A POWER POINT PRESENTATIONBYDR.SANGEETA CHOWDHRY&DR.SUNIL SHARMADEPARTMENT OF FORENSIC MEDICINE&TOXICOLOGYGOVT. MEDICAL COLLEGEJAMMU (JAMMU AND KASHMIR)
It is an alkaloid obtained from the leaves of cocatree, (Erythroxylon coca) and is a powerfuladdictive stimulant that directly affects the brain.It is typically sold to users as a fine, white,crystalline powder. It is a colourless, odourless,with a bitter/numbing taste, slightly volatile,melting point 96 degree Celsius and should beprotected from heat and sunlight.It dissolves easily in alcohol but slightly soluble inwater. Once taken orally, it causes numbness ofthe tongue and mucous membrane of mouth.
Forms: Hydrochloride SaltFreebaseCrackHydrochloride Salt: It is the powdered form ofcocaine, dissolves in water and when abused, canbe taken I/V or snorted. Freebase: Compound that has not been neutralizedby an acid to make hydrochloride salt. It can besmoked. Crack: it is produced when the hydrochloridemolecule is removed by ether extraction, whichfrees the basic cocaine molecule (freebase). Theterm ―CRACK‖ describes the cracking sound heardwhen cocaine freebase is smoked.
PRINCIPLE ROUTES OF ABUSE Intravenous Snorting (application to nasal mucous membrane) Smoking/inhalation(free basing) Ingestion/chewing: both cocaine and leaves of cocaplantsCocaine may be inhaled through a straw orrolled in paper currency, or a coke spooncontaining 5-20 mg of the drug of the drug isused to snort.
Cocaine has been classified as aSchedule II drug by the United States.Cocaine is extracted and refined fromthe Coca plant.Now a days, cocaine can besynthetically made. An ester ofbenzoic acid and a base containingnitrogen is synthetic cocaine.
GEOGRAPHICAL DISTRIBUTIONThis plant originally grew in South Americabut now is cultivated in India, Sri Lankaand Java. Nowadays, grows throughoutthe tropical regions, whole of LatinAmerican Countries such as Columbia,Mexico, Ecuador, and other countriessuch as Chile, Peru, India, Indonesia, SriLanka, etc.Bolivia-leading producer-80% world totalcocaine producer.
HIGH RISK GEOGRAPHICAL AREAS Bolivia Peru Brazil – Amazon region Ecuador Columbia Chile
FEATURESPlant is 8-12 feet tall.Category: ShrubsFruits: Red oval shaped, 1 cm size andproduces only one seed.Seeds: Brownish ovalStem diameter: 16cms
LEAVES Green, smooth, glossy, opaque, oval, taperingat extremities, 2-3 cm wide and 3-11 cm long. Leaves when chewed have pleasant, pungenttaste. Poisonous parts: Leaves Toxins: Methylbenzoylecgonine is one of atleast 12 alkaloids extracted from the leaves ofE. coca. All have ecgonine as commonconstituent. Some other alkaloid are:cinnamylcocaine, hygrine, tropococaine,truxillines, isotropylcocaine, cocaicine.
COMMON NAMES FOR COCAINE CRACK PASTA BAZOOKA SPEEDBALL (Mixture of cocaine and heroin.Taken I/V) SNUFF SNOW COKE CADILLAC TORNADO WHITE LADY
CRACK PASTA BAZOOKASPEEDBALL SNUFFSNOWCOKECADILLAC TORNADO WHITE LADY
ACTION Cocaine produces a hyper adrenergic state. It increase the synaptic concentrations of themonoamine neurotransmitters, norepinephrine andserotonin by binding to transporter proteins inpresynaptic neurons and blocking uptake. It is also a local anesthetic as it blocks initiation andconduction of nerve impulse, desensitizes theterminal nerves and causes vasoconstriction bydecreasing axonal membrane permeability tosodium ions. When taken I/V or inhaled, stimulates the cerebralcortex for a short time, followed by depression.
