1) Alcohol affects nearly every system in the body and alters neurochemical processes in the brain. Low doses may provide some health benefits but more than 3 drinks per day increases cancer and disease risk and decreases lifespan by about 10 years.
2) Worldwide, alcohol causes over 2 million deaths annually, accounting for 3.7% of deaths globally. In India, 20-30% of adult males and 5% of females consume alcohol.
3) Alcohol is absorbed quickly from the stomach and small intestine. Repeated use can lead to tolerance through increased metabolism and neurochemical changes in the brain. Blood alcohol concentration determines the level of impairment.
Asphyxia
Classification of Asphyxia
Mechanical Asphyxia
Mugging/ throttling
Mechanical Asphyxia
Pathological Asphyxia
Toxic or chemical Asphyxia
Environmental Asphyxia
Traumatic Asphyxia
Positional/postural Asphyxia
Iatrogenic Asphyxia
Tardieu’s or Bayard’s ecchymosis/spots
Hanging
Classification of Hanging
Cause of Death in Hanging
Fatal period in Hanging
Factors which influence the appearance of ligature mark ??
Judicial Hanging
Hangman’s fracture
Strangulation
ligature strangulation
Cause of death
Throttling or Manual Strangulation
Hyoid Bone Fractures
AUTOEROTIC
CHEMICAL Asphyxia
CHOKING
SMOTHERING Asphyxia
POSITIONAL Asphyxia
Drowning
Classification of Drowning
Typical or wet drowning
Mechanism of fresh water drowning
Mechanism of death in fresh water drowning
Mechanism of sea water drowning
Mechanism of death in sea water drowning
Atypical drowning
Dry drowning
Immersion syndrome
Near drowning
Shallow water drowning
Epidemiology of drowning
Cause of Death
Postmortem Examination
Froth
Reference
Drowning is an inhalation of liquid in respiratory tract leading to suffocation and death. it can be wet or dry drowning depending upon the water entering in trachea. some times water touching the larynx leading to spasm and complete closure leading to dry drowning.
Inorganic (non metallic) irritant Poisons by Sunil Kumar Dahasunil kumar daha
Please find the power point on Inorganic (non metallic) irritants poisons. I tried to present it on understandable way and all the contents are reviewed by experts and from very reliable references. Thank you
Regional injuries, types of scalp injuries with details of scalp anatomy, types of skull fractures, coup and counter coup injuries, mechanism of skull fractures.
Article 3 of Universal Declaration of Human Rights states “everyone has
the right to life, liberty and security of a person”
Article 21 of the Constitution of India guarantees no person shall be
deprived of his life or personal liberty except according to the procedure
established by law”
Thus right to life, liberty and security of a person are recognized as a
fundamental right by the Universal Declaration of Human Right (article
3 of 1948 and article 21 of the Indian Constitution
Asphyxia
Classification of Asphyxia
Mechanical Asphyxia
Mugging/ throttling
Mechanical Asphyxia
Pathological Asphyxia
Toxic or chemical Asphyxia
Environmental Asphyxia
Traumatic Asphyxia
Positional/postural Asphyxia
Iatrogenic Asphyxia
Tardieu’s or Bayard’s ecchymosis/spots
Hanging
Classification of Hanging
Cause of Death in Hanging
Fatal period in Hanging
Factors which influence the appearance of ligature mark ??
Judicial Hanging
Hangman’s fracture
Strangulation
ligature strangulation
Cause of death
Throttling or Manual Strangulation
Hyoid Bone Fractures
AUTOEROTIC
CHEMICAL Asphyxia
CHOKING
SMOTHERING Asphyxia
POSITIONAL Asphyxia
Drowning
Classification of Drowning
Typical or wet drowning
Mechanism of fresh water drowning
Mechanism of death in fresh water drowning
Mechanism of sea water drowning
Mechanism of death in sea water drowning
Atypical drowning
Dry drowning
Immersion syndrome
Near drowning
Shallow water drowning
Epidemiology of drowning
Cause of Death
Postmortem Examination
Froth
Reference
Drowning is an inhalation of liquid in respiratory tract leading to suffocation and death. it can be wet or dry drowning depending upon the water entering in trachea. some times water touching the larynx leading to spasm and complete closure leading to dry drowning.
Inorganic (non metallic) irritant Poisons by Sunil Kumar Dahasunil kumar daha
Please find the power point on Inorganic (non metallic) irritants poisons. I tried to present it on understandable way and all the contents are reviewed by experts and from very reliable references. Thank you
Regional injuries, types of scalp injuries with details of scalp anatomy, types of skull fractures, coup and counter coup injuries, mechanism of skull fractures.
Article 3 of Universal Declaration of Human Rights states “everyone has
the right to life, liberty and security of a person”
Article 21 of the Constitution of India guarantees no person shall be
deprived of his life or personal liberty except according to the procedure
established by law”
Thus right to life, liberty and security of a person are recognized as a
fundamental right by the Universal Declaration of Human Right (article
3 of 1948 and article 21 of the Indian Constitution
Uploader's Note:
The following Text, information and materials used in this presentation do not own by the uploader.
This presentation is all about Alcoholism-sign, effects, symptoms and treatment..
Special thanks to Mayo clinic organization for providing information for this presentation...
thank you.. and enjoy...
"keep moving forward"
When people think of the word “alcoholic,” they generally come up with the image of a middle-aged man, divorced or facing divorce, probably also a smoker or illicit drug user. However, a study in 2001-2002 found that contrary to many people’s preconceptions, alcoholism takes on more varied forms and often starts young, around or before turning 20. Although alcoholism can develop differently, there are 5 main categories that individuals with alcoholism generally fall into. Learn about the characteristics of each group through this slide show. For more information about alcoholism recovery for anyone struggling with an alcohol addiction, contact an admissions counselor at Pyramid Healthcare: 1-888-694-9996.
