Laws related to poisons, Medicolegal duties of a doctor in poisoning cases, Classification, Diagnosis, Lab analysis and Treatment of Poisons

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2. Definitions
History
Epidemiology
Law of poisons
Duties of a Medical Practitioner
Nature of poisoning
Classification of poisons
Types of poisoning
Diagnosis of poisoning
Laboratory analysis
Management
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3. Toxicology is the science dealing with properties,
toxicity, fatal dose, detection and estimation of,
interpretation of the results of toxicological analysis
and treatment of poisons.
Forensic toxicology deals with the medical and legal
aspects of the harmful effects of chemicals on human
beings.
Poison is a substance (solid, liquid or gaseous) which if
introduced in the living body or brought into contact
with any part there of will produce ill-health or death,
by its constitutional or local effects or both.
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4. 1. The Drugs And Cosmetics Act 1940
2. The Drugs And Cosmetic Rules 1945
3. The Pharmacy Act 1948
4. The Drugs Control Act 1950
5. The Drugs And Magic Remedies Act 1954
6. The Narcotic Drugs And Psychotropic Substances
Act 1985
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5. Regulates the function of Central Drug Laboratory,
appointment of licensing authorities and manufacture,
distribution and sale of drugs
THE DRUGS AND COSMETIC RULES
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6. Drugs to be sold only on prescription of registered
medical practitioner.
Eg: Barbiturates, antibiotics, amphetamines, etc.
SCHEDULE H DRUG
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7. A medical facility that provides free, immediate,
expert treatment advice and assistance over the
telephone in case of exposure to poisons
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8. A. Medical Duty: Diagnose and treat
B. Legal Duty:
Information to Police – Must report all MLC to the police.
Sec 39 CrPC – Public to give information of certain offences
Sec 176 IPC – Omission to give information
Sec 201 IPC – Causing disappearance of evidence
Sec 202 IPC - Intentional omission to give information of offence
Examination of Scene of Crime
At the hospital – Preservation of body fluids, clothes and send
for analysis
Arrange for Dying Declaration
In case of food poisoning, Notify public health authorities
In case of death – no death certificate is issued 8

9. A. Homicide:
Colorless, odorless, tasteless
Easily available
Cheap
Highly toxic
No Antidote available
No Postmortem changes
No test available to detect it
Symptoms should resemble a natural disease
Symptoms should appear late after administration to
avoid suspicion
Eg for deal homicidal poison: aconite, thallium, arsenic,
digitalis 9

10. B. Suicide:
Produce an easy/painless death(eg: opium, barbiturates)
Easily available(OP, aluminum phosphide)
Easily taken in food or drink
Highly toxic
Cheap, color, odor or taste are not important
Eg for ideal suicidal Poison: opium, barbiturates, OP.
C. Para suicide: (para, “near” or “resembling”)
Refers to suicide attempts or gestures and self harm
where there is no actual intention to die
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11. D. Accidental:
Ingestion in mistake for harmless substance(acid
ingested as it appears like water)
Inhalation of vapors through accident(MIC vapor inhaled
in Bhopal gas tragedy)
Incorrect preparation of medicines that contain a poison
E. Abortion:
E.g: cantharides, calotropis, arsenic, aconite
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12. F. Aphrodisiacs:
Substance that increases sexual desire.
E.g: arsenic, cannabis, cantharides, cocaine, opium,
strychnine
G. Arrow poisons:
Tip of arrows for hunting and to kill enemies
Ideal arrow poison must be poisonous parenterally and
safe orally
E.g: Plant based: abrus precatorius, aconite, calotropis,
croton oil, curare, strychnine
Animal based: Batrachotoxin(BTX) 12

13. H. Cattle poisoning:
To obtain hides
E.g: abrus, aconite, oleander, strychnine, calotropis,
nitrates
I. Stupefying:
To stupefy travelers for robbery or women for sexual
assault.
E.g: cannabis, chloral hydrate, datura
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16. Hematological system: anticoagulants(warfarin)
Immune system: immunosuppressive agents
Hepatotoxic agents: alcohol, paracetamol, phosphorus
Nephrotoxic agents: cantharides, cephalosporins,
sulfonamides
Pulmonary toxic agents: chlorine, phosgene, silica
CNS: Organophosphates, Strychnine
CVS: digitalis, oleander
Dermatological: arsenic, camphor
Reproductive system: alkylating agents
Endocrine system: thiouracil, calcitonin 16

