2. TOXICOLOGY :
Toxicology is the science dealing with properties,
action, toxicity, fatal dose, detection, estimation of,
interpretation of the result of toxicological analysis
and management of Poisons
Forensic Toxicology:
Branch of Forensic Medicine dealing with Medical
and Legal aspects of the harmful effects of chemicals
on human beings.
3. POISON:
Any substance which when
Administered in living body through any route
(inhalation, ingestion, injecion, surface absorption etc)
Will produce ill-health or death by its action which is
due to
Its physical,
Chemical or
Physiological properties.
Eg: alphos, sulphuric acid, arsenic etc.
4. Drug (WHO 1996):
“Drug is any substance or product that is used or
intended to be used to
Modify or
Explore physiological systems or
Pathological states
For the benefit of the recipient.”
Eg: Paracetamol, Ciprofloxacin, Salbutamol, Oestrogen, Insulin
Etc.
5. Clinical Toxicology:
Deals with human diseases caused by, or associated
with abnormal exposure to chemical substances.
• Toxinology :
Refers to toxins produced by living organism which
are dangerous to man,
E.g.: snake venom, fungal and bacterial toxins etc.
6. • Acute poisoning
Caused by an excessive single dose, or several dose
of a poison taken over a short interval of time.
•
• Chronic Poisoning
Caused by smaller doses over a period of time,
resulting in gradual worsening.
Eg: arsenic, phosphorus, antimony and opium.
7. • Sub-acute poisoning
Shows features of both acute and chronic poisoning.
• Fulminant poisoning:
Produced by a massive dose.
In this death occur rapidly, sometimes without
preceding symptoms.
8. LAWS IN RELATION TO MEDICINE
(1) The drug and cosmetic act, 1940:
Regulate all kinds of drugs
Import,
Manufacture,
Distribution and
Sale.
Its main feature is to control purity, quality and
strength of drug.
9. (2) The drug and cosmetic rule, 1945:
Regulate storage, display, dispensing, sale,
labeling, prescribing etc.
Schedule
▫ C- biological and special products,
▫ E- poison,
▫ F- vaccine and sera,
▫ G- hormones,
▫ J- list of diseases for which No drug should be advertised,
▫ H- drugs to be sold on prescription of RMP,
▫ L- antibiotics, antihistaminics and other chemotherapeutic
agents
10. 3. The pharmacy act, 1948 :
Allows only registered pharmacists to compound, prepare
and dispense medicine
4. The drug control act, 1950 :
(sale, supply and distribution, fixing of prices )
5. The drug and magic remedies act, 1954
11. The Narcotic Drugs And Psychotropic Substance
Act, 1985.
Psychotropic subs alters mental function
e.g. LSD, amphetamine, barbiturates etc
Narcotics causes dullness of senses and induces sleep
e.g. cannabis, opium and cocaine.
The law prohibits of these drugs
Cultivation,
Manufacture,
Possession,
Sale purchase
Import export etc
Except for medical and scientific purpose.
12. Sources of Poison:
• Domestic or household sources –
Detergents, Disinfectants, Cleaning Agents, Antiseptics,
Insecticides, Rodenticides Etc.
• Agricultural and horticultural sources-
Insecticides, Pesticides, Fungicides and Weed Killers.
• Industrial sources –
Poisons are Manufactured or Poisons are Produced as by Products.
• Commercial sources-
Store-houses, Distribution Centres and Selling Shops.
13. • From uses as drugs and medicines
Wrong Medication, Overmedication And Abuse Of Drugs.
• Food and drink –
Preservatives of food grains or other food material,
Additives, colouring and odouring agents
accidental contamination of food and drink.
• Miscellaneous sources-
Snakes bite poisoning, city smoke, sewer gas poisoning etc.
22. • Stupefying Agent:
Dhatura, Cannabis, Chloral Hydrate.
• Agents Used To Cause Bodily Injury:
Corrosive Acids and Alkali.
• Cattle Poison:
Abrus precatorius, Calotropis, Plumbago.