Alcoholism & Narcotic Addiction – a growing menace,Causes of Alcoholism & Narcotic Addiction ,Effects of Alcoholism,Effects of Narcotic Addiction,
The real cost of Alcoholism & Narcotic Addiction
What connects BMW’s ultimate driving machines and IoT? Take a look at what went down at HARMAN’s Connected Services’ event, at a BMW performance track and understand how Data, Device and Design; the three key dimensions of disruption are revolutionizing different industries.
Our passionate, professionally trained counselors provide several areas of specialization, offering individual and group services to couples, families, and youth in the St. Louis community.
AN OVERVIEW ABOUT PHARMACOLOGICAL ACTIONS,TOXICITY PHARAMETERS,GUIDELINES FOR SAFE DRINKING,CLINICAL USES,METHYL ALCOHOL.THIS FOR ALL MEDICAL AND PHARMACY STUDENTS.
Substance abuse can be defined as using a drug in a way that is inconsistent with medical or social norms and despite negative consequences.
Substance abuse denotes problem in social vocational, or legal area of the person’s life
Substance abuse refers to the harmful or hazardous use of psychoactive substances , including alcohol and illicit drugs.
This lecture covers all the effects of alcohols on various systems of the body.
It also covers the management of acute alcohol intoxication, withdrawal syndrome and alcohol dependence.
Uses of Methanol as well pharmacology of its toxicity is also explained.
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
Acute scrotum is a general term referring to an emergency condition affecting the contents or the wall of the scrotum.
There are a number of conditions that present acutely, predominantly with pain and/or swelling
A careful and detailed history and examination, and in some cases, investigations allow differentiation between these diagnoses. A prompt diagnosis is essential as the patient may require urgent surgical intervention
Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis producing ischemia from reduced arterial inflow and venous outflow obstruction.
The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25 to 50 percent
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Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
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These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
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- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
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Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
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Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
2. Introduction
• Alcohol (beverage ethanol ) distributes
throughout the body , affecting almost all
systems and altering nearly every neurochemical
process in the brain.
• Low doses of alcohol have some health benefit.
• The intake of more than three standard drinks per
day on a regular basis enhances the risk for
cancer and vascular disease, and alcohol use
disorders decrease the life span about 10 years.
1.HARRISONS PRINCIPLES OF INTERNAL MEDICINE 18th edition vol 2; chapter 392
alcohol and alcoholism no 3456-3552.
3. Epidemiology
• Worldwide, an estimated 2.3 million people die
from alcohol related causes.
• 3.7% of all deaths, of this 6.1% among men and 1.1
% among women
• WHO estimated 2 billion people worldwide
consume & 76.3 million with disorder arising out of
harmful use.
• In India around 20-30 % of adult males and around
5 % adult females use alcohol.
PARKS TEXTBOOK OF PREVENTIVE AND SOCIAL MEDICINE ; 21 EDITION ,CHAPTER 18 mental
health- alcoholism and drug dependence no 774.
4. PHARMACOLOGY AND NUTRITIONAL IMPACT OF ETHANOL
• Blood levels of ethanol are expressed as mg or gm of ethanol per dL (e.g., 100
mg/dL = 0.10 g/dL)
• With values of 0.02 g/dL resulting from the ingestion of one typical drink. In
round figures, 340 mL (12 oz) of beer, 115 mL (4 oz) of nonfortified wine, and 43
mL (1.5 oz) (a shot) of 80-proof beverage such as whisky, gin, or vodka
• Each contain 10–15 g of ethanol and represent a standard drink
• 0.5 L (1 pint) of 80-proof beverage contains 160 g (about 16 standard drinks), and
750 mL of wine contains 60 g of ethanol.
One unit = 10 gm of alcohol
One oz = 30ml
Proof =2*%ethanol by volume
One drink = 44ml of whiskey(80%proof), 3- 5oz wine or 12 oz beer.
BAC –blood alcohol conc.
0.1%BAC =100 mg alcohol in 100ml blood. .
HARRISONS PRINCIPLES OF INTERNAL MEDICINE 18th edition vol 2; chapter 392 alcohol and alcoholism no
3456-3552
5.
6. Absorption
GIT ,20% in stomach, rest in small intestine
80%-90% absorption within 30-60mins.
Absorption also depends on other factors
Females attain higher blood alcohol level.
BAC decreases by 15-25 mg /100ml/ hr.
Inhalation –pulmonary vascular bed.
PHARMACOLOGY
C2H5OH
Colorless, odourless liquid
M.Wt - 46
1gm ethyl alcohol – 7.1 kcal energy .HARRISONS PRINCIPLES OF
INTERNAL MEDICINE 18th edition vol 2; chapter 392 alcohol and alcoholism no 3456-
METABOLISM
7. • Alcohol supplies calories (a drink contains 300 kJ, or
70–100 kcal), these are devoid of nutrients such as
minerals, proteins, and vitamins. In addition,
alcohol can also interfere with absorption of
vitamins in the small intestine and decreases their
storage in the liver with modest effects on folate
(folacin or folic acid), pyridoxine (B6), thiamine (B1),
nicotinic acid (niacin, B3), and vitamin A.
• A heavy ethanol load in a fasting, healthy individual
is likely to produce transient hypoglycemia within
6–36 h, secondary to the acute actions of ethanol
on gluconeogenesis. This can result in temporary
abnormal glucose tolerance tests.
• HARRISONS PRINCIPLES OF INTERNAL MEDICINE 18th edition vol 2; chapter 392 alcohol and alcoholism
no 3456-3552
8.
9. Alcoholics may have thiamine deficiency because of
the following:
• Inadequate nutritional intake: Alcoholics tend to intake less than the
recommended amount of thiamine.
• Decreased uptake of thiamine from the GI tract: Active transport of thiamine
into enterocytes is disturbed during acute alcohol exposure.
• Liver thiamine stores are reduced due to hepatic steatosis or fibrosis.
