real physiological antidotes.
Other examples are
atropine and morphine.
strychnine and barbiturate.
oximes and organophosphorus compounds etc.
(D) Universal antidote :
They counteract the action of poison,
If identity of which is not known or where there is suspicion of
more than one poison having been ingested.
Composition :
(1) Magnesium oxide - 1 part
(2) Tannic acid ? 1 part.
(3) Powdered animal charcoal - 2 parts.
It is a combination of physical and chemical antidotes.
Animal charcoal adsorbs alkaloid;
tannic acid precipitates alkaloids, glycosides and some metals;
magnesium oxide neutralizes acids without formation of gas.
Universal antidote
In emergency, the fol owing may be used as an alternative
(prepared from common household articles) :
(1) Scrapping from wal - I part.
(2) Strong black tea - l part.
(3) Charred toasted bread - 2 parts.
Coma cocktail
In a poisoned comatose patient where identity of the
poison is not known a combination of :
( l) Dextrose - I00 ml of 50% solution.
(2) Thiamine (Vit B1) - I00 mg.
(3) Naloxone - 2 mg. may be given i.v.
with the apprehension that these persons are the victims of
opiate, alcohol or any hypoglycaemic agent poisoning.
for children : thiamine is omitted and the concentration of
dextrose is reduced to 20% to 2.5%.
Even when the patient is not suffering front poisoning with
these, administration of this solution will not cause harm
to the patient.
CHELATING AGENTS
These are agents which inactivate metal ic ions with
formation of an inner ring structure in the molecule. The
metal ic ion becomes the member of the ring.
These agents form non-toxic stable but soluble compounds
with metals like Arsenic. Copper, Calcium, Mercury. Lead etc.
A. BAL (Dimereaprol,
B. EDTA
C. DMSA
D. DMPS
E. Penicillamine
F. Desferal
A. BAL (Dimereaprol,
( British anti-lewisite):
Used as an antidote for :
Arsenic, Mercury, Copper and other heavy metal
poisoning.
The metals have affinity for sulphydryl (SH) radicals
and combine with them in the tissues displacing
hydrogen. thus renders the enzymes non-functioning
as their activities depend on the SH-group.
BAL has two unsaturated SH-groups which combine
with the metal and thus dislodge the metal from its
combination with the SH-radical of tissue enzyme
and thus the tissue becomes free from the harmful
effects of the metal.
BAL
Dose: 3-4 mg/kg BW
2 ml ampule (100mg/ml) as a preparation of
10% BAL in peanut oil/arachis oil with 20%
Benzyl benzoid given deep intra-muscular
(gluteal)
4 hourly for first 2 days fol owed by twice daily for
10 days.
BAL should be given at the least within 4 hours
of poisoning to get adequate result.
BAL cannot be given through intra venous route : as the
preparation contains oil and wil cause oil embolism.
BAL
untoward effects of use of BAL :
Anorexia. nausea. vomiting. restlessness. salivation.
lacrimation. body ache. rise of temperature. fal of
blood pressure. sense of constriction in the chest.
Burning pain in the eyes. throat etc.
Contraindications
(1) Pre-existing liver damage.
(2) Severe form of kidney damage.
(3) ) Cadmium poisoning - as cadmium-BAL combination
is nephrotoxic
(4). In G-6PD deficiency individuals it causes haemolysis.
B. EDTA (Ethylene Diamine Tetra-acetic
acid, Calcium disodium versenate)
Used as an antidote in Manganese, Cadmium, Iron, Copper
poisoning.
It forms readily soluble, non-ionized non-toxic compounds with the
multivalent heavy metals.
Dose : 5 to 25 mg/kg of body weight. 5 cc ampoules of 20%
solution in normal saline or 5% glucose-saline 250 to 500 cc,
concentration not exceeding 3%. is given through intravenous route
in a time period not less than two hours and to be continued for 5
days twice daily.
Contraindications :
(1) Raised intracranial tension.
(2) Damaged kidney.
Untoward effect of use of EDTA
Hypersensitive reactions. fever. headache. malaise.
fatigue. nausea. vomiting. vertigo. fal of blood pressure
C. DMSA (Succimer ,
Meso 2, 3-dimercaptosuccinic acid)
Used as antidote in lead, arsenic, mercury poisoning.
It is less nephrotoxic.
It can be given in patient with G-6PD deficiency where BAL
cannot be used.
In combination with EDTA, it is more effective in the
treatment of lead poisoning.
It is superior to EDTA because it does not cause redistribution
of lead in the brain.
Dose : 10mg/kg of body weight 8 hourly oral y for 5 days,
then in the same dose I2 hourly for I4 days.
D. DMPS
(2,3-mercaptopropane 1-sulphonate)
Used as an antidote in arsenic, Lead and mercury
poisoning.
It can be used both oral y & parantaral y.
Dose : 5 mg/kg of bw. intravenously
or 250 mg infusions every 4 hourly for 24 hours,
then 100 mg twice daily. oral y for 24 days.
E. Penicil amine (Cuprimine) :
It is a product of hydrolysis of penicillin.
It possesses a stable SH-group.
Used as an antidote in Copper, Lead. Mercury. Zinc poisoning.
it can be given oral y. Also IV.
Dose : 30 mg/kg of BW oral y in four divided doses (upto 2 gm)
with pyridoxine 25 to 50 mg/day for 7 to I0 days.
It can also be given by slow intravenous route at the dose of 1
to 3 gms in normal saline for 2 to 4 days.
Untoward effects
Hypersensitivity; pyridoxine deficiency in prolonged use.
Rarely skin rash. fever. leucopenia. thrombocytopenia.
nephrotic syndrome can also occur.
F. Desferal (Desferrioxamine) :
It is water soluble and has affinity for iron.
in acute iron poisoning.
It can be given oral y. intramuscular or by I/V route
Dose : 8 to I0 gms oral y,(dissolved in distilled water )
which prevents absorption of iron from stomach.
It can also be given intramuscularly : as 1 gm stat
and then 0.5 gm twice or thrice daily as required. Or
Intravenously. 1 to 2 gm in 5% glucose saline in 500
ml and not to exceed 15 mg/kg of body weight/hour
or 80 mg/kg of body weight/day
ROUTE
/kg BW
1 BAL
I/M
3-4mg/kg
2 EDTA
Oral/iv
3 DMSA
4 DMPS
5 Penicil amine
6 Desferral
ORAL/
8-10 gm
I.M./
1 gm stat-0.5 gm
I.V.
bd/tid
1-2 gm slow ivin 5%
glu
(3) Elimination of poison already
absorbed in the system
After 6 to 8 hours of ingestion of poison, it is expected
that it might have been considerably absorbed in the
system.
Elimination of absorbed poison can be done in the
fol owing ways
(a) Renal excretion :
(a) It can be improved by giving oral y plenty
of water, tea or lemonade.
(b) urine is to be maintained acidic : in
strychnine amphetamine, or quinine
poisoning, and
(c) urine to be made alkaline : in salicylate or
long-acting barbiturate poisoning,
(d) osmotic diuresis : by i.v. 20% mannitol
500 ml in 12 hours or by frusemide : in aspirin
, Pheno-barbitone poisoning.
(b) Catharsis
Sodium sulphate 30 gm in plenty of water helps in elimination of
poison through stool.
Magnesium sulphate or castor oil can also be used.
Castor oil ? 1/2 oz. (Contraindicated in chlorinated insecticide
poisoning as it may increase intestinal absorption)
Vegetable cathartics should better be avoided.
liquid petroleum, solvent for fat soluble agent prevent
absorption from intestinal tract
sorbitol 50 ml of 70% solution is better purgative, but in child
may cause electrolyte disturbance
Contraindications :
1. Corrosive acid or alkali poisoning - As it may cause intestinal damage.
2. Where there is excess fluid loss fol owing vomiting or purging.
(c) Use of diaphoretics :
Application of heat by covering the body with blanket
Application of hot water bottle or
Administration of hot drinks.
can cause excess sweating, but is of doubtful value in
speeding excretion of the toxic agent.
In case of poisoning with aspirin or where there is high
rise of temperature, cold sponging may be helpful.
(d) Dialysis :
Helpful in speeding excretion of poisons.
Can be used in alcohol. long acting barbiturate and
salicylate poisoning.
Exchange transfusion - particularly in children - is
very beneficial. But dialysis is not useful in
poisoning by librium. Valium, heroin, digitalis,
antihistamine etc.
(e) Charcoal haemoperfusion :
The technique is same as haemodialysis.
Here the perfusion column replaces the dialysis bath.
Acrylic hydrogel is commonly used for this purpose.
This method can be used in barbiturate poisoning.
3. Whole bowel irrigation :
? involve use of polyethylene glycol with
electrolyte lavage solution which is non
absorbable, osmotical y active compound
? Should be administered via nasogastric tube
6. Peritoneal dialysis :
? alcohol, long acting barbiturate, chloral hydrate
lithium, salicylate, bromide, inorganic mercury,
quinidine theophyl ine and sodium chlorate are
effectivel y removed by peritoneal dialysis.
? For adult exchange : 2 liter
? For children under 5 year : 200 ml
? exchange transfusion is useful in children in
barbiturate, CO, salicylate poisoning.
7. Hemodialysis :
useful for removing alcohol, methanol,
ethylene glycol, chloral hydrate, lithium,
trivalent arsenic, acetamenophen, bromide,
phenobarbital, salicylate, flouride, sodium
chlorate,digitalis.
8. Charcoal hemoperfusion : it is useful even with
highly protein bound substances that have large
volume of distribution and are lipid soluble
e.g. barbiturate, salicylate, paraquat, phenytoin,
theophylline, chloral hydrate, digitalis, glutethimide,
methaqualone, methotrexate, phenobarbital,
carbamazepine, paracetamol.
Blood is circulated extra corporeal y from an
arterial source through a filter filled with adsobtive
material that is charcoal coated with various
polymers (acrylic hydrogel) or resin and then back
to patient's venous side
(4) Symptomatic treatment
(4) Symptomatic treatment
The symptoms arising out of poisoning are to be
treated in general lines.
Nausea, vomiting, gastric pain, diarrhoea, oedema
glottis, shock, respiratory difficulties, cardiac
failure, renal failure. cerebral oedema, convulsion,
delirium, coma etc. require treatment.
For shock : Head to be kept at lower level than feet at least 9
inches, till the blood pressure reaches l00/60 mm of Hg.
For oligernic shock : fol owing dehydration : Blood Transfusion or
blood plasma or dextran fol owed by 5% glucose saline may
be given.
Electrolyte balance : is to be maintained in diarrhoea.
vomiting or kidney damage.
Body should be covered by blanket along with hot water bottle.
In case of rise of temp. above l02?F :Cold sponging is
beneficial.
To relieve pain : Morphine l/4th gr im/pethidine 100
mg im can be given.
For abdominal colic : Atropine can be given.
For convulsions : fol owing strychnine poisoning :
Procaine by iv route or paraldehyde i/m route is
advocated
For asphyxia or in al cases of unconsciousness :
Airway is to be kept clean and unobstructed.
lntratracheal intubation/tracheostomy is to be done.
if required. In al cases of poisoning. patient should
be kept under close observation and proper nutrition
should be maintained
DUTIES OF MEDICAL
PRACTITIONER
Duties and legal obligations of a
registered medical practitioner
(1) In al suspected cases of poisoning,
The primary duty is to diagnose and treat the patient.
He will try to detect the nature and character of the poison
responsible for poisoning.
(2) He will try to col ect al detailed history regarding the onset
of signs and symptoms and its progress to exclude and
differentiate the condition from any disease process.
So also he will enquire whether a number of people of the
same locality are suffering from similar type of signs and
symptoms at the same time after taking food or drinks from
common source.
Whether the patient suffered from same type of signs and
symptoms previously and whether any treatment was given
to the patient prior to the attendance.
(3) Physician will try to assess the nature of
poisoning - whether suicidal. homicidal or
accidental.
(4) If the physician is not sure, he should not
express any opinion as to the type of the
poison, Other- wise action for damages can
be brought against him.
(5) In case of suicidal or accidental poisoning : private
practitioner is not legal y bound to inform the legal
authority as per the provision and obligation of Sec.
39 Cr. P.C. (which refers that public is to give information of
commission of certain offences to the Police) because this
Sec. does not include Sec. 309 l.P.C. (which refers attempt to
commit suicide).
But in case of suspected homicidal poisoning, the
physician is bound by law (Sec. 39 Cr. P.C.) to inform
the matter to the legal authority.
Non-compliance of which is punishable : Sec. I76 l.P.C.
A medical officer, working in Govt. Hospital.
Will have to inform al cases of suspected
poisoning, Irrespective of whether suicidal.
accidental or homicidal.
The physician is absolved from the said duty. if he
knows that persons like chowkidar, Panchayat
members or other similar persons, under the
provision of Sec. 39 Cr. P.C.. has already informed
the matter to the proper authority.
(6) CONSULTATION : Physician will have to consult with
a practitioner of higher professional standard
regarding the case in confidence, for the second
opinion and keep him aware of progress or
deterioration of the condition at intervals.
(7) MAINTAIN DETAILED RECORDS : of the case
starting from history, signs and symptoms,
treatment, progress or deterioration including dates
and times of examination of the patient.
8) He is required to preserve suspected food or drink.
ful or empty container. foils of capsules or tablets or paper
packets. if available at or near the place of incidence. if
the same was detected.
he wil have to preserve stomach wash material. vomitus.
urine. stool and the sweating if stained with those after
proper labeling.
And to confirm the nature and character of the poison.
Failure : punishable :
Sec. 201 l.P.C. (causing disappearance of evidence).
(9) Suspected homicidal poisoning cases should
better be treated in the Hospital or Nursing home.
If the physician is to treat the patient at patient's
residence, he will have to appoint ful time nurses of
his confidence and only they will give food. drinks.
medicines to the patient and by no one else. So also.
no one. other than the trustworthy nurses will be
al owed to stay with the patient (special y when
friends. relatives are the suspicious persons).
(10) As per Sec. I75 Cr. P.C.. the physician is bound to supply al the
information to the queries of investigating police officers or
Magistrates on demand. even in a suspected case of suicidal or
accidental poisoning not to speak of homicidal cases.
Non-compliance or deliberate concealing of the facts wil make him
liable for prosecution under Sec. 202 l.P.C.
Supply of false information is prosecuted under Sec. I93 l.P.C.
(11) arrange for recording dying declaration : in case of apprehension
of death
(12) In case of death. irrespective of nature of death he wil have to
inform the matter to the police and recommend for PM exam.
(13) He wil not issue any death certificate and if at al to be issued to
be mentioned about poisoning and marl: `Police case'.
Viscera to be preserved in a case
of suspected poisoning
Bottle : (1) Whole of the stomach with its contents and upper
30 cm of the smal intestine in adult or whole of smal
intestine in children.
Bottle(2) : At least 500 gm of liver with the gal bladder and
common bile duct in adults and whole of it in children. &
Halves of each kidney.(not a ful single kidney as One kidney
may be non-functioning.)
Bottle (3) BLOOD (10 ml)
Bottle (4) preservative
preservation in special cases
Heart : In acute arsenic, yel ow oleander poisoning.
Brain : Barbiturate poisoning.
Brain and Spinal Cord : At least 200 to 300 gm of
brain with spinal cord in neurotic & spinal poisoning.
alcohol poisoning. barbiturate poisoning.
Lung: In Coal gas. Sulphur dioxide. CO poisoning.
Spleen : In haemolytic poisoning.
Ends of long bones : In heavy metal poisoning like
arsenic. antimony etc.
Uterus & its appendages :
in case of suspicion of use of any abortifacient poisons local y.
in case of suspicion of criminal abortion.
Blood : 50 to, I00 ml to be preserved without any
preservative (in suspicion of poisoning with a
volatile substance).
Urine : Not less than I00 ml in alcohol. Phenol.
Datura poisoning.
Skin : 2.5 cm x 2 cm with subcutaneous tissue and
muscle from site of injection in suspicion of
poisoning by injection.
preservative of viscera :
saturated solution of NaCl, is used commonly,
though ideal preservative is rectified spirit.
S. S. of NaCl cannot be used as preservative in (AVA)
(1) Aconite; (2) Corrosive acids; (3) Vegetable poisons; (4)
Heavy metals like corrosive substances.
rectified spirit cannot be used in (pappa;k)
(1) Alcohol; (2) Acetic acid; (3) Phenol:(4) Phosphorus; (5)
Paraldehyde (6) Kerosene oil.
Qualitative detection of a poison is sufficient for
giving opinion about poisoning.
quantitative detection of poison is required in
(1) When there is history of ingestion of a drug or poison in
repetitive smal doses.
