Cardiac poisons forensic aspects part1

aconite, nicotine, digitalis, quinine - medico legal aspects

1. Cardiac poisons-part1 DRM BALAJI SINGH COURTESY: DR GAUTAM BISWAS , SLIDESHARE

2. Cardiac poisons first four poisons discussed in part 1, next four in part 2 Aconite Nicotiana tabacum Digitalis Pupurea Quinine Nerium Odorum Cerbera thevetia Cerbera Odallam Cleistanthus Collinus

3. Aconite : Radix aconiti , Monk’s hood, mitha zaher ( Hindi), mitha bish (Hindi), wolf’s bane, women’s bane, devil’s helmet or blue rocket

4. Aconite All parts of the plant are poisonous, however, the root and root tubers are the most potent poisons. Dry root is conical or tapering, shows bases of the broken rootlets and shriveled with longitudinal wrinkles. It is 5–10 cm long, 1.5–2 cm thick at the upper end and dark brown in color. Roots are mistaken for horseradish root.

5. Similar plants useful in Ayurvadic medicine ATIVISA - Aconitum heterophyllum Aconitum palmatum. aconite Aconitum heterophyllum Aconitum heterophyllum

6. Aconite Active principles: Aconitine, pseudo-aconitine, indaconitine, picraconitine and aconine. Properties of aconitine : Colourless, transparent, rhombic crystals. Insoluble in water, but readily soluble in benzene and chloroform.

7. Action Toxicity of aconitine and related alkaloids are due to their actions on the voltage-sensitive sodium channels of the cell membranes of excitable tissues. Aconitine first stimulates and then paralyzes the peripheral terminations of sensory and secretory nerves , CNS, and nerves of the myocardium, skeletal and smooth muscles. It does not affect the higher centers of the brain as consciousness remains intact till the end.

8. System Signs and symptoms GIT Nausea, vomiting, salivation, pain in the abdomen and diarrhoea. Bitter-sweet taste, severe burning and tingling of tongue, mouth, perioral area and throat, followed by numbness. CVS Pulse is slow, feeble and irregular, and low BP chest pain, palpitations, sometimes sinus tachycardia, ventricular ectopics and ventricular tachycardia/fibrillation. CNS headache, giddiness. Vertigo, restlessness, Muscle Weakness of limbs with twitchings and spasms. Respiratory System Respiration is slow, labored and shallow. Ocular Pupils alternately contract and dilate (hippus). Diplopia and impaired vision occurs. Others Temperature is subnormal and skin is cold.

9. hippus Video on hippus is attached ,If you are watching online ,Please right click on YouTube symbol ,

10. Aconite …actions Terminal stages are marked by severe pain and paralysis of facial muscles. Many victims remain conscious until near death; some complain of yellow-green vision and tinnitus . Death is due to respiratory failure or ventricular fibrillation .

11. Mitha zahar (sweet poison- meaning in Hindi) Fatal dose Root: 1–2 g. Aconitine: 2–5 mg. Fatal period : 2–6 hours (h).

12. Treatment There is no specific antidote for aconite, and treatment is supportive. i. Gastric lavage with tannic acid/activated charcoal. ii. Inotropic therapy is required if hypotension persists, and atropine (0.5–1 mg IV) should be used to treat bradycardia. iii. Ventricular arrhythmia is treated with amiodarone and flecainide . iv. Symptomatic treatment

13. Postmortem Findings Not specific , those of asphyxia- cyanosis, congestion, Petechial haemorrhages iii . Stomach : Fragments of root may be found in the stomach. iv. Lungs : Haemorrhagic pulmonary oedema. v. Heart : Diffuse or contraction-band necrosis in myocardium

14. Medico-legal Aspects It is often regarded as an ideal homicidal poison. Advantages are: a. It is cheap and easily available. b. Lethal dose is small and the fatal period is short. c. Color can be masked by mixing it with pink colored drinks. d. Taste can be masked by mixing it with sweets or by giving it with betel leaves. e. Extremely unstable and destroyed by putrefaction, hence cannot be detected by chemical analysis .

