FORENSIC TOXICOLOGY

ALL SUBSTANCES ARE

POISONS;THERE IS NO SUCH THING
AS NON POISON
* paracelsus
 CAUTION IS ADVISED WHILE
DECONTAMINATING A VICTIM OF
POISONING, OVERENTHUSIASM MAY
RESULT IN ELIMINATING THE
PATIENT,NOT THE POISON

* John Morrison
 1 Million illness - World wide

 >50000 deaths/year in India

 WHO –3 million acute poisoning/year

22000 deaths/year

 At present there are > 9 million natural

& synthetic chemicals
• TOXICOLOGY :

Is the science dealing with properties,

actions, toxicity, lethal dose, estimation &
interpretation of the results of the
toxicological analysis and treatment of
poisons
• FORENSIC TOXICOLOGY –

Is the science dealing with the medical

& legal aspects of the harmful effects of
poisons on human beings
• TOXINOLOGY :
Is the science refers to toxins produced by
living organisms which are harmful to man.
Eg: Bacterial & Fungal toxins, Poisonous
plants, Venom of snakes, Spiders, Bees etc
• CLINICAL TOXICOLOGY

Deals with human diseases caused by or

associated with abnormal exposure to
chemical substances.
 Poison
• POISON Is a substance (solid, liquid or
gaseous) which when introduced into the
living body or brought into contact with any
part thereof, will produce ill effect or death
by its local or systemic effects or both
• No boundary between Medicine & Poison

 Medicine in a toxic dose is Poison

 Poison in small dose may be a Medicine

In Law the real difference between Medicine & Poison is the

intent with which it is given to a person
Sec 284 IPC: Punishment for careless handling
of poisonous substances

Sec 328 IPC: Punishment for causing hurt by a

means of a poison with the intention to
commit an offence
 Purpose of study
* Is it a case of poisoning Disease ?
Death ?
* If so what type of poison ?
* What is the route of entry ?
* Is it suicidal, accidental, homicidal ?
• Information to police
• Collection of material
- to diagnose & to institute treatment.
To notify concerned authorities:
- food poisoning
* To prevent adulteration of food, drugs &

Environmental pollution

* Stupefying agents used in buses, railways

etc

* Cattle poisoning to collect hides

 POSSESSION ,SALE & CONTROL OF
POISONS
THESE ARE GOVERNED BY :

POISONS ACT (1919):

• Amended in 1958 & repealed in 1960
* Regulates importation, possession & sale of
poisons
*Issue of license for possession & sale of
poisons.
 Drugs & Cosmetic Act (1940)
• Amended in 1964
• Deals with import, manufacture, distribution
& sale of drugs & cosmetics
• Cosmetic means any Article intended to be
rubbed, poured, sprinkled or sprayed on or
introduced into human body for cleansing,
beautifying, promoting attractiveness or
altering the appearance-but not soap
 Drugs & Cosmetic Rules (1945)

• Concerned with standard & quality of drugs

• Includes all drugs used for therapeutic

purpose - Allopathic, Homeopathic,
Ayurvedic, Unani & Siddha
 Here the drugs are classified into
various schedules

• Schedule C- Biological products

• Schedule E- List of poisonous substances
under ayurvedic, siddha &
unani systems
• Schedule F- Vaccines & Sera
• Schedule G- Hormone preparations
• Schedule H- Barbiturates, Amphetamines,
Reserpine etc(to be sold retail
on prescription of RMP)

• Schedule J- No advertisement for cure or

prevention of blindness,
cancer, cataract, epilepsy etc
• Schedule L- Anibiotics, antihistamines &
other chemotherapeutic agents
 Pharmacy Act (1948)

• To allow only registered pharmacist to

compound, prepare, mix or dispense any

medicine
 Drugs control Act (1950)

• Regulates sale ,supply & distribution of drugs

• Fixing the maximum price of drug which is

charged by dealer or producer
 Drugs & Magic Remedies
( Objectionable advertisement) Act 1954

• To maintain ethical standards – advertising

• Bans Advertisement which offend decency or

morality,&
to prevent self medication & treatment which
cause harmful effects
Prohibits advertisement of magic remedies in
relation to
 Enhancement of potency

• Cure for incurable disease

• Talismans or charms like mantras

• Correction of menstrual disorders

Narcotic drugs & psychotropic substances
(NDPS) Act (1985)