ABSORPTION/METABOLISM AND EXCRETION Cocaine is rapidly absorbed from the mucousmembranes and subcutaneous tissues. About 30-50% of cocaine is metabolised by hepaticesterases and plasma pseudo cholinesterase,resulting in the formation of ecgonine methyl ester.Spontaneous nonenzymatic hydrolysis of another30-40% results in benzoylecgonine. Only 1-5% of cocaine is excreted unaltered throughth kidneys within 6 hours of use. Half Life: 30-90 min. A metabolite of cocaine, ―COCAETHYLENE‖ hasbeen found in blood and urine of patients who abuseboth alcohol and cocaine
DETECTION Metabolites can be detected for varying lengths of time inurine depending upon the dose consumed and sensitivity ofthe assay. Metabolites in urine is generally detected in urine for 24-72Hrs. even after brief consumption. Metabolites also detectable in blood, saliva, hair and sweat. With chronic use it is deposited in body in fats/CNS. and isslowly released. Hence, can be detected in urine for evencouple of weeks. Blood and saliva: Provide accurate conc. of the drugconsumed. Urine: Provides longer window of opportunity for detection.
SIGNS AND SYMPTOMSSigns and symptoms of acutepoisoning include elevated pulse,blood pressure, respiration andtemperature. Onset occurs within 7seconds after inhalation, 15 secondsafter taking I/V, 3 minutes after nasalinsufflations and 10 minutes after oralingestion.
SIGNS AND SYMPTOMSCocaine can be taken into the body byinsufflations , (snorting or sniffing), bysmoking, ingestion and by intravenousroute.There are three stages in acutepoisoning:
SIGNS AND SYMPTOMSStage I: It is the stage of earlystimulation.There is sense of well being, euphoria,excitement, and talkativeness. Drynessof mouth and throat is seen.Tachycardia, hypertension andhyperthermia are seen. Vertigo andnausea may be there. There isnumbness in mouth.
SIGNS AND SYMPTOMSStage II: It is a stage of advancedstimulation in which hallucinations areseen. Vomiting, muscle twitching,hyperthermia, (cocaine fever),dyspnea, and convulsion may be seen.Circulatory and respiratory systemsstart failing.
SIGNS AND SYMPTOMSStage III: It is a stage of depressionwhere paralysis of muscles, loss ofreflexes, and coma are seen. Deathmay occur.
STAGE OF EXCITEMENTSYSTEM SIGNS AND SYMPTOMSLocal Feeling of numbness or tingling at the places ofapplicationFace FlushedSkin PaleGIT Bitter taste, dryness of mouth, vomiting, diarrhea,hyperactive bowel soundsCNS Feeling of well being, euphoria, restlessness, excitement,talkativeness, delirium, maniacal, hallucination, tremors(i.e. twitching of small muscles, especially facial andfinger) and tonic-clonic seizures. Reflexes areexaggeratedRS Tachypnea, dyspnea, cyanosisCVS Tachycardia, hypertension, ventricular arrhythmiasTemperature HyperthermiaOcular Pupils are dilated resulting in blurred vision
FEELING OF NUMBNESS OR TINGLING AT THE PLACES OFAPPLICATIONLOCAL
OCULAR---PUPILS ARE DILATED RESULTING IN BLURRED VISION
STAGE OF DEPRESSIONAfter an hour, respirationbecomes slow, there is profusesweating, and patient becomescalm and dull.
STAGE OF DEPRESSIONSYSTEM SIGNS AND SYMPTOMSCNS Coma, areflexia, pupils fixed and dilated, flaccid paralysisand loss of vital support functions.RS Cheyne-stroke respirations, apnea, pulmonary odema,cyanosis, respiratory failureCVS Ventricular dysrhythmias results in weak, rapid, irregularpulse and hypotension, circulatory failure and cardiacarrest.
