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General Toxicology

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0% found this document useful (0 votes)
26 views147 pages

General Toxicology

Uploaded by

Areej Rehan
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
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FORENSIC MEDICINE

• It is that branch of Medicine which


deals with the application of medical
knowledge to the purpose of law and
furthering of justice.

2
TOXICOLOGY
Toxicum: Poison (Latin)
Toxikom: Arrow poison (Greek)
Logia: Science (Latin)
TOXICOLOGY
It is the science which deals with the
poisons with reference to their
sources, properties, mode of actions,
symptoms which they produce, lethal
dose, treatment, methods of their
detection and autopsy findings.
Branches of Toxicology
1. Forensic Toxicology
2. Clinical Toxicology
3. Occupational Toxicology
4. Environmental Toxicology
5. Analytical Toxicology
6. Behavioral Toxicology
7. Veterinary Toxicology
1. Forensic Toxicology:

• It deals with the medical and legal


aspects of the harmful effects of
poisons on the human body.
2- Clinical Toxicology:
• It is involved with specific
disease caused by toxic
substance, the signs and
symptoms that are produced by
them and how they can be
treated.
3- Occupational Toxicology:
• This deals with toxic effects of
physical or chemical substances
of working place on the health
of a person.
4- Environmental Toxicology:
• This deals with the harmful effects of
chemicals that are encountered by man
in the atmosphere or by contact during
occupational activities or introduced by
ingestion of food substances.
5- Analytical Toxicology:
• Study of various methods and tests used to
analyze and determine which toxic agent is
present?
6- Behavioral Toxicology:
Study of behavioral
abnormalities induced by toxic
agents such as drugs or
chemicals.
7- Veterinary Toxicology:
• Involves studying the toxic
effects of poisonous substances
on animals and how they can
be treated
Forensic Toxicology
It deals with the medical and legal aspects of
the harmful effects of poisons on the
human body.

A- General Toxicology :
• It deals with the general characteristics,
modes of actions, classification and
treatment of all the poisons.
B- Special Toxicology:
• It deals with the specific poisons
separately in details.
GENERAL TOXICOLOGY
Poison
• It is a substance which, when
administered, inhaled or ingested, is
capable of acting deleteriously on the
human body.
In law the real difference between a
medicine and a poison is
• the intention with which it is given
• .Dose
Poisoning
• It is the condition when toxic effects of a
poison are produced.
• It may be human poisoning or cattle
poisoning.
• The human poisoning may be suicidal,
homicidal, stupefying or accidental.
Different Types of Poisoning
1-Human Poisoning
A- Suicidal:
The poisons used for suicidal
purpose are;
potassium cyanide, hydrocyanic
acid, opium and
organophosphours compounds
B- Homicidal:
The poisons used for homicidal
purpose are; aconite,
organophosphours compounds,
oleander, strychnine.
Human Poisoning
C- Stupefying:
The poisons used for stupefying
purposes are; alcohol, dhatura
and cannabis indica.
D- Accidental:
Accidental poisoning commonly
takes place as a result of (1)
careless in storing poisoning and
non-poisons materials together
(2) quack remedies (3) bites by
snakes and scorpions.
2- Cattle Poisoning
• Cattle poisoning is generally resorted by
chamars for the sake of hides. Rarely, cattle
are destroyed by owners when they are
useless.
• The poison used to destroy cattle are;
abrus precatorius, arsenic, yellow oleander,
and nux vomica.
Classification Of Poisons
Classification Of Poisons
The classification of poisons may be in many
ways.
a) According to their mode of action.
b) If they are increasing or decreasing the
functional activity of a system?
c) .Medico-legal classification
d) .Keith- Sympson’s classification
Classification of poisons
A) According to their mode of action, poisons
are classified into seven groups
1. Corrosives
2. Irritants
3. Neurotics
4. Cardiac
5. Asphyxiants
6. Miscellaneous
1). Corrosives
• These are highly active irritants and not only
produce inflammation but also actual
ulceration of the tissues.
 Classified
1. Strong Acids
2. Strong Alkali
A. Strong Acids
i. Mineral Acids e.g. sulphuric acid, hydrochloric
acid and nitric acid.
ii. Organic Acids e.g. oxalic acid, carbolic acid, acetic
acid and salicylic acid.
iii. Vegetable Acids e.g. hydrocyanic acid.

B. Strong Alkali
The examples are sodium hydroxide, potassium
hydroxide and carbonates of ammonium/pot./sod.
2. Irritants
 Irritants poisons produce symptoms of pain
in the abdomen, vomiting and purging. On
post mortem examination, redness or
ulceration of the G.I.T is seen.
Classified
 Inorganic
 Organic
 Mechanical
A.Inorganic
i. Metallic e.g. arsenic, antimony, mercury, lead,
copper, zinc and manganese etc.
ii. Non-metallic e.g. phosphorus, chlorine, bromine
and iodine etc.
B. Organic
i. Vegetable e.g. castor oil seeds, abrus precatorius,
ergot, capsicum, semecarpus anacardium (marking
nut).calotropis (madar).
ii. Animal poisons e.g. snakes, cantharides and
poisonous insects.
C. Mechanical
These are mechanical substances such as powdered glass,
chopped hairs and diamond dust etc.
3. Neurotics
• Poisons which act Chiefly on the nervous system.
• Chief symptoms are usually drowsiness, delirium, stupor,
coma and convulsions or paralysis.
• The poisons of this group have specific action on the brain,
spinal cord and peripheral nerves ,the poisons being
known as cerebral, spinal and peripheral respectively.

