Dr . SALINI CHANDRAN Toxicology - PowerPoint Presentation

1. Dr . SALINI CHANDRANToxicology

2. Toxicology is the science dealing with properties, actions, toxicity, fatal dose, detection of, interpretation of the result of toxicological analysis and treatment of poisons  Forensic toxicology deals with the medico-legal aspects of the harmful effects of chemicals on human beings Clinical toxicology deals with diagnosis and treatment of human poisoningToxicology

3. Poison is a substance (solid, liquid or gas), which if introduced in the living body, or brought into contact with any part thereof, will produce ill health or death, by its constitutional or local effects or bothpoison

4. should be cheap and easily available Should be colorless, odorless and tasteless Capable of being administered with food materials without being detected Should be highly toxic Signs & symptoms should resemble a natural disease Least Postmortem changes and not to be detected by any chemical tests e.g. Fluorine and Thallium, but commonly used are Arsenic and AconiteIdeal Homicidal Poison

5. Should be cheap and easily available Should be tasteless or be of pleasant taste Capable of being administered with food materials Should be highly toxic Should be capable of producing painless deathe.g. Opium and Barbiturates, but commonly used are Organophosphorus compounds and EndrinIdeal Suicidal Poison

6. Stupefying Poisons: Datura, Cannabis indica, Chloral Hydrate. Abortificient Poisons: Calotropis, Oleanders, Aconite, Croton, Semecarpus, Cantharides, Ergot, Lead, Arsenic, Mercury, and Potassium permanganate. Cattle Poisons: Abrus precatorius, Oleanders, Calotropis, Organophosphorus, Arsenic, Aconite, Strychnine, etc Arrow Poisons: Abrus, Croton, Aconite, Strychnine, Curare and Snake venom etc

7. Types of PoisoningAcute Poisoning – large single dose – frequent smaller - produces signs and symptoms fastChronic Poisoning – small doses over a period of timeSub-acute Poisoning – between acute and chronicFulminant Poisoning- massive dose-death sudden due to shock ,peripheral vascular failure

8. Inhalation - FastestParenteralInjectionsApplication on mucous memranesNatural orificesIntact skinRoutes of Absorption

9. Sudden onset of abdominal pain, nausea, vomiting, diarrhea and collapse (Arsenic) Sudden onset of coma with constriction of pupils (Organophosphates) Sudden onset of convulsions (Strychnine) Sudden onset of delirium with dilated pupils. (Datura) Diagnosis of Poisoning

10.  COLOR CHANGES on affected skin and mucous membrane. (black color in H2SO4 & HCl, brown in Nitric acid) PM STAINING may be Dark brown/yellow in Phosphorus, Cherry red in CO, Chocolate color in Nitrates, Nitrobenzene etc. Cyanide – Brick RedDiagnosis of Poisoning in the Dead

11. GARLIC like (P, Arsine gas, Arsenic, organophosphates) SWEETISH (Ethanol, Chloroform)ACRID (Paraldehyde, Chloral hydrate)BITTER ALMONDS – cyanideHOSPITAL ODOUR- Phenol(carbolic acid)BURNT ROPE – Cannabis(marijuana)MUSTY (fishy) – zinc phosphide , Aluminium phosphideROTTEN EGG (H2S, Mercaptans)ODOUR from nose and mouth

12. 1. Phosphorus 2. Arsenic 3. Antimony 4. Hyoscine 5. Strychinne 6. NicotinePOISONS RESISTING PUTREFACTION

13. 274 – adulteration of drugs284 – Negligent conduct with respect to poisons324 – Causing hurt (including poisoning)326 – Causing grievous hurt by dangerous weapons or means (including poisoning) 328 – causing hurt to commit an offenceIPC sections

14. MiosisMydriasisNystagmusBarbituratesCaffineNicotineOpiatesOrganophosphatesAlcoholCO CocaineCyanideDaturaAlcoholBarbituratesDrugs causing pupillary changes

