TOXICOLOGY: PART 1😊

TOXICOLOGY: PART 1

Toxicology and Toxinology

• Toxicology: Study of poisons
• Toxic poisons

• Toxinology: Study of toxin (Biological substance)

Poisoning

Autopsy

• Performed by opening cranial cavity first
• Helps identify poison by smell

Identification of Poisons Based on Smell

• Hippus drinking alcohol (), with barbie () eating a cone (aconitase)

Duties of a Doctor in Poisoning Case

• Legal duties:
• Compulsory duty
• Preserve the evidence
• Police intimation (33 BNSS)
• Mnemonic: Tring tring (3 3) → Send Police intimation
• Punishments
• Disappearance of evidence: [P] 238 BNS
• Mnemonic: 24 hour time disappeared at 23.8 hours
• Failure to inform police: [P] 211 BNS
• Mnemonic: Both (2) Called Police at 11 O Clock → but busy → failed to give info
• False information provided: [P] 212 BNS
• Mnemonic: Both (2) Called Police at 12 O Clock → hungry → gave false info

• Medical duty:
• Done 1st and then legal duties are taken up
• Stabilization & treatment:
• Decontamination:
• Removal of unabsorbed poisons
• Gastric lavage:
• Oral poisons
• Morphine → Even if it is given IV
• Activated charcoal
• Via Adsorption
• Removal of absorbed poisons:
• Hemodialysis
• ↑ Urinary excretion of poisons
• Antidote: Neutralize poison
• Multidose activated charcoal:
• For drugs undergoing enterohepatic circulation

• Barbie () aspirin () + Alcohol () kudichitt thee () Lit () cheyth → needed dialysis

• Thallium

Note on Absorption

• Most rapid route of absorption of poison: Inhalational.

Gastric lavage

• Absolute contraindication:
• Corrosives: D/t risk of perforation
• (Except carbolic acid:
• It cause → thickening of mucosa → Leathery mucosa)

• Relative contraindications:
• Aspiration pneumonitis
• Coma
• Volatile
• Kerosene, hydrocarbon
• Convulsant (Strychnos):
• Precipitate convulsion
• Can use once stabilized

Urinary excretion of poisons by

• Alkalization:
• For acidic drugs
• NaHCO3
• Salicylates (Aspirin)/barbiturates/TCA/Methotrexate

• Acidification:
• For alkaline drugs
• Ammonium chloride
• Strychnine
• Morphine
• Atropine
• Put acid → Strike () & Attack () More ()

Antidotes

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• Eli Lilly’s kit in Cyanide Poisoning



1. Inhalational Amyl Nitrate
• Form MethHb
• Shortest acting
2. Sodium nitrite → IV
• S/E: MethHb
3. Sodium thiosulphate → IV
• Mnemonic: Edi Lillyy → Amy () Nightil () soda () kudichitt thiiyil (thiosulphate) chaadi
• Mnemonic: Cyanide () jolly kku Aami (Amyl nitrate) 12 (Vit B12) vayassullapo Soda (Sodium thiosulphate) kond koduth
• Others for cyanide:
• DOC: Hydroxocobalamin (Vit B12)
• PAPP-A

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NOTE: Lilles index

Maddreys discriminant function

• In ALD → decide whether to give steroid

• Give steroid if > 32

• Monitor response after steroid → Lille index

• Mad () Lille () took steroid after alcohol

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Mx of Digitalis Toxicity:

1. Correct the cause.

2. DOC for Digitalis induced tachyarrhythmias
• Lignocaine

3. In Severe Poisoning → Heart block
• Digibind (Digoxin immune Fab)



• Salvador has mustache () → Not cute (↓↓ QT) → Likes more PR (↑↑ PR)

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CHELATING AGENTS

• Used for heavy metal poisoning

1. BAL (British Anti Lewisite)/ Dimercaprol

• Indications: BAL/MAL
• B - Bismuth poisoning
• M - Inorganic Mercury
• A - Arsenic poisoning
• L - Lead poisoning

• C/I of BAL (MIC)
• Cadmium
• Fe - Iron
• Organic mercury
• Mnemonic: Dont bring BAL to cafe

2. Ca Na 2 EDTA

• Mnemonic: MILK

• ↑ Renal excretion of poison

• C/I in renal failure and mercury

• Indications:
• M – Manganese poisoning
• I – Iron poisoning
• L – Lead poisoning
• K – Cadmium poisoning

3. d- Penicillamine

• Used for Cu poisoning and Wilson disease
• Other Chelating agents for Wilsons
• Zinc (↓ absorption of copper)
• Trientine
• Copper get stuck → try ent → trientine

4. Fe chelating agents

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• Desferrioxamine/Deferoxamine
• Injectable
• DOC for acute Iron poisoning
• When Iron level > 500 Microgram/dl
• Monitor for hypotension, pulmonary toxicity.
• Oxygen → acute → IV → but BP falls and Lung injury

• Deferiprone
• Oral
• Used for chronic Iron overload
• Agranulocytosis
• needs weekly blood monitoring
• Best for cardiac iron;
• Chronic Ferry Pirates (Feripirone) → oral
• Prone (Deferiprone) Close (Clozapine) Car (Carbamazepine) → Agranulocytosis

Morphine poisoning features

• Coma

• Pinpoint pupil

• Respiratory depression

• Hypothermia

• Hypotension

• Mnemonic:
• Travelleing with Ox
• Ethiyapo (Ethelene glycol) Ox () nte Kaalu (Calcium gluconate) Flu (HF) ayi

Corrosives

• Never neutralize (avoids increasing burnt area)

• Wash with water, brush off chemical powder

Sulphuric Acid

• Mnemonic: Sulphuric acid = Black + White

• Carbonisation:
• Black necrotic tongue, stomach mucosa, skin

• Hygroscopic action:
• Chalky white teeth

Nitric Acid

• Mnemonic: Nightil (Nitric acid) Manjapathrathinu (Yellow) Pic (Picric) eduth X (Xanthoproteic) site il itt

• Yellow discoloration:
• Skin, teeth, mucosa

• Nitric acid when react with tissue:
• Form Picric acid
• Called Xanthoproteic reaction

Vitriolage

• Failure, punishable under 397 BNSS
• 397 BNSS
• Acid attack
• Sexual assault
• Posco victims
• Free first aid/treatment compulsory
• Police intimation to be done by the doctor
• Mnemonic:

• Acid attack, punishable under 124 BNS
• Mnemonic: Count from 1 to 4 (124) → pour acid

Carbolic Acid/Phenol

• Absorbed by all routes

• Disinfectant: Delay in putrefaction

• Mnemonic:
• Car → carnta Fan (Phenol)→ Leather (Leathery mucosa)
• Car Thii (Pyrocatechol) pidich
• Black deposits () ayi full
• Pacha (Green urine) vellam vach anakkum

note: Ochronosis:

• seen in alkaptonuria, Hydroquinone, Carbolic acid ingestion

• IV disc calcification

note: Garrod’s tetrad

• Cystinuria

• Alkaponuria

• Albinism

• Pentosuria

OP Poisoning

• Oximes can only be given with atropine
• (Worsen poisoning if given alone)

• Atropinisation (Airway secretions are dried & clear):
• Stop atropine

Celphos

• ↓ Mg

• Mnemonic: Call Mugil ittapo adiyil poi

Aluminium Phosphide

Source

• Common grain fumigant and rodenticide

• Available as tablets/pellets containing AlP (3 g each)

Mechanism of Toxicity

• Reaction with water or gastric acid → releases Phosphine gas (PH₃)
• AlP + 3H₂O → Al(OH)₃ + PH₃
• AlP + 3HCl → AlCl₃ + PH₃

• Phosphine gas causes:
• Inhibition of cytochrome oxidase
• Cellular hypoxia
• Free radical injury and lipid peroxidation

Toxic Dose

• 150–500 mg of AlP (½–1 tablet) may be fatal

• Mortality: 70–90% (very high)

Clinical Features

1. GI Symptoms

• Burning pain in mouth, throat, epigastrium

• Nausea, vomiting, diarrhea

• Garlic odor from breath

2. CVS (Most common cause of death)

• Severe myocarditis and refractory shock

• Hypotension unresponsive to fluids and vasopressors

• ECG: ST-T changes, arrhythmias, QT prolongation

• Echocardiography: global hypokinesia, ↓ EF

3. Respiratory

• Pulmonary edema

• ARDS

4. CNS

• Restlessness, agitation, altered sensorium, coma

5. Renal and Hepatic

• Oliguria, metabolic acidosis, hepatic dysfunction

Investigations

• ABG: metabolic acidosis

• ECG: myocarditis, arrhythmia

• Serum Mg: low

• Phosphine detection: by silver nitrate paper test
• Paper turns black (due to formation of silver phosphide)

Treatment

General

• No specific antidote

• Gastric lavage: with KMnO₄ (1:1000) or coconut oil (deactivates PH₃)

• Avoid water for lavage (enhances gas release)

Supportive Care

• Shock management:
• IV fluids
• Vasopressors: dopamine, norepinephrine
• Avoid adrenaline (increases mortality)

• Correct acidosis: IV sodium bicarbonate

• Magnesium sulfate:
• Stabilizes myocardium, antioxidant effect
• 1 g IV every 6 h

• Mechanical ventilation if respiratory failure

• ECMO or intra-aortic balloon pump in refractory cases (experimental benefit)

Postmortem Findings

• Garlic odor from body/organs

• Congested organs, petechial hemorrhages

• Fatty degeneration of liver, heart, kidney

Key Points for INI-CET

• Poison: Aluminium phosphide → Phosphine gas → Garlicky smell

• Fatal feature: Refractory shock due to myocarditis

• Diagnostic test: Silver nitrate paper blackening

• No antidote

• KMnO₄ / Coconut oil lavage preferred

• Magnesium sulfate → cardioprotective

• Avoid adrenaline

Barium carbonate

• (Rat poison)

• White, odourless

• ↓ K+.

• Mnemonic: Barry (white [white] rat) car (Barium carbonate) pottich (Potassium ↓↓)

 

Oxalic Acid

• Acid of sugar

• Seen in ink/stain remover

• Oxalic acid + calcium (In the blood):
• Hypocalcemia
• Tetany
• Calcium oxalate crystals:
• D/t cast in urine
• Oxaluria
• Renal tubular necrosis

• Ox writing in envelope With Ink

Hydrofluoric acid burns

• Labs: ↑ S. K+, ↓ S. Ca2+, ↓ Mg, ↑H+ (acidosis)

• Arrhythmias (cause of death)

• Management: Calcium gluconate

Boric Acid Poisoning

• Boiled Lobster Syndrome

• Rarely fatal in adults
• large dose needed for serious toxicity

• Stage 1:
• Non-specific GI symptoms.

• Stage 2:
• Boiled lobster rash → intense generalized erythema → desquamation in 1–2 days.

• Severe effects:
• Cardiovascular collapse, seizures, renal failure.

• Main symptoms:
• Blue-green vomit, diarrhea, bright red rash.

• Treatment:
• Dialysis or exchange transfusion (anecdotal benefit).

Metallic Irritants

ANS

3

• Irritating Zinc

• Stupid Chloral

• Abort the Qween

• Potassium Corrodes

• Accumulate in body

• Removed by chelating agents

• M/c acute heavy metal poisoning: Arsenic

• M/c chronic heavy metal poisoning: Lead

Arsenic

• Dye Industry

• Dark red stools

• ⛔ the enzyme - Phosphoglycerate kinase
• 1,3 bisphosphoglycerate → 3-phosphoglycerate
• PGs are Arse

Treatment:

• Acute
• Dimercaprol (BAL) > EDTA

• Chronic
• DMSA

Metalloid

• Acute:
• Gastroenteritis
• Resembles cholera
• Loose stools
• Red velvety stomach mucosa

• Chronic:
• Arsenicosis
• Hydroarsenicism

Arsenicosis: 

• Mnemonic: ARSENIC Poisoning
• Aldrich Mees lines:
• Transverse white line in nail
• Also in thallium
• Aldrich → Arsenic; Mesa → Thalli

• Alopecia
• Raindrop pigmentation:



• In skin flexors
• Skin eruption:
• Hyperkeratosis in palms & soles
• Mixed Neuropathy:
• Symmetrical, peripheral, sensory motor polyneuropathy
• Ischemia (Periphery) : Gangrene
• Due to vasospasm
• Black foot disease
• Cardiac
• Pancytopenia:
• Normocytic normochromic anemia
• Bone marrow suppression

Samples:

• Urine (Reliable) > Blood

• Detected in exhumed bodies, cremated remains, decomposed bodies
• Bone, nail, hair

Tests:

• March test

• Reinsch test

• Neutron activation analysis

• Atomic absorption spectrometry

• Note: Endrin poison is also detected in exhumed bodies.

Mnemonic Story:

• A girl named Marsh Reinsh Guzett puts henna nail polish, wears black footwear, goes out on a rainy day, eats garlic noodles and red velvet cake, gets cholera.
To rescue her, a ferry comes. She gets yellow liver and finally dies.
(Fatal dose: 100–200 mg)
Sampling from mummies
Delays rigor mortis

Thallium Poisoning

• Use: Glass industry, rodenticides, pesticides

• Mechanism:
• High affinity for sulfhydryl groups
• Interferes with K⁺-dependent enzymes
• Hematopoietic system spared

• Clinical Features
• Mild: Joint pain, loss of appetite, drowsiness
• Severe: Colic, vomiting, muscle pain, convulsions, psychosis, tremors, delirium, coma
• Characteristic:
• Alopecia (after 2 weeks)
• Loss of outer 1/3 eyebrows
• Brownish-black pigmentation near hair roots
• Mees’ lines (nails)
• Butterfly rash on face
• Stocking-glove neuropathy, paresthesias, cranial nerve involvement

• Treatment
• Gastric lavage: potassium iodide / Prussian blue + activated charcoal
• Hemodialysis (within 48 hrs)

Mercury

• Occupation: Hatters, Glassblowers

• Types: Elemental
• Not orally absorbed
• Vapour: Toxic

Toxicity:

Chronic toxicity/Hydrargyrism (Mnemonic: METAL)

• Slate grey stomach mucosa

• Minamata disease:
• Fish consumption (Methyl Hg)

• Erethism:
• Mad hatter syndrome
• Neuropsychiatric
• Emotional instability

• Tremors:
• Coarse intentional tremors (Glassblowers/hatters shakes)

• Acrodynia:
• Calomel/swift fever disease
• Aka Pink disease
• Pink, peeling
• Painful peripheries
• Usually paediatric

• Lentis:
• Anterior capsule brownish deposit (Malt brown reflex)
• Vision isn’t affected

• Mnemonic:
• Meena emotionally unstable () ayirunnu, tremors () varum,
• Brown lens (anterior capsule brown ddeposits) vachittundu
• Meena Fish (Minamata - fish eating) ishtam ayirunnu → Slate grey color (stomach) fish → stomach same color ayi
• Meena Pink (Pink disease) Peel () cheyyan swift () caril (calomel) poi
• Peel cheythapo peripheries (Painful peripheries) full pain ayi
• Deshyam vannu → Glass () thallipottich motham vapor (vapor → toxic) aaki

Note:

Lead

Chronic lead poisoning/Saturnism: 

• Acquired porphyria → also called Plumboporphyria

• Associated industries: Battery, automobiles, paint.

• Route:
• Children: Oral
• Adult: Occupational inhalation

Mnemonic: ABCDEFG

• Saturn → Leading planet → 2 rings (cabots, cirum oral pallor)

• Abdominal pain

• Blue gums → Burtonian line

• Drop

Letter	Symptom/Sign
A	• Anemia with coarse basophilic stippling ↳ ⛔ rRNA degradation • Lead a course NOTE: Fine Basophilic stippling: • Megaloblastic anemia, Thalassemia
B	• Burtonian lines: ↳ (Bluish lines over gums.)
C	Constipation, abdominal colic ↳ (AKA painter's colic, Saturnine colic/Dry belly ache) Calcification Bone line (Calcium deposition) ↳ Metaphyseal dense opacity
D	Drop (Motor nerve palsy) ↳ (wrist drop, foot drop – neuropathy)
E	Encephalopathy ↳ (infants: ataxia, vomiting, stupor, seizures, coma)
F	Facial pallor ↳ earliest sign ↳ Most consistent finding ↳ Circumoral
G	Gout ↳ Saturnine gout

Ringed sideroblasts in bone marrow

Note:

• Burtonian lines also in:
• Mercury
• Copper
• Lead
• Molar, canine, lateral incisors

RBC Inclusions

Inclusion	Composition	Seen in
Howell–Jolly bodies	• DNA remnants	• Post-splenectomy • Megaloblastic • Sickle cell disease (NOT THALASSEMIA) • Dyshematopoiesis • Hemolytic anemia
Reticulocytes	• Residual RNA (bluish network)	• Hemolysis • Blood loss • Response to therapy
Basophilic Stippling	• Ribosomal RNA	• Coarse → Lead poisoning • Fine → Thalassemia, Megaloblastic Anemia • Also seen in 5’ Pyrimidine nucleotidase
Heinz bodies	• Hb denaturation • Stained by Crystal Violet stain • (Supravital stain)	• G6PD
Pappenheimer Bodies	• Iron granules	• Sideroblastic anemia • Post-splenectomy
Cabot Rings	• Arginine-rich • Mitotic spindle remnants • Figure of eight/loop	• Severe anemia • Megaloblastic anemia • Sideroblastic anemia
Hemoglobin H inclusions	• β4 tetramers • (precipitated Hb H)	• α-thalassemia (Hb H disease)
Siderotic Granules	• Iron • In Prussian blue stain	• Sideroblastic states
Target cells	ㅤ	• Thalassemia • Iron deficiency anemia • Liver disease • Post-splenectomy • Hemoglobin C disease
Dohle bodies	• ER remnant	• Bacterial sepsis
Perinuclear hof	• Golgi apparatus	• Plasma cells

Phosphorus

• Antidote:
• Copper sulfate

White Phosphorus

• Toxic

• Luminous

• Protoplasmic poison

• Diwali poison

• Yellow fatty liver

• Emit fumes:
• Cause Spontaneous combustion
• So kept under water

• Garlic odor

Red Phosphorus

• Not toxic

Acute poisoning

• Smoky stool syndrome

• Vomitus and stool luminescent

Chronic poisoning

• Phossy jaw/Glow jaw/Lucifer jaw

• Occupational inhalational disease

• Osteomyelitis: Osteonecrosis of jaw
• Painful
• Swelling
• Multiple pus discharging sinus:
• Garlicky odour

Note

Cadmium

• cadBurry Muttai → Bone, Ittai
• Itai itai ds → Ouch ouch
• Bone pain