15. M L I……. Accidental poisoning occurs due to: a. Eating the roots mistaking it for horseradish. b. Use of quack remedies, aconite, aconitum etc. c. Taking of alcohol mixed with aconitine to increase intoxication. d. Consumption of herbal decoction made from aconite roots. It is also used as an abortifacient, cattle and arrow poison. Suicide is not common. horseradish Aconitum heterophyllum aconite

16. Nicotiana tabacum

17. Nicotiana Tabacum (Tobacco) All parts of the plant are poisonous, except the ripe seeds. Dried leaves contain 1–8% nicotine. Leaves contain toxic alkaloids, like nicotine, anabasine, nornicotine and lobeline (in Indian tobacco). An average cigarette delivers 1–3 mg of nicotine. Properties of nicotine : Colorless, hygroscopic oily liquid. Burning acrid taste and disagreeable odor. Action It acts on the autonomic ganglia, which are stimulated initially, but are depressed and blocked at the later stages. It also acts on the somatic neuromuscular junction and afferent fibers from sensory receptors.

18. Signs and Symptoms Acute Poisoning CVS : Tachycardia followed by bradycardia, hypotension, arrhythmia, RS Tachypnea followed by respiratory depression and collapse. GIT : Burning acid sensation, nausea, vomiting, abdominal pain, salivation and odour of tobacco. CNS : Headache, restlessness, confusion, vertigo, sweating, convulsions and coma.

19. Chronic Poisoning RS : Cough, wheeze, dyspnoea, chronic bronchitis and lung cancer may develop. CVS : Anaemia, palpitations, irregularity of heart, angina pectoris and Berger's disease. Thrombo angitis obliterance GIT : Anorexia, vomiting and diarrhoea. CNS and others: Impaired memory, blindness, tremors, insomnia, anxiety and headache. Obstracted blood vessels

20. nicotine Fatal dose nicotine: 60–100 mg. Tobacco: 15–30 g. Fatal period : 5–15 minutes.

21. Treatment of acute nicotine poisoning i. Gastric lavage with charcoal, KMnO4. ii. Purgatives. iii. Cardiac monitoring. iv. Dopamine or dobutamine to correct hypotension, atropine to correct bradycardia v. Diazepam for convulsions and symptomatic treatment. In chronic poisoning , clonidine has shown encouraging result

22. Post mortem Findings i. Brownish froth at mouth and nostrils. ii. Stomach may contain fragments of leaves or smell of tobacco . iii. Features of asphyxia are seen

23. Medico-legal Aspects Accidental poisoning results from ingestion, excessive smoking and application of leaves or juice to wound or skin. Commonest legalized drug of addiction / habit. For malingering, leaves are soaked in water for some hours and placed in axilla at bed time, mild symptoms of poisoning are seen by next morning. Suicidal/homicidal cases are rare Is smoking on open roads or other public places legal in India? Just like alcohol, smoking also legalized only in permitted areas in India.

24. Passive smoking also dangerous “Section 4 of the Cigarettes and Other Tobacco Products Act (COTPA) describes about Prohibition of Smoking at Public Places which is applicable from 2nd October, 2008” What is Public Place It includes all the places visited by the public such as auditorium, hospital, railway stations, public offices, courts, educational institutions, libraries, canteens, banks, clubs. It also includes the open spaces such as premises of the hotels and restaurants. Punishment : Fine of Rs. 200 if anyone is found smoking at public places. The Government has put up an Amendment Bill in the Parliament where it has been raised upto Rs. 1000. It has also been decided by the Health Ministry that the minimum age for buying tobacco related products is 21 which was earlier 18 and the same has been incorporated in the amendment bill.

25. Green tobacco sickness commonly occurs in tobacco growing States. Workers handling leaves may absorb alkaloids through skin. Symptoms include nausea, vomiting, diarrhoea, diaphoresis (profuse perspiration artificially induced), and weakness that usually resolve with symptomatic treatment.

26. Digitalis Purpurea ( Foxglove) Active principles : Its roots, leaves and seeds contain several glycosides—digitoxin, digitalin, digitalein and digitonin are the most poisonous. Actions Glycosides are substances found in plants, and are composed of a sugar and a non-sugar compound, the later having toxicological action The glycosides act directly on the heart muscle (prolong diastolic period) and improve the function of the failing heart. In toxic doses, excitability is increased with extra systoles. Signs and Symptoms Toxic symptoms are due to overdose or by a cumulative action.