17. Depends upon the amount of poison taken, the time
period over which poison taken
Hyperacute- produced by a single massive dose. Death
occurs very rapidly. No time for signs and symptoms.
Acute- excessive single dose, but less than that used in
hyperacute poisoning.
Subacute- gradually over some time. Doses taken are
small and over a short period of time.
Chronic- very minute doses taken over a long period of
time. E.g: plumbism
Acute on chronic- the victim is suffering from chronic
poisoning on top of it acute poisoning occurs. E.g: chronic
drug abuse
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18. Sudden appearance of symptoms-
GIT: abdominal colic and pain, vomiting, hematemesis
Hepatic: jaundice
CNS: paralysis, tremors, convulsions, seizure, coma
Renal: oliguria with proteinuria and hematuria
Natural diseases
Any association with food
Multiple victims
Causes of acute abdomen: heavy metals, mushroom poisoning
Vomiting and diarrhea: OP, irritants
Constipation: botulism, iron, lead, lithium
Tremors: caffeine, carbon monoxide, alcohol
Convulsions and seizures: OP, DDT, ethanol withdrawal, lead, lithium18

19. Clinical signs:
1. BP:
Hypotension: cyanide, clonidine, antidepressants,
heroin
Hypertension: ethanol, OP, nicotine, atropine, LSD,
nicotine
2. Heart rate:
Bradycardia: clonidine, cholinergics, cyanide, opioids,
OP, digitalis
Tachycardia: alcohol, cocaine, cyanide
Cardiac arrhythmias: alcohol, caffeine, tobacco
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20. 3. Ocular signs:
Miosis: alcoholic coma, nicotine, caffeine,
carbamates
Mydriasis: alcohol, ergot, CO, cocaine,
Datura, viper bite
4. Ears(buzzing): camphor, ergot,
salicylates, quinine
5. Pulmonary:
Bradypnea: cyanide, narcotics, ethyl
alcohol
Tachypnea: cyanide, carbon monoxide,
methanol, paracetamol 20

21. 6. CNS signs:
Ataxia: alcohol, narcotics
Coma: CO, lead, OP, sedative
7. Urine:
Yellow/brown: myoglobin, quinine, cresol
Red/brown: bilirubin, hemoglobin, myoglobin
Blue/green: bile, biliverdin
Black: blood
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22. In the dead:
PM findings:
External:
i. Stains: clothes, corners, or other surface of the body
ii. Natural orifices: presence of poisonous material
iii. Skin: injection marks, jaundice
iv. Marks of violence: abrasions, bruises, wounds
Internal:
i. Odour
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24. ii. Mouth, throat and associated
structures: erosions, ulcerations,
evidence of inflammation
iii. Esophagus: softening and
desquamation of mucosa(alkalis),
ulceration(corrosives),
perforation(corrosive ingestions)
iv. Duodenum: perforation(alkalis)
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25. v. Respiratory tract: edema of glottis (corrosives),
edema of lungs(gaseous poisons)
vi. Stomach:
Hyperemia of mucus membranes caused by irritants
at cardiac end and greater curvature
Softening: corrosives
Ulcers: Magenstrasse
Perforation
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26. Color changes in the mucus membrane:
Black, charred- H2SO4,HCl, oxalic acid
Blue- amytal, copper sulfate
Brown- cresol
Cherry red- CO
Congested- phosphorus
White- arsenic
Yellow- nitric acid
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27. Stomach and contents
Upper 30 cms small intestine and contents
Liver(200-300gm)
Kidney – half of each
Blood- 30ml
Urine- 30ml
Food or medicine
Sample of preservative used
Individual organs in specific poisonings
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28. 1. Saturated solution of common salt: MC used
Contra-indicated in: corrosive poisoning, aconite,
plant poisons and heavy metal poisoning.
2. Rectified spirit:
Contra-indicated in: kerosene, phenol, alcohol,
phosphorous, paraldehyde, acetic acid poisoning.
3. Sodium Fluoride: for blood, CSF, vitreous humor and
urine.
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29. Immediate resuscitative measures
Removal of unabsorbed poison from the
body
Removal of absorbed poison from the body
Administration of antidotes
Symptomatic treatment
Adequate follow up
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30. A- AIRWAY = endotracheal intubation, tracheostomy
B- BREATHING= adequate tidal volume, ABG
C- CIRCULATION= pulses(presence or absence), IVF,
CPR
D- DEPRESSION OF CNS= GCS
E- EVALUATION OF PATIENT= breath sounds, heart
sounds, enlarged liver(hepatotoxic poisons), lack of
bowel sounds – anticholinergic poisons, ECG,
elimination of poison
D also stand for decontamination(ocular- copious
saline lavage, skin- copious water, then soap and
water, GIT- emesis, lavage), dextrose, dialysis,
disability evaluation, drugs 30