• Used For Malingering:
Semicarpus Anacardium
23. Characteristics of Ideal Homicidal
and Suicidal Poison
Characteristics Suicidal Homicidal
Accessibility Cheap & Easy Cheap & Easy
Antidote Difficult Difficult
Lethal Dose Small Small
Lethal Period Small Long
Taste Pleasant Pleasant
Signs / Symptom Few or None Resemble Disease
E.g. Cyanide, Opium , Insulin, Arsenic, Aconite
Barbiturates,
Thallium,
Organophosphorus,
Madar,strychnine
24. Route of Administration/absorbtion:
Oral (commonest) e.g. alphos, acids,
Inhalation: gas poison
Parenteral
▫ (IM, IV, Sub-Cutaneous, Intra-Dermal)
Natural Orifices other than mouth
▫ (Nasal, Rectal, Vaginal, Urethral),
Ulcers, wounds and intact skin.
25. Fate of poison in body
▫ A part, of the poison eliminated unabsorbed by means of defecation and
vomiting.
▫ Liver detoxify or metabolize the poisons.
▫ By evaporation or oxidized or destroyed in the body.
• Excretion of poisons:
Unabsorbed poisons are excreted through faeces and vomits.
Absorbed poisons are excreted mostly by urine.
A part of volatile poison is exhaled out .
Some portion of poison is excreted through bile, saliva, milk, sweat,
tear, hair and nails.
26. Factors influencing the actions of a
poison in the body.
• 1. Quantity:
A high dose of poison acts quickly and often resulting in fatal
consequences.
A moderate dose causes acute poisoning.
A low dose may have sub -clinical effects and causes chronic
poisoning on repeated exposure.
27. • 2. Form:
▫ Physical state:
Gaseous or volatile poisons are very quickly absorbed.
Liquid poisons are more rapid than solid poisons.
Powder act more quickly than coarse substance.
• Some poisonous vegetable seeds may pass through the intestinal
canal ineffective when taken intact due to their impermeable
pericarp. But when taken crushed, they may be rapidly fatal.
28. ▫ Chemical combination:
Chemically pure arsenic and mercury are not poisonous because these
are insoluble and are not absorbed.
But white arsenic(arsenic oxide) and mercuric chloride are deadly
poisonous.
Barium sulphide is deadly toxic but barium sulphate is non-toxic.
▫ Mechanical combination:
Action of poison is altered when it combines with mechanically
inert substances.
29. • 3.Mode of Administration:
Absorption rate is different for different routes
GAS > IV > IM > SC/ID > WOUND > SEROUS SURFACE >
INGESTION > NATURAL ORIFICES > UNBROKEN SKIN
• 4. Condition of patient
Age:
Poisons have greater effect on two extremes of age
30. • State of body health:
• A well built person with good health can tolerate the action of
poison better than a weak person.
▫ Presence of disease :
In certain diseased conditions some drugs are tolerated
exceptionally well e.g.: sedatives and tranquilizers are tolerated in
very high dose by manic and deliriant patients.
•
31. • Intoxication arid poisoning states –
In certain poisoning cases some drugs are well tolerated, like, in case
of strychnine poisoning, barbiturates and sedatives are better
tolerated.
Whereas in case of barbiturate poisoning any sedative or tranquilizer
will accentuate the process of death.
32. ▫ Sleep
Absorption and action of the poison is also slow.
But depressant drugs may cause, more harm
▫ Exercise –
Action of alcohol on C.N.S. is slowed during exercise because more
blood is drawn to the muscles during exercise.
33. ▫ Cumulative action of poisons:
cumulative poisons (poisons which are not readily
excreted from the body and are retained in different
organs of the body for a long time) like
Lead may not cause any toxic effect when enters the body in
low dose.
But when such poisons enter over a long period of time, may
cause harm when their concentration in different tissue
reaches high level due to their cumulative property.
34. • Tolerance may develop by individuals on long term
exposue to a particular poison.
• Idiosyncracy: some persons may react adversely to a
particular drug though the general population tolerates
the drug well.
35. Duties of a Doctor
▫ Doctor must record preliminary particulars,
▫ If summoned by the investigating police officer or
magistrate must cooperate.
▫ Notify cases of homicidal poisoning to the nearest police
station as per s. 39 Cr PC
Failing which he is liable for prosecution proceedings under
section 176 IPC.
