23.introduction to TOXICOLOGY.pptx

introduction to toxicology

1. INTRODUCTION TO TOXICOLOGY DR. SASWATA BISWAS DEPARTMENT OF FMT MEDICAL COLLEGE, KOLKATA

2. DEFINITIONS TOXICOLOGY is the study of the adverse effects of chemicals on living organisms. It includes the study of the symptoms, signs, mechanisms, treatments, post mortem appearances, detection of poisons etc. TOXINS are poisons produced by living cells or organism. FATAL DOSE is the amount of drug that would kill 50% of the test population. FATAL PERIOD is the time in which a person dies if given fatal dose. VENOMS are special category of poisons that must be injected by one organism to another to produce harmful effects. XENOBIOTICS are drugs and chemicals foreign to the body.

3. DEFINITIONS Medical definition of poison: It is a substance which when introduced in a living organism in small quantities produces ill health or disease in a very short interval on a biochemical basis . Legal definition of poison: Administration of any substance with the intention of causing injury or death, and which causes injury or death as a result, is legally sufficient for awarding punishment, whether the substance is one which can be medically called a poison or not.

4. ACTS RELATED TO POISONS The Poisons Act 1919 The Drugs and Cosmetics Act 1940 The Drugs and Cosmetics Rule 1945: Contains several important Schedules: Schedule C: Biological and special products Schedule E(1): Poisonous substances Schedule F: Vaccines, antisera and diagnostic antigens Schedule G: Drugs to be taken under medical supervision Schedule H: Prescription drugs Schedule J: list of 51 diseases for the cure of which no drug can be advertised

5. ACTS RELATED TO POISONS The Drugs Control Act 1950 The Drugs and Magic Remedies (Objectionable Advertisement) Act 1954 The Medicinal and Toilet Preparations( Excise Duty) Act, 1956 The Narcotic Drugs and Psychotropic Substances (NDPS) Act, 1985

6. MEDICOLEGAL ASPECTS OF POISONS SEC. 85 IPC: Criminal Act done under involuntary intoxication SEC. 86 IPC : Criminal Act done under voluntary intoxication SEC. 274 IPC : Adulteration of drugs- 6 months/+ Rs 1000 fine SEC. 275 IPC : Sale of adulterated drugs- 6 months/+ Rs 1000 fine SEC. 276 IPC : Sale of drug as a different drug or preparation- 6 months/+ Rs 1000 fine SEC. 277 IPC : Fouling water of public spring or reservoir- 3 months/+ Rs 500 fine SEC. 278 IPC : Making atmosphere noxious to health- Rs 500 fine

7. MEDICOLEGAL ASPECTS OF POISONS SEC. 284 IPC : Negligent conduct with respect to poisonous substance- 6 months/+ Rs 1000 fine SEC. 324 IPC SEC. 326 IPC SEC. 328 IPC: Person gives or otherwise administers a stupefying, intoxicating or unwholesome agent, (a) with an intention of causing hurt or(b) with intent to commit or to facilitate the commission of an offence or (c) knowing it to be likely that he will thereby cause hurt- 10 years + fine SECONDARY POISONING

8. NATURE OF POISONING HOMICIDE: Characters of an ideal homicidal poison: Should be colourless, odourless and tasteless[ most important] Should be easily available Should be cheap Its symptoms should resemble a natural disease Symptoms should appear late after admission to avoid suspicion Should not produce vomiting Should be highly toxic Fatal period should be less once symptoms have appeared There should be no available antidote There should be no post-mortem changes Should disappear from the body after death There should be no available test to detect it.

9. NATURE OF POISONING SUICIDE: Characters of an ideal suicidal poison are: Should produce an easy death[ most important criteria] Easily available Capable of being easily taken in food or drink. Cheapness, colour, odour, taste are not so important criteria. PARASUICIDE [or pseudocide ] : refers to suicide attempts or gestures and self harm where there is no actual intention to die.