• A. Cerebral neurotics
• B. Spinal Neurotics
• C. Peripheral Neurotics
A. Cerebral neurotics

i. Somniferous/Narcotics
These are the substances used to reduce the pain and induce the
sleep.eg opium and its derivatives
ii. Inebriants
This group of poisons are characterized by two sets of symptoms-
excitement and narcosis. The classical example is alcohol.eg
Alcohol, anesthetics, hypnotics, fuels & op compounds.
iii. Deliriants
The poisons in this group cause the delirium.
Dhatura, atropa belladonna, hyocyamus niger and cannabis
indica(Bhang).
B. Spinal Neurotics

• The poisons which act chiefly on spinal card.


e.g. Nuxvomica & its alkaloids.
C. Peripheral Neurotics
 Acting mainly on peripheral nerves, e.g. curare,
conium etc.
4. Cardiac
• These are poisons acting on the heart,
e.g. digitalis, oleander, aconite and nicotine.
5. Asphyxiants
• These are poisons acting on the lungs and
include irrespirable gases, such as e.g.
 Carbon monoxide
 Carbon dioxide
 Sewer gas
 Some war gases.
7. Miscellaneous
• Poisons having widely different pharmacological action
are put together in this group. Examples are
• Common House-hold poisons.
• Analgesics and Antipyretics e.g. Aspirin and
Paracetamol
• Antihistaminics e.g. Chlorpheniramine etc
• Tranquillisers e.g. Chlorpromazine & Meprobamate.
• Anti depressants e.g. Amytriptyline & Immipramine.
• Stimulants e.g. Amphetamines.
• Hallucinogens e.g. LSD, Mescaline & Phencyclidine
• Street drugs
• Abortificent drugs; Ergot etc
B) -Classification of Poisons
The poisons may be classified depending upon the
increasing or decreasing of the functional activity
of a system.
CNS Stimulants
 Belladonna (on brain)
 Strychnine (on spinal cord)
 Morphine (on medulla)
CNS Depressants
 Alcohol, chloroform, opium etc (on brain).
 Nicotine (on ganglions)
Muscles Exciters
Digitalis, Adrenaline(cardiac muscles)
 Ergot (smooth muscles)
Muscle relaxants
 Aconite (cardiac muscles)
 Nitrites (smooth muscles)
 Curare (voluntary muscles)
C) -Keith Simpson’s classification
1. Analgesics Aspirin, paracetamol

2. Hypnotics Chloral hydrate,


barbiturates
3. Sedatives & Diazepam, largectal
tranquilisers

4. Tofranil
Anti-depressants (clomipramine)
5-Narcotics Opium alkaloids
C)-Keith Simpson’s classification

6. Stimulants Amphetamine, cocaine


7. Abortifacient Purgatives

8.Industraial Volatile products, so2


gases petroleum

9. Corrosives Hcl, H2SO4 etc

10- Irritants Phosphorus, Lead,


Mercury etc.
D)-Medicolegal classification
1- Suicidal: Barbiturates, wheat pills etc.
2- Homicidal: Aconite, arsenic etc.
3- Accidental: Love philter, household products etc.
4- Stupefying: Dhatura, cannabis indica etc.
5. Abortifacient: Madar, ergot etc
Exposure Types Of a Poison
Acute: Referred as being less than 24 hours
duration.
Sub-acute: Describes exposures over a relatively
short duration period time often less than
one month.
Chronic: Describes repeated exposures for a
significant portion of an individual life
span (more than 3 months).
Sub chronic: Describe exposures shorter than chronic
exposures but longer than subacute (1-3
months is typical for mammals).
Exposure Routes of Poisons
1-Enteral: Mouth, rectum, mucous membranes.
2-Parentral: Injunctions e.g sub-cutaneous, I/m.
i/v ,intra- artenial, intra-peritoneal.
3-Inhalation: Air passages.
4-External application: Skin, wound.
5-Natural orifices: Rectum, vagina, urethra,
nose, eyes.
6-Sublingual: Under tongue.
Absorption in descending order
• 1/v inhalation intra-peritoreal

• . sub-cutaneous 1/M oral


. Mucous membrane topical
(skin).
Action of Poisons

1. Locally acting: These act only at the site of


application such as skin/mucosa e.g corrosive poisons.
2. Remotely acting: These act only after being
absorbed into the circulatory system e.g. narcotic and
cardiac poisons.
3. Both locally and remotely acting: These act by
local and remote actions e.g. carbolic acid etc.
4. Generally acting: These evoke response from a
wide variety of tissues beyond the limits of one or two
systems e.g. arsenic, mercury, lead, barbiturates etc.
Factors influencing the actions of a
Poisons
1- Route of administration
• Sublingual, inhalation, & intravenous routes
allow more rapid absorption.
• Poisons are quite rapidly absorbed through
intramuscular, subcutaneous, rectal, urethral
and vaginal routes.
• An ingested poison acts more rapidly than
rectal route because of more absorptive
power of stomach and intestines.
Absorption in descending order
• 1/v inhalation intra-peritoreal