27. Therapeutic uses Lanoxin Tablets (digoxin) is a cardiac glycoside that has specific effects on the myocardial tissue and is used to treat heart failure by increasing left ventricular ejection fractions and arrhythmias such as atrial fibrillation by controlling the ventricular response rate. Digoxin derived from the leaves of a digitalis plant. Digoxin in therapeutic doses make the heart beat stronger and with a more regular rhythm. Digoxin is used to treat heart failure. it also used to treat atrial fibrillation , a heart rhythm disorder of the atria .

28. System : Signs and symptoms GIT Nausea, vomiting, pain in abdomen, burning sensation, diarrhea CVS Bradycardia, extrasystoles, ventricular tachycardia and fibrillation, atrial fibrillation, faintness, precordial oppression, heart block. CNS Headache, fatigue, confusion, anxiety, depression, disorientation, drowsiness, hallucinations, delirium. RS Labored and sighing respiration. Ocular Transient ambylopia, blurring, photophobia, scotoma, diplopia, color aberration. Skin Urticaria. The patient becomes drowsy and the condition may deepen into coma. Convulsions may precede death.

29. Death occurs from cardiovascular collapse. Fatal dose Digitalis: 2–3 g. Digoxin: 5 mg. ( 10 ampules of digoxin ) Digitalin: 15–20 mg. „Powdered leaves: 2.5 g. Fatal period : 1–24 h.

30. Treatment ECG monitoring is necessary as a guide to treatment. Gastric lavage is done with a solution of tannic acid and activated charcoal. Purgatives may be given. Atropine is given in a dose of 0.6 mg IV to treat bradycardia Potassium chloride may be given to reduce extrasystoles. Specific antidote for cardiac arrhythmias is lignocaine 100 mg IV or novocaine or propranolol. Trisodium EDTA may help to lower serum calcium levels. Symptomatic treatment.

31. Postmortem Findings Non-specific changes are seen. There may be irritation of the gastric mucosa. Digitalis leaves or seeds may be found in the stomach. Medico-legal Aspects It is a cumulative poison , and persons taking it for a long time may suddenly develops symptoms of poisoning. Accidental poisoning due to overdose of a medicinal preparation or from eating leaves by mistake or by folk remedies. Homicidal poisoning may possible , and no suspicion of poisoning may arise due to similarities of symptoms of heart disease.

32. Quinine The bark of Cinchona plant contains quinine, quinidine, cinchonidine and other alkaloids. Quinine occurs as white needle-shaped, odorless, crystalline and bitter powder. Actions It is a protoplasmic poison with anesthetic and sclerosing effect. It stimulates and then depresses the CNS. It causes circulatory failure by direct and indirect actions. Cinchona

33. Signs and Symptoms pain in the abdomen, vomiting, diarrhoea, headache, giddiness, tinnitus, partial deafness, loss of vision, scotoma, confusion, muscular weakness, itching, tachycardia, hypotension and cyanosis. There may be oliguria, haemolysis, haematuria and uraemia. Respiration is rapid and shallow, pupils are fixed and dilated, delirium and coma. Death occurs from respiratory failure. cinchona

34. Cinchonism or quinism is caused by repeated therapeutic doses or overdose of quinine. Symptoms are tinnitus, vertigo, deafness, diplopia, scotoma, blindness, skin rash, hypo glycemia and cardiac arrhythmias. Fatal dose: 2–8 g. Fatal period: About 6 h.

35. Treatment Gastric lavage is done, and magnesium sulfate is used for purgation. Activated charcoal . For cardiac toxicity, IV bolus of sodium bicarbonate is given. Ventricular tachycardia may be treated with magnesium IV or overdrive pacing. Intravenous fluids are given to promote diuresis. Protection of vision: Blocking of bilateral stellate ganglion is sometimes recommended. Symptomatic treatment Assisted ventilation. Continuous cardiac monitoring is needed.

36. Postmortem Findings Non-specific. Organs are congested, and hemolysis of red cells may be found. Kidney : Renal tubules may be blocked by hemoglobin. Medico-legal Aspects Accidental poisoning occurs due to medicinal overdose. Suicide/homicide is rare. It is used as an abortifacient in folk remedies.

37. Cinchonism Definition of cinchonism a disorder due to excessive or prolonged use of cinchona or its alkaloids and marked by temporary deafness , ringing in the ears, headache, dizziness, and rash, cardiac rhythm irregularities.

38. Thank you …………. Just Relax ……….. next poisonous plants will be discussed in “ cardio toxic poisons part2”