Prevention of illicit traffic in narcotic drugs &

psychotropic substance( NDPSA) Act (1988)
 NDPS act 1985
• Repealed the 2 opium acts
• Prevent illegal manufacture of narcotic and
pyschotropic drugs
• Punishment for drug trafficking
• Narcotic drug: coca leaf ( cocaine), Cannabis,
opium straw and includes manufactured drugs
• Psychotrophic substances: natural or synthetic
substances mentioned in the schedule
 Penalties
• Small quantity: 6 months imprisonment
with Rs 10,000 fine
• Greater than small and lesser then
commercial: 10 years imprisonment,
1lakh fine
• Commercial quantity: upto 20 years
imprisonment and 2 lakhs fine
 Poison information centre
• First appeared in Holland in 1949

• National poison centre established in Guy’s

hospital London

• In India it was established in AIIMS, Delhi in

1994
• POISINDEX & INTOX are the software
programmes used
 Functions

• Provide immediate round the clock toxicity

assessment & treatment recommendation
over telephone
• Call

History obtained

Severity assessed

Treatment recommended or referral

 Poisoning in India

• Suicidal –Ideal suicidal poison characters

-Cheap
-Easily available
-Highly toxic
-Tasteless or pleasant taste
-Can be easily taken in food or drink
-To produce painless death
• Ex ;Organophosphates, Organochlorines
& Carbamates
 Homicidal poison
• Cheap
• easily available
• Colourless, odourless, Tasteless
• Easy to administer in food, drink or medicine
without suspicion
• Highly toxic
• S/S resembles a natural disease, not to cause
sudden death – to escape suspicion
• No antidote
• No P.M. changes
• Rapidly destroyed , cannot be detected by
P M or chemical examn.
Eg- organic compounds of flourine and
thallium , arsenic & aconite
• Stupefying

Datura
Cannabis
Chloral hydrate
 Accidental poison
• Carelessness while storing

• Remedies by quacks

• Bites by poisonous animals

• Chemicals in Industry & Household

 Cattle poisoning
• Accidental or intentional

• By enemy to take revenge

• Chamars for Hides

• Owners to kill useless animals

• Eg’s- Abrus precatorius , Oleander ,
calotropis , aconite , OP compounds
• Arrow poisons- Abrus , croton oil ,
calotropis , aconite , Curare

• Abortificients – calotropis , oleander , aconite

, semicarpus , ergot

• Aphrodisiacs – cantherides , cocaine ,

cannabis , opium , strychnine
 Routes of administration
Important for – Treatment & P M
Examination

• Inhalation - through air passage

• Parenteral route - SC, IM, IV, IA,

intrathecal, intraperitonial
• Sublingual
• Enteral route - by mouth or rectum
• Natural orifices - vagina, nose, eyes,
urethra

• External application - wounds, unbroken

skin
Eg’s- Organic phosphates , nicotine , Lewisite
gas , phenol , Endrin , hydrcyanic acid ,
harmones
 Classification of poisons

• Classified according to mode of

action
CINCAM
 CORROSIVES
1. STRONG ACIDS

(A) MINERAL/INORGANIC

(Sulphuric Acid, Nitric acid,

Hydrochloric Acid)

(B) ORGANIC

(Carbolic Acid, Oxalic Acid,

Salicylic & Acetic Acids)
2. STRONG ALKALIES
Caustic soda & potash
Carbonates of Na, K, Ca
 IRRITANTS

• Abdominal pain, vomiting, purging

• PM: Redness & Ulceration of GIT
1.Inorganic
(A) Non-metallic- Phosphorus, Chlorine,
Bromides, Iodine

(B) Metallic – Lead, Arsenic, Mercury,

Antimony, Copper, Zinc,
Magnesium
2.Organic

(A) Vegetable –Castor, croton, Abrus,

Capsicum, Calotropis, semecarpus
anacardium , Ergot

(B) Animal – Cantharides, Snakes,

Scorpions, Spiders,
Poisonous Insects
3. Mechanical

Powdered glass, chopped hair,

diamond dust, dried sponge
 Neurotoxic
• Act on CNS
• Alkaloidal poisons

• Exhibit – Headache, Giddiness, Delirium,

Stupor, Coma, Convulsions or Paralysis

• , S/S & P.M. Changes- Naked eye nil

Confirmed by History
Chemical analysis
 Cerebral poisons
• Somniferous : Opium & its alkaloids