• . sub-cutaneous 1/M oral


. mucous membrane topical
(skin).
2-Dose
• As a general rule small doses produce
therapeutic action, large doses produce toxic
effects.
• Non-toxic substances become toxic in large
doses.
• Large dose acts rapidly and effects are severe
but sometimes vomiting reduces effects e.g
cuso4.
Certain exceptions to this general rule are:
a) Idiosyncrasy: some individuals have an
idiosyncrasy towards certain drugs and even
small amounts may cause intense symptoms.
• Idiosyncrasy means an abnormal response to a
certain drug due to inherent personal
hypersensitivity to that agent or drug.
• This is seen with morphine, cocaine, quinine,
iodine, bromide, aspirin, and food articles, such
as mushrooms, pulses, eggs, shelf-fish, etc.
b) Allergy: allergy means hypersensitivity acquired
as a result of previous administration of the toxic
agent or induced by the simultaneous presence
of another poison.
• Penicillin is the most important modern example
of acquired hypersensitivity.
c) Tolerance: Development of body or tissue
resistance to the effect of a drug so that large
doses are required to produce the original effect.
• Continuous indulgence in alcohol and tobacco
confers a comparative immunity form their toxic
effects even when taken in large doses.
d) Synergism:
Two poisons, as for example, alcohol and
barbiturates in nontoxic doses, when
administered simultaneously may cause toxic
symptoms due to synergism or potentiating.
• Synergism means that the final response is
greater than the sum of their individual
actions.
e) Cumulative poisons:

some poison such as arsenic, lead, mercury,


barbiturates, strychnine, digitalis, and carbon
monoxide tend to accumulate in the body.
They are known as cumulative poisons.
• Their repeated administration even in small
quantities might cause toxic manifestations
or chronic poisoning by cumulative action.
Toxicity Rating
Internationally toxicity rating
scale has been made to classify
the poisons depending upon
their fatal dose.
Toxicity Rating Scale
(By Gosselin RE and his colleagues)

Usually fatal dose Toxicity rating


Less than 5mg/kg Super toxic-6

5-50 mg/kg Extremely toxic-5


50-500 mg/kg Very toxic-4

500mg-5gm/kg Moderately toxic-3

5-15 gm/kg Slightly toxic-2

More than 15gm/kg Non-toxic-1


3-Age:

• Age has got considerable relationship to


dosage for any poisonous substance, e.g.
dosage required for children is usually half
that in an adult.
4-Health of individual:
OR
PRESENCE OF DISEASE

• A healthy, normal individual can withstand a


poison ingested for a longer duration than an
individual unhealthy and debilitated.
5-Concentration of poison:
• This factor is highly responsible for the
development classical effects on any poison
or drug, e.g. concentrated sulphuric acid acts
as corrosive producing burns while in diluted
form, it acts as an irritant..
6-Physical state of poison:
• This means the state of existence of a poison,
I.e. gas, liquid or solid state.
• For gas, inhalation is the best route for rapid
onset of action.
• For liquids, onset of action is more rapid than
solids when administered orally.
• Among solids, fine powder acts faster than
coarse powder.
7-Chemical/Mechanical combination
• Chemicals in combination may become inert e.g
Ag NO3 + HCl Agcl + HNo3
Strychnine + Activated charcoal.
• Chemicals in combination may become poisonous
e.g Cyanide salt in stomach HCl,
Barbiturates + Alcohol.
• Mechanically e.g.
Alkaloid taken with charcoal fails to act.
Banana, milk present in stomach lessen the effects
of Corrosive/irritant poisons.
8- Condition of Stomach
• If stomach is full. symptoms/signs delay.
• Fatty food delay s/s except in phosphorous.
• Snake venom harmless by mouth.
• Carbonated beverages increase the rate of
intestinal absorption by increase in gastric
emptying time with evolution of co2.
9- Metabolism of toxic agents

• Mostly toxic agents are metabolized to less


toxic compounds and are excreted by kidney.
• Some compounds are metabolized to more
toxic e.g Methanol
10- Habit, Tolerance & Drug dependence