15. AlcoholDaturaNicotine BradycardiaAconiteDigitalis Opiates OrganophophatesDrugs causing tachycardia

16. Private practitioners are bound to inform the police in case of homicidal poisoning In suicidal and accidental-If the person dies If private practitioner is summoned by the investigative police officer, he is bound to divulge all information Govt : medical practitioner – Has duty to inform all cases Duty to arrange for Dying Declaration Duties of Medical Practitioner

17. Airway , Breathing, Circulation, Depression of CNS(correction) Decontamination/Dextrose/Drugs Removal of unabsorbed poisons: Inhaled poisons: Fresh air Injected poisons: Ligature application Contact poisons: Immediate removal of clothing and washing thoroughly Ingested poisons: Gastric LavageGeneral Lines of Treatment

18. Gastric Lavage (stomach wash) It is useful within 3 hrs of ingestion salicylates,phenothiazymes,tricyclic antidepressants – (14 -16 hrs) Ewald’s or Boas tube Children – Ryle’s tubeEmesisGastrointestinal decontamination

19.  1cm diameter & 1 ½ meter long Has got lateral openings or 30-40 French tube. Middle portion has got a suction bulb Other features are Mouth gag, 50 cm mark, etc. 250 ml of Warm water is put over funnel of the tube and is taken out by the suction pump. This washing is preserved for analysis 1:5000 KmNO4 sol., 5% NaHCO3 sol. Or 4% Tannic acid 1 % sodium or potassium iodide is used for the lavageGastric Lavage

20. Patient position – left lateral ,head dependentAbsolute CI is Corrosive poisoning due to danger of perforation of stomach. (Exception: Carbolic Acid poisoning) Convulsant poisons Comatose patients Volatile poisons Esophageal varices HypothermiaGastric Lavage

21.  It is useful within 3 hrs of ingestion Done with ipecac syrup(30 ml)Contraindications As in gastric lavage Severe heart disease Advanced Pregnancy Emesis:

22. Activated Charcoal: Particles are small but with high absorptive capacity and it acts mechanically by adsorbing and retaining within its pores organic and some mineral poisonsDemulcents: These are substances which form a protective coating on the gastric mucous membrane and thus do not permit the poison to cause any damage Examples include Milk, Starch, Egg white, Mineral oil, Milk of Magnesia,Fats and oils should not be used for fat soluble poisons like, Kerosene, Phosphorus, OP compounds, DDT, Phenol, AcetoneBulky Foods: They act as mechanical antidote to glass powderADMINISTRATION OF ANTIDOTE

23. They counteract the action of poison by forming harmless or insoluble compounds by oxidizing poisons Common Salt: Decomposes Silver Nitrate by direct chemical action Albumen: Precipitates Mercuric Chloride Dialyzed Iron: Neutralize Arsenic poisonChemical Antidotes

24.  These are substances which produce exactly the opposite actions to that of poison e.g. atropine – PHYSOSTIGMINEStrychnine - BARBITURATESPhysiological Antidotes:

25. These agents act by forming stable and soluble complexes by the inner ring structure which can combine with the METALLIC POISONS e.g. British Anti Lewisite (BAL) and Ethylene diamine tetra-acetic acid (EDTA)superior to BAL in Ars and MercuryPenicillamine – maximum efficiencyDmsa (succimer)superior in leadDMPSDesferroxamine- Acute iron poisoningChelating agents

26. two parts activated charcoal, one part tannic acid, and one part magnesium oxide Universal Antidote

27. URINARY ALKALIZATION: Aim for a Urinary pH of 7.5-8.5 Indications: poisoning with chlorpropamide, phenobarbitone, salicylates, phenoxy acetate herbicidesWHOLE BOWEL IRRIGATION Magnesium citrate Sodium sulphate 30 gm. Sorbitol 50 ml 0f 70% solution polyethyleneglycol Extracorporeal techniques: HEMODIALYSIS: Multiple-dose activated charcoal: This can increase elimination of some drugs by interrupting their enteroenteric & enterohepatic circulation PERITONEAL DIALYSISCHARCOAL HAAEMOPERFUSIONELIMINATION OF POISONS