• Impaired thiamine utilization: Magnesium, which is required for the binding of
thiamine to thiamine-using enzymes within the cell, is also deficient due to
chronic alcohol consumption. The inefficient utilization of any thiamine that
does reach the cells will further exacerbate the thiamine deficiency.
• Ethanol per se inhibits thiamine transport in the gastrointestinal system and
blocks phosphorylation of thiamine to its cofactor form (ThDP).
Butterworth RF, Gaudreau C, Vincelette J et al. (1991). "Thiamine deficiency and wernicke's encephalopathy in
AIDS". Metab Brain Dis 6 (4): 207–12.
10. • The other most prominent actions relate to boosting GABA activity,
especially in GABAA receptors.
• Enhancement of this complex chloride channel system contributes to
anticonvulsant, sleep-inducing, antianxiety, and muscle relaxation
effects of all GABA-boosting drugs.
• Continued use of this drug increases density of GABAA receptors,
while alcohol withdrawal states are characterized by decreases in
GABA-related activity.
• Ability of acute alcohol to inhibit postsynaptic N-methyl-d-aspartate
(NMDA) excitatory glutamate receptors, while chronic drinking and
desistance are associated with an upregulation of these excitatory
receptor subunits.
• Relationships between greater GABA and diminished NMDA receptor
activity during acute intoxication and diminished GABA with
enhanced NMDA actions during alcohol withdrawal explain much of
intoxication and withdrawal phenomena.
HARRISONS PRINCIPLES OF INTERNAL MEDICINE 18th edition vol 2; chapter 392 alcohol and
alcoholism no 3456-3552.
11. • Drinking alcohol acutely increases dopamine levels in the
brain, changes in dopamine pathways are also linked to
increases in "stress hormones," including cortisol and
adrenocorticotropic hormone (ACTH) during intoxication
and decreases in these hormones during withdrawal.
• Such alterations are likely to contribute to both feelings of
reward during intoxication and depression during falling
blood alcohol concentrations.
• Alcohol-induced changes in opioid receptors, with acute
alcohol also causing release of beta endorphins.
HARRISONS PRINCIPLES OF INTERNAL MEDICINE 18th edition vol 2; chapter 392 alcohol and
alcoholism no 3456-3552.
13. Behavioral Effects and Tolerance
• "Legal intoxication" with alcohol in most states requires a blood
alcohol concentration of 0.08 g/dL, while levels of 0.04 or even lower
are cited in other countries. In INDIA 0.15g/dL.
• Effects of Blood Alcohol Levels in the Absence of Tolerance.
Blood level g/dL Usual Effect
Less then 0.03 Not noticeable
0.03-0.05 Selective impairment
0.05-0.10 Slight impairment
0.10-0.15 Under the influence
0.15-0.20 Drunk
0.20-.30 Very drunk
0.30-0.35 Stupor to coma
Over 0.35 Comatose to death
ESSENTIALS OF FORENSIC MEDICINE K S NARARYAN REDDY 28TH EDITION ; chapter 30 CNS DEPRESSANTS no 497-514
14. Selective impairment: (0.03-0.05gm/dL) increase in reaction time; impairment of
complex skills such as flying an aircraft or driving a motor vehicle. Detectable
only on detailed examination
Slight impairment: (0.05-0.10gm/dL) flushed face; dilated pupils; euphoria; loss of
restraint
Under the influence: (0.10-0.15gm/dL) flushed face; dilated pupils; euphoria; loss
of restraint ; test errors; stagger on sudden turning.
Drunk: (0.15-0.20gm/dL) flushed face; dilated sluggish/inactive pupils; clouding of
intellect; incoordination of thought, speech and action; staggering gait with
reeling and lurching while making sudden turns.
Very drunk:(0.20-.30gm/dL) flushed or pale face; pupil inactive, contracted or
dilated; mental confusion; marked incoordination of thought, speech and
action; staggering gait with reeling and lurching while making sudden turns ,
vomiting amnesia.
.PARKS TEXTBOOK OF PREVENTIVE AND SOCIAL MEDICINE ; 21 EDITION ,CHAPTER 18 mental health-
alcoholism and drug dependence no 774.
15. Repeated use of alcohol contributes to acquired tolerance, at least three
types of compensatory mechanisms.
(1) After 1–2 weeks of daily drinking, metabolic or pharmacokinetic
tolerance can be seen, with up to 30% increase in the rate of hepatic
ethanol metabolism.
(2) Cellular or pharmacodynamic tolerance develops through
neurochemical changes that maintain relatively normal physiologic
functioning despite the presence of alcohol. Subsequent decreases in
blood levels contribute to symptoms of withdrawal.
(3) Individuals learn to adapt their behavior so that they can function
better than expected under influence of the drug (learned or behavioral
tolerance).
1.HARRISONS PRINCIPLES OF INTERNAL MEDICINE 18th edition vol 2; chapter 392 alcohol and
alcoholism no 3456-3552.
17. Acute ethyl poisoning
• Ethyl alcohol depresses central nervous system irregularly
in descending order from cortex to medulla.
• 1. Stage of excitement: (0.03-0.10%) feeling of well being and
pleasure resulting from inhibition of higher centres. Drinker
converses well , laughs and smiles readly or becomes angry easily. He
may disclose secrets.
• 2. Stage of incoordination: (0.10-0.30%) incoordination of
thought, speech, and action, which manifest as impaired judgement,
confusion, slurred speech, and staggering gait. May become morose ,
euphoric or irritable depending on his inherent emotions. Nausea
and vomiting are common. Pupils dilated. Offences committed in this
stage. Impaired judgment may lead to accidents, sexual excesses,
violence and crime.
.PARKS TEXTBOOK OF PREVENTIVE AND SOCIAL MEDICINE ; 21 EDITION , chapter 18 mental health-
alcoholism and drug dependence no 774.
