Cardiac poisons Tobacco or tambaku Nicotiana tabacum a
Cardiac poisons Tobacco or tambaku
• Nicotiana tabacum: a plant of solanacaea family is largely cultivated all over India • The dried leaves of nicotiana tabacum is used : in the form of a smoke or snuff, it is also chewed in the form of lime alone or with lime and paan. • For manufacturing cigar and cigarattes • As a germicide and insecticide for spraying in fields.
• ACTIVE PRINCIPLES • Nicotine and nicotianine • Both first stimulate and then paralyse vagal and autonomic ganglia • CLINICAL FEATURES • Burning, acid sensation in mouth and throat, spreads down from oesophagus to the stomach • Salivation, nausea vomiting and severe diarrhoea • Breath stinks of tobacco. Initially respiration is rapid and laboured but later on becomes slow and gasping.
• Pulse is slow in beginning then later on become fast with hypertension. Cardiac arrhythmia may occur. • Headache, giddiness, faintness and numbness • Muscular weakness, tremors and cold sweats • Confusion and contracted pupils • Delirium and convulsions • Unconciousness
• Cause of death • Respiratory failure caused by failure of respiratory muscles • CHRONIC POISONING • Chronic cough, bronchitis, laryngitis, pharyngitis, dermatitis, and irritation in eyes. • Emphysema and bronchial asthma • Increased incidence of lung cancer • Prone to coronary heart disease, lip cancer of buccal mucosa, hyperacidity and peptic ulcer
• Sudden cessation of smoking leads to withdrawal syndrome • Hypertension , irregular pulse, extrasystole Atrial fibrillation • Angina pectoris may also occur • FATAL DOSE: 1 -2 DROPS • Crude nicotine: 40 -60 mg • Nicotine fatal blood level: 1 mg/dl • Fatal period: 5 -15 min
• Treatment • Stomach wash with warmwater containig powdered charcoal with 0. 01% solution of potassium permagnate. • Saline purgatives • Injection atropine to check salivation and visual disturbances • Injection: hexamethonium- respiratory stimulant • Oxygen inhalation, artificial respiration • Anticonvulsants, diazepam
• Digitalis for tachycardia • Vasodialators • Methacoline for amblyopia • Immediate cessation of smoking PM APPEARANCE Stomach The odour of tobacco and fragments of leaves maybe found Mucous membrane- congested and inflammed Brain , lung, liver: congested
MEDICOLEGAL ASPECTS Accidental poisoning Commonest drug of abuse From ingestion From excessive smoking From infusion given as enema From the application of leaves on a broken wound In children: by sucking juice from a tobacco pipe or drinking hookah water • Persons employed in a tobacco factory • Homicidal poisoning: used as a common agent in infanticide • •
Suicidal poisoning: unusual ACONITE Aconite is the root of aconitum plant All parts of the plant are poisonous but chiefly the root is poisonous • Dry root : conical in shape, arched , presenting bases of broken rootlets, contracted into wrinkles, bitter sweet in taste • •
Aconite
• Active principles • Aconitine, pseudoaconitine, indaconitine and bikhaconitine • MECHANISM OF ACTION • First stimulates and then paralyses the peripheral , sensory and secretory nerve endings • CLINICAL FEATURES • GIT: bitter sweet taste, severe burning and tingling of lips, tongue , mouth and throat followed by numbness and anaesthesia of these parts. This gradually spreads over the whole body
• Nausea, salivation , difficulty in swallowing, pain in abdomen and vomiting. • Eyes: alternate contraction and dialatation of pupil , diplopia and impaired vision • NERVOUS SYSTEM: vertigo , restless, speech disorder, weakness, muscular twitching and spasm • CVS: pulse: slow feeble and irregular • BP falls and circulatory collapse • ECG shows ectopics and heart block
• RESPIRATION : fast then becomes slow , shallow and laboured • CAUSE OF DEATH: cardiac and/ or respiratory failure • FATAL DOSE: 1 -2 gm of root • Fatal period : 1 - 5 hours • TREATMENT: emetics • Stomach wash • Maitainance of body heat and BP • Monitoring of cardiac symptoms • Atropine for bradycardia
Novocaine for arrhythmia Oxygen and artificial respiration Administer glucose saline to combat collapse PM Appearance Fragments of roots maybe found in the stomach Stomach and intestine mucous memberane congested and inflammed • Bronchial tree may show frothy mucus • • •
• Medico legal aspects • Accidental poisoning: common, due to overdose as largely used as a medicine • Roots maybe eaten mistaking it as horse radish roots • Suicidal and homicidal poisoning; common; it is given with beetle leaf to mask it’s taste • It is given with liquor to enhance the intoxicating effect • Used as abortifacient or as cattle poison • Used as arrow poison
DIGITALIS OR FOXGLOVE Active principles Digoxin, digitalin, digitonin Clinical features GIT: anorexia, thirst, nausea, vomiting, severe abdominal pain, and watery diarrhoea • CVS : Heaviness in the precordial region , irregular pulse, varied types of arrhythmias with heart block • ECG changes: inverted T wave, prolonged PR interval, shortened QT interval • • •
• OTHERS: vertigo, severe distressing headache, fatigue malaise and fainting, slow and gasping respiration • Pupils are dialated, visual disturbances and photo phobia • Delerium, hallucination and convulsions may also occur • Urine maybe suppressed • CAUSE OF DEATH • Ventricular fibrillation • FATAL DOSE; 2 -3 gm of digitalis
Fatal period: few hours to 24 hours TREATMENT Stomach wash Emetics Atropine for bradycardia Inject lignocaine for ventricular tachycardia and other cardiac symptoms • Maintain electrolyte , fluid and potassium balance • • •
• PM Appearance • Fragments of digitalis leaves maybe found in the stomach • Internal organs: inflammed and congested MEDICO LEGAL ASPECTS Accidental poisoning: occasional from an overdose or by eating leaves by mistake Homicidal and suicidal poisoning: occasional
• Nerium Odorum (White Oleander, Kaner) • All parts of the plant are poisonous. • Active principles: Nerin consisting of three glycosides— neriodorin, neriodorein and karabin. 5 • Action It is similar to that of digitalis causing death from cardiac failure. Neriodorein causes muscular twitching and tetanic spasm which is more powerful than strychnine. Karabin acts on the heart like digitalis, and on the spinal cord like strychnine
White oleander
• Signs and Symptoms • �Locally, contact dermatitis. • �Inhalation of flowers may cause headache, dizziness, respiratory difficulty and nausea. • �Ingestion causes vomiting, pain in the abdomen, frothy salivation, difficulty in swallowing and articulation. Later on, there is restlessness, muscular twitchings, tetanic spasms and lock jaw. The pulse is slow and weak, respiration is rapid, blood pressure falls, and there is fibrillation and AV block. This is followed by exhaustion, drowsiness, coma, respiratory paralysis and death from heart failure.
Fatal dose: Root: 15– 20 g; leaves: 5– 15. Fatal period: 24 h. Treatment i. Gastric lavage. ii. Administration of an anesthetic is usually necessary. • iii. Morphine injection seems to be beneficial. • iv. Symptomatic treatment • • •
• Postmortem Findings • Non-specific findings. Petechial hemor rhage on the heart is a characteristic feature. • Organs are congested • Medico-legal Aspects • �Suicide is common • �It is used as an abortifacient, applied both locally and internally. � • Homicide is rare. ).
• �Accidental poisoning is sometimes met with when decoction is used: • a. Externally to reduce swelling. • b. As a remedy for venereal diseases. • c. As a love-philter (increases attraction between the giver and taker). • Cerbera Thevetia (Yellow Oleander, Pila Kaner) All parts of the plant are poisonous.
Yellow oleander
• Active principles: • Glycosides—thevetin, thevotoxin, cerberin and peruvoside • On ingestion, there is burning sensation in the mouth with tingling of the tongue, dryness of throat, vomiting, diarrhea, headache, dizziness, dilated pupils, drowsiness and loss of muscular power. Pulse is rapid, weak and irregular, blood pressure falls. Heart block, collapse and death is due to peripheral circulatory failure
• Fatal dose: Seeds: 8– 10; root: 15– 20 g. • Fatal period: 2– 3 h. • Treatment i. Gastric lavage. Single-dose activated charcoal is beneficial and safe. ii. Molar solution of sodium lactate IV and 5% glucose to combat acidosis. iii. Atropine 1 mg, 2 ml of adrenaline 1: 1000 and
• 2 mg of noradrenaline (if blood pressure is low) to counteract heart block. v. Digoxin-specific antibody fragments is effective in reverting life-threatening cardiac arrhythmias. iv. Symptomatic treatment • Postmortem Findings • Non-specific. • i. Signs of GIT irritation may be seen • . ii. Stomach and duodenum may be congested and may show fragments of seeds. • iii. Congestion of visceral organs are seen. Medicolegal aspects: Same as Nerium odorum.
• Quinine • The bark of Cinchona plant contains quinine, quinidine, cinchonidine and other alkaloids • Action • 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.
• Signs and Symptoms • On ingestion, there is pain in the abdomen, vomiting, diarrhea, headache, giddiness, tinnitus, partial deafness, loss of vision, scotoma, confusion, muscular weakness, itching, tachycardia, hypotension and cyanosis. � • There may be oliguria, hemolysis, hematuria and uremia.
• �Respiration is rapid and shallow, pupils are fixed and dilated, delirium and coma. • �Death occurs from respiratory failure. • Cinchonism or quinism is caused by repeated therapeutic doses or overdose of quinine. • Symptoms are tinnitus, vertigo, deafness, diplopia, scotoma, blindness, skin rash, hypoglycemia and cardiac arrhythmias
. Fatal dose: 2– 8 g. Fatal period: About 6 h. Treatment i. Assisted ventilation, if necessary. Continuous cardiac monitoring is needed. • ii. Gastric lavage is done, and magnesium sulfate is used for purgation. • iii. Activated charcoal. • iv. For cardiac toxicity, IV bolus of sodium bicarbonate is given. • •
• v. Ventricular tachycardia may be treated with magnesium IV or overdrive pacing. • vi. Intravenous fluids are given to promote diuresis. • vii. Protection of vision: Blocking of bilateral stellate ganglion is sometimes recommended. • viii. Symptomatic treatment
• Postmortem Findings • Non-specific. Organs are congested, and hemolysis of red cells may be found. 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.
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