INEBRIANT POISONS
Dr.Pavan Kumar
Sedative drugs are those that decrease activity,
moderate excitement, and exert a calming effect.
Hypnotic drugs are those produce drowsiness
and sleep resembling natural sleep.
ALCOHOLS
Monohydroxy alcohols
Ethyl alcohol
Methyl alcohol
Dihydroxy alcohols
Ethylene glycol
Propylene glycol
Trihydroxy alcohols
Glycerol
ETHYL ALCOHOL
Synonyms
Ethanol
Grain alcohol
Physical appearance
Clear, colorless liquid
fruity odour
Sweetish burning taste
Source
Ethyl alcohol is produced by the
fermentation of sugars by yeast
Absolute alcohol = 99.95% alcohol
Rectified spirit = 90% alcohol
Uses 1. Beverage
2. Solvent
3. Medicinal
Antihistaminic syrups
Surgical spirit
Ethanol sponging
Antidote
Methyl alcohol poisoning
Ethylene glycol poisoning
5. Preservative
PERCENTAGE OF ALCOHOLS BY VOLUME
IN BEVERAGES
1. Vodka - 40-45%
2. Rum - 40-45%
3. Whisky, gin, brandy - 40-45%
4. Port, sherry - 20%
5. Wine, champagne - 10-15%
6. Beers - 4-8 %
TOXICOKINETICS
Absorption
20% stomach, 80% small intestine
Peak blood level
30-90 mts
Metabolism
Liver, ADH pathway(major), MEO system of ER
Fatal dose
6gm/kg ADULT, 3mg/kg CHILDREN
ALCOHOL DEHYDROGINASE (ADH)
Ethyl Acetalde
Alcohol hyde
Co2 + Krebs
Acetyl Co. A or
H2O cycle
Acetic Acid
MECHANISM OF ACTION
1. Fluidization
2. GABA-A receptors
3. NMDA gated glutamate receptors
THE GABAA RECEPTOR COMPLEX
Cl-
Cl-
Cl-
Cl-Cl- INSIDE
CL- ION CHANNEL
B Cl-
A G Cl-
Cl- B E
R A Cl-
Cl- D t
B B Cl- Z O
A H
OUTSIDE
PHARMACOLOGICAL ACTION OF ALCOHOL
1. Skin
2. CNS
Stimulation –depression-coma
3. CVS
Vasodilatation, tachycardia(moderate doses)
4. GIT
Low concentration increases GIT secretions
5. GUS
Diuresis, enhanced sexual inclination.
ACUTE ALCOHOL INTOXICATION
BAC STAGE OF CLINICAL FEATURES
INTOXICATION
0-50 Sobriety Near normal behavior
50-100 Euphoria Feeling of well being,increased self
esteem,fine movements effected.
100-150 Excitement Emotional instability,increased reaction time,
150-200 Confusion Disoriention,confusion,vertigo,diplopia,slurred
speech,staggering gait.
200-300 Stupor Diminished responses,inability to
walk,vomiting.
300-500 Coma Unconsciousness ,subnormal
temperature ,incontinence of urine,respiratory
compromise
>500 Death Death due to respiratory failure.
7 DS OF ACUTE ALCOHOL INTOXICATION
Descent
Delighted
Delirious
Dazed
Dejected
Dead drunk
Dead
DIAGNOSIS
Bedside test
BAC
Pre-coma Coma
Barbiturate overdose Diabetic coma
Co poisoning Coma due to
hypnotic,sedatives.
Hypoglycemia
Head injury CVA
Psychotic states
The patient is NEVER “just
drunk” until all other
possibilities are excluded.
CAUSE OF DEATH
1. By the direct depressive effect on the
brain stem via the respiratory system.
2. Death may be due to aspiration of
vomit.
MANAGEMENT OF ALCOHOL INTOXICATION
1. Airway protection
2. Stomach wash
3. Thiamine 100 mg IV
4. 50% dextrose -50-100 ml IV
5. IV.Fluids
6. Flumazenil
POSTMORTEM FINDINGS
On opening the body alcohol smell.
Acute inflammation of the stomach.
All internal organs are congested and
edematous.
Blood is usually fluid and dark.
Brain: edema and congested.
ETHANOLISM
1. Pathological desire
2. Blackouts during intoxication
3. Withdrawal symptoms after ceasing
MEDICAL COMPLICATIONS OF ETHANOLISM
Liver
Pancreas
CVS
CNS
RS
Endocrine
Blood
Neuropsychiatric
FATTY LIVER
ALCOHOLIC CIRRHOSIS
DILATED
CARDIOMYOPATHY
WITHDRAWAL FEATURES
Common abstinence syndrome
Shakes, jitters
Fine tremors
GI upset
Restlessness
Peaks at 24 hours
The patient may feel “shaky” for up to 2
weeks
HALLUCINATIONS
Distorted vision
Misinterpretation of visual stimuli (snakes, worms)
Auditory hallucinations
SEIZURES (“RUM FITS”)
Usually in the first 24 hours
Major motor seizures in bursts of 2 to 6
May progress to status epilepticus
DELIRIUM TREMENS
- 24 to 72 hours after reducing intake
- Restlessness, tremors, hallucinations, seizures
Dilated pupils, flushed face, tachycardia,
nausea, vomiting.
- 15% mortality from dehydration, electrolyte
imbalance, and aspiration.