10. NATURE OF POISONING ACCIDENTAL: Mistakenly ingested Inhalation of vapours through accident Excessive self medication Drug addiction Infected foods Animals [snakes, scorpions etc]

11. NATURE OF POISONING ABORTION: Most irritant poisons APHRODISIACS: is a substance that increases sexual desire ARROW POISONS: should be poisonous parenterally but safe orally CATTLE POISONING STUPEFYING

12. CLASSIFICATION OF POISONS ACCORDING TO SYMPTOMS PRODUCED ACCORDING TO USE ACCORDING TO AFFECTED TARGET ORGANS

13. CLASSIFICATION OF POISONS ACCORDING TO SYMPTOMS PRODUCED CORROSIVES : a. Strong Acids: Inorganic and Organic b. Strong alkalis c. Metallic salts IRRITANTS : a. Inorganic: Non-metallic and Metallic b. Organic: Plant and Animals c. Mechanical

14. CLASSIFICATION OF POISONS SYSTEMIC : a. CNS poisons CEREBRAL : CNS stimulants, CNS depressants, Deliriants SPINAL PERIPHERAL NERVE POISONS CVS poisons Asphyxiants MISCELLANOUS

15. ACCORDING TO AFFECTED TARGET ORGANS AFFECTING HEMATOLOGIC SYSTEM : Anticoagulants AFFECTING IMMUNOLOGICAL SYSTEM HEPATOTOXIC AGENTS : H EMOLYTIC POISONS, E THANOL, P ARACETAMOL, A FLATOXIN, T OXAPHENE, I RON, C HLORPROMAZINE NEPHROTOXIC AGENTS : Glomerular Injury: cocaine, estrogens , gold, NSAIDS, penicillamine PCT necrosis: P henols, P igments, C antharides, C ephalosporins, C orrosive sublimate, T etrachloride carbon DCT necrosis: C isplatin, A mphotericin, G lycols PULMONARY TOXIC AGENTS CNS TOXIC AGENTS CVS TOXIC AGENTS DERMATOTOXIC AGENTS AGENTS AFFECTING REPRODUCTIVE SYSTEM/ ENDOCRINE SYSTEM

16. TYPES OF POISONING HYPERACUTE/ FULMINANT POISONING ACUTE POISONING SUBACUTE POISONING CHRONIC POISONING ACUTE ON CHRONIC POISONING

17. TYPES OF ACUTE DRUG FATALITIES PRIMARY DRUG FATALITIES SECONDARY DRUG FATALITIES DRUG ASSOCIATED FATALITIES

18. TOXICITY RATING GOSSELIN, SMITH AND HODGE SCALE TOXICITY RATING TOXICITY CLASS FATAL DOSE FOR 70 KG PERSON 6 SUPER TOXIC < 5 mg/kg 1 grain [< 7 drops] 5 EXTREMELY TOXIC 5-50 mg/kg 4 ml 4 VERY TOXIC 50-500mg/kg 30ml 3 MODERATELY TOXIC 0.5-5gm/kg 30-600ml 2 SLIGHTLY TOXIC 5-15gm/kg 600-1200ml 1 PRACTICALLY NON-TOXIC >15gm/kg >1200ml

19. POISON CONTROL CENTERS A poison control centre (PCC) or poison information centre (PIC) is a medical facility that provides free, immediate, expert treatment advice and assistance over the telephone in case of exposure to poisons. First established in Netherlands in the late 1940s. In India, National Poisons Information Centre(NPIC) was started in AIIMS in 1995. SIGNIFICANCE: mortality during shifting of patients to hospital is reduced. CONTACTING PCCs: toll free phones 24*7*365 ADVICE: provided not only to patients directly but also to hospital emergency departments and private practitioners. TOLL FREE NO. NPIC: 1800 116 117 PIC NO. (EASTERN INDIA): 1800 345 0033

20. DIAGNOSIS OF POISONING

21. IN THE LIVING Diagnosis of poisoning in the living consists of: CLINICAL HISTORY CLINICAL SIGNS LABORATORY INVESTIGATIONS

22. CLINICAL HISTORY Find out all of this information: Which drug(s) were taken? When was it taken? How much was taken? How was it taken? Why was it taken? Was anything else taken? Obtain a clinical history from family/friends or paramedics: - patient’s behavior prior to arrival - changing vital signs - seizures

23. CLINICAL HISTORY There is sudden appearance of symptoms. Major symptoms are associated with GIT, Hepatic and CNS. There is association with food intake. There are multiple victims. Some poisonings may mimic natural diseases.