28. LiverKidneyStomachSmall intestineBlood UrineRoutine viscera to be preserved

29. Dextrose – 100ml of 50% solutionThiamine – 100mgNaloxone - 2mgUNIVERSAL ANTIDOTE COMA COCKTAIL

30. Corrosives are the poisons that fixes, destroys and corrodes tissuesConcentrated acids: • Mineral acids, eg. Sulphuric acid, Hcl, HNo3 • Organic acids, eg. Carbolic acid, Oxalic acid Concentrated alkalies • eg. Caustic potash, NaOH, KOH etc.sulphuric acid - (oil of vitriol)CORROSIVES

31. Teeth chalky white – sulphuric acidPerforation of stomach common – sulphuric acidStomach has consistency of wet blotting paper – sulphuric acidCrowns of teeth yellow – nitric acidxanthoproteic reaction – nitric acidPupils dilatedFatal dose 10-15ml HCl 15-20mlGive nothing by mouthCORROSIVES

32. Can give demulsantsDo not neutralise with strong alkaliesDo not give bicarbonate - CO2 gas - risk of perforationCorroded areas brown or black,HCl - grayVITRIOLAGEThrowing of sulphuric acid to face – jealousy or revengeGrievous hurt

33. OXALIC ACIDacid of sugar, salt of sorrel Colourless, transparent prismatic crystals, Natural constituent of plants eg spinachFATAL DOSE : 15‐20 gm FATAL PERIOD: 1‐2 HrsDo not loose poisonous property even when dilutedVOMIT usually contains altered blood with mucous and HAS A COFFEE GROUND APPEARANCEHypocalcaemiaSigns of TETANY

34. OXALIC ACIDFulminant poisoningUraemia-oxalate crystals in renal tubulesMetabolic acidosis, VFTREATMENT • Stomach wash– Ca lactate, Ca gluconate ( antidote is any prep of Ca • Ca gluconate 10%, 10ml i.v

35. CARBOLIC ACID ( phenol) • Colourless, prismatic, needle like crystals, with burning sweet taste with carbolic/ phenolic smellFATAL DOSE : 10‐15 gm FATAL PERIOD: 03 TO 04 Hrs S/S Poisoning is called CARBOLISMCorroded mucosa appears whitish, lips , mouth and tongue corroded WHITE AND HARDENEDCARBOLURIA - Urine is colourless to slight green at first but turns green or even black on exposure to air.Phenol is partly oxidised TO HYDROQUINONE AND PYROCATECHOL, The further oxidation of Hydroquinone and pyrocatechol in the urine is the cause of green colorationCARBOLIC ACID

36. CHRONIC POISONING ( Phenol marasmus)OOCHRONOSIS pigmentation of skin and cornea and cartilages CAUSTIC ALKALIESEffect esophagus> gastric mucosa So STRICTURE FORMATION MUCH MORE COMMON with alkalies then with acidsOH‐ ion cause saponification of fats LIQUIFACTIVE NECROSISCARBOLIC ACID

37. FATAL DOSE: • NaOH, KOH: 5 gm Potassium carbonate: 18 gm • Sodium carbonate: 30 gm Ammonia: 5‐10 ml • FATAL PERIOD: Usually 24 HrsCAUSTIC ALKALIES

38. Active principle: – ABRIN ( toxic protein that disables ribosomes, inhibits protein synthesis, antigenic properties, hemolytic properties)ABRINE- an amino acid; haemagglutinin, ABRALIN- a glycoside F.D. : 1 SEED F.P. : 3- 5 DAYSSUI’S – Needles – cattle poisoning, rarely for homicide. Resembles VIPERINE SNAKE BITE.TREATMENT :Anti abrin Abrus Precatorius Indian Liquorice

39. Active principle: • Toxalbumin RICIN, a water soluble glycoproteinF.D. : 10- 20 seeds F.P. : 3-5 days Treatment: • Gastric lavage • Emetics and demulscents • symptomaticRICINUS COMMUNIS (CASTOR, ARANDI) 

40. Active principle: uscharin, calotoxin, calactin, calotropin (cardiac glycoside) and gigantin (contained in serum)Medico- legal importance • Madar juice is commonly used as an ABORTIFACIENT, • May be used for homicide , suicide or infanticide • ANIMAL POISON ARTIFICIAL BRUISE ARROW POISONCalotropis gigantea/ calotropis procera madar or akdo