• Inebriants : Alcohol & Anaesthetics

• Sedatives & Hypnotics : Barbiturates,

Chloral hydrates
• Fuels: Petroleum, Kerosene, Naphtha
• Insecticides : organophosphorus comp
• Organochlorines: DDT, Endrin

• Coal tar insecticides: Naphthalene

(D) Deliriants: Datura, Belladona,

Hyoscyamus, Cannabis, Cocaine

2. Spinal – strychnine, Gelsemium

3. Peripheral : Curare, Conium

Cardiovascular :

Digitalis, Oleander, Aconite, Tobacco,

Nerium odorum, Quinine , cerbera odollum

Asphyxiants : Irrespirable gases

Co,Co2,H2S,Coal gas, Sewer gas, War gases
etc.
 MISCELLANEOUS
• Poisons having widely different actions
- Analgesics & Antipyretics
- Anti histaminics
- Tranquillisers
- Antidepressants
- Hallucinogens-LSD, Peyote & Mescaline
- Food poisoning & Botulism
• Anti depressants : Tricyclic compounds

• Stimulants : Amphetamines

• Hallucinogens: LSD, Peyote &

Mescaline

• Food poisoning
 Types of poisoning
• Acute - excessive single dose or several small
doses over a short period of time
• Chronic – smaller doses over a period of
time. Eg- arsenic, antimony , opium
• Subacute poisoning
• Fulminant poisoning- massive dose, death
without preceding symptoms
 Actions of poisons
1. Local : Corrosion – Acids & Alkalies
Irritation & inflammation-Cantharides
& tartar emetics
Pupil dilatation – Atropine

2. Remote :Due to absorption of poison:

Cerebral – Alkaloids, Opium
Spinal – Strychnine
Paralysis – Curare
Non-specific – shock
3. Local & Remote : Oxalic acid
Carbolic acid

4. General actions: Arsenic, Mercury,

DDT

Having wide range of actions

 Factors modifying the actions of poisons
1. DOSE : Deleterious effects depends on
dose
Small quantity no toxic effect
Large quantity serious toxic effect-exceptions

A. IDIOYNCRASY:
IDIOYNCRASY
Abnormal response to a drug as a result of
an inherent personal hypersensitivity to the
agent in question. Small amounts cause
intense symptoms
Ex- Morphine, Cocaine, Codeine, Aspirin

Food - Mushrooms, Pulses,

Eggs, Shellfish etc
They are not tolerated by some individuals
B. Allergy
Hypersensitivity acquired as a result of
previous administration of the toxic agent or
induced by the simultaneous presence of
another poison.

Example- Penicillin
Sera
C. Habit
Diminishes effects of certain poisons
• Tolerance-it is the ability of an organism to
show less response to a specific dose of a
chemical than it showed on a previous
occasion from the same dose
Ex- Opium, Alcohol, Tobacco
Strychnine & Arsenic
D. Synergism Or Potentiation

Final response is greater than the sum of

their individual actions

Ex- Alcohol & Barbiturates

E. Large dose of poison acts differently

Example:
Copper sulphate – vomiting,
Arsenic-High dose Death by shock
Small dose- G.I irritation
F. Cumulative poisons:
poisons
Some poisons get accumulated in the body
Example:
Arsenic, Hg, Pb, Barbiturates,
CO, Digitalis, Strychnine

Repeated administration on small doses results

in toxic effect or chronic poisoning by
cumulative action
 2. FORM OF POISON
A. PHYSICAL STATE
Gases & vapours – Act quickly (because of
absorption)

Liquids
Solids--- Here fine powder act faster

Synthetic substance:
substance coated – action delayed
made soluble in alkalinity of small intestine
 B. CHEMICAL COMBINATION

Some become inert by combination

Ex-
Acids+ Alkalies,
AgNO3+ HCL acid,
Strychnine + tannic acid
Some poisons become toxic by combination
Ex-
1. Lead carbonate + Copper arsenate-
Insoluble in water but soluble in HCL
2. Metallic Copper + Arsenic – toxicity
3. Alcohol + Barbiturates - due to synergism
 C.MECHANICAL COMBINATION