• By long continued use of some drugs like


opium, tobacco, alcohol, cocaine etc,
individual can tolerate large doses not can
prove fatal for non-users.
• Long continuous use of some drugs may
results in drug dependence.
11-SLEEP and Intoxication
• Bodily functions are at low metabolic level
during sleep and intoxication. The action of a
poison is therefore delayed if a person goes
to sleep after taking it or if a person is
intoxicated when he takes poison.
How one is poisoned
• How it gets in? (Administration)
• Where does it go? (Distribution)
• What happens to it? (Metabolism)
• How do you get rid of it? (Elimination)
Fate Of Poison in the Body
Before Absorption:
Initially after introduction a poison may:
a) Exert local action like corrosion or irritation
at the site of introduction.
b) Cause vomiting due to local irritation.
c) The remaining poison in the following ways.
After Absorption:
a) No change in chemical composition: The body
fails to change its chemical composition and can
be detected in the tissue or excreted in its
original form.
b) Biotransformation: Mostly occurs in the liver in
which metabolic alteration leads to the
formation of various metabolites.
c) In the blood the drug or its metabolites act on
the target organs to which it has specific affinity.
Excretion
The main routes of excretion are Urinary Tract,
intestine, Bile, Sweat glands, Saliva, Breast milk
& Lungs.
Chronic Deposition:
• Certain tissues as epidermis, nails and hair may
retain inorganic poisons for long time. E.g.
Arsenic.
• Skeleton may hold Lead and radioactive metals
for a long time.
DIAGNOSIS OF POISONS
The diagnosis of the poisons may be done in
two aspects. We have to see that;
A- Poisoning is acute or chronic?
B- Diagnosis is being made in living or dead body?
A- Poisoning is acute or chronic?

1- Acute Poisoning
The following steps are taken to
diagnose the poison:
a. Mode of onset of symptoms.
b. Examination of signs/symptoms.
c. Laboratory investigations.
1- Acute Poisoning
a- Mode of onset of symptoms : Sudden
Symptoms rapidly increase in severity & are
followed by death or recovery.
Commonly the following systems with
their symptoms are involved in acute
poisoning.
GIT: Nausea, vomiting, diarrhea.
CNS: Convulsions and CNS depression.
Resp: Difficulty in breathing.
b- Examination of signs/symptoms
i- Blood Pressure
Increased in the poisoning of amphetamines,
cocaine and nicotine.
Decreased in the poisoning of hypnotics, alcohol
and opium
ii-Pulse Rate
Increased in dhatura, alcohol and nicotine.
Decreased in aconite, opium, organophosphorus.
b- Examination of signs/symptoms
iii-Body Temperature
Increased in amphetamines dhatura,
cocaine.
Decreased in barbiturates, opium and CO.
iv- Pupillary changes
Miosis (constriction of pupils) is found in
opium,organophosphate and barbiturates.
Mydriasis (dilatation of pupils) is found in
alcohol,cocaine and atropine.
b- Examination of signs/symptoms
v- Smell of vomitus
 Phenol----- ---peculiar smell
 Cyanide-------bitter almond
 Alcohol -------Ether smell
 Acetic acid----Vinegar like smell
vi-Colour of vomitus:
 Black vomitus-----H2SO4.
 Bluish green ------CUSO4.
 Grayish white ----Mercury.
 Coffee ground ----Arsenic.
c- Laboratory investigations.
• Ingested food
• Vomitus
• Stomach wash
• Blood
• Urine
• Faeces
2- Chronic Poisoning

Symptoms appears gradually in chronic poisoning


within months or years.
Usually symptoms are malaise,
wasting, abdominal pain, paralysis &
neuropathy.
Repeated attacks of the symptoms may occur.
There is remission of symptoms on removal of patient
from his surroundings.
Poison can be detected in the food, medicine,
vomiting, urine or stool.
B- Diagnosis is being made in
living or dead body?
1. Diagnosis in living cases
It is done by
a. Circumstantial evidence/history
b. Clinical examination
c. Investigations
2. Diagnosis in Dead Case
It is done by
a. Circumstantial evidence
b. Postmortem exam.
c. Investigations
Purposes of diagnosis in living cases

1. To keep the individual alive.


2. Prevent occurrence of serious damage.
3. Help court of law.
Diagnosis in living cases
i. Circumstantial Evidence
 Response of relative and friends.
 Environment around patient, e.g.,
chairs and table, etc.
 Behavior of the person looking after the
case.
ii. Clinical Examination
 General appearance and behavior of patient. He
may be aggressive (alcohol poisoning) or restless
(amphetamine, withdrawal of barbiturates, heroin).
 Slurred speech---barbiturates.
 Drowsy speech---heroin.
Examine temperature, pulse, B.P, Respiration.
 Examine clothes, body, breath, vomitus for any
 smell.
 Examine oral cavity and eye for any findings.
Polyneuritis e.g. in acute and chronic poisoning of
arsenic, alcohol and organphosphorus.
3. INVESTIGASTIONS
• Skin washes
• Stomach washes
• Fecal material
• The poison is detected by chemical
analysis.
DIAGNOSIS IN DEAD
It depends on four factors
1. Circumstantial evidence of poisoning
2. Postmortem examination
3. Chemical examination
4. Experiments on animals
1- Circumstantial Evidence Of Poisoning
• Clues of poisoning can be taken form the
friends and relatives.
• Where from the poison was purchased.
• Environment of the victim.
• Behavior of the relatives.
• Undue haste of the relatives to dispose off
the body without postmortem should be
suspicious.
2- Postmortem examination

• GIT irritation and corrosion may be found in


irritants and corrosives.
• If there is any doubt, send the tissues to the
histopathalogist for examination.
• Specific color of Postmortem Lividity for
some specific poisons.
• Specific smell
Poison identification by color of
postmortem lividity (PML)

PM lividity color Poison

Blue Copper sulphate


Brick red Cyanide
Cherry red Carbon monoxide
Yellow/brownish Phosphorus
Poison identification by cadaveric smell
Odour Poisons
Garlic odour Arsenic, phosphorus
Burnt rope Cannabis
Phenolic odour Carbolic acid
Bitter almond Cyanide
Fruity odour Ethyl alcohol
Rotten eggs Hydrogen sulphide
Fishy odour Zinc phosphide
3- Chemical examination

• Most definite proof in dead body.


