CARDIAC POISONScoihxouhdouhdoudh9udh9udg9udg8udg8udgd.pptx

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1. CARDIAC POISONS ACONITE OLEANDER DIGITALIS TOBACCO HYDROCYANIC ACID QUININE

2. Mechanism of action of Cardiac Glycosides Inhibition of Na-K-adenosine triphosphatase pump- ---increased level of intracellular Na + and decreased level of intracellular k + --- hyperkalemia. Increased level of intracellular Ca ++ ------ dysrhythmia Increased cardiac vagal tone ---- bradycardia and heart block

3. ACONITE Mitha Bish / Mitha Zaher Bish / Bikh Monk’s hood Devil’s helmet Blue rocket Wolfsbane

4. Historical importance Death of Jewish High Priest Alkimos in 159 BC was regarded Stroke related. However description of severe pain suggested aconite poisoning. Roman Emperor Trajan [98-117 AD] banned the growing of this plant in all Roman domestic gardens. Roman poet Ovid [43 BC-AD 18] called aconite ‘Stepmother’s poison’. It is highly suspected that Roman Emperor Claudius died in 54 AD following acute aconite poisoning administered by his spouse Agrippina.

5. Mythology and Magical History Ancient Greeks had that belief that aconite used to grow up wherever the saliva of mythical three headed dog Cerberus ( the guardian of Hell) fell on the ground. In magical world it was supposed to be used in treatment of Lycanthropy (capacity of human turning into wolves) and was also fed to wolves (an approach in lycanthropy) to kill them (so aconite is also being called WOLFSBANE ).

6. Which part of the plant is poisonous? All parts of the plant are poisonous, but roots are most poisonous . Botanical name: Aconitum napellus , Aconitum ferox Position: cardiac poison Fatal dose: Root: 1-2 gm Aconitine: 2-4 mg Fatal period: 2-6 hours.

7. Specimen: Aconite Root Length: 5-10 cm Thickness: 1.5-2 cm When fresh: when cut color is white inside and becomes pink on exposure to air Dry root: conical or tapering, dark brown in color, usually arched and shrivelled with longitudinal wrinkles and having scars or bases of broken rootlets on the surface. Taste: sweet initially, later acrid. Has got similarity with : horseradish root

8. Active principles It contains several alkaloids like: Aconitine Mesaconitine Pseudoacinitine Picraconitine Indaconitine bikhaconitine Aconine

9. Mechanism of action Recent theory: Aconite alkaloids opens up Na+ channels by binding at site 2- ---Na + channel activation------Na + influx through them----increased inotropic action while delaying final repolarization phase of action potential----causes premature excitation of myocardial muscles ---as a consequence of repeated depolarization Na + channels become refractory to excitation. Previous theory: aconite 1 st stimulates and then paralyzes peripheral termination of sensory and secretory nerves, CNS, nerves of myocardium, skeletal and smooth muscles. But it does not affect higher centres of brain so that consciousness remain intact till death.

10. Signs and Symptoms on Ingestion GIT: Sweetish taste felt in mouth---burning sensation in mouth Burning sensation passes from mouth to stomach, followed by tingling and numbness in mouth, tongue and pharynx. Salivation, nausea, vomiting, diarrhoea, pain abdomen Later mouth becomes dry and there will be thirst and dysphagia. Respiratory: slow, shallow, laboured. Skin: cold, clammy skin, profuse sweating, pallor Temperature: decreases.

11. 6. Eyes: Impaired vision Diplopia Pupil: contract and dilate alternatively in initial stage [HIPPUS] with fluctuation in pupillary diameter (1-2 mm)—widely dilate later. 7. CNS: Headache, giddiness, vertigo, restlessness Numbness and tingling over entire body Consciousness remain clear till end.

12. 8. M uscular: Weakness in limbs—patient unable to stand or walk Twitching and muscular spasms Shooting pain in muscles Convulsion 9. CVS: Pulse: slow, feeble, irregular Hypotension. Initial tachycardia, followed by bradycardia Atrial and ventricular arrhythmias, resistant to electric defibrillator Ventricular ectopics AV block, bundle branch block

13. Management: Gastric lavage with luke warm water and weak solution of Tannic acid (1000-1200 mg in 1-2 litres of water) to precipitate alkaloids. Activated charcoal Atropine 0.5-1mg IV immediately to improve respiratory rate and heart rate, may be repeated if required. Cardiac monitoring and Anti-arrhythmic drugs Symptomatic management. Cause of death: Mostly due to Ventricular fibrillation May be due to respiratory failure.

14. Post mortem findings Aconite is very much unstable and readily destroyed by putrefaction. So quick toxicological analysis is most important in diagnosis. Fragments of roots may be detected in stomach content. GIT mucosa: congested with patchy Submucosal hemorrhage All viscera are congested

15. Medicolegal aspects Homicide: Aconite is often considered as an ‘ Ideal Homicidal Poison’ because of the following advantages: Easily available and cheap Lethal dose is small Fatal period is short Taste is somewhat sweetish, however taste can be masked by mixing it with sweets or giving it with betel leaves Color can be disguised by mixing it with pink colored drinks Extremely unstable, destroyed by putrefaction, so it can not be detected by chemical analysis if not done quickly.

16. 2. A ccidental: Eating the roots mistaking it for horseradish Taking alcoholic drinks mixed with aconite to increase intoxication Used by hakims and quacks for treatment of rheumatic pain, carbuncle, furuncle 3. Suicide: not common now a days. 4. Also used as cattle poison, arrow poison and as abortifacient.

17. Yellow Oleander Pila kaner Kalkey phool

18. Which parts of the plant are poisonous? All parts of the plant are poisonous Highest concentration of cardiac glycosides is present in kernel of seeds , followed by leaves and fruit. Botanical name: Cerbera thevetia / Thevetia peruviana/ Thevetia nerrifolia. Position: cardiac poison. Fatal dose: 8-10 seeds Fatal period: 2-3 hours

19. Active principles: Cerberin : acts like strychnine Thevetin A, Thevetin B (powerful cardiac poison) Thevotoxin: less toxic than Thevetin and resembles digitalis in action. Nerifolin Peruvoside Ruvoside Leaves: lanceolate Flower: yellow, bell shaped, 5 lobes spirally twisted Fruit: globular, light green in color, contains single large nut.

20. Specimen: Yellow Oleander Nut Identification: pale brown colored nut with a deep groove along the edge, shaped like two triangles are joined by their bases. Each nut contains 5 pale yellow seeds.

21. Medicolegal aspects Homicide: rare Suicide: common in villages Abortifacient: applying locally in form of paste or taking powdered seeds or roots orally Cattle poison in form of powdered seeds. Accidental: When taken mistakenly, specially in cases of children. In process of procuring abortion. Medicinal over dosage when used by quacks for treatment of venereal diseases, antipyretic, purgative, for treatment of ulcer and cancer, asthma, externally to reduce swelling or used as love-philtre.

22. Mechanism of action: Cardiac glycosides resemble Digitalis in action and thus inhibits Sodium-Potassium ATPase. Cerberin : acts like Strychnine. Signs and symptoms: on chewing and ingestion: GIT: Burning sensation in mouth, tongue, throat, followed by tingling sensation. Sensation of dryness in throat. Nausea, vomiting, diarrhoea---dehydration---features of hypovolemic shock (fall in blood pressure, rapid, irregular and feeble pulse) 2. Pupil: dilated

23. 3. N euromuscular: muscular twitching, tetanic spasm, loss of muscle power. 4. CNS: headache, dizziness 5. CVS: Ectopic ventricular rhythm (most common) Ventricular tachycardia (sometimes bidirectional ) and fibrillation Atrial fibrillation Heart block Sometimes cardioversion resistant fatal ventricular fibrillation or refractory cardiogenic shock. ECG findings : ventricular arrhythmia, AV block, lengthened PR segment, shortened S-T interval, flattened or inverted T wave

24. Management Gastric lavage with weak solution of KMNO 4 —then suspension of activated charcoal is left in stomach to adsorb the residual poison—remove afterwards. Strict cardiac monitoring , use 12 lead ECG. To treat bradycardia : bolus dose of atropine 2mg or infusion 0.6mg/ hr. To treat hypotension: 5% glucose saline with adrenaline 2ml (1:1000 dilution) and 2mg of noradrenaline. To treat acidosis : Molar solution of sodium lactate IV. To treat severe bradycardia following AV block : temporary pacing To treat Ventricular fibrillation: low energy DC cardioversion

25. 8. Antidote: Digoxin Specific Antibody Fragments or Fab: Use : in toxicity of digoxin, digitoxin and all types of cardiac glycosides. Availability: Digibind [38 mg/vial], DigiFab [40 mg/vial] in lyophilized form. Vial is reconstituted with 4 ml of sterile water. Dose: 400 mg over 20 minutes, followed by 400-800 mg over 4-8 hours by infusion. 9. Symptomatic treatment. Cause of death : peripheral circulatory failure.

26. Postmortem appearance It resists putrefaction, thus can be detected even long after death and also in exhumed decomposed bodies. Stomach and upper part of intestine : may contain fragments of seeds, congested. Congestion of other viscera.