(2) Medicine used in overdose.
(3) in cases of drug addicts. where there is a possibility of the
poison being already present.
(4) Production of some poison within the body during the
process of decomposition.
When detection of poison by chemical
examination becomes unreliable
Unreliability of detection of poisons by chemical
examination : .
(1) Poisons which gain access to the body as a
constituent of food materials (oxalates of Na. K. Ca.
Nl-la through vegetables like spinach. cabbage.
guano etc.).
(2) Poisons which are present normal y in the body
tissue. as a constituent. in the form of salts.
(3) Poisons being used therapeutical y.
When poisons cannot be detected
during chemical examination
(1)
Completely evaporated in cases of volatile poisons.
(2)
Oxidized in the body : Alkaloids. Glucosides.
(3)
Detoxicated or eliminated : Through excretory channels
like kidney. skin etc.
(4)
Faulty preservation
S/S
Poisons which resist putrefaction:
(1) Carbon monoxide;
(2) Cyanides;
(3) Fluoride:
(4) Barbiturates;
(5) Organophosphorus compounds;
(6) Endrine;
(7) Datura;
(8) Strychnine
(9) Yel ow oleander;
(10) Nicotine;
(11) Arsenic;
(12) Antimony:
(13) Mercury;
(14) Lead;
(15) Thal ium.
Name some Hal ucinogens
(1) LSD; (2) Opiate; (3) Alcohol; (4) Cannabis;
(5) Cocaine; (6) Amphetamine; (7) Mescaline.
Poisons which can be identified on
examination of eyes.
( 1) From dilatation of pupils-
(a) Alkalies; (b) Barium:(c) Alcohol; (d) Barbiturate; (e) DDT; (f) Endrine;(g)
Datum; (h) Atropine; (i) I-Iyocyamus; (j) Cocaine;(k) Calotropis; (I) Cyanide;
(m) Ephedrine; (n) Carbon monoxide; (o) Amphetamine; (p) Antihistainine.
(2) From constriction of pupils ?
(a) Carbolic acid;(b) Otzanopbosphorus compounds; (c) Opium; (d)
Nicotine; (e) Barbiturate; (I) Caffeine; (g) Clonidine; (h) Carbamates;(i)
Nicotine; j) Methyl dopa; (k) Benzodiazepincs;(I) parasympathomimetic`
(3) From alternate constriction and dilatation of pupils ?
(a) Aconite; (b) Barbiturates (at times).
(4) From nystagmus --
(a) Alcohol; (b) Barbiturate;(c) Carbamazepine; (d) Phencyclidine; (e)
Phenytoin.
Poisons which can be identified from the
smel of breadth
(1) Acetone likes smel :Aspirin. alcohol. choloroform
(2) Garlic like smel : Phosphorus. arsenic. thal ium.
Tel urium. selenium. dimethylsulphoxidc
(3) Kerosene like smel : Organnphosphorus compounds
(4) Radioactivity oi breadth : Radio-active substances ;
(5) Phenolic / hospital like smel Carbolic acid. Creosole ;
(6) Vinegar like smel : Acetic acid
(7) I-iydrocynnic acid. cyanide
(8) Almond like smel : Opium;
(9) Moth bal like smel : Camphor. Naphthalene
(10) Pear like smel : Chloral hydrate. Paraldehyde.
Poisons which can be identified
from the smel of breath
(11) Oil of wintergreen'(Methyl sylicyiate)
(12) Fishy smel : Aluminium phosphide. zinc phosphide
(13) Coal gas like smel : Carbon monoxide
(14) Rotten egg like smel : Carbon disulphide. hydrogen
sulphide, disulphiram. mercaptans
(15) Burnt roap like smel : Cannabis.
(16) Kerosene oil;
(I7) Shoe polish like smel : Nitrobenzene ,
(I8) Endrine;
(I9) DDT;
(20) Nicotine.
?Poisons which has got affinity for
haemoglobin.
(1) Sulphuric acid. Nitric acid. hydrochloric acid
(Converts Hb into acid haematin).
(2) Carbon monoxide (Forms carboxyhaemoglobin)
(3) Hydrogen sulphide (Forms suIphmethaemoglobin
(4) Lead (90% of blood lead combines with red cel s).