36. ▫ In Government Institutions, all types of poisoning cases intimated
to the police station as a routine.
▫ Poisoning must be subjected for autopsy.
▫ body should not be released to the relatives before inquest.
▫ A doctor should never grant a death certificate stating the cause of
death before an autopsy is conducted.
▫ False information, if any, furnished to the police can lead to
prosecution proceedings under section 193 IPC.
37. ▫ Recording of a dying declaration
▫ Material objects like stomach wash, vomits, excreta,
blood, urine etc. are to be preserved for chemical
analysis.
▫ All relevant records connected with poisoning cases
must be kept under safe custody.
38. Laws in relation to poison and drugs:
• Different sections of Indian penal code related to poisons are as
follows
▫ Sec. 272 I.P.C. - Punishment for adulterating food or drink intended for
sale, so as to make the. same noxious, may extend upto 6 months
imprisonment of either term and/or fine upto one thousand rupees.
▫ Sec. 273 I.P.C. - Punishment for selling noxious food or drink may be
imprisonment of either description for a period of 6. months and or fine
upto one thousand rupees.
▫ Sec. 274 I.P.C. - Punishment for adulteration of drugs in any form with
any change in its effect knowing that it Will be sold and used as un-
adulterated drug, may be imprisonment of either description for a period-
of 6 months and or fine.
•
39. ▫ Sec. 275 l.P.C. - Punishment for knowingly selling adulterated
drugs with less efficacy or altered action serving it for use as
unadulterated may be imprisonment of either description for 6
months and or fine.
▫ Sec. 276 I.P.C. - Punishment for selling a drug as a different
drug or Preparation, may be imprisonment of either description
which may extend up to 6 months and or fine. .
▫ Note - In the State of West Bengal, the punishment for these
offences described under sections 272 to 276 may be up to
imprisonment for life with or without fine.
▫ Sec. 277 I.P.C. – Punishment for fouling water of public spring
or reservoir may be imprisonment of either description which
may extend up to a period of 3 months and or fine.
40. ▫ Sec. 278 I.P.C. - Punishment for voluntarily making
atmosphere noxious to health is fine which . may extend upto five
hundred rupees.
▫ Sec. 284 I.P.C. Punishment for negligent conduct with respect
to poisonous substance may be imprisonment of either
description which may extend up to 6 months and or fine which
may extend up to one thousand rupees.
▫
▫ Sec. 328 I.P.C. :Punishment' for causing hurt by means of
poison or any stupefying, intoxicating or unwholesome drug or
any other thing with the intent to commit an offence shall be
imprisonment of either description for a term which may extend
to ten years with or without fine.
41. If poison is known then treat specific poison
If not known on general lines of management
Main aim to stay the patient alive by supporting
respiration and circulation
Assisted by getting rid of poison by metabolism,
excretion.
Use of antidote by getting rid of poison.
TREATMENT OF POISONING:
42. Removal of unabsorbed poison
Use of antidote
Elimination of absorbed poison
Treatment of general symptoms
Maintenance of patient's general condition
OBJECTIVES:
43. Depending Upon Route of Entry
a.INHALEED POISON: (CO,H2,S)
Remove from sources to fresh air
Artificial respiration
Keep airway patent (posture drainage)
REMOVAL OF UNABSORBED POISON:
44. a. INJECTED POISON: (hypnotics, insulin,
sedatives)
A tight tourniquet proximal to point of injection
Must be relaxed for one min after 10 min.
Wound may be excised and poison removed
45. a. CONTACT POISON:
Spilled or sprayed on skin, eyes or wound
Best way is to wash it out with water
Neutralize it by an antidote.
46. a. INGESTED POISIONS
Remove from stomach as much as possible by Vomiting, and
stomach wash.
If patient is conscious and cooperative and vomiting is not contra
indicated. Induce it by tickling the fauces and by use of Emetics
Contraindications are;(corrosive, petroleum, distillates, coma,
Strychnine ) ( cardio-resp. diseases, Advanced pregnancy)
47. Warm water.
Mustard powder ( Table spoon = 15 gm)
Two table spoons of NaCl + 200ml tepid water)
Apo morphine 6 mg s/c followed by
Nalaxone Hcl 5-10 mg i.m/i.v causes vomiting in 3-5 min.