CENTRAL NERVOUS SYSTEMCOMA AREFLEXIAPUPILS FIXED AND DILATEDFLACCID PARALYSIS LOSS OF VITAL SUPPORT FUNCTIONS
VENTRICULAR DYSRHYTHMIAS CIRCULATORY FAILURE CARDIAC ARRESTCARDIO VASCULAR SYSTEM
Tea coloured urine may indicaterhabdomyolysis and potential renalfailure. In fatal cases, the onset andprogression are accelerated, withconvulsion and death frequentlyoccurring in 2-3 minutes.Fatal dose :-20 mg I/V; 500mg to 1.4 gmsorally.Fatal period:- few minutes to 1-2 hours.
LONG-TERM EFFECTSIt is powerful addictive drug.Once having tried, an individual mayhave difficulty in predicting the extentto which he will continue to use thedrug.Abusers are of upper class societypeoples to enhance self image orimprove professional performance.
REASON FOR ADDICTION?Its stimulant and addictive effects arethought to be primarily a result of itsability to inhibit the re-absorption ofdopamine by nerve cells.Note: Dopamine is directly or indirectlyinvolved in addictive properties ofevery major drug of abuse
COCAINE IN BRAIN In normal communication process, dopamine isreleased by neuron into the synapse, where it canbind with dopamine receptors on neighboringneurons. Normally dopamine is then recycled back into thetransmitting neuron by a dopamine transporter. If cocaine is present, it attaches to the dopaminetransporter and blocks the normal recyclingprocess, resulting in a building up of dopamine inthe synapse which contributes to the pleasurableeffects of cocaine.
CRACK BABIES• "Crack baby" is a term for a child born to a motherwho used crack cocaine during her pregnancy.Cocaine use during pregnancy can affect apregnant woman and her unborn baby in manyways. During the early months of pregnancy, it mayincrease the risk of miscarriage. Later in pregnancy,it can trigger preterm labor (labor that occursbefore37 weeks of pregnancy) or cause the baby togrow poorly. As a result, cocaine-exposed babiesare more likely than unexposed babies to be bornwith low birth weight (less than 5.5 lb/2.5 kg).• ………………………….cont……………………..
CRACK BABIES• Low-birth weight babies are 20 times more likely todie in their first month of life than normal-weightbabies, and face an increased risk of lifelongdisabilities such as mental retardation and cerebralpalsy. Cocaine-exposed babies also tend to havesmaller heads, which generally reflect smallerbrains. Some studies suggest that cocaine-exposedbabies are at increased risk of birth defects,including urinary-tract defects and, possibly, heartdefects. Cocaine also may cause an unborn baby tohave a stroke, irreversible brain damage, or a heartattack.
CRACK LUNGThis may occur within 1-48 hoursafter cocaine smoking. It is ahypersensitivity pneumonitiswherein there is chest pain,cough, hemoptysis, dyspnea,bronchospasm, pruritus, fever,diffuse alveolar infiltrates withouteffusion, and pulmonary andsystemic eosinophilia.
CRACK DANCINGIt refers to the extra pyramidal phenomenaand other movement disorders that aresometimes associated with cocaineabuse. One of the side effects of cocaineis a phenomenon which is informallycalled "crack dancing" - involuntarymovements, jerks, and twitchesaccompanied by obsessive thinking,which can continue to persist long afterthe use of the drug is halted.
COCAINISM(COCAINOMANIA/COCAINOPHAGIA)Abusers can tolerate upto 1ogms/day.SIGNS AND SYMPTOMS Emaciation Anorexia Digestive disturbance Significant loss of libido Impotence Gynecomastia Galctorrhea Major derangements in menstrual cycle in women—amenorrheaand infertility Face is pale, shifty gaze, sunken eyes, dilated pupils. Tongue andteeth are black, and ulceration of nasal septum. Degeneration of CNS with hallucinations, convulsions anddelirium may occur.
COCAINE BUGSPHENOMENON/MAGNAN‘S SYNDROMEThis is seen in cocaine addicts. Grains of sand arelying under skin or some small insects arecreeping on the skin giving rise to itchingsensation – a form of tactile sensation/hallucination (Formication). This may cause:- Loss of libido Impotence Gynecomastia Irregular menstrual cycle Infertility Amenorrhea……………..cont…………….