41. Datura Atropa belladonna Hyoscyamus niger Cannabis indica CocaineDELIRIANT POISONS

42. Active principle contains alkaloids: hyoscyamine hyoscine or scopolamine Traces of atropineDatura

43. Earliest symptom: Bitter taste in mouth  Inhibition of salivation: Dryness of mouth and throat (dry as a bone)  Difficulty in talking  Dysphagia  Unquenchable thirst  Dilatation of cutaneous blood vessels  Face is flushed (red as a beet)  Pupils: Dilated  Insensitive to light  Power of accommodation near vision paralyzed (Blind as a bat)  Inhibition of sweat secretion & stimulation of heat regulating center:  Body temp. raised  Skin dry and hot (hot as a hare) Vomiting , Giddiness, unsteady gait (drunken individual) Initially restless and confused Later delirious, mutters indistinct words (mad as a wet hen)Datura

44. FATAL DOSE & FATAL PERIOD Seeds: 100 to 125 Alkaloids: 60 mg (Adult) 4 mg (Children) Death occurs within 24 hoursML IMPORTANCEROAD POISON – stupefying persons for robbery, rape etcAntidote - physostigmineDatura

45. a colorless ,odorless, crystalline ALKALOID with better taste prepared from the LEAVES of THE ERYTHROXYLON COCA PLANTCrack. White lady, snowRoute of Administration Cocaine can be administered as a drug of abuse in the following ways Cocaine hydrochloride Snorting (intranasal) Intravenous injectioningestioncoccaine

46. Hyperthermia – cocaine feverAmotivational syndromeChronic cocaine poisoningBlack tongueCOCAINE BUGS – MAGNAN’S BUGS –sensation of grains of sand under skinSPEEDBALL – Combination OF COCAINE AND HEROIN - injectedBROMPTONS COCKTAIL-mixture of cocaine + morphine (heroin) + chlorpromazine+alcohol,earlier used for pain management in terminal illnes like cancer. cocaine

47. Common Names :Indian hemp or cannabis sativa in IndiaTHC – major psychoactive ingredient in the marijuana plantcannibinol and cannbidiol also components but less present in plantsNames: marijuana, hashish, charas, bhang, ganja, sinsemillaBHANG Least potent form Also called siddhi, patti, sabji Prepared from dried leaves & fruit shootsCannabis indica/sativa

48. Mildest and contains 15% of active principle MAJOON : Sweet prepared with bhangGANJA Consists of flowering tops of the female plant It is mixed with tobacco and smoked in pipe Contains active principle in conc. of 25% MARIHUANA OR MARIJUANA Common names are pot, grass tea, Mary Jane Smoked in pipe or rolled in cigarette called REEFERS OR WEED Cannabis indica/sativa

49. CHARAS OR HASHISH Resin exuding from leaves and stems Dark green or brown color Smoked with tobacco in a pipe ‘hookah’ Active principle is in con of 25- 40% It is the most powerful of all cannabis preparationsCannabis indica/sativa

50. RUN AMOK :It is a psychotic disturbance caused by the continued use or even first time use of cannabis It is characterized by a frenzied desire of the person to commit murders He first kills a person against whom he may have real or imaginary enmity and then kills anyone who comes in his way until the homicidal tendency lasts. Then he may commit suicide or surrender himself.Cannabis indica/sativa

51. TOLERANCE & PSYCHOLOGICAL DEPENDENCE  Develops when the drug is consumed over a prolonged period of timeMAJUN AND CHARAS used BY ROAD POISONers HASHISH INSANITY (Chronic Poisoning)Patient suffers from hallucinations and delusions of a persecuting natureChronic use reduces serum testosterone and sperm countCannabis indica/sativa

52. Nicotiana TabacumNereium Odorum Cerebera Thevetia Cerebera OdallumAconiteDigitalisCARDIAC POISONS

53. Alkaloids - Nicotine , NornicotineRapidly acting poisonFATAL DOSE :-50-100MG of Nicotine 15 TO 30GM of crude tobaccoFATAL PERIOD:- 5-15 minutesBrownish froth at mouth and nostrilsNicotiana Tabacum