18. • 3.Stage of narcosis: pt passes into deep sleep and
responds only to strong stimuli. Pulse is rapid,
temperature subnormal, breathing Sertorius, &
pupils may contracted. Macewans sign seen. If this
stage lasts for more then 12hrs, death ensues from
paralysis of cardiac or respiratory center or later
from effects of pulmonary edema.
• Recovery occurs with acute depression and
gastrointestinal irritation which continue for 24hrs
or longer. Headache is also present as an hang over
effect and is due to cerebral edema. Hang-over
means a temporary state of indisposition usually
following recovery from drunkenness.
3.PARKS TEXTBOOK OF PREVENTIVE AND SOCIAL MEDICINE ; 21 EDITION ,CHAPTER 18 mental
health- alcoholism and drug dependence no 774.
19. • Fatal dose : depend on age and habits of the pt and
the strength of liquor taken. Death usually occurs
from large quantity taken in short time.
Concentration of 0.35gm/dL & above of alcohol in
blood is generally sufficient to cause death.
• Fatal period: usually 12 to 24 hrs though death may
be delayed for 5 to 6 days.
• Cause of death : depression of respiratory center.
May be lethal at relatively lower blood levels when
combined with other CNS depressants such as
barbiturates, carbon monoxide, or morphine, & in
presence of some natural disease of heart or lungs.
3.PARKS TEXTBOOK OF PREVENTIVE AND SOCIAL MEDICINE ; 21 EDITION ,CHAPTER 18 mental health-
alcoholism and drug dependence no 774.
20. Associated acute problems
Alcoholic ketoacidosis.
Alcoholic hypoglycemia.
Fluid & electrolyte imbalance.
Wernicke’s encephalopathy
Acute effects on heart.
Acute GI effects.
Acute alcoholic myopathy.
Trauma
Associated other substance poisoning.
2.ESSENTIALS OF FORENSIC MEDICINE K S NARARYAN REDDY 28TH EDITION ; chapter 30 CNS
DEPRESSANTS no 497-514.
21. Alcoholic ketoacidosis:
High anion gap acidosis
Normal or low glucose level
Chronic alcoholics
Binge drinking wks before symptoms
Dehydration, starvation due to vomiting ,gastritis
Altered mental status
Kussumal breathing
Ketotic breath
Lab finding
high anion gap acidosis
↑beta hydroxybutyrate : acetoacetate
↓insulin level
Exclude other causes of ↑A;G acidosis
.ESSENTIALS OF FORENSIC MEDICINE K S NARARYAN REDDY 28TH EDITION ; chapter 30 CNS
DEPRESSANTS no 497-514.
23. Chronic alcoholic found unresponsive
Symptoms
neuroglycopenic →confusion,fatigue,seizure,
loss of consciousness→death
autonomic responses → palpitation ,tremor ,
sweating
Signs
pallor ,diaphoresis
tachycardia,raised systolic B.P
transient focal neurological signs
3.PARKS TEXTBOOK OF PREVENTIVE AND SOCIAL MEDICINE ; 21 EDITION ,CHAPTER 18 mental
health- alcoholism and drug dependence no 774.
Alcoholic hypoglycemia
24. Water and electrolytes disorders
Immediate ↑ in urine volume followed by ↑ADH.
Hydration also depends on
-diet, nonalcoholic fluids, type of drinks
-vomiting, diarrhea, infection
Water intoxication & hyponatremia in severe chronic
alcoholics→seizure & altered sensorium
Central pontine mylenolysis
• Other electrolytes abnormalities
Hypomagnesemia
Hypophosphatemia
Hpokalemia
Hypocalcemia
3.PARKS TEXTBOOK OF PREVENTIVE AND SOCIAL MEDICINE ; 21 EDITION ,CHAPTER 18 mental
health- alcoholism and drug dependence no 774.
25. Wernicke-korsakoff’s syndrome
As high as 12.5% in alcoholics.
Major reversible cause of death.
If untreated 10-20% mortality rate.
Thiamine deficiency is the root cause.
Magnesium deficiency in thiamin resistant cases.
Clinical features
global confusion
ocular abnormalities
ataxia
.Neurology in Clinical Practice e-dition, 5th Edition Bradley, Daroff, Fenichel & Jankovic;
chapter 61 Deficiency Diseases of the Nervous System no 1650-1654.
26. Acute effect on heart
Direct negative inotropic effect & vasodilation.
PR & QT prolongation
Both supraventricular & ventricular arrhythmia.
“holiday heart syndrome”
Various degree of heart block.
Acute alcoholic myopathy
Acute muscle necrosis mainly in binge drinkers
Alcoholism is the most common cause of rhabdomyolysis
Raised CKMM, myoglobinuria,
Acute tubular necrosis→↑urea ,creatinine
ESSENTIALS OF FORENSIC MEDICINE K S NARARYAN REDDY 28TH EDITION ; chapter 30 CNS DEPRESSANTS no
27. Acute gastrointestinal effect
Acute gastritis & esophagitis.
Epigastric distress and gastrointestinal bleeding.
Mallory-weiss tear.
Acute hepatitis & pancreatitis.
2.ESSENTIALS OF FORENSIC MEDICINE K S NARARYAN REDDY 28TH EDITION ; chapter
30 CNS DEPRESSANTS no 497-514.
29. Management
Airway
Breathing
Circulation
Intubate if poor gag reflex
Finger stick glucose , iv dextrose
Thiamin 100 mg im/ iv stat.
iv dextrose
magnesium
.ESSENTIALS OF FORENSIC MEDICINE K S NARARYAN REDDY 28TH EDITION ; chapter
30 CNS DEPRESSANTS no 497-514.
30. . 2 mg naloxone
Exclude other causes of intoxication
ABG
Osmolar gap.
2Na+ + BUN/2.8 + Glu/18 + Eth/4.6
Serum electrolytes
Anion gap.
Correct other electrolyte abnormalities
Phenytoin
CT scan
ESSENTIALS OF FORENSIC MEDICINE K S NARARYAN REDDY 28TH EDITION ; chapter 30 CNS DEPRESSANTS
no 497-514.