• Action of poison altered

- when combined Mechanically with inert substances

• Alkaloids with Animal charcoal- fail to act

• Acids & Alkalies – diluted with water- act as irritants

• Poisons act slowly when stomach is full or
with fatty food

• Sp. gravity of poison & fluid- should be same-

when poisonous powder given with fluid

• That is why Arsenic mixed with milk, tea,

coffee
 3. METHODS OF ADMINISTRATION
Action is rapid in gas & vapourous form
Next - IV, IM or SC
Least when swallowed

Snake venom- Toxic -Injected

Harmless - ingested
Cocaine : Injected- Acts as Local anesthetic,
Swallowed – As Deliriant or Convulsants
 4.CONDITION OF THE BODY
A. AGE:
1. Children cannot tolerate adult dose
2. Children more susceptible than adults-
particularly to Opium
but Atropine & Calomel better tolerated
B Old Age: General health & Vigour is bad
poison has greater effect
 STATE OF HEALTH

Weak persons more prone- because of

decrease glycogen( liver)

Effect is more when kidney & liver –

diseased
Ex- Morphine & Mercury
• Cardiac poisons dangerous in heart diseases

• Narcotics – danger in Coma

• Increase in tolerance- increased dose is

required
Ex-
Opiates & Hypnotics in Mania & Delirium tremens,
Strychnine in paralysis
 C. SLEEP & INTOXICATION

Action is delayed during sleep because of

decrease in metabolic activity & also in
intoxication
 FATE OF POISON IN THE BODY
• Solid & Liquid – vomiting & Diarrhoea
• After Absorption
1. Excreted unchanged – urine
2. Biotransformation
- Liver ( imp. org )
It is the enzyme catalysed chemical
transformation of drugs/chemicals within the
living organism.
The metabolites formed are much less lipid
soluble, hence not reabsorbed by the tubules.
 Elimination
• Can bpe unchanged or as water soluble
metabolites
• The rate and pattern of drug elimination is
according to the following kinetics
First order kinetics – most drugs
rate of drug elimination is directly
proportional to plasma conc
Zero order kinetics- Ethyl alcohol
rate of elimination is independent of the
plasma conc

Mixed order kinetics- phentyoin,

warfarin
dose dependent kinetics
 Excretion

• Urine, Intestines, Bile ducts, Sweat glands,

Saliva, Mucous or Serous outflows, Breast
tissue (during lactation)& the Lungs.
• Deposited in certain tissues
Epidermis, nails, hairs ( inorganic poisons)
Bony skeleton- Lead & radioactive
substance
 DIAGNOSIS OF POISONING
I. IN LIVING:
A. ACUTE POISONING
* Sudden Onset (s/s)
* Do not confirm to ordinary illness
* Others affected
* Increased in sensitivity---- death or
recovery
Rule out acute symptoms- natural disease.
Detect poison-food, fluid, medicine, vomit, urine,
stool etc
B. CHRONIC POISONING
* Insidious & Gradual
* They wax & wane
* Exacerbation of S/S after administration
of food, medicine or fluid
* Remission or disappearance after
removal from source.
Detect Poison:
Poison
In food, fluid, medicine administered or
vomit, stool, urine etc of the victim
Suspicion:
Suspicion Repeated attacks of undiagnosed
G.I.Irritation [ Homicide ]
S/S of Chronic poisoning-malaise, chronic ill
health ,Cachexia
Poisoning in dead
 Externally
• Body and clothes may show stains or marks
of vomit, faeces or poison itself
• Suphuric acid and hydrocholoric acid- black
or grey
• Nitric acid – brown or yellow

• Carbolic acid- Greyish white

 Colour of P.M staining
• Dark brown or yellow – Phosphorous,
acute copper poisoning
• Cherry red – CO

• Chocolate colour – nitrites, aniline,

nitrobenzene
• HCN poisoning – Bright red
 Smell from the mouth and nose
• Garlicky like – Phosphorus , arsine gas ,
arsenic, thallium
• Sweet or fruity – Alcohol, chloroform
• Acrid – Paraldehyde , chloral hydrate
• Rotten eggs – Hydrogen Sulphide
• Fish or musty – Zinc phosphide
• Bitter almond- HCN
 Internally
• Smell : cranial cavity to be opened first.