54. Common oleander ,pink oleander ,rose laurelContains cardiac glycosides- Oleandrin Nerin Rosagenin Folinerin FATAL DOSE :-15-20gm of the root; 5-15 leavesFATAL PERIOD:-20-36 hrsNERIUM ODORUM

55. Suicidal-decoction of root,leaves and seeds or pasteHomicide rareAbortifacient- internallyCattle poison-juice of the root is applied on a piece of cloth andInserted into the anus of the animalNERIUM ODORUM

56. Yellow oleander Cardiac glycosides ThevetinThevetoxinNerifolinPeruvosideRuvosideCERBERA THEVETIA

57. FATAL DOSE :-8-10 seeds;15-20gms of root; 5-10 leavesFATAL PERIOD:-UncertainSuicideAbortifacientCattle poisonCERBERA THEVETIA

58. ACTIVE PRINCIPLES : CerebrinCerebrosideOdollinOdolotoxinThevetin CerapainCERBERA ODALLUM

59. FATAL DOSE :-Kernel of one fruitFATAL PERIOD:-1-2 days or more PM APPEARANCESThose of asphyxiaCongestion of organs with petechial hges TREATMENTStomach washAtropineCorrect hyperkalaemiaCERBERA ODALLUM

60. Suicide –mixed with jaggery or molassesHomicide-powdered kernel added to alcoholBark leaves and milky juice as emetics and purgativesCERBERA ODALLUM

61. Monk’s Hood,blue rocketContains alkaloidsAconitinePseudoaconitine MesoaconitineIndaconitineBikhaconitinePicraconitineAconineJesaconitineACONITE

62. FATAL DOSE -1-2gm root,4-5mg of aconitineFATAL PERIOD-2-6 hrsHIPPUS – Alternate contraction and dilatation of pupilsMistaken for horseradishConsidered as ideal homicidal poisonWith betel nut –to mask its taste-homicideAbortifacientCattle poisonArrow poisonACONITE

63. INEBRIANT – ALCOHOLFollowing absorption, the concentration of alcohol in the blood reaches a maximum in about 45-90 minutes after ingestionStage of Excitement (Blood level: 50-150 mg%) Stage of In-coordination (Blood level: 150-250 mg%Stage of Coma (Blood level > 250 mg%)Pupils are contracted but on stimulation of the person, e.g. by pinching or slapping .Causes them to dilate with slow return (MCEWAN’S SIGN).CNS DEPRESSANTS

64. FATAL DOSE (non-addict) : 150-250 ml of absolute alcohol consumed in 1hour.Common clinical syndromes associated with chronic alcoholismDELIRIUM TREMENS : acute organic brain syndrome, usually seen within 2-4 days of complete absence from heavy alcohol drinking. There is an acute attack of insanity in which there is: Clouding of consciousness with disorientation in time and space. Coarse muscular tremors of face, tongue and hands. Insomnia with reversal of sleep-wake cycle and loss of memory. Psychomotor agitation, ataxia, uncontrollable fear and tendency to commit suicide/homicide/violent assault or cause damage to propertyETHYL ALCOHOL

65. ACUTE ALCOHOLIC HALLUCINOSIS: 24 – 36 hrs after withdrawal  Korsakoff’s psychosis often follows Wernicks’s encephalopthy so they are referred to as WERNICKE-KORSAKOFF SYNDROME Cause: Severe, untreated thiamine deficiency, secondary to chronic alcohol abuse. WERNICKE’S ENCEPHALOPATHY :This is an acute reaction due to severe thiamine deficiency, the commonest cause being chronic alcohol abuse.MALLORY WEISS SYNDROME: Tears of mucosa of lower oesophagus with haemorrhagingETHYL ALCOHOL

66. SATURDAY NIGHT PALSY : from falling asleep with one's arm hanging over the arm rest of a chair, compressing the radial nerve.DRUNKENNESSMICTURITION SYNCOPEALCOHOLIC PALIMPSETS: Automatism after taking alcoholETHYL ALCOHOL