Poison which causes depression of sexual power.
chronic opium poisoning, ganja poisoning
Poisons which inhibit enzyme system
(1) Organophosphorus compounds (inactivate and
neutralize n-cetyl cholinesterase by 25% to 30%).
(2) Arsenic. Mercury. Lead. Antimony (Combining with --
`SH' radicle).
(3) Hydrocyanic acid (Inhibits cytochrome enzyme system)
(4) Barbiturate and hypnotics (Interfering dehydrogenase
system).
poisons which wil produce blister-like patches on skin.
(I) Carbon monoxide; (2) Barbiturates; (3) Meprobamate.
Poison which wil produce parkinsonism like symptoms.
Chr. Manganese poisoning.
Poison which wil produce thyrotoxic crisis like symptoms :
Dinitro- orthocresol
Poison which causes sex perversion :
Cocaine (Also causes Nymphomaniac,Satyriasis. Homosexuality).
Poison which causes Heat stroke like hyperpyrexia: Datura.
Poisons /drugs which has metal ic taste.
(1) Arsenic; (2) Lead; (3) Copper; (4) Mercury; (5) Iron; (6)
Cadmium: (7) Lithium; (8) Metronidazolc; (9) Ethambutol; (10)
Disulphiram: (11) Acetaldghyde; (12) Iodine.
poisons: which can be identified
from of urine.
(1) Oxalic acid (From calcium oxalate crystals);
(2) Carbolic acid (From olive green colouration);
(3) Alcohol: (4) Ether: (5) Chloroform (From smel ).
From change in colour of urine.
(1) Red or pink - Aniline. phenytoin. Phenothiazine. ibuprofen.
(2) Reddish brown -- Chloroquine. Metronidazole. phenacetin. iron.
(3) Orange - Rifampicin. phenothiazine.
(4) Purple - Porphyrin.
(5) Brownish black --- Homogentisic acid.
(6) Yel ow -- Fluorescein dye. riboflavin.
(7) Yel owish orange - Vitamin A. Carrot.
(8) Yel owish brown -- l-`urazolidone. Nitrofurantoin. sulphamethoxazolc.
pritnaquine. ~
(9) Brownish green - Cresol. phenol.
(10) Greenish blue - Methylene blue. thymol.
Poison which on ingestion wil show barium like radio-
opaque shadow on x-ray abdomen : Arsenic trioxide.
Poison which are radio-opaque.
(1) Heavy metals: (2) Iron; (3) Potassium chloride.
iodide and permanganate; (4) Sodium chloride; (5)
iodides;(6) Chloroform;(7) Chloral hydrate;
(8)Ammonium chloride; (9) Acetyl salicylic acid;
(10)Carbon tetrachloride;(11) Methotrexate;
(12)Vitamins; (13) Penicil in G and K;
(14) Phenothiazine; (15) Acetazolamide.
Poison which has depilatory action :
Madar juice. Orpiment (arsenic trisulphide). Realgar
(arsenic bisulphide)
Poison which cause fal of hair : Thal ium. Radiation.
Poisons /drugs which cause alopecia :
(1) Arsenic; (2) Gold salts; (3) Lead; (4) Mercury; (5)
Tital iumz (6) Iodine; (7) Selenium; (8) Chloroquine; (9)
Quinacrine; (10) Androgens; (11) Anticoagulants; (12)
Amphetamines; (13) Cimetidine; (14) Heparin; (15)
Hcxachlombenzene; (16) Metltyldopa; (17) Levodopa;
(18) Methotrexate; (19) Thiocyanates; (20) Oral
contraceptivcas; (21) Vitamin A.
poison: which cause dermal
pigmentation
(1) Reddish colouration ?
(a) Rifampicin; (b) Borates; (c) Clofazimine.
(2) Brownish colouration --
(a) Arsenic;(b) Chromium; (c) Phenacetin; (d) Nitrates
and nitrites; (e) Metltyldopaz (f) Levodopa.
(3) Bluish colouration --
(a) Mercury; (b) Silver; (c) Bismuth; (d) Oxalic acid; (e)
Tetracycline; (e) Oxalic
acid: (2) Phenothiazine.
(4) Yel owish colouration ?
(a) Chloroquine; (b) Picric acid; (C) Quinacrinc; (d) Carotene;
(e) Sodium nitrate; (f) Nitrazepam.