Facilitate gastric lavage by removing contents.
Produce gastric/intestine reflux (Tab).
HOUSE HOLD EMETICS
48. • INTRODUCTION
Gastric lavage is a method of gastrointestinal decontamination.
Performed in the setting of an ingested overdose or acute poisoning,
to decrease the absorption of substances in the stomach.
This technique was first described in 1812.
DEFINITION
Gastric lavage also commonly called stomach wash or gastric
suction, is the process of cleaning out of the contents of the stomach.
It has been used for eliminating poisons from the stomach.
GASTRIC LAVAGE
49. GASTRIC LAVAGE
If not contra indicated-may be
life saving but should be
undertaken within 6 hours.
Contraindicated in corrosives.
exception in carbolic acid.)
Certain measures should be
taken such as
Strychnine poisoning ( control fits )
Kerosene poisoning ( airway
should be sealed ) Hypothermia
( Body temp should be maintained.)
50. Abnormal or absent pharyngeal/upper gastrointestinal anatomy
Active or substantial antecedent vomiting
Caustic ingestion.
Coagulopathy.
Decreased mental status
CONTRAINDICATIONS
51. Inactive or diminished airway reflexes
Large pills
Large or sharp foreign body
Nontoxic or minimally toxic ingestion
Signifiant aspiration risk (e.g., hydrocarboné
ingestion)
53. In prone or semi prone position
Head should be down.
Flexible rubber tube about 12.7mm diameter
And 1½ met . in length.
Lips to cardiac end 45 cm.
Air should be injected (sound heard)
PROCEDURE (Gastric Lavage)
54. ¼ Litters of water (35 C )
First – funnel is up them down.
Subsequent washings e ½ liters of water
1st
washing is preserved.
Color of fluid is noted till it return unchanged.
Last fluid should be kept in stomach.
55.
56.
57.
58. • Apply the lignocaine gel on tube for lubrication
Insertion of tube
59. Insert the tube gently up to the marked and tell
the pt to swallow it
61. • Administer 100 - 300 ml(10 to 15ml/kg bwt) of lavage fluid via the tube
(in children, administer 50 - 100 ml). Then, manually agitate the stomach.
After that, withdraw the fluid.
62. Repeat this until the lavage return is clear. Generally,
anywhere from 5 to 20 L are required to thoroughly cleanse
the stomach.
Remember to save the aspirate for toxicology screening.
After completion of the lavage, activated charcoal may be
administered via the orogastric lavage tube.
Technique con…..
73. • DEFNITION:- Remedies which counteract or
neutralize the effects of poisons without causing
appreciable harm to body .
• IT IS USED WHEN
A poison may not have been completely removed.
The poison is already absorbed.
The poison has been administrated by routes other than
ingestions.
ANTIDOTES
74. 1. Mechanical or physical.
2. Chemical.
3. Physiological or Pharmacological
4. Universal.
CLASSIFICATION
75. Impede the absorption of poison such as demulcents,
bulky food and activated charcoal
Demulcents:
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, etc.
Fats and oils should not be used for fat soluble poisons like,
Kerosene, Phosphorus, OP compounds, DDT, Phenol, Acetone, etc.
1.MECHANICAL OR PHYSICAL
76. Bulky Foods:
They act as mechanical antidote to glass powder by imprisoning the
particles within its meshes and thus prevents damage by the sharp
glass particles
Activated charcoal (alkaloid poison, strychnine)
This is a fine, black, odorless powder
Produced by destructive distillation of various organic materials,
usually from organic pulp and then treating at high temperatures.
This process increases the absorptive capacity
Particles are small but with high absorptive capacity and it acts
mechanically by adsorbing and retaining within its pores organic
and some miner
Usually given mixed with water
77. Helpful in Barbiturates, Atropine, Benzodiazipine, Opiates,
Quinine, Strychnine, Phenothiazines, Pyrethrins, Aluminium
Phosphide, etc.