31. Blood alcohol conc (BAC)
Enhanced elimination
evacuation after 1 hr little benefit
activated charcoal.
fructose
haemodialysis
metadoxine (300-900mg iv) (VIBOLIV, ALCOLIV)
.ESSENTIALS OF FORENSIC MEDICINE K S NARARYAN REDDY 28TH EDITION ; chapter
30 CNS DEPRESSANTS no 497-514.
(pyridoxine–pyrrolidone carboxylate)
32. Methanol poisoning
CH3OH(wood alcohol)
Solvent ,antifreeze, paint
remover.
Epidemics of methanol toxicity.
Poisoning mainly by ingestion
Clinical effects
Inebriated but lack of euphoria.
1-72 hrs of latent period.
Fatal dose 60-240 ml.
Vertigo ,nausea, vomiting, diarrhea, abdominal
pain,dyspnea,agitation.
Blurred vision, photophobia, ↓
visual acuity
Bradycardia, blindness, seizures,
coma
ESSENTIALS OF FORENSIC MEDICINE K S NARARYAN REDDY 28TH EDITION ; chapter 30 CNS
DEPRESSANTS no 497-514.
33. Physical examination
constricted visual field, fixed & dilated pupils,
retinal edema & hyperemia of disc
resp apnea , opisthotonus & seizure in pts dying of
Methanol intoxication
Lab finding
high anion gap acidosis (correlates with
mortality)
high osmolar gap
serum methanol> 20 mg/dl symptoms
> 50 mg/ dl serious
> 100 mg/ dl ocular signs
ESSENTIALS OF FORENSIC MEDICINE K S NARARYAN REDDY 28TH EDITION ; chapter 30 CNS
DEPRESSANTS no 497-514.
34. Specific treatment
aggressive tt of acidosis
ethanol
achieve BAC of 100- 150mg
/100ml
loading 0.8gm/ kg of 5 – 10%
ethanol
followed by 130mg/kg/hr.
oral loading if no iv preparation
if dialysis,250-350 mg/kg/hr.
ethanol indications
methanol >20
mg/100ml,symptomatic
acidosis, need for HD.
ingestion >o.4ml/kg
Folic acid 30 mg iv every 4 hrly
Leucovorin 1-2mg/kg iv
4-methyl pyrazole(fomepizole ) 15-20
mg/kg iv
Haemodialysis not haemoperfusion
Haemodialysis indications:
methanol>20-50mg/100ml
acidosis not responsive to
bicarbonate
formate levels > 20 mg/100ml
visual impairment
renal impairement
Dialysis till methanol level≈0mg/100ml
and acidosis clears.
ESSENTIALS OF FORENSIC MEDICINE K S NARARYAN REDDY 28TH EDITION ; chapter 30 CNS
DEPRESSANTS no 497-514.
35. Alcoholism (Alcohol Abuse or Dependence)
• Alcohol dependence is defined in DSM-IV as repeated alcohol-related
difficulties in at least three of seven areas of functioning that cluster
together over a 12-month period. Two of these seven items, tolerance and
withdrawal, may have special importance as they are associated with a
more severe clinical course.
• Alcohol abuse is defined as repetitive problems with alcohol in any one of
four life areas—social, interpersonal, legal, and occupational—or repeated
use in hazardous situations such as driving while intoxicated in an individual
who is not alcohol dependent. About 50% of those with alcohol abuse
continue to have alcohol problems 2–5 years later, but only 10% of these
patients—including adolescents—go on to develop alcohol dependence.
• The lifetime risk for alcohol dependence in most Western countries is about
10–15% for men and 5–8% for women.
1.HARRISONS PRINCIPLES OF INTERNAL MEDICINE 18th edition vol 2; chapter 392 alcohol and
alcoholism no 3456-3552
36. Current risk terms
Abstinence : no alcohol use
Moderate drinking :
Men: no more than 2 standard drinks per drinking d
Women: no more than 1 std drink per drinking d
Elder persons(>65y): no more than 1 std drink per drinking d
Risky or hazardous drinking :
Men : More than 4 std drink per drinking d/ More than 14 std drink per drinks per wk
Women : More than 3 std drink per drinking d/ More than 7 std drink per drinks per wk
Elder persons(>65y): More than 3 std drink per drinking d/ More than 7 std drink per drinks per wk
.CONNS CURRENT THERAPY BOPE KELERMAN 2013, SECTION 16 PSYCHIATRIC DISORDERS- ALCOHOLISM no 921-927.
37. Three types of chronic alcohol abuse seen
1. regular daily excessive drinking
2.regular heavy drinking on weekends only
3.long periods of sobriety interspersed with binges that last days, weeks,
months.
Familial influence
1. a family history of alcoholism , son of an alcoholic father
2. family history of teetotalism (i.e, avoidance of alcohol under any
circumstance)
3. an alcoholic spouse
.NMS PSYCHIATRY 5th edition JOUHUA T. THORNHILL 4, chapter 5 substance related disorder
chapter 7 no 158-159
38. Screening
• Alcohol Use Disorders Identification Test
(AUDIT)
• CAGE questionnaire
• TWEAK questionnaire
• CRAFFT questionnaire
• S-MAST-G questionnaire
.CONNS CURRENT THERAPY BOPE KELERMAN 2013, SECTION 16 PSYCHIATRIC DISORDERS- ALCOHOLISM
no 921-927.
39. Screening
Add all scores to obtain a total > 8 for men or > 4 for women indicates a higher risk of alcohol use disorder
• Alcohol Use Disorders Identification Test (AUDIT)
41. • Two or more points indicate possible alcohol problem
.CONNS CURRENT THERAPY BOPE KELERMAN 2013, SECTION 16 PSYCHIATRIC DISORDERS- ALCOHOLISM no 921-927.