67.   METHANOL - alcohol dehydrogenase - FORMALDEHYDE - aldehyde dehydrogenase - FORMIC ACID methanol itself not toxic. Formaldehyde very toxic, but very rapidly metabolised to formic acid. Formic acid responsible for the toxicity related to methanol ingestionsMETHYL ALCOHOL

68. OPTIC NERVE BECOMES OEDEMATOUSSudden loss of vision or complete blindness due to optic neuritis may occur.Permanent loss of visionTreatmentETHYL ALCOHOLMETHYL ALCOHOL

69. Dried juice of poppy (papaver somniferum) morphine .codine,thebaine,papaverine.narcotineHEROIN is a natural derivative(BROWN SUGAR)COMAPINPOINT PUPILSMorphine-200mgCodine-800mgAntidote: NALOXONEBODYPACKER SYNDROMETest :Marquis testOPIUM

70. INHIBITION OF ACETYL CHOLINESTERASEMuscarinic effects: SLUDGEWhite frothCHROMOLACHRYORRHOEA – Red tearsTreatment:Oximes – PralidoximeAtropine for Muscarinic effectsFATAL DOSE – Malathion - 1gmORGANOPHOSPHATES

71. Alkaloid- STRYCHNINEAction on anterior horn cells- on glycineOpisthotonusTrismusRisus sardonicusNUX VOMICA

72. Resembles TETANUSAntidotes : BarbituratesRigor mortis earlyPostmortem caloricityANTIDOTE: BARBITURATESFATAL DOSE: 50-100mg,one crushed seedFP – 1-2 hrsTest: Toad testNUX VOMICA

73. COCO2Cyanide present inbitter almondscherry, plum kernels .cassava(amygdalin)apricot ,peach kernels etcAsphyxiant poisons

74. Colourless, highly volatile liquidOdour of BITTER ALMONDS Powerful protoplasmic poison Interferes with action of CYTOCHRME OXIDASEHistotoxic anoxiaHYDROCYANIC ACID( Hydrogen cyanide, Prussic Acid)

75. FATAL DOSE – 50mg pureHCN 2.5 ml dilute HCN KCN -0.2-0.5 gm Sodium cyanide-.15gmFATAL PERIOD-2-10 minutesAntidotes : Amyl nitrate, sodium thiosulphate, sodium nitrateBRICK/BRIGHT RED coloured postmortem stainingFROTH at mouth and nostrilsTest: LEE JONES TEST

76. Anaemic anoxiaInterferes with cytochrome oxidaseCOHB is formedTreatment - Hyperbaric oxygenCHERRY RED Postmortem stainingCO

77. SnakesCOBRA & KRAIT –venom is NEUROTOXICVIPER – Venom is HAEMOLYTICSEASNAKE – Venom is MYOTOXICCOBRA & KRAIT Cause of death – RESPIRATORY FAILUREVIPER – HAEMORRHAGE AND SHOCKSEA SNAKE –RENAL FAILURE Animal irritants

78. FATAL DOSE :- COBRA-12mg RUSSEL’S VIPER 15mg ECHIS-8mg KRAIT-6mgFATAL PERIOD – COBRA AND KRAIT-1/2 -6HRS -VIPER-1-2 DAYSTreatment – POLYVALENT ANTISNAKE VENOM SERUM Snakes

79. CantharidinRenal damageSCORPIONBoth neurotoxic and haemolytic venomcantharides

80. Red and yellowYellow- translucent , waxy and luminous, toxicStored in waterUsed in incendiary bombsFulminant poisoningAcute: GARLICKY ODOUR OF BREATHPHOSPHOROUS

81. Chronic – PHOSSY JAW – toothache , ulcerative stomatitis, necrosis , osteomyelitis of jawJaundiceYellow/Brown Postmortem stainingFatal dose:1mg/kg of body weight(60-120mg)PHOSPHOROUS

82. GI and CNSDescending bilaterally symmetrical motor paralysisAbducent & OcculomotorBOTULISM