Less useful in Corrosives, Heavy metals, Cyanide, Hydrocarbon
and Alcohol poisons
Dose is 30-60gm in children
60-100gm in adults
5-10 % the amount of poison ingested
78. Charcoal (1g/kg)
First line decontamination method
MDAC- very useful
First dose: 1 g / kg body weight
Subsequent doses: 0.5 g / kg body
weight at 6th
hourly up to 48 hours.
Charcoal dose
80. Mg2So4 or Na2So4 ( purging)
NaHCO3 ( Aspirin poisoning )
Activated charcoal (absorbs Alkaloids)
Liquid paraffin (demulcent)
KMnO4 – (oxidizing agent)
IN CHILDREN
8 – 12 fr
25 CM
Stomach wash with 50ml glass syringe
SOLUTIONS USED
81. By direct chemical reaction
By oxidizing-to non toxic compound as
a. Dilute acetic acid - alkalis
b. Dilute alkalis as milk of magnesia - acids (bicarbonates
are not used - rupture of stomach)
c. Tannin (strong tea)- alkaloids, glycosides, metals
d. Kmno4 oxidizes (barbiturates, phosphorus, cyanide),
(1:1000)-dilution, (100-150ml left in stomach)
2. CHEMICAL
82. Produce effects which are opposite to that effects of
the poison as
Atropine for pilocarpine
Diazepam for strychnine
Naloxone for morphine
3.PHYSIOLOGICAL OR PHARMACOLOGICAL
83. Atropine and oximes for organ phosphorus
N-acctylcystine for paracetamol
Mazicon for Benzodiazepines
(however antagonism is always not complete and
undesirable side effects may be there)
84. These agents act by forming stable and soluble
complexes by the inner ring structure which can
combine with the metallic poisons
CHELATING AGENT
85. BAL also called dimercaprol
It is given deep i.m. As a 10% solution in
arachis oil with benzyl benzoate.
In severe poisoning – 3 mg/kg bw × 4 hourly × 2 days,
then 6 hourly × 1 day, then 12 hourly × 10 days
CI : liver ds, G-6-PD deficiency, cadmium and
Fe poisoning
Uses: ar
86. EDTA(EDTA(Ethylene Diamine Tetra acetate) arsenic m(Renal
damage-contra indicated))
1 gm × BD × 5 days x slow i.v.i. in isotonic glucose saline
CI : renal ds
Uses: Pb, Cu,cobalt,cadmium.
Pencillamine (cuprimine)
It is a degradation product of pencillin
Uses: cu, pb, hg poisoning, wilson ds
Dose: 2 gm / day in four divided doses orally
Desferrioxamine
Uses: iron poisoning, haemachromatosis
87.
88. Urinary alkalization:
This is also known as alkaline diuresis
IV bicarbonate 1 lit. of 1.26% over 3 hrs is given
Potassium levels can fall, so add 20-40 mmol. potassium to each
lit. of IV fluids given
Aim for a Urinary pH of 7.5-8.5
Indications: poisoning with chlorpropamide,
phenobarbitone, salicylates, phenoxy acetate herbicides
ELIMINATION OF ABSORBED POISON
90. Extracorporeal techniques:
Hemodialysis: can be considered for poisoning with
salicylates, ethylene glycol, methanol, ethanol, theophylline & lithium
Haemoperfusion: can be considered for poisoning with
theophylline, phenobarbitone & carbamazepine
91. This can increase elimination of some drugs by
interrupting their enteroenteric & enterohepatic
circulation
The dose given is 50 gm (1 gm/kg in children) of
activated charcoal every 4 hrs.
Indications: poisoning with carbamazepine, dapsone,
quinine, phenobarbitone, theophylline
Multiple-dose activated charcoal:
92. Warm and comfortable
Avoid risk of infection
Administration of antibiotics
Psychiatric counseling
MAINTAINENCE OF PATIENT GENERAL CONDITION
95. • It can be graded in the following way based upon the
amount of substance.
Extremely toxic : 1mg / kg or less.
Highly toxic : 1.5mg /kg
Moderately toxic : 50-500mg/kg
Slightly toxic: 0.5-5.0gm/kg
Non toxic : 5-10gm/kg
Harmless : more than 10gm/kg
W.H.O. Toxicity rating chart