Poison: which can be identified on
examination of teeth
(1) Sulphuric acid (Chalky white):
(2) Nitric acid (Yel ow);
(3) Cocaine (Black).
Poisons which can be identified on examination of gum.
(1) Copper sulphate (Bluish green/ Purple line at the
junction of teeth and gum.
(2) Lead (Strippled bluish line at the junction of teeth and
gum).
(3) Cocaine (Black).
Poison identified from
color of hypostasis
(1) Cold - bright pink.
(2) C0 poisoning ? pinkish.
(3) ln CO3 poisoning -- deep blue.
(4) In aniline dye poisoning - deep blue.
(5) HCN poisoning - cherry red.
(6) Potassium chlorate, potassium bichromate poisoning ?
chocolate brown.
(7) Phosphorus poisoning - dark brown.
(8) Nitrate poisoning - reddish brown.
(9) KCN. NaCN poisoning - brownish.
(10) Nitrobenzene poisoning - dark purple.
Poison which will cause green coloration of cartilages :
In Chr. Carbolic acid poisoning(Phenol marasmus).
When phenol was routinely being used as a disinfectant. It
is characterised by anorexia, loss of body weight. headache
vertigo. dark coloured urine (alkaptonuria) with deposition
of homogentisic acid in cartilage. ligaments and fibrous
tissue and in the
cornea- The condition is cal ed Ochronosis.
Poisons where KMnO4 is used as an antidote :
(1) Alkaloids; (2) Amidopyrin; (3) Barbiturate; (4)
Phosphorus; (5) Cyanides.
Dialysis
Indications :
(1) Deep coma: (2) Anuria; (3) Low BP. (4) Apnoea.
Poisons where haemodialysis and peritoneal dialysis is helpful. _
(1) Alcohol; (2) Barbiturate; (3) Methanol; (4) meprohamate; (5)
Aspirin; (6) Salicylatcs; (7) Phenacetin; (8) Amphetamines; (9)
Arsenic; (10) Lead; (11) Mercury; (12) lodides; (13) Bromine;
(14) Quinine; (15) Strychnine: (16) Antibiotics; (17)
Sulphonamides; (18) Carbon tetrachloride.
Poisons where dialysis is not helpful.
(1) Anticholinergics; (3.) Antihistamines; (3) Anti-depressants; (4)
Toiranil (5) Valium; (6) Librium; (7) Methaqualone; (8) Heroin; (9)
Phenothiazine.
Exchange transfusion is more helpful : In children. rather
than adults. (In case of poisoning with Barbiturate.
Salicylate. C0. C02
Toxicity of a chemical substance is graded
(1) Extremely toxic -1mg/mg of body weight or less.
(2) Highly toxic - 1to 50 mg/kg of body weight.
(3) Moderately toxic -- 50 to 300 mg/kg body wt
(4) Slightly toxic --- 0.5 to 5 g/kg of body weight.
(5) Practical y non - toxic - 5 to 15 gm/kg body wt.
(6) Relatively harmless - 15 gm/kg of body weight
Consciousness grading
(Reed's classification )
The degree of loss of consciousness can be assessed
clinical y by the response of the patient to painful stimulus
and is graded as fol ows
(a) Gr. 0 - Ful y conscious.
(b) Gr. I - Drowsy but responds to vocal command.
(c) Gr. ll - Unconscious but responds to minimal stimuli.
(d) Gr. Ill - Unconscious but responds to only maximal
painful stimuli.
(e) Gr. IV - Unconscious and no response whatsoever. Loss
of al the reflexes including corneal, laryngeal
and pharyngeal reflexes.
What is standard painful stimulus `
Standard painful stimulus is rubbing of sternal region of the
chest of the patient with the clenched list.
`Glasgow Coma Scale'
Alternatively, now-a-days `Glasgow Coma Scale` is
considered to be the single most neurological
observation for graduation of the level of conscious
ness.
Terms and grading which require definition (like
`Coma'. `Stupor'etc.) should better be avoided.
This scale is based on 3 criteria ?
(a) Eyes open.
(b) Best verbal response.
(c) Best motor response.
Graph is prepared basing on the consecutive
observations and progressive changes as fol ows :
This post was last modified on 12 August 2021