42. CRAFFT questionnaire
One yes response indicates need for further assessment; two yes
responses indicates risk of alcohol use disorder
.CONNS CURRENT THERAPY BOPE KELERMAN 2013, SECTION 16 PSYCHIATRIC DISORDERS- ALCOHOLISM no 921-
927.
43. The Short MAST-GERIATRIC VERSION (SMAST-G)
PleaseanswerYes or No to the followingquestions: Yes No
1. Whentalkingwithothers,doyoueverunderestimatehowmuchyoudrink?
2. Aftera fewdrinks,haveyousometimesnoteatenorbeenabletoskipa meal
becauseyoudidn’tfeel hungry?
3. Doeshavinga fewdrinkshelpdecrease yourshakinessortremors?
4. Doesalcohol sometimesmakeithardfor youto rememberpartsoftheday or
night?
5. Do youusuallytakea drinkto calmyour nerves?
6. Do youdrinkto take yourmindoffyourproblems?
7. Haveyou everincreasedyourdrinkingafterexperiencingalossinyour life?
8. Has a doctoror nurseeversaidtheywereworriedorconcernedaboutyour
drinking?
9. Haveyou evermaderulestomanageyour drinking?
10. Whenyoufeel lonely,doeshavingadrinkhelp?
SCORING:
Score1 pointfor each‘yes’answerandthentotal theresponses
2+ points = are indicativeof an alcohol problem
.CONNS CURRENT THERAPY BOPE KELERMAN 2013, SECTION 16 PSYCHIATRIC DISORDERS- ALCOHOLISM
no 921-927.
45. Diagnosis of alcohol use problems
• Alcohol abuse (> 1 in last year )
• Alcohol has caused or contributed to repeated: failure to
fulfil obligation at home, school, or work.;arrests or other
legal problems; physical fights; driving ,swimming.
• Alcohol dependence (>3 in the last 12 mnth):
development of physical tolerence,;binging episodes;
reduced time in other pleasurable activities; drinking
persists despite physical or psychological problems.
• Alcohol withdrawal (> 2 within hours to days after
lowered blood alcohol levels ): autonomic hyperactivity;
hand tremor; insomnia; anxiety; seisures;hallicinations;
nausea vomiting
46. Intervention
• Assess: screen patients with AUDIT or with CAGE or CRAFFT or S-
MAST-G questionnaires as appropriate and compute average
drinks per week.
• Advise: give feed back in the form of concern, direct conclusions,
and recommendations
• Agree: when the patient concurs that a change in drinking would
be beneficial, agree on a specific goal to cut down to a particular
daily and weekly limits for low risk drinking or to stop drinking.
Agreement should be recorded and a copy given to the pt both as
a reminder and motivator for behavioural change.
• Assist : work with the pt to formulate concrete steps to
implement the drinking reduction plan, how to avoid high risk
drinking situation , keep a record of alcohol intake.
• Arrange: set up follow up support and counseling visits or refer
pts meeting dependence criteria for specifically treatment. Seek
medical treatment if withdrawal symptoms occur.
.CONNS CURRENT THERAPY BOPE KELERMAN 2013, SECTION 16 PSYCHIATRIC DISORDERS- ALCOHOLISM no 921-927.
48. .CONNS CURRENT THERAPY BOPE KELERMAN 2013, SECTION 16 PSYCHIATRIC DISORDERS- ALCOHOLISM no 921-927.
49. .CONNS CURRENT THERAPY BOPE KELERMAN 2013, SECTION 16 PSYCHIATRIC DISORDERS- ALCOHOLISM no 921-927.
50. • Pharmacological therapy:
• Benzodiazepines – diazepam 10-20mg(valium) &
chlordiazepoxide 50-100mg(librium) CIWA-Ar score
less then 8.
• Long acting barbiturates , phenobarbital (120mg
loading followed by 60mg 6hrly) for CIWA-Ar score
of 10 or more.
• Thiamine 100mg/day for 3 days counter act
thiamine deficiencies
.CONNS CURRENT THERAPY BOPE KELERMAN 2013, SECTION 16 PSYCHIATRIC DISORDERS- ALCOHOLISM no 921-927.
51. • Asssessment of motivation : pt who is willing to consider
abstaining completely for 1 month has at least some
motivation to give up.
Medication management:
• Disulfiram(antabuse) – works by inhibiting the metabolism of
alcohol, causing build up of acetaldehyde, a noxious
substance .( 125-500mg/day).
• Naltrexone : reduction of craving of alcohol, (vivitrol long
acting I.M, once monthly 300mg reduces non compliance)
• Acamprosate(campral): taurine analogue works on GABA and
glutamate neurotransmission, reduce relapse to drinking, two
333mg tab 3 times daily who have ceased alcohol at least
5days.
• Topiramite (topamax): titrated over 5wks between 50mg and
300mg daily.
.CONNS CURRENT THERAPY BOPE KELERMAN 2013, SECTION 16 PSYCHIATRIC DISORDERS- ALCOHOLISM no 921-927.
52. Involvement of family:
• A family intervention in which all family members
confront the patients drinking, help the patient to deal
with denial.
• Refusal by spouse to remain with the pt unless he or
she stops drinking
Alcoholics anonymous (AA): highly useful treatment
group and found most effective treatment model.
Behaviour therapy : punishing drinking (e.g disulfirum)
and rewarding sobriety (e.g. by paying the pt for
abstinence)
On going emotional support by primary physician.
.CONNS CURRENT THERAPY BOPE KELERMAN 2013, SECTION 16 PSYCHIATRIC DISORDERS- ALCOHOLISM no 921-927.
58. Alcohol liver disease
• Risk factors:
• Drinking pattern- >80gm of alcohol / day
• Sex- women
• Genetics – HLAB8 , hep B & C acts as co factor
• Nutrition- alcohol increases daily requirement of
cholin, folic acid, protein deficiency promotes
the toxic of alcohol
.SLEISENGER AND FORDTRANS 9th edition gastrointestinal and liver disease Vol2 Section IX –
Liver;CHAPTER 84 – Alcoholic Liver Disease no 1394.
59. • Mechanism of liver injury
1. direct toxic effect of alcohol
2. acetaldehyde: binds with phospholipids, amino residues, &
sulphydryl groups and thus becomes reactive and toxic; binds to tubulin
and impairs the microtubules of cytoskeleton.
OTHER MECHANISM
1. Changes in intracellular redox potential
2. Mitochondrial swelling
3. Liver cell water protein retention
4. Hypermetabolic state
5. Increased liver fat
6. Immunological liver damage
7. Fibrosis
8. Cytokine mediated injury.
.SLEISENGER AND FORDTRANS 9th edition gastrointestinal and liver disease Vol2 Section IX –
Liver;CHAPTER 84 – Alcoholic Liver Disease no 1394.
60. Morphological change
• Fatty liver: presence of more than 5gm of fat/ 100gm of liver tissue.
Lab features
a. Hyperbilirubinemia
b. AST/ALT > 2 in 80% ( due to pyridoxine deficiency)
c. ALP elevated in the absence of cholestasis
d. GGT/ALP ratio 5 or higher in 50% cases
e. GGT blood levels > 30U & Carbohydrate Deficient Transferrin > 20U
( specificity and sensitivity > 70 % )
f. Other blood increased MCV > 91 and sr uric acid > 7mg/dl
.SLEISENGER AND FORDTRANS 9th edition gastrointestinal and liver disease Vol2 Section IX –
Liver;CHAPTER 84 – Alcoholic Liver Disease no 1394.
61. Alcohol hepatitis:
• c/f: anorexia, nausea, weakness, icterus, weight loss or fever.
• Morphological change : liver cell damage, neutrophilic infiltration,
pericellular & perivenular fibrosis, mallory hyaline or mallory body.
• Physical signs: hepatomegaly(95%), hepatic tenderness (50-60%), signs of
portal htn (40-70%) jaundice, fever, upper GI bleeding (30%) & evidence of
hepatic encephalopathy.
• Lab features: bilirubin increase , AST & ALT elevated, PT prolonged.
Hepatic cirrhosis:
• Morphological change : micronodular type.
• c/f: asymptomatic 10-20%, commonly presents with complications and
stigmata of CLD
• Lab features: transaminases incresed, hypoalbuminaemia , PT prolonged.
• Prognosis : Discriminant function = 4.6 *increased PT (sec) + sr bilirubin
(mg)
.SLEISENGER AND FORDTRANS 9th edition gastrointestinal and liver disease Vol2 Section IX –
Liver;CHAPTER 84 – Alcoholic Liver Disease no 1394.
62.
63. Treatment
• Dicremination factor > 32 can be tried with steroids
prednisone 40mg/day for four weeks and then taper or
pentoxyphylline.
• Abstinence from alcohol
• Dietary supplementation
• Avoid precipitating factors( infection)
• Treatment of withdrawal syndrome
• Treatment of complications ( ascites, SBP, hepatorenal
syndrome, hepatic encephalopathy, upper GI bleed)
• hepatic transplantation in selected cases
.SLEISENGER AND FORDTRANS 9th edition gastrointestinal and liver disease Vol2 Section IX –
Liver;CHAPTER 84 – Alcoholic Liver Disease no 1394.
64. Fetal alcohol syndrome(FAS)
Any unborn child, male
or female of any race
might be affected by the
alcohol that a mother
consumes while she is
pregnant.
FAS in 1 to 2 births /
1,000 in U.S each year.
65. Drunkenness
• Is a condition produced in a person, who as taken
alcohol in a quantity sufficient to cause him to
lose control of his faculties to such an extent, that
he is unable to execute safely, the occupation in
which he was engaged at the particular time.
• Model scheme of medical examination:
suggested by special committee of British
Medical Association “the drinking driver” 1965.
2.ESSENTIALS OF FORENSIC MEDICINE K S NARARYAN REDDY 28TH EDITION ; chapter 30 CNS
DEPRESSANTS no 497-514.
66. 1. Exclusion of injuries and pathological state: head injury,
metabolic disorder, neurological condition, drugs, pre-existing
psychological disorder.
2. History: relevant events obtained from accused person while
observing him. The amount and time of liquor taken should be noted.
3. General behaviour: state of dress, speech, self control.
4. Memory and mental alertness: memory of recent events,
calculations
5. Hand writing: time taken, repetition or omission of words , ability to
read his own hand writing, sign his name.
6. Pulse: rapid and usually bounding.
7. Temperature: surface temp is usually raised.
8. skin: moist, dry, flushed or pale
9. Mouth: smell of breath
10. Eyes: general, visual acuity, intrinsic muscles (pupils ) ,extrinsic
muscle (nystagmus)
.ESSENTIALS OF FORENSIC MEDICINE K S NARARYAN REDDY 28TH EDITION ; chapter 30 CNS DEPRESSANTS
no 497-514.
67. 11. Ears: gross impairment of hearing
12. Gait: manner of walking, reaction time to
direction to turn, manner of turning
13. Stance. Romberg's sign
14. Muscular coordination: placing finger to nose,
placing finger to finger, picking medium sized objects
from the floor.
15. Reflexes: knee and ankle delayed or sluggish.
Planter reflex may be extensor or flexor
16. Pulmonary, cardiovascular and git systems :
presence or absence of disease
17. Tests: nerve conduction speed, pupillary reflex
time ..ESSENTIALS OF FORENSIC MEDICINE K S NARARYAN REDDY 28TH EDITION ; chapter 30 CNS
DEPRESSANTS no 497-514.
68. • 18. Lab invest :
Blood: preserved in 100mg sodium fluoride and 30 mg potassium
oxalate for 10ml.
