TOXICOLOGY : PART 2😊

TOXICOLOGY : PART 2

Plant Toxins

Toxic Plants and Seeds

Ricinus communis (Castor / Arandi)

• Ricin (Biological weapon)
• Mnemonic: Ramuttan kanich weaponise cheyyum

• Crushed seeds:
• Castor Oil is not toxic
• Residue is toxic

• Mnemonic: Rise () in a 6 adi () castle () → to eat Rambuttan (look alike) and castor oil → before poor (non toxic) cockroach (cockroach looking seeds) eats it

Abrus precatorius (Gunchi / Roti seeds / Rosary / Crab’s eye)

Active Principles:

• Abrin

• Abralin

• Abrine

• Abric acid

Features:

• Powdered seeds used

• Inserted using Sui/Sin needles

• Ideal cattle poison

• Resembles viperine bite

Mnemonic: Abra ca dubra → kunnikuru vari eriyum → paambu varum

Semecarpus anacardium (Bhilawa / Marking nut / Dhobi’s nut)

 

• Semecarpol

• Bhiluawanol

• Crushed seed produces black juice

• Used for malingering (produces artificial bruise)
• Causes blisters

• Same car (same carpus) nte Bill vannapol (Bhiluawanol) → Thuni kazhuvan (dhobi) poi → Last Black juice () kudich

Feature	True Bruise	Artificial Bruise
Vesicles	Absent	Present
Colour	Changes with time	–
Margins	Diffuse, irregular	Regular
Itching	⊖ (Absent)	⊕ (Present)

Croton tiglium (Jamal gota)h nan

• Crotin (Toxalbumens)

• Crotonoside

• Crotonic acid

• Crushed seed:
• Oil and residue both toxic
• 4 - 5 crushed seeds

• Causes:
• Acute onset diarrhea
• Gastroenteritis

• Jamal Jamalu () → dance kalikkumbo scrotathil (croton) chavitttum → testis vayattil varum → gastreroenteritis and diarrhea () → all gone (all toxic)

 

 

Disease	Toxin	Food product	Preventive methods
Endemic ascites (Severe liver toxicity → Ascites and jaundice)	Pyrrolizidine (Crotalaria seeds in Millets → jhun jhunia)	Adulterated millets	Sieving
Aflatoxicosis (Storage fungus) ↓ Hepatocellular Carcinoma	Aflatoxin (Aspergillus flavus)	Stored grains (Ground nuts)	Low humidity < 10% and improving ventilation
Ergotism (Field fungus on flowering plants) St Anthony’s fire	Ergot alkaloid (Claviceps purpurea)	Rye, sorghum, bajra	Floating plant in 20% salt solution

Neurolathyrism

• Lathyrus sativa → Khesari dal

• Beta Oxalyl Amino Alanine (BOAA)

• UMN lesion (Spastic paralysis).

• Prevention:
• Vit C, steeping, and parboiling

• Joints involved: Knee > Hip & ankle.

Stage	Name of Stage	Clinical Features
I	Asymptomatic (Latent)	-
II	No stick	Limping
III	One stick	Crossed gait
IV	Two stick	Cannot walk without support
V	Crawler	Unable to walk

• Mnemonic:
• Neurolathyrism → Bent (bow) BCD
• Walking with Laathi (Lathyrus) → we Boooo (BOAA)
• Kesariya thera → Paadi nadakkunnu → Stick vach
• Bow (BOAA) legs (spastic paralysis) → B (parBoiling) C (Vitamin C) D (Dal)

Epidemic dropsy

• Adulterated mustard oil
• Toxin:
• Sanguinarine
  (Argemone mexicana)
 

• Sangi (Sanguinarine) mexica (mexicana) yil oil (mustard oil) theych Veenu (dropsy) neeradichu (fluid overload) → neela color ayi (Nitric acid chromatography)

• Thatti veenathu (dropsy) eduthu kalayanam (deweeding)

• MOA: Sanguinarine → ⛔ → Glucose metabolism → ↑ Pyruvic acid.

• Clinical features:
• Non-inflammatory, bilateral swelling of legs, with diarrhoea
• Glaucoma.
• Ascites.
• Pedal edema.
• Pleural effusion.
• Congestive cardiac failure.

• Management:
• Pre-testing:
• Nitric acid chromatography test (More sensitive). 
• De-weeding

Calotropis (Madar / Akdo)

• Calotropin

• Calotoxin

• Calactin

• All parts toxic

• cardiac glycoside

• Star (Star shaped) pillarkk → Trophy (calotropis) kodukkunnath → Toxic (all toxic) anu

Capsicum annuum

• Capsicin

• Capsaicin

• Hunan’s syndrome:
• Contact dermatitis
• occupational exposure

• Mnemonic:
• Capsicum → kanthari mulavu → arachu theeckkumbo contact dermatitis
• Unnan (hunan) → Kanthari () mulaku

Somniferous Plants

Papaver somniferum (Opium):

• AKA Afim/Madak.

• Sleep-inducing.

• Milky exudate from unripe capsule → crude opium.

• Morphine poisoning features

• Antidote : Naloxone sodium.

• Opium was transported by British to China in exchange for tea, silk and porcelain pots.

• Methadone is the Method number 1 for (detoxification);
• reducing withdrawal symptoms in opioid addicts 

Heroin:

• AKA Smack/junk/brown sugar/tar.

• Constituent: Diacetyl morphine.

• Semisynthetic derivative of morphine.

• Highly addictive and physical dependence

• Routes of abuse:
• Inhaling vapour: Chasing the dragon.
• Inject into vein: Main lining.
• Inject to skin: Skin popping.
• Speed ball: CNS stimulant (Cocaine) + CNS depressant (Heroin).
• Hot Shot= Heroin + Strychnine
• Micky Finn = Chloral hydrate

• Rx:
• A/c → Naloxone
• Withdrawal → Methadone

• Mnemonic:
• Heroin → female → highly addicting → always end in depression
• HEROINE... When u see a heroine u will forget ur pain.. u will be relaxed.. pr bp all come down.. pupil constricted.. Heroine nalla method actor aanu

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Deliriants

Datura:

• Muttering delirium.

• Active principle:
• Hyoscine.
• Atropine.

• Anticholinergic symptoms:
• Dilated pupil.
• Photophobia
• Dried secretion.
• Delirium.
• Dry skin
• Dysarthria
• Dysphagia
• Drunken gait
• Death

• hyperthermia

• Roots & seeds most toxic.

• Fruit:
• Thorn apple contains seeds.

• Stupefying agent:
• Railway poison.
• Road side poison.

• Antidote: Physostigmine.

• Features in a PYQ:
1. Painful swallowing, photophobia, inability to pass urine, hyperthermia
2. Symptoms of alcohol with hyperthermia

• Mnemonic:
• That (Datura) Hot (hyperthermia) single (single fruit) Aunty (Anti cholinergic),
• In railway and road side
• Good physique (physiostigmine)
• Hayyo (Hyoscine) Attractive (Atropine) anu → We Mutter (Muttering delirium) cheythondirkkum

Atropa Belladonna

• Belladonna alkaloids

• deadly nightshade

• Atropine, 1-hyocyamine, and scopolamine

• anticholinergic syndrome

• Not a cardiac poison

Symptoms:

• Skin: Flushed, dry, warm

• Mucosa: Dry mouth, dry eyes

• Temperature: Hyperthermia

• Eyes: Mydriasis, blurred vision (blindness), photophobia

• CNS: Delirium, hallucinations, seizures, coma

• Cardiac: Tachycardia

• GIT: Decreased bowel sounds, urinary retention

Antidote:

• Physostigmine

Cannabis:

• Most common illicit substance (India and World).

• Some of the most common substances used:
• In India, Tobacco>Alcohol
• In world, Alcohol>Tobacco

• Now, the most common substance is Caffeine

• AKA Grass/Rope/Hash/Joint/Weed/Indian hemp/MJ/Charas/Marijuana
• Burnt rope smell → Cannabis
• Can full of grass
• Can full of rope
• Can with Charakk MJ

• Active principle: ∆-9 Tetrahydrocannabinol (∆-9 THC).
• Mnemonic: Teach (TH) to take cannabis (C)

Preparation	Part of plant	Active principal %
Bhang	Dried leaves	< 15 %
Ganja (Joint/Reefer)	Dried flower (Female plant)	15 - 25 %
Charas/Hashish	Dried resin	25 - 40 %
Hash oil	Resin	Most potent: 60 - 70 % Highest concentration of TetraHydroCannabinol
Majoon	Sweet prepared with Bhang	ㅤ

• Mnemonic:
• Bank(bhang) il ninn leave (leaf) eduth flower(dried flower) kond gancha() yude aduth poyi. Dry (dried resin) aayirunna charakkine (charas) rasippikan(resin) oil( hash oil) itt

• Source:
• Hemp plant or Cannabis Sativa.

Cannabis Intoxication

• Symptoms:
• Euphoria.
• Sense of Time Distortion (slowing down).
• Redness of Conjunctiva.
• Increased Appetite.
• Vivid dreams
• "stoned" or "high."
• Hallucinations.
• High dose: Delirium.

Cannabis Withdrawal

• Symptoms:
• Irritability, Anxiety.
• Sleep difficulty (Insomnia, disturbing dreams).
• Decreased Appetite,
• Decreased Mood.
• Only Mild Physical:
• Tremors, sweating, Fever, Abdominal Pain.

Associated Phenomena with Cannabis

Chronic cannabis abuse:

• Mnemonic: AIR

• CanaBIS ⇒ BUS (hindi) ⇒ Stop → Amotivation → amok
• Amotivational syndrome.
• Unwillingness to persist in tasks.
• Apathetic, Lethargic, weight gain.
• Occurs after chronic use.
• Insanity:
• Hashish/Hemp insanity.
• Psychotic symptoms (Delusions, Hallucinations).
• Disappear within a month of stopping use.
• Cannabis is a risk factor for Schizophrenia.
• Run amok:
• Homicidal f/b suicidal
• Homicidal impulse.
• Development of Rage
• may hurt or kill others.
• Not criminally liable: 22 BNS
• Two two loose screws → Not liable

• Bad Trip
• Restlessness
• Fearful
• Panic Symptoms

• Flashback:
• Re-experiencing symptoms days or weeks after last use.

Treatment

• Mild withdrawal:
• Supportive care.

• Moderate to severe:
• Short-term Benzodiazepines.

Cocaine

• Source: Erythroxylum coca plant.

• Excited delirium.

• AKA Coke/snow white lady/she/crack smokable.

• M/c route of abuse: Snorting.
• Huffing:
• Drug inhaled from a cloth

• Effects of Vasoconstriction:
• Rhinorrhea,
• nose bleed,
• Nasal Septal Perforation.
• Jet Black Pigmentation of tongue (long-term use).

Acute poisoning:

Body packer syndrome.

• Accidental rupture of swallowed cocaine (Smuggling).

• Sympathomimetic action (↑HR, ↑BP, ↑temp, ↑sweating, dilated pupils).
• u can remember it as a coconut fell on head of a guy with fever..
• he will be agitated
• hyper reflexive 
• heart rate increased
• pupil dilated and restless 

• Feeling of well-being.

• Treatment
• Amyl nitrate
• Mnemonic: Coconut Amy de thalayil veenu

Chronic abuse:

• Septal perforation (snorting).

• Black staining: Tongue/Teeth.

• Peripheral gangrene (peripheral vasoconstriction).

• Cocaine bugs/Magnan syndrome/formication.

• Tactile hallucination.

Adverse Effects of Cocaine

• Potent Sympathomimetic.

• Causes Vasoconstriction:
• Leads to Hypertension, end-organ damage.
• Increases heart rate.
• Can cause Myocardial infarction.

Cocaine Intoxication

• Euphoria, Mydriasis, Tachycardia, Hypertension.

• Cardiac Arrhythmias, Seizures.

• Auditory Hallucinations, Paranoid Ideations.

• Cocaine bugs (Formication):
• Tactile Hallucinations of insects crawling under the skin.
• Leads to scratch marks.

• Dependence:
• Strong Psychological Dependence.
• Mild Physiological dependence.

Cocaine Induced Psychotic Disorder

• Hallmark:
• Paranoid Delusions,
• Auditory Hallucinations.

• Mimics Schizophrenia.

Treatment

• Withdrawal is usually mild.

• No pharmacologic agents reduce withdrawal intensity.

Speed Ball

• Combination of Cocaine + Heroin.

Ethanol:

Methanol:

• Illicit liquor, AKA wood alcohol.

• Mass poisoning: Hooch tragedy.

• Symptoms:
• Abdominal pain/vomiting.
• Blurring of vision.
• Blindness (Optic atrophy).

• Only High anionic gap metabolic acidosis (HAGMA).

• Antidote:
• Fomepizole 
• Inhibit - Alcohol dehydrogenase
• Ethanol.
• Compete with methanol for aldehyde dehydrogenase
• ↓ formation of Formaldehyde (toxin)

Ethylene Glycol:

• Anti-freeze solution.

• Oxalic acid:
• Hypocalcemia.
• Urine cast
• Renal tubular damage.
• Calcium monohydrate stones (envelope)

• Glycolic acid
• HAGMA

• Net:
• Ethylene glycol → HAGMA + Hypocalcemia
• Methanol → HAGMA only

• Treatment:
• Fomepizole.
• Ethanol.
• Calcium gluconate.

Methanol Metabolites

1. formaldehyde

2. formic acid

3. lactic acid

 

Ethylene glycol metabolites

• Glycoaldehyde

• Glycolic acid (Toxic)

• Oxalic acid + α Hydroxy β Ketoadipate

Spinal and Cardiac Poisons

Spinal Poison:

Strychnos Nux Vomica:

• AKA Kuchila.

• Even 1 crushed seed is fatal.

• Active principle:
• Strychnine (Most potent).
• Brucine.
• Loganine.

• Bruce (hulk) → strike (strychnine) → Logan (wolverine)

• Acts on anterior horn cell ( ⛔ Glycine) → Result in excitation → Muscle convulsions)
  (Resembles tetanus)
• All muscles will be affected → Opisthotonus
• Consciousness intact.

• Alternate spells of convulsions & relaxation with
• progressive ↑ in convulsions &
• ↓ in relaxation period
• Eventually die

• Presentation:
• Risus sardonicus.
• Opisthotonus (M/c) (A): Backward hyperextended spine.
• Pleurosthotonus (C): Lateral flexion of spine.
• Emprosthotonus (B): Forward hyperflexion spine.
• Mnemonic: Bent forward infront of emperor

• Post-mortem caloricity (Autopsy).

• DO NOT GIVE GASTRIC LAVAGE

• Early rigor mortis and Late Putrifaction

Cardiac Poisons:

• Nerium odorum
• Active Principle: Nerin

• cerebra thevetia

• digitalis
• fox glove

• Mnemonic: Car DONA (Digitalis, Oleander, Nicotine, Aconite).

• Mnemonic:
• Digitalis → digits - Fingers → gloves (Fox glove)

Aconite:

• AKA blue rocket/Mita zaher/Devil’s helmet.

• Active principle: Aconitine.

• All parts toxic,

• most toxic: Root
• Meetha zehar/Monks hood
• Methan Monck devil - with cone ice cream get heart attack

• Perioral paraesthesia.

• Neurotoxin and cardiotoxin

• Mnemonic: Aconite → A cone (helmet, rocket) Ice cream (Vaa maravikkum - perioral parasth) → heart (carditoxin) nte root (most toxic) vare maravikum (neurotoxin)

Asphyxiants

• Chemical Asphyxiants:
• Carbon monoxide (CO), Cyanide, Hydrogen sulfide.

Snake Venom

• Ophiology: Study of snakes.

• Ophiotoxemia: Envenomation (By snake venom).

• Mnemonic:
• Venomous snake have smaller head and large body (scales) → to make biting easier
• Crane → pick from under (infralabial) the floor (four)
• Cobra → 3 bra (3) → mukalil (supralabial) kidakunnu

Venomous vs Non-venomous Snake:

• Note:
• Large scaled venomous snake:
• Cobra: 3rd supra labial scale largest.
• Krait: 4th infra labial scale largest.

Venomous snakes:

Mnemonic:

• If straight → build bunglow

• Naja naja → dancing → common people

• King → Hannah montana

• Cobras - CNS

• Viper - Vessels

• Sea snake - Skeletal muscle pain d/t swimming

• Abrus needle injection resemble Viper

• 20 min whole blood clotting test (WBCT):
• Collect 2ml blood in a test tube
• Normal/elapid bite: clot within 20 mins.
• Viper bite: no clot even after 20 mins.

MANAGEMENT OF SNAKE BITE

1st aid:

• Mnemonic: RIGHT
• Reassure patient.
• Immobilize entire limb: Sutherland’s wrap /crepe bandage/cloth.
• To occlude lymphatics.
• Never use ligation/incision/tourniquet.
• Get to hospital immediately.
• Tell doctor about any systemic symptoms that manifested on the way.

At hospital:

• Observation

• IV Neostigmine + Atropine.
• Cobra poisoning only (NOT KRAIT)
• New bra

Anti-snake venom:

• Only if ophitoxemia (ASV can precipitate anaphylaxis).

• No test dose (But continuous monitoring).

• IV 8 - 10 vials.

• Bound with free toxin

• No effect on already occurred damage

• Effective for “Big 4”
• (Common cobra, Krait, Russell’s viper, Saw-scaled viper).
• Mnemonic: Saw () Russels () Common () Trait (Krait)

Scorpion

• Indian red scorpion > Black scorpion.

• Venom: Neurotoxic & hemotoxic.

• Pain: Main clinical feature.

Autonomic storm (children):

Treatment:

• Initial
• Prazosin

• Antidote
• Anti-scorpion venom

Blister Beetle (Spanish Fly) – Cantharide Poisoning

• Mnemonic: Canthan nte kude ride nu poi → Priapism, ↑ Libido
• but got blisters (painful blisters)

• Active principle: Cantharidin
• 1 beetle: 0.2–0.7 mg cantharidin
• Indian flies: 3% cantharidin

• Local effect:
• Painful blisters

• Oral effects:
• ↑ Libido (aphrodisiac)
• Priapism (painful penile erection)

• Fatal dose: 15–30 mg cantharidin

• Toxicity: Nephrotoxic → chronic renal failure, uremia

Organophosphorous (OP) Poisoning

Cholinergic syndrome (< 1 day):

• Ix: RBC cholinesterase > Pseudocholinesterase.

• Treatment:
• Supportive measures.
• Atropine (Specific)
• Oxime

• Cause of mortality
• Respiratory failure

Intermediate syndrome (1 - 4 days):

• Proximal muscle weakness

• Cranial nerve palsy

• Unresposive to atropine & oximes

Delayed syndrome (1-4 weeks):

• Distal neuropathies.

• D/t incomplete treatment

• Slow release of OP back to system from adipose tissue

NOTE

• Pin point pupil
1. Carbolic acid
2. Morphine
3. OPC poisoning
• Garlicky odour
4. Heat stroke