• Mouth and throat: inflammation, erosion

staining

• Oesophagus: look for desquamation of the

mucous membrane, ulceration, stricture
formation, perforation
• Upper respiratory tract
• Stomach
 Hyperaemia
Softening
Ulcers
Perforation
Contents
• Other parts of the GI tract, liver, kidneys,
heart
• Bladder, uterus and vagina in cases of
criminal abortion

• Death caused by poison depends on the

evaluation of the clinical, toxicological
and anatomical evidence
 Preservation of Viscera in
poisoning
• Death is suspected due to poisoning

• Deceased was intoxicated or used to

drugs
 The usual viscera sent….
1. Stomach and its contents
The upper part of the small intestine Bottle 1
and its contents
2.Liver 200 to 300gm Bottle 2
Kidneys half of each

3. Blood 30ml. Minimum 10ml - Bottle3

4. Preservative - Bottle 4
 Preservatives used
• Saturated solution of Sodium chloride –
most commonly used
• Rectified spirit

• Sodium or potassium flouride for blood

• NOT TO BE PRESERVED IN FORMALDEHYDE

 Other viscera to be preserved
• Heart – Strychnine, Digitalis
• Brain – alkaloids, OP compounds,
barbiturates, anaesthetics
• Spinal cord – strychnine , gelsemium
• Bile – narcotic drugs, cocaine,
methadone
• Vitreous humour – alcohol
• Lung – gaseous poisons
• Injectable poisons – skin

• In heavy metals – bone, nails, skin

• Uterus in cases of criminal abortion

• Muscle – in badly putrefied bodies

• Fat – insecticides and pesticides

 TOXICITY RATING OF POISONS
(LETHALITY RATING)
• USUAL FATAL DOSE TOXICITY RATING
< 5mg/ kg 6 super toxic
5-50mg/kg 5 Extremely toxic
50-500mg/kg 4 very toxic
500mg-5gm/k 3 moderately toxic
5gm-15gm/kg 2 slightly toxic
>15gm/kg 1 practically non
toxic
THE DUTIES OF A DOCTOR IN SUSPECTED CASES
OF POISONING
Medical duties-give first aid to save life
[must]

Legal duties
1-Intimation:All cases to be intimated
to police

2-Documentation:note down
age, Sex, Address, brought by,
Treatment given etc
 3Preservation:vomitus,urine,faeces,etc

4-Consultation:seniors for further Tt.

5-Treatment: first aid to save life

6-Dying declaration :if about to die

record dying declaration

7-Death certification :if dies never

issue death certificate, inform police
• All homicidal cases should be informed to the
police under 39 CrPc
• Non compliance punishable under sec 201
IPC
• If he conceals some information he may be
prosecuted under sec 202 IPC
• All suicidal or accidental poisonings need not
be reported to the police in private set up
• In govt setup all have to be reported
 GENERAL MANAGEMENT OF POISONING

• A B C D of resuscitation

A- Airway
B- Breathing
C- Circulation
D- Depression (CNS)
 MAIN OBJECTIVES

I. Removal of Unabsorbed poison

II. Use of Antidotes
III.Removal of Absorbed poison
IV. Treatment of General signs &
symptoms
V. Maintenance of patient’s general
condition
VI. Psychiatric evaluation
I . REMOVAL OF UNABSORBED
POISON FROM THE SYSTEM
1] INHALED:

2] INJECTED:

3] CONTACT:

4] INGESTED:
 1. INHALED POISONS
- Remove to fresh air
- Clear airway
- Artificial Respiration
- 95% O2 + 5% CO2

• Ex- CO, Coal gas, Septic tank gas,

Automobile Exhaust
 2. INJECTED POISONS
-Clean the area
-Prevent spread
* Immobilization
* Tournique
* Incision & Suction

• Ex- Insulin, Snake & Insect Bite, Hypnotics

 3. CONTACT POISON
- Wash with Plain water
- Specific Antidote (Neutralise)

• Ex - Spilled
- Sprayed – Skin, Eye, Wound
- Vagina, Rectum & Urinary Bladder
 4. INGESTED POISON
A. EMESIS B. GASTRIC LAVAGE
(Vomiting) (Stomach wash)
 EMESIS
1. Tickling the fauces
2. Emetics (Substances inducing vomiting)

• Contraindications
Corrosives – Rupture of stomach
Strychnine – Convulsions
Kerosene & volatile –Fatal if inhaled
Coma - Aspiration
 House Hold Emetics
• Warm water
• 1 table spoonful (15gm)-mustard powder
• 2 table spoonful Salt + 200ml water

* Ipecac Syrup – 30 ml
* ZnSO4 1.2 gms in 200ml water
* Amm.carbonate -1-2gms in water
• Apomorphine- 6mg SC vomiting centre

• Advantages
- Vomiting in 3-5mts
- Facilitates gastric lavage
- Reflux of upper G.I Contents
 GASTRIC LAVAGE
(STOMACH WASH)
INDICATIONS
 Better if done within 4-6hrs
 Patient is non cooperative
 Patient is in coma
 Poison administered parentrally
 By cuffed Endotracheal tube
STOMACH WASH TUBE
RYLE’S TUBE
 LAVAGE FLUIDS
1. Warm water

2. Saline (0.9% or 0.4%)

3. Oxidising solutions-Alkaloids & Salicylates

1. Potassium permanganate for Alkalies &

2. Tannic acid Salicylates
3. Iodinated water
4. Sodium thiosulfate solution(25%)- Cyanide

5. Desferrioxamine(2g in 1L H2O)- Iron

6. Castor oil & Warm water (1:2)- Carbolic acid

7. Calcium gluconate or Lime H2O (Calcium

hydroxide in H2O)- Oxalic acid
Followed by-
Activated charcoal or Cathartics-Instilled
• COMA COCKTAIL
• Naloxone-2mg
• Thiamine-100mg
• Dextrose-50ml 50%
• Suction bulb siphons out the stomach
contents
• Continue the procedure till there is clear,
colorless and odourless fluid from the
stomach.

• Ryles tube, 10 to 12 size french cathether

may be used in infants and children
 Procedure
• Patient in left lateral position with mouth at
lower level than larynx
• Inserted into the mouth by depressing the
tongue and passing it downwards till the
oesphagus ( 50 cm mark)
• Mouth gag to be used in uncooperative cases
• Lavage fluid in inserted into the stomach
• Contraindications for stomach wash
• Absolute contraindication
-All corrosive poisons
except
-Carbolic acid
– Relative contraindications
• Coma
• Strychnine poisoning
• Petroleum dist
• Esophageal varices
• Hypothermia
 USE OF ANTIDOTES

• Which counteract or neutralize the effect of

Poison

• INDICATIONS:
– Poison not removed by Emesis or G.Lavage
– Poison absorbed
– Routes of administration other than ingestion
 CLASSIFIED ACCORDING TO MODE OF
ACTION

Mechanical or Physical
(Act by impeding absorption of Poison)

Demulcents:
Prevent absorption by forming coat on
gastric mucosa

Ex: Fats, Oils, Milk, Egg albumin

-Not used in phosphorus, kerosene, OP
compounds
B. Bulky food: By imprisoning particles
Ex: Banana
 Activated charcoal( Medicoal)
• Black, odourless powder
• Destructive distillation of various organic
materials from wood pulp
• Activating agents like steam, CO2
• Mechanical adsorption
• Organic poisons and to a lesser degree
mineral poisons
• 15-30g in children & 60-100g in adults

• Multidose Activated charcoal: 1-2g/kg,

Rpt 0.5g/kg after 4-6 hrs interval

• Not useful in heavy metal poisoning,

cyanide, hydrocarbons, alcohol
 CHEMICAL ANTIDOTES

(Act chemically to form a non-toxic,

insoluble compound or By oxidising)

Ex: Acetic acid or Vinegar - Alkalies

Mg oxide or Cal oxide - Acids
Ferric oxide - Arsenic
• Tannin- Alkaloids, Glucosides
• KMnO4(1:1000) (Oxidising agent)-
Organic substances, Alkaloids, Amidopyrin,
Antipyrin, Barbiturates, Phosphorus,
Cyanide

• Iodine-15drops in 200 ml of water- ppt

heavy metals
 UNIVERSAL ANTIDOTE
• Indication : unknown poison
2 or more poison

• Powdered charcoal – 2parts (neutralise alkaloid

(Burnt toast)

• Mg.oxide (milk of mg) -1part (neutralise Acids)

• Tannic acid -1part (ppt alkaloids,

glucosides (strong tea)
metals)
 PHYSIOLOGICAL OR
PHARMACOLOGICAL ANTIDOTES

• Produce effects which are opposite to that of poison without

chemical combination

Ex: Nalaxone – Morphine poison

Atropine & Oximes – O.P.Poison
• Atropine and physostigmine are the only two
physiological antidotes
• Other examples
 Cyanides and amyl nitrite
 Barbiturates and picrotoxin or
amphetamine
 Strychnine and barbiturates
 Chelating agents
(Metal complexing agents)

• Used in Heavy metal poisoning

• They produce a firm non-ionized cyclic

complex (chelate) with cations & form stable,
soluble, non-toxic complexes with calcium &
heavy metals
 BAL (British Anti-Lewisite/
Dimercaprol)

• Uses: Arsenic, Mercury, Lead, Copper

• Dose :3mg/kg - 4th hrly X 2days
- 6th hrly X 3rd days
- 12th hrly X 10 days
• has 2 unsaturated sulphydryl groups
 EDTA
• Sodium calcium EDTA
Uses –Lead, Mercury, Copper, Iron etc
Dose: 1gm BD X 5 days
• In lead poisoning:
Ca.complex of EDTA(5ml amp of 20%
solution)-slow I V with isotonic glucose saline
• Superior to BAL for treatment in arsenic and
mercury
 Penicillamine :( Cilamin-250,
Cuprimine)

• Uses –Copper poisoning orally

- Wilson’s disease

• Dose : 30mg/kg, upto 2gm/d in divided doses

• Maximum efficacy for the heavy metals
 Desferrioxamine (Desferal-500mg
vial)

• Uses – Iron poisoning,

Haemochromatosis

• Dose: 8-12gm in 60ml water – orally

2gm in 5% laevolose solution IV
if necessary repeat 12th hrly
 DMSA (succimer) dimercapto
succinic acid

• Uses : Lead, Mercury, Arsenic, G6PD deficiency

• Dose :10mg/kg -8th hrly X 5 days orally

-12th hrly X 14 days

• Higher therapeutic index

DMPS ( dimercapto propane
sulfonate)

Uses – Mercury, Lead, Arsenic

Dose -5mg/kg in 6 divided doses- IV

followed by 100mg BD –orally X24 days

III. ELIMINATION OF THE ABSORBED POISON

INDICATIONS
1. Severe poisoning
2. Progressive deteriorating
3. increased risk of morbidity & mortality
4. Normal route of excretion impaired
5. Poison caused delayed & toxic effects
6. Patient with CVS, Resp diseases
 RENAL EXCRETION

Fluid, Tea, Lemonade- orally

Forced alkaline diuresis for Salicylates

and Barbiturates
 PURGING

Sod. Sulphate 30gm with more water

MgSo4 – avoided in renal failure

Sorbital 50ml of 70%(not for children)

 WHOLE BOWEL IRRIGATION

• Polythelene glycol with electrolyte lavage

solution by nasogastric tube

• Children -0.5 lt/hr < 5yrs

Adults - 2lt/hr

• Useful in- Iron, Lithium overdose, Cocaine

Heroin, Sustain release preparations
 DIAPHORETICS

Heat application- Blankets, Hot water

Heat Beverages-Hot tea, Milk, Lemonade
Perspiration- Pilocarpine nitrate 5mg SC
Less by- Alcohol
- Salicylates vasodilatation
-Antipyretics
 PERITONEAL DIALYSIS
Uses – Alcohol, Chloral hydrate,
Salicylates, Theophylline, Barbiturates

CHARCOAL HAEMOPERFUSION- salicylates,

paraquat, phenytoin, pentobarbitol

EXCHANGE TRANSFUSION
in children, CO, Barbiturates, Salicylates
 HAEMODIALYSIS
Ethanol, Methanol, Chloral
hydrate, Phenobarbitol, Digitalis,
Thiocyanates etc

FORCED ALKALINE DIURESIS

promotion of excretion of drugs
which are weak acids, like penobarbitol
IV.
IV SYMPTOMATIC TREATMENT

V. MAINTANANCE OF PATIENT GENERAL

CONDITION

VI. ADEQUATE FOLLOW UP:

COMPLICATIONS,
PSYCHIATRIC TREATMENT
Thank you