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32. A. INHALED POISONS-
(CO, H2S, Cl2)
Fresh air
Air passages
Endotracheal
intubation
Artificial respiration
and O2
Diuretics
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33. B. INJECTED POISONS
Reassurance
ABCDE
Shock
Allergies
Remove sting
Local vasoconstriction
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35. C. CONTACT POISONS-
Eye
Skin
D. INGESTED POISONS-
1. Emesis- substance that induces vomiting when
administered orally or by injection. (IPECAC)
2. Gastric lavage
3. Whole bowel irrigation- which are not absorbed by
activated charcoal
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37. 1) Identify the specimen
- Gastric lavage tube/ ewalds tube
2) Draw and label its parts
3) Mention its contraindications
- Corrosive poisoning except carbolic
acid, oxalic, acetic acids
- Convulsant poisoning - strychnine
- Comatose patients
- Volatile poisons like kerosene and
petrol 37
Funnel
Rubber tube
Wooden mouth gag
Lateral opening
100 cm mark
Suction bulb

38. 1) Identify the specimen
- Ryle's tube/Nasogastric tube
2) Draw and label its parts
1st mark - 40cm – cardia of stomach
2nd mark - 50cm – body of stomach
3rd mark - 55cm – pylorus of stomach
4th mark - 65cm – duodenum
3) Mention its indications
- For stomach wash in poisoning
- Aspiration of gastric contents for
analysis
- For nasogastric feeding and
medications
4) Mention its contraindications
- Acid poisoning
- meningitis 38
Lateral openings

39. A. Diaphoretics- drugs that increase sweating(blankets,
antipyretics, hot beverages like tea, coffee)
B. Enhanced renal excretion
C. Urine alkalization- in barbiturates, salicylates
poisoning
D. Urine acidification/ forced acidic diuresis- in cocaine,
strychnine
E. Hemodialysis- in barbiturates, boric acid, alcohols
F. Peritoneal dialysis- alcohol, barbiturates, lithium
G. Hemoperfusion- large volumes of patient’s blood are
passed over an adsorbent substance to remove toxic
substances. In Barbiturates, paraquat, CCl4 poisoning
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40. Based on mechanism of action:
Mechanical or physical antidotes
Chemical antidotes
Chelating agents
Serological antidotes
Physiological or pharmacological antidotes
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41. Work mechanically on poisons within GIT.
Adsorbents: which adsorb poisons on to their
surface
eg: activated charcoal
Demulcents: prevent their absorption by making a
protective coating on stomach wall.
eg: milk, starch, egg white, milk of magnesia
Diluents: dilute the poison rendering them
ineffective
eg: plain water, bulky food
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42. 1) Identify the specimen
- Activated charcoal
2) Write its uses
- mechanical/physical antidote for
following poisoning:
Barbiturates, BZD, antidepressants,
antiepileptics, theophylline,
tetracycline, beta blockers
3) Mention its contraindications
- Intestinal obstruction
- GI Perforation
- Haemorrhage
- Pesticides 42

43. Neutralize the poisons chemically within the GIT.
ACIDS: neutralize alkalis
eg: canned fruit juice, lemon juice, vinegar
ALKALIS: neutralize acids.
eg: alkaline hydroxides(calcium, magnesium)
ALBUMEN: mercuric chloride and copper poisoning
IODINE: for lead, mercury, silver poisoning
KMnO4: for atropine, opium, strychnine, phosphorous
poisoning
TANNIC ACID: precipitates metals, nicotine, strychnine,
cocaine
Universal antidote: 2 parts activated charcoal; 1 part
MgSO4; 1 part tannic acid
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44. Chemicals that form soluble, complex molecules with
metal ions, inactivating them so that they cannot react
with other elements.
1. BAL(British anti- Lewsite, Dimercaprol)
Indications: Mercury, Arsenic, Lead(MAL)
2. BAL analogues:
DMSA(2,3 DiMercaptoSuccinic acid)- MAL
DMPS(2,3 DiMercapto-1- Propane Sulfonic Acid)- MAL
EDTA- MAL, cadmium, cobalt, copper, manganese
D-Penicillamine-copper, zinc, mercury, lead, etc.
Desferrioxamine- acute iron poisoning
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45. Antisnake venom
Antispider venom
Fab therapy for
digitalis
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46. Work at the target cell by producing
pharmacological effects exactly opposite to those
produced by poison.
Examples:
Amyl nitrite- cyanide
Barbiturates- strychnine
Physostigmine- atropine
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48. Treat
Anxiety and agitation
Allergic reactions
Cardiac arrhythmias
Cerebral edema
CNS depression:
Coma Cocktail- DNB(Dextrose, Naloxone,
thiamine(B1)
Convulsions
Vomiting 48

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