24. GASTRO-INTENSTINAL SYMPTOMS CAUSES OF ACUTE ABDOMEN: Black widow spider bite Drugs Heavy metals Improperly canned foods Mushroom poisoning CAUSES VOMITTING AND DIAHORREA All irritants Organophosphorus CAUSES CONSTIPATION Anticholinergics, Antipsychotics, Antispasmodics, Atropine, TCAs Botulism Iron, Lead, Lithium Opium and derivatives

25. POISONS MIMICKING NATURAL DISEASES POISON DISEASE Abrus Precatorius Viper bite Arsenic(acute) Cholera Arsenic(chronic) Addison’s disease, Measles Bromide Acne Carbolic acid Alkaptonuria Dinitro compounds Thyrotoxicosis Iodide Mumps Organophosphorus Asthma Phosphorus Jaundice Strychnine Tetanus Thallium Guillain Barre syndrome Zinc, some other metals Flu, Malaria

26. PHYSICAL EXAMINATION: Vital Signs: You MUST obtain a full set of vital signs, including blood glucose. Vital signs are the key to your initial management of the patient....

27. Vital signs: Pulse Bradycardia Tachycardia (P.A.C.E.D.) (F.A.S.T.) Propanolol , poppies Freebase Anticholinesterases Anticholinergics Clonidine, CCB’s Antihistamines Ethanol Amphetamines Digoxin Sympathomimetics Solvents Theophylline

28. Vital signs: Temperature Hypothermia Hyperthermia (C.O.O.L.S.) (N.A.S.A.) Carbon monoxide Nicotine Opiates Antihistamines Oral hypoglycemics Salicylates Liquor Sympathomimetics Sedatives/Hypnotics Anticholinergics

29. Vital signs: Blood pressure Hypotension Hypertension (C.R.A.S.H.) (C.T.S.C.A.N.) Clonidine, CCB’s Cocaine Reserpine Thyroid supplements Antihypertensives Sympathomimetics Antidepressants Caffeine Aminophylline Anticholinergics Sedative/Hypnotics Amphetamines Heroin (opiates) Nicotine

30. Vital signs: Respiration rate Hypoventilation Hyperventilation (S.L.O.W.) (P.A.N.T.) Sedative/Hypnotics PCP Liquor Pneumonitis Opiates Acetyl salicylic acid/ Amphetamine Weed (marijuana) Noncardiogenic pulmonary edema Toxic met. acidosis

31. Physical: Neurologic exam Altered Mental status Seizures (AEIOU TIPS) (OTIS CAMPBELL) Alcohol Organophosphates Endocrine/Epilepsy Tricyclics Intoxication INH/Insulin Oxygen Sympathomimetics Uremia Camphor/Cocaine Trauma/Tumor Amphetamines Infection Methylxanthines Psychological PCP Shock/Strokes Benzo withdrawal Ethanol Lead, Lithium Lidocaine, Lindane

32. Physical exam: Pupils Miosis Mydriasis (C.O.P.S.) (A.A.A.S) Cholinergics Antihistamines Clonidine Antidepressants Opiates Anticholinergics Organophosphates (Atropine) Pontine bleed Sympathomimetics Phenothiazines (Cocaine) Sedatives/Hypnotics