• It is detected on food, vomitus, stool,
blood ,any fluid, stomach contents,
secretions.
• Others as hair, nail, bone, skin and
muscles are also send for analysis.
4- Experiments On Animals

• Suspected food, medicine and poison


can be separated from viscera of victim
and can be fed to animals like dogs, cats
etc.
• Signs and symptoms can be observed.
Routine Specimens Sent to Chemical Examiner

Bottle No.1:
It contains stomach and its contents.
Both ends of the stomach are tied with ligature.
Bottle No 2:
It contains
a) 60 ounces of liver with gallbladder
b) One kidney
c) Half spleen
Bottle No 3:
A portion of small intestine in parts at
least 3 feet, ligatured at both ends along
with its contents.
Bottle No 4:
Sample of preservative used.
In case of above all, saturated saline is
used.
Routine Specimens Sent to Histopathalogist
One half brain, heart and one lung. In these
the preservative is formalin or alcohol.
Additional samples
Additional samples are Blood, Urine, Long
bones, Bone marrow, Muscles, Nails, Hairs,
Skin, etc. to the appropriate authority.
The preservative for blood and urine is
sodium fluoride.
Add preservative, seal and label the each bottle as
a) Postmortem No.
b) Date/time of PM examination.
c) Name of the dead body.
d) Signature of the doctor.
DUTIES OF A DOCTOR
IN CASE OF POISONING

1. Medical Duties
2. Legal Duties
Medical Duties
1. Assess the patient’s condition and start
immediate treatment to save his life.
2. Refer doubtful cases to the nearest hospital
without delay.
3. Inform relatives of patient about serious
condition of the patient.
4. Carry out all necessary investigations.
5. Determine the route of exposure and the time
elapsed since the incident.
Legal Duties
1. Record the name, age, sex, occupation
address, date and time & two identification
marks.
2. In case of homicidal poisoning must be
reported to the police.
3. If death occurs due to accidental or suicidal
poisoning the police must be informed.
4. If death is imminent, arrange for dying
declaration.
Legal Duties
5. Collect and preserve the following
specimens properly in separate containers:
Stomach wash, Vomitus, Urine and Blood.
6. Collect the evidence of the poisoning from
the scene of crime.
 Utensils used for preparation of poison.
 Bottle or container of poisonous food or drink.
 Clothes or bed sheet stained with vomitus,
urine or other things.
Legal Duties
7. If death occurs,
 Must be informed to police.
 Arrange for postmortem examination
and collect the viscera.
8. If there is food poisoning, send the food
to chemical examiner for examination.
9. Medical documents should be prepared.
General Treatment of Poisoning
Aims of Treatment:
1. To relieve the symptoms.
2. To make him alive.
3. To get ride of poison by its metabolism,
excretion or removal.
Steps for Treatment:
1. Clinical evaluation
2. History/Diagnosis of poison
3. Elimination of unabsorbed poison
4. Elimination of absorbed poison
5. Use of antidotes
6. Treatment of general symptoms
7. Maintenance of patient’s general
condition.
1- Clinical Evaluation/Assessment
A- Respiratory system
Findings:
Air way obstruction, mucosal swelling and
secretions, posterior displacement of tongue,
dyspnoea, hoarseness of voice, cyanosis etc.
Management:
Chin lift, intubation (nasopharyngeal or
naso-tracheal tube), tracheotomy, and artificial
oxygen therapy.
B- Cardiovascular system
Findings:
Shock, vasoconstriction, metabolic acidosis
and oliguria.
Treatment:
1. Give I/V Fluids, monitor cardiac function and
record urine output.
2. I/V dopamine to increase B.P (200mg in 250ml).
3. Nor-epinephrine 8mg (in 500 ml) I/V.
4. Inj. Adrenaline S/C
C- Central Nervous system:
For Assessment of level of Unconsciousness
a) The Reed’s classification of a comatose patient
Grade o: Arousable to speech and touching.
Grade 1: Respond to painful stimuli and have
intact reflexes.
Grade II: Do not respond to painful stimuli and
most reflexes are normal.
Grade III: Do not respond to painful stimuli but
reflexes are absent.
Grade IV: Deeply comatose, reflexes absent with
respiratory and circulatory failure.
b) CNS Assessment with GCS
(Glasgow Coma Scale)
Clinical Response Scores
i)Eye opening: E4
 Spontaneously 4
 To speech 3
 To painful stimuli 2
 None 1
ii) Best verbal response: V5
 Orientated 5
 Confused 4
 Inappropriate words 3
 Incomprehensible sounds 2
 None 1
b) CNS Assessment with GCS
Clinical responses Scores
iii) Best motor responses M6
 Obeys commands 6
 Localization to pain 5
 Normal flexion to pain 4
 Spastic flexion to pain 3
 Extension to pain 2
 None 1
The response of the patient is expressed by summation
 Coma Score (E+V+M)= 03 to 15
 Maximum Score =15 (conscious)
 Minimum Score =3(Deeply comatose)
2-HISTORY/DIAGNOSIS
 Correlate the history with physical examination.
 Ask time and amount of poison taken.
 Describe the exposure- where, when, why, how
much, and witness of the event etc.
 Obtain confirmatory history from the witness.
 Symptoms occurred between ingestion &
presentation (vomit, dyspnoea, convulsion and
level of consciousness).
 What therapy was given before.
 Past medical history- allergy to any drug,
psychiatry or any trauma.
3-Removal of unabsorbed poison
a) Inhaled poison:
When a poison has been inhaled such as CO, or coal gas,
CO2, automobile exhaust, gas from septic tank;
1. Patient should be removed to fresh air.
2. A clear airway should be ensured.
3. Artificial respiration should be given at once.
b-Injected poison:
4. Application of tourniquets (ligatures) proximal to the
point of application.
5. Multiple incision & suction.
6. Examples of injected poisons are hypnotics, insulin,
snake-bite (two marks) & insects bite (1 mark).
c- Contact poison
If the poison be spilled or sprayed on skin, eye or
wound or be inserted into vagina, rectum or
bladder, wash it with plain water, if special antidote
is known, poison can be neutralized.
d-Ingested poison:
In ingested poisons there are 4 methods.
1-Emesis (vomiting),
2-Gastric lavage,
3-Activated Charcoal and
4- Catharsis.
1. EMESIS/INDUCING VOMITING

 The substance most commonly used is the syrup of


ipeca the dose of 30 ml (adult)
 Emesis is done only in conscious & alert patient.
Contra-indications:
• Coma
• Infants
• Corrosives
2.Gastric Lavage
 It should not be considered unless a patient has
ingested a potentially life-threatening amount of a
poison and procedure can be undertaken within 60
minutes of ingestion ideally .
 Still it can be done up t0 4-6 hrs after ingestion.
For some substance gastric lavage can be performed
even afer 24 hrs. i.e
• Aspirin
• Opioids
• Anti-cholinergics
Type of tube:Adult 30 guage jaques
tube(child: Ryel’s tube)
Length of tube inserted: 50 cm adult &
25 cm (child)
Procedure:
 Lubricate the tube with glycerin &
pass.
 use mouth gag.
 Confirm the position of the tube in
stomach.
 300 ml of warm water or saline is
poured (100 ml in child).
Syphon Principle
This is the principle under which gastric lavage is performed.
According to it “Fluids flow from higher levels to lower levels.”
Position of patient:
 The patient should be in left lateral position with the level of
head below that of the body.
 This allow pooling of stomach fluid in the cardiac end and assists
in its drainage.
Fluids used in Gastric Lavage:
 Warm water
 Saline (0.9% or 0.45%)
 Oxidizing solutions as KMNO4 (1:5000),
Tannic acid and Iodinated water. These are preferred
in alkaloid poisons or salicylates.
 Sodium thiosulphate for cyanide poisoning.
 Desferrioxamine for iron.
 Castrol oil & warm water for carbolic acid.
 Calcium gluconate for oxalic acid.
Contra-Indications of Gastric Lavage
i. Corrosives (except carbolic acid): May lead to perforation
when tube is passed.
ii. Convulsions: Passage of the tube can act as a stimulus to
precipitate fits and the person may aspirate if he has a
convulsion during the procedure.
iii. Petroleum distillates: They are volatile and can be aspirated.
iv. Esophageal varices: Trauma during tube insertion may lead
to massive hemorrhage.
v. Marked hypothermia: The repeated introduction and
removal of solutions can lead to decrease body
temperature.
vi. Severe electrolyte and acid base imbalance.
Complications of Gastric Lavage
 Aspiration pneumonia, hypoxia and
hypercapnia due to aspiration.
 Electrolyte imbalance
 Laryngospasm during tube insertion.
 Mechanical injury to the throat, esophagous,
and stomach.
3- ACTIVATED CHARCOAL
Activated charcoal is a fine, black,
odourless and tasteless type of
amorphous carbon.

Source: Destructive distillation of wood.