Widmark: evolved a formula which takes into account the size and
sex of person and the type of alcohol liquor consumed,
a=prc
a-weight of alcohol(gm) in body; p-body weight (in kg); c-
concentration of alcohol on blood (mg/kg); r- is constant (0.6 for
men, 0.5 for women)
1. kozelka and hine test is macro method 2. cavett test is a micro
method. ( in a test tube 1ml of unknown solution+ one drop
sulphuric acid + one ml of acetic acid, heat gently for one min,
strong fruity odour is positive.
.ESSENTIALS OF FORENSIC MEDICINE K S NARARYAN REDDY 28TH EDITION ; chapter 30 CNS DEPRESSANTS
no 497-514.
69. Sample Relative concentration of alcohol at
equilibrium
Whole blood 1
Plasma/serum 1.12 to 1.2
alveoli 0.0021
Spinal fluid 1.1 to 1.27
brain 0.8
vitreous 1.3
Urine 1.3
Liver 0.8
70. • Breath: alcohol absorbs radiation in infrared region of
spectrum and that the amount of infrared light absorbed
by vapour is proportional to concentration of alcohol in
that vapour.
60-100ml of breath is received in dry balloon and analysed
by drunkometer, drunkotester, intoximeter, alcometer. The
end portion of a prolonged forced expiration gives correct
results. Alcohol in deep lung air is dependent on that of
arterial blood (2100-2300 of alveolar blood contains same
amount of alcohol in 1ml of blood)
.ESSENTIALS OF FORENSIC MEDICINE K S NARARYAN REDDY 28TH EDITION ; chapter
30 CNS DEPRESSANTS no 497-514.
71. Urine: in order to compare the urine and blood, a
ratio of 1.3:1.0 is usually accepted when urine and
blood are in equilibrium.
Disadvantages: 1.time lag before equilibrium
between blood and urine reached; max concentration
reached 20-25 min later than in blood.
Vitreous: not change after death due to putrefaction,
at equilibrium , for every unit of alcohol in blood ,
there are 1.2 units in vitreous
.ESSENTIALS OF FORENSIC MEDICINE K S NARARYAN REDDY 28TH EDITION ; chapter 30 CNS
DEPRESSANTS no 497-514.
72. References
1.HARRISONS PRINCIPLES OF INTERNAL MEDICINE 18th edition vol 2; chapter 392 alcohol and
alcoholism no 3456-3552.
2.ESSENTIALS OF FORENSIC MEDICINE K S NARARYAN REDDY 28TH EDITION ; chapter 30 CNS
DEPRESSANTS no 497-514.
3.PARKS TEXTBOOK OF PREVENTIVE AND SOCIAL MEDICINE ; 21 EDITION ,CHAPTER 18 mental health-
alcoholism and drug dependence no 774.
4.CONNS CURRENT THERAPY BOPE KELERMAN 2013, SECTION 16 PSYCHIATRIC DISORDERS- ALCOHOLISM no
921-927.
5.SLEISENGER AND FORDTRANS 9th edition gastrointestinal and liver disease Vol2 Section IX –
Liver;CHAPTER 84 – Alcoholic Liver Disease no 1394.
6.Neurology in Clinical Practice e-dition, 5th Edition Bradley, Daroff, Fenichel & Jankovic;
chapter 61 Deficiency Diseases of the Nervous System no 1650-1654.
7.PARIKHS TEXT BOOK OF MEDICAL JURISPRUDENCE FORENSIC MEDICINE AND TOXICOLOGY, 6TH
EDITIOIN PART 5 CLINICAL AND FORENSIC TOXICOLOGY SECTION 10, CHAPTER 50 INEBRIANT
POISONS 10.14-10.34.
8.NMS PSYCHIATRY 5th edition JOUHUA T. THORNHILL 4, chapter 5 substance related disorder chapter 7
no 158-159
74. Ethylene glycol poisoning
Colourless, odourless ,nonvolatile,water
soluble.
Paints,polishes, cosmetics,antifreeze.
Viscous & sweet –poorman’s substitute for
alcohol.
Minimal lethal dose 1-1.5ml/kg.
Peak level 1-4 hr.
• Clinical effects
Stage 1– inebriated without odour of alcohol.
(1-12hrs) other CNS symptoms.
Stage 2-- CVS changes
(12-24 hrs)
Stage3-- ARF
(24-72 hrs)
Lab finding:
oxalate crystals in urine.
hypocalcemia
↑A: G acidosis
tt mainly on history & clinical
symptoms.
Specific treatment:
ethanol
pyridoxine
thiamine
magnesium
4-methyl pyrazole(antidote)
HD
3.PARKS TEXTBOOK OF PREVENTIVE AND SOCIAL MEDICINE ; 21 EDITION ,CHAPTER 18 mental health-
alcoholism and drug dependence no 774.
75. Isopropyl alcohol poisoning
2-propanol,isopropanol.
Clear, volatile ,bitter taste,aromatic
odour
Solvent, & disinfectant.
2nd to ethanol as most commonly
ingested alcohol.
Twice potent than ethanol as CNS
depressant.
Toxic dose--- 1ml/kg of 70 % solution.
Lethal dose---2-4ml/kg.
80% absorbed from GIT in 30 mins.
Dermal absorption & inhalation.
.PARKS TEXTBOOK OF PREVENTIVE AND SOCIAL MEDICINE ; 21 EDITION ,CHAPTER 18 mental health- alcoholism and drug dependence no 774.
76. Diagnosis
inebriated with –ve or low
ethanol.
elevated osmolar gap
ketosis without acidosis
>50mg/dl toxic,200-
400mg/dl lethal.
Treatment:
GI evacuation.
dialysis if 3-4 ml /kg of
70% solution
blood level
>400mg/dl
unrespnsive
hypotension
renal
failure,coma.
.
PARKS TEXTBOOK OF PREVENTIVE AND SOCIAL MEDICINE ; 21 EDITION ,CHAPTER 18 mental health-
alcoholism and drug dependence no 774.