33. Physical: Dermatological exam Diaphoresis Red Skin Blue Skin (S.O.A.P.) CO Cyanosis Sympathomimetics Boric Acid MetHb Organophosphates Anticholinergics Aspirin PCP Blistering Barbituates , CO, Sedative hypnotics, snake/spider bites

34. Odors... Bitter almonds: Cyanide Mothballs: Camphor Garlic: Organophosphates, Arsenic Peanuts: Rodenticide Carrots: Water hemlock Rotten eggs: Sulfur dioxide, H 2 S Wintergreen: Methyl salicylates Gasoline: Hydrocarbons Fruity: DKA, Isopropanol Pears: Chloral hydrate

35. LABORATORY INVESTIGATIONS URINE BLOOD ECG EEG HAIR SALIVA SWEAT X-RAY

36. SOME POSSIBLE CAUSES OF COLOURED URINE COLOUR POSSIBLE CAUSES YELLOW/BROWN BILIRUBIN,HEMOGLOBIN,MYOGLOBIN, CHLOROQUINE,CRESOL,QUININE RED/BROWN BILIRUBIN,HEMOGLOBIN,MYOGLOBIN, PORPHYRIAS, DESFERROXAMINE,LEVODOPA BLUE/GREEN BILE,ACRIFLAVINE,CRESOL BLACK PHENOL,HOMOGENTISIC ACID

37. A SELECTED LIST OF RADIOOPAQUE DRUGS AND POISONS [C-H-I-P-S] Chloral Hydrate Calcium Carbonate Cocaine packets Heavy metals Halogenated Hydrocarbons Iron Phenothiazines, Phosphorus, Play-doh Slow release drugs, Sodium chloride

38. DIAGNOSIS OF POISONING IN THE DEAD Mainly consists of the following things: CLINICAL HISTORY POST MORTEM APPEARANCES LABORATORY ANALYSIS EXPERIMENTS ON ANIMALS MORAL AND CIRCUMSTANTIAL EVIDENCE

39. POST MORTEM APPEARANCES EXTERNAL : Stains PM staining Smell Natural orifices Skin Marks of violence

40. POST MORTEM APPEARANCES INTERNAL: Smell Mouth, Throat and associated structures Esophagus Stomach Doudenum Respiratory tract Intestines Liver, kidney Heart Genito-urinary system

41. STOMACH FINDINGS IN CASE OF POISONING HYPEREMIA SOFTENING ULCERS PERFORATIONS STOMACH WALL CONTENTS OF THE STOMACH

42. COLOUR CHANGES IN MUCUS MEMBRANE OF STOMACH COLOUR POISON BLACK, CHARRED SULPHURIC, HYDROCHLORIC, ACETIC ACID BLUE AMYTAL CAPSULE, COPPER SULPHATE BROWN CRESOLS BUFF WHITE CARBOLIC ACID CHERRY RED CO CONGESTED IRRITANTS GREEN FERROUS SULPHATE PINK SONERYL SLATE GREY MERCURY WHITE PARTICLES ARSENIC YELLOW NITRIC ACID

43. LABORATORY ANALYSIS COLLECTION OF SPECIMENS : Blood and Bile, post mortem diffusion SEPARATION OF POISON FROM TISSUE . WHAT VISCERA SHOULD BE PESERVED: Stomach and its contents Small intestine and its contents Liver- 500 gm with gall bladder Kidney- one half of each kidney Blood – 30 ml Urine- 30 ml Food or medicine

44. MORAL AND CIRCUMSTANTIAL EVIDENCE The evidence consists of: Motive Possible gain to accused from poisoning his victim Evidence of witnesses about recent purchase of poison Behaviour of accused before and after commission of offence Recovery of poison from possession of accused Relationship between accused and victim.

45. DUTIES OF A MEDICAL PRACTIONER IN A CASE OF SUSPECTED POISONING MEDICAL LEGAL Information to the police : ALL CASES. Applies to both government and private facilities. At the hospital: collection of body fluids and clothes and handing over to the police. Arrangement for dying declaration. Information to public health authorities.