Uses: Decreases the absorption of various
drugs by adsorbing them on its
surface.
Each gram of Activated Charcoal
works out
to surface area of 1000m2.
Indications: Useful in poisoning with:
Salicylates
Paracetamol
Barbiturates
Antidepressants
Procedure: Used as a water slurry (4 parts of
water added to desired quantity of
activated charcoal) after emesis or
gastric lavage.
Dose: 1 gram/kg body weight.
Side effects: Sometimes the following can be seen:
Vomiting, diarrhea, constipation, pulmonary
aspiration and intestinal obstruction.
Contra-indicators: It is not used in the cases of:
Corrosives, Heavy metals and Alcohol.
Methods for preparing:
There are two basic methods of making
charcoal. These are Direct and Indirect.
1. The direct method: Used heat from the
incomplete combustion of the organic matter
which is to become charcoal. The rate of
combustion is controlled by regulating the
amount of oxygen allowed into the burn and is
stopped by excluding oxygen before the charcoal
itself begins to burn.
2. The indirect methods uses an external heat
source to “cook” organic matter contained in a
closed but vented airless chamber (retort).
4- CATHARTICS

These are substances which increase the motility of


the GI tract and help to expel the poison from the
body before it is absorbed e.g. Mag: Sulphate, Sod
Sulphate and Sorbitol etc.
Mechanism of action: By increasing the GIT
motility, the contact time between the poison and
the GI mucosa is decreased and so the poison is
propelled out soon with the passage of stools.
Contraindications: Corrosives, abdominal trauma,
intestinal obstructions, electrolyte imbalance.
REMOVAL OF ABSORBED POISONS FROM THE BODY
The following methods can be used:
1. Neutralization of absorbed/unabsorbed poisons
2. Forced Diuresis
3. Dialysis: It is of two types
a) Hemodialysis
b) Peritoneal Dialysis
4. Hemoperfusion
5. Plasma Exchange
6. Exchange Transfusion
1- Neutralization Of Absorbed/unabsorbed Poisons
This is done by the use of Antidotes and
Chelating agents.
A- Antidotes:
These are the substances which on
administration counteract or neutralize
the effect of poison without causing any
harm to body.
A- Antidotes Contd…

Indications:
These are used when:
• Poison is absorbed Emesis has failed.
• Gastric lavage is contra-indicated.
• Poison has been administered by
other route than the oral.
• After emesis or lavage to neutralize
residual poison.
Classification/Types Of Antidotes
Antidotes are of the following types:
1. Mechanical/Physical Antidote
2. Chemical Antidotes
3. Physiological Antidotes
4. Pharmacological/Receptor Antidotes
5. Dispositional Antidotes
6. Universal Antidotes
1-Mechanical/Physical Antidotes
These substances act mechanically and
prevent the absorption of poison. They are
of two types:
a) Demulcents:
Those which form a coating on the mucous
membrane of stomach and retard the
absorption of the toxin through the
stomach mucosa e.g. Beaten egg white,
Starch, Fats and Oils.
1-Mechanical/Physical Antidotes Contd…
b) Diluents: Which dilute the substances
ingested for e.g. water and milk.
c) Bulky foods: Like banana which is used
in broken glass and boiled rice.
d) Adsorbents: Which retard the
absorption of drug by binding to it e.g.
Activated Charcoal.
• These are contraindicated in absent
bowel sounds or intestinal obstruction.
2- Chemical Antidotes
These substances undergo some chemical
reaction with the poison and form another
compound which is either non-toxic or lesser
toxic. e.g.
• Dilute acids for strong alkalis.
• Dilute alkalis for strong acids
• Calcium salts for oxalic acid.
3- Physiological Antidotes
• These are the substances that act on the
biological systems and physiological
mechanisms of the drug oppose the
effects of the poisons; e.g.
• Epinephrine ---- in anaphylactic
reactions of drugs.
• Barbiturates ---in strychnine poisoning.
• Physostigmine—in atropine poisoning.
4-Pharmacological Antidotes/ Receptor
Antidotes:
These are the substances that oppose the
action of a poison by acting on the same
receptor where a poison acts to produce its
action; e.g.
• Naloxone---for Morphine poisoning.
• Atropine---for Organ-phosphorus poisoning.
• Flumazenil—for Benzodiazepine poisoning.
5-Dispositional Antidotes

These substances alter the poisons


absorption, metabolism, distribution and
excretion to reduce the amount available
for the tissue to be exposed to.
E.g.
 N-acetyl cystine in Paracetamol toxicity.
 Ethanol is used in Methanol and Ethylene
glycol poisoning.
6. Universal Antidote

It is a combination of physical and chemical


antidotes. It is given when;
• the exact nature of the poison is not known.
• when more than one poison has been taken.
6. Universal Antidote Contd…

Composition:
• Activated charcoal (Burnt toast)--- 2 parts
It adsorbs alkali.
• Mg02 (Milk of Magnesia)--- 1 part
It neutralizes acid.
• Tannic Acid ( Strong Tea)--- 1 part
It Precipitates certain Glycosides and metals.
Dose: 1 table spoonfull mixed and stirred in glass
of water.
B. Chelating Agents
 These are specific antidotes against some
metallic poisons.
 These produce a firm non-ionized cyclic complex
(chelate) with cations.
 These compounds can form stable, soluble, non-
toxic complexes with metallic poisons.
Mechanism of action

 Chelating agents are compounds that


inactivate metal ions with the formation of
an inner ring structure within the molecule.
 The metal ion becomes a member of the
inner ring and hence isn't free to exert its
actions any more.
 The compounds that are formed are no more
toxic and are excreted in urine.
PROPERTIES OF AN IDEAL CHELATING AGENT:

• Great affinity for metals.


• Form stable, non-toxic complexes with metals.
• Possess high water solubility.
• Have minimum toxicity.
• Tissue distribution is similar to metals.
• Excretion/elimination of metal chelator complex
without breakdown.
• Lack of redistribution to brain and other critical
organs.
• Favorable out come.
TYPES Of Chelating Agents

Following are the most commonly used


Chelating Agents:
a. BAL
b. EDTA
c. Penicillamine
d. Desferrioxamine
a) BAL (British Anti-Lewisite)
BAL (Dimercaptopropanol), was originally
used as an antidote for Lewisite, a
vesicant containing Arsenic that was used
as war gas. It was introduced in World
War-II. W. Lee Lewis was an American
Scientist who developed the war gas.
Dimercaprol forms a soluble complex
with the metal and it is excreted in urine.
Indications:
Used in heavy metals like Arsenic, Mercury,
Silver, Gold, Lead, Antimony, Thallium, Copper
and Bismuth.
Contraindication:
in liver disorders.
Dose:
2-3mg/kg body weight I/M, 4 hrly for 10 days.
B) EDTA: (Ethylene diamine tetra acetate)
Indication: Heavy metals like arsenic, lead,
mercury and copper poisoning.
Dose: 1 gram twice daily for 5 days iv.
Contraindication: Renal damage.
c) Penicillamine (Cuprimine)
It is a degradation product of penicillin and is
used orally
Indications: It is the treatment of choice in lead,
copper and mercury poisoning.
Dose: 30mg-/kg body wt. in 4 divided doses /day
orally.
It is a specially useful in hepatolenticular
degeneration (Wilson's disease) which is
caused by a disorder of copper metabolism.
d) Desferrioxamine :
It chelates iron. It is used in the treatment of acute
iron poisoning. In certain chronic diseases which
are characterised by excessive retention of iron in
the tissues, it is useful in accelerating the removal
of iron from the body.
Patients who need repeated blood transfusions
and are at risk of iron overload e.g. Thalasemia.
It removes Iron from Ferritin, Hemosiderin, a little
from Transferrin but not from Hemoglobin and
Cytochromes. Dose: Orally 8-10 grams,
IM 0.5 to 1 gram, twice a day,
IV 1-2 gm in 5% of 500 ml of D/Saline.
ELIMINATION OF ABSORBED POISONS FROM
THE BODY
The following methods can be used:
1. Forced Diuresis
2. Dialysis: It is of two types
a) Hemodialysis
b) Peritoneal Dialysis
3. Hemoperfusion
4. Plasma Exchange
5. Exchange Transfusion
1- Forced Diuresis
This procedure is based on
increasing the volume of
flow of urine through the
kidney.
Example:
Mannitol
Frusemide
Objective is to maintain 300-
400 ml/hr urine output.
2- Dialysis
It is a process of separating
macromolecules from ions and low
molecular weight compounds in
solution by the difference in their rates
of diffusion through a semi-permeable
membrane, through which crystalloids
pass readily but colloids pass slowly or
not at all.
A-Hemodialysis
Removal of certain elements
from the blood by virtue
of the difference in the
rates of their diffusion
through a semi-
permeable membrane
while being circulated
outside the body, the
process involves both
diffusion and ultra
filtration.
A- Hemodialysis Contd…

Duration: Procedure is continued for 6-8 hrs.


Indications: in Methanol, Salicylate,
Barbiturates, Amphetamines,
Phenytoin, Lithium, Arsenic and
Mercury poisoning.
Haemodialysable poisons

Amphetamines Etyhl alcohol Methaqualone

Arsenic Ethylene glycol Methyl alcohol

Barbiturates Isoniazid Methyl drops

Bromides Isopropyl alcohol Phenytoin

Camphor Lithium Salicylates

Copper Meprobamate Theophylline

* This list is not complete 141


B) Peritoneal Dialysis
The only difference is that the
membrane that is separating
the blood and the Dialysate
Solution is the peritoneal
membrane that lines the
peritoneal cavity. This is the
membrane across which the
diffusion of substance take
place.
This is done for salicylate
poisoning.
3- Hemoperfusion
Principle: The drug which are
protein bound drug adsorbs to
the columns of activated
charcoal and hence can be
removed. This involves
involvement of the Ion-
Exchange principle.
Indications: Specially used in
lipid soluble drugs and in
Barbiturates, sedatives, digitalis
and salicylate poisoning.
4- Plasma Exchange
• Suitable for proteins
bound drugs.
• Volume of blood from the
patient is removed & all
the blood elements are
returned back replacing
plasma with a crystalloid
solution (Plasmaphresis)
e.g. Paraquat poisoning.
5- Exchange Transfusion
• It is only feasible in
children and is used
in the poisoning of
salicylate,
barbiturates, iron
salts, CO etc..
Hyperbaric Oxygen
• Hyperbaric oxygen therapy (HBOT) is breathing
100% oxygen while under increased atmospheric
pressure.
• Oxygen Chamber: When a patient is given 100%
oxygen under pressure, hemoglobin is saturated,
but the blood can be hyperoxygenated by dissolving
oxygen within the plasma

146

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