MANAGEMENT
Oxygen, monitor, IV (RL or NS)
Check blood sugar
Consider D50 and thiamine
Minimum stimulation
Sedation
Phenobarbital
Benzodiazepines
MANAGEMENT OF ETHANOLISM
1. Treatment of withdrawal
2. Aversion therapy
Disulfiram
3. Supportive psychotherapy
MEDICO LEGAL ASPECTS
AUTOPSY FINDINGS
Congested conjunctiva
Characteristic odour in the vicinity
And stomach contents
Cerebral and pulmonary congestion
Stigmata of chronic alcoholism
Cirrhosis of liver
Cardiomyopathy
CHEMICAL ANALYSIS OF VISCERA
Apart from routine viscera
Brain one hemisphere
CSF
Vitreous
Blood should be collected from a peripheral vein
FORENSIC SIGNIFICANCE
Brawls, assaults, suicides, and homicides are
commonly associated with alcohol.
Sec 86 IPC
Sec 85 IPC
Infamous conduct
METHYL ALCOHOL POISONING
Synonyms
wood spirit
Wood naphtha
Colonial spirit
Physical appearance
Clear, colourless, volatile liquid
USES
Antifreeze
Denatured spirit
Leather dyes
Windshield wash fluid
Embalming fluid
FATAL DOSE
70-100 ML
MECHANISM OF ACTION
CLINICAL FEATURES
Symptoms may be delayed to 12-24 hrs
Initially
Nausea, vomiting, pain abdomen
vertigo
Headache with meningismus
Ocular toxicity
Blurred vision
Flashes of light
Visual field impairment
Metabolic acidosis
Tachycardia, hypotension
Convulsions, coma
Kussmaul’s breathing
Death is due to respiratory failure.
DIAGNOSIS
High anion gap acidosis
Blood methanol level- > 50 mg/dl
MANAGEMENT
1. Stomach wash with sodium bicarbonate
2. Ethanol:
Specific antidote
Route: intravenous or oral
Dose:
10% ethanol at a dose of 10 ml/kg IV over 30 mts
Followed by 1.5 ml/kg/hr
As to produce blood ethanol levels of 100 mg/dl
3.Fomipazole
Inhibits alcohol dehydrogenase
4. Sodium bicarbonate
To correct metabolic acidosis
5. Folinic acid
Enhance excretion of formic acid
6. Hemodialysis
7. Supportive measures
MEDICO - LEGAL ASPECTS
Autopsy findings
Cyanosis
Liver and kidney toxic damage
Lungs –edematous
Along with routine viscera
cerebral hemisphere also preserved
FORENSIC SIGNIFICANCE
Manner-accidental
Due to the mixing of methanol with ethanol
Called liquor tragedies or
Hooch tragedies
ETHYLENE GLYCOL
Colorless odor less bitter liquid
Used as antifreeze, and coolant.
Fatal dose-70-100 ml
MOA
Metabolites glycolaldehyde, glycolic acid
They inhibit metabolic pathways.
CLINICAL FEATURES
First stage (CNS stage)
Up to 12 hours
Second phase (CVS stage)
12-24 hrs
Third stage(renal stage)
24-72 hrs
Diagnosis
High anion gap metabolic acidosis
Calcium oxalate crystals in the urine
Treatment
Stomach wash with activated charcoal
Antidote-ethanol
Fomepizole
Hemodialysis
Soda bicarbonate
Pyridoxine and calcium gluconate
Autopsy findings
Cerebral edema, toxic damage to liver, kidneys
Oxalate crystals in the brain, spinal cord, and kidneys.
BENZODIAZEPINES
Examples
Alprazolam,clonazepam,diazepam.
Uses
Anxiety, seizures, insomnia.Mania.
Toxicokinetics
70-99% are bound to plasma proteins.
Metabolized in liver
MOA
Acute poisoning
Mild
Ataxia, drowsiness,weakness.
Moderate-severe
Vertigo,slurred speech,nystagmus,coma,
Hypotension, respiratory depression
COD: Respiratory depression
Chronic poisoning
Tolerance
Withdrawal symptoms-anxiety, insomnia, headache,
Diagnosis
GC-MS from urine
Treatment
Acute poisoning
De contamination- stomach wash
Activated charcoal
Airway management
IV fluids
Hypotension- inotropes
Flumazenil-antidote
Chronic poisoning
Substitution with phenobarbitones.
Propranolol-for withdrawal symptoms
Forensic significance
Drug abuse
Suicides
Date rape
(Anterograde amnesia with Nitrzepam)
BARBITURATES
Classification
Uses
Toxicokinetics
Oxidized in liver
Excreted in urine as glucuronides
Fatal dose
Phenobarbitone 6-10 grams
Amobarbitone, pento, seco – 2-3 grams
Clinical features
Slurred speech, ataxia, miosis, lethargy,
CNS depression, coma, shock
Hypothermia
Skin blisters
Death may be due to respiratory or cardiac failure.
Diagnosis: TLC,GC,HPLC
EEG-Alfa coma-poor prognosis
Treatment
Gastric lavage
Activated charcoal
Forced alkaline diuresis
Hemodialysis
Supportive
ET intubation
Mechanical ventilation, IV fluids.
Autopsy findings
Cyanosis
Froth at nostrils
Skin blisters on dependent parts
Congested lungs and viscera
Forensic significance
Suicidal poisoning
Truth serum
CHLORALHYDRATE
Adulterant of illicit liquor
Micky fin or knock-out drops
White crystalline powder soluble in water,
Alcohol, pungent smell, bitter taste
Fatal dose 10 gms
Overdosage: GIT disturbance, hepato renal damage
Cardiac arrhythmias
Treatment
Management of arrhythmias, drug-resistant
Bretylium, flumazenil