LOSS OF LIBIDO IMPOTENCE GYNECOMASTIAIRREGULARMENSTRUAL CYCLE INFERTILITY AMENORRHEA
COCAINE BUGSPHENOMENON/MAGNAN‘S SYNDROMEThe tongue and teeth may be jet black.Chronic complication of nasalinsufflations in the form of rhinitis, nasalerosions or perforation or sinusitis maybe seen. Chronic cough or bronchitis maybe seen due to smoking. Due to chronicuse through intravenous route, theperson may have infection andthrombosis of vein. Since cocaine usersshare needles too, they may have highrisk of AIDS infection.
DIFFERENTIAL DIAGNOSISCocaine over dose may resemble Lithium toxicity Antidepressants Neuroleptic malignant syndrome Thyroid storm Hyper adrenergic states
DIAGNOSTIC CRITERIA FORNEUROLEPTIC SYNDROMETHYROID STORM HYPER ADRENERGIC STATES
TREATMENT If injected, apply tourniquet above the part;if applied to nose or throat, wash-out withwarm water or saline. If swallowed, gastriclavage should be done withKMnO4 and /oractivated charcoal. To control seizures: diazepam in dosesupto 0.5mg/kg I/V may be given over anperiod of 8 hour period. Physical restraintshould be avoided due to the risk ofrhabdomyolysis and hyperthermia.
TREATMENT Dysrhythmias should be treated according tostandard protocol. Ventricular arrhythmia ismanaged by giving 0.5-1 mg of propranolol I/V. Short acting, direct vasodilators (esomolol) andshort acting beta-blockers are indicated fortachycardia and hypertension. Thiamine 100mg I/V Intensive supportive therapy is needed in case ofacute intoxication. Airways are kept clean, artificial respiration andoxygen inhalation as required.
MEDICO-LEGAL SIGNIFICANCE Cocaine is widely used as drug of abuse. Accidental deaths have been reported with overdoses.Homicidal poisoning is rare. Sometimes, it is smuggled across countries by individuals byswallowing several small plastic bags or balloons or condomsfilled with cocaine and then they take flight to other countries.Once reaching the destination, they take purgative to passthese bags through stool. Sometimes, small packets are keptin rectum or vagina. Once these packets are retrieved, theyare cleaned and sold at very high prices. This process is calledBody packer syndrome or Bodystuffing. Sometimes, these packets rupture insidestomach or rectum and a large dose of cocaine is released.The person may die because of such dose.……………………..cont…………..
MEDICO-LEGAL SIGNIFICANCE Such persons are sometimes caught at airport and maybe brought for medical examination. X-ray andultrasound can be done to see bags and purgative orenema is given to retrieve such bags. It is believed to increase the libidinal drive and increasethe duration of sexual act by paralyzing the sensorynerves of glans penis. Sometimes, prostitutes inject a solution of cocaine intovagina. This gives the individual who is having sex withthem a sense of local constriction and hence morepleasure. But the person can get intoxicated as cocainegets absorbed. It causes lowering of moral values, loss of decency andself-respect.
AUTOPSY FINDINGS Non- specific findings Patients may have linear excoriations, ‗crack pipe‘ burns ofthe fingers or thumbs, thermal burns of the face and upperairways Track marks in the usual sites such as the antecubital fossae,and at unusual sites such as the tongue and on the feet maybe seen Intense asphyxia signs and cardiac dilatation may be seen Injection marks Atrophy, inflammation of nasal mucosa Endocarditis due to aseptic I/V infusion of drug Pulmonary granulomatosis due to infusion of adulteratedparticles viz. starch, talc, etc.Note:- blood should be preserved by adding fluoride
‗CRACK PIPE‘ BURNSTHERMAL BURNS OF THE FACETRACK MARKSINJECTION MARKS