NEUROTICS (ALCOHOL)

Introduction to Neurotics (Alcohol)

  1. CEREBRAL :
    • CNS DEPRESSANTS – e.g., Alcohol, GA, Opioid analgesics, Sedatives, Hypnotics.
    • CNS STIMULANTS — e.g., CAD, Caffine, Amphetamine, Methylphenidate.
    • DELIRIANTS — Dhatura, Cannabis, Cocaine, Atropa belladona, Hyocyamus.
  2. SPINAL :
    • e.g. Strychnos nux vomica, Gelsemium.
  3. PERIPHERAL :
    • e.g. Conium , Curare.

Inebriants

  • Inebriant —produces Intoxication
  • Light headedness, confusion, disorientation, drowsiness.
  • Prolonged sleep -> recovery -> gam Hangover (headache, irritability, lethargy, nausea & abdominal discomfort).

ETHYL ALCOHOL

  • Oldest recreational drug
  • Used in India since 3000 BC
  • Sura , a beverage distilled from rice meal, wheat, sugarcane, grape and other fruits.
  • 3rd most common drug of abuse after caffine and nicotine
  • C2H5OH
    • Transparent, colourless, volatile liquid with spirituous odor and burning taste.
  • Absolute Alcohol = 99.95%
  • Rectified Spirit = 95%
  • Industrial Methylated Spirit = 90% ethanol + 9.5% methanol + 0.5% crude pyridine
  • Fermentation of sugar by yeast — till (15% vol)
  • “Proof spirit”
    • At 11°C weighs exactly 12/13 part of an equal measure of Distilled Water
    • Approx 57.06% ethanol by volume
    • It is minimum conc. of ethanol which when mixed with gunpowder would ignite
  • “Underproof’ and “Overproof”
    • % of Alc content x 2 = Proof (In U.S.)
    • One unit = 8-10 gm

Percentage by Volume

  • Vodka : 40-50%
  • Rum : 40-60%
  • Whisky , Gin, Brandy : 40-75%
  • Pert, Sherry : 20%
  • Wine, Champagne : 10-15%
  • Beers : 5-8%
  • Consumption = 1-2 drinks per day
  • Safe Limits of Alcohol = 210 g in men & 140 g in women (Per week)

ABSORPTION

  • Requires no digestion
  • Immediately by Simple diffusion
  • 20% from Stomach ; 80% from Small intestine.
  • 60% absorbed in 30-60 min, 90% in 60-90 min.
  • Detected in blood within 2-3 min.
  • Max.conc.in blood within 45-90 min. (mainly 1hr).

Factors Increasing Absorption

  • Carbonatedsdrinks
  • Warm
  • Conc.= 10-20%
  • Habituated drinkers
  • Gastrectomy

Factors Decreasing Absorption

  • Cold
  • Conc.
    • 10% (Dilution e.g. Beer)- takes double time
    • 40% – Pyloric Spasm
      • Reduced gastric motility
      • Irritation of mucosa & mucus secretion
  • Food (Fat and Protein)
    • Fatty meal – delays by many hours
    • Mixed meal -reduces max conc. by %
  • Diseases : Achlorhydria , Chronic gastritis
  • Drugs: Benzine, Atropine, etc. (reduce gastric emptying)

Distribution

  • More :
    • Alveolar air (diffusion)
    • Water content
  • Less :
    • RBC
    • Fat (Adipose tissue, Obese, Females)
    • Venous (10% less than Arterial)
  • Equilibrium :
    • Capillary = Arterial =Brain (1-3min)
    • Venous (1 hr)
  • Females have 25% higher blood alcohol canc. for the same amount consumed d/t :-
    • small volume of distribution
    • small aqueous compartment
    • more variable absorption from gut
    • lower activity of gastric ADH enzyme
    • faster hepatic clearance
    • higher conc. of acetaldehyde
    • poor solubility in body fat

EXCRETION

  • All routes.
  • 10% is excreted.
  • 5% – Breath
  • 5% – Urine
  • Traces- Sweat, saliva, milk, tear and feaces.
  • Skin glands -> Odour

Metabolism

  • 90% is Metabolised
    • 90% of which is oxidised in Liver
    • 10% is metabolised by Cytochrome P4502E1
  • Disappears from blood at 10-15 ml/hr (15mg/100mI/hr)
  • Elimination varies: 12-27mg/100mI/hr (Av=18mg)
  • Fast
    • With large dose
    • Chronic alcoholics (30-40mg/100ml/hr)
  • Slow – Liver damage
  • 10% of metabolized is deposited in tissues as lipids (cholesterol and neutral fat)

ACTIONS

  • Endogenous (Metabolism or bacterial activity in GIT)
  • Stimulant and selective depressant (Primarily RAS)
  • Effects –
    • Frontal lobes (mood changes)
    • Occipital lobes (visual disturbances)
    • Cerebellum (loss of coordination)
  • Like hypoxia on neural cells ( reduces activity)
  • Depresses cells of Conduct, Judgement & Self-criticism with release of inhibitory tone
    (unrestrained behavior).
  • Decreased Brain function -> deceased Vitals
  • Generalized vasodilatation (Skin) -> Hemorrhage
  • Hypnatic.
  • Diaphoretic -> Sensation of warmth -> Heat loss.
  • Tachycardia(at lower conc.) -> Bradycardia (at higher conc. »300mg%)
  • Toxic to every organ, d/t acetaldehyde or change in redox potential.
  • Blocks metabolism and increases levels of some drugs.
  • Moderate consumption -> Increased HDL & Decreased LDL
  • Increased Appetite (Increased salivary & gastric juice)
  • Carminative (Brandy)
  • Diuresis (d/t Decreased ADH)
  • Spirituous liquor -> Heamorrhagic gastritis

Causes of Death

  • CNS Depression (respiratory centre)
  • Aspiration of Vomit
  • Chronic effects of Alcohol

ACUTE POISONING

  1. STAGE OF SOBRIETY (0-50mg%)
    • At 30mg% – impaired cognitive function ,
      motor coordination & sensory perception.
  2. STAGE OF EXCITEMENT (50-100mg%) :
    • Feeling of well being & slight excitation.
    • Action , emotion & speech are less restrained.
    • Lowering of inhibitions.
    • Inc. confidence and lack of self control.
    • Forgets good manners and is careless.
    • Decreased Visual acuity at conc.
      • 20mg% in abstainers
      • 20-33mg% in moderate drinkers
      • 40-70mg% in heavy drinkers.
    • Judgment & motor control affected at 25-50meg%.
    • Altered time & space perception.
    • Pupils = Dilated.
    • 40-100mg% = “ALCOHOL GAZE NYSTAGMUS”.
    • 50-100mg% = loss of inhibitions & laughter.
    • 100-150mg% = slurred speech, unsteadiness & nausea.
    • Mental concentration is poor & judgment is impaired.
    • Increased Attention & Recall memory.
    • Increased Sensitivity to pain (at 80mg%).
    • Reaction time (at 5Omg%).
    • Increased Sexual desire & impaired performance (prolonged intercourse without ejaculation).
  3. STAGE OF INCOORDINATION (150-250MG%)
    • Sense perception & skilled movements are affected.
    • Alteration in conduct.
    • Carefree, cheerful, ill-tempered, irritable, excitable, quarrelsome , sleepy, etc.
    • Incoordination in fine & skilled movements (altered speech and fine finger movements)
    • Nausea and Vomiting.
    • Alcoholic smell (in breath).
    • Face = flushed , Pulse = rapid, Temp = Subnormal.
    • Decreased Sense of touch, taste, smell & hearing.
  4. STAGE OF COMA
    • Motor & sensory cells affected deeply
    • Speech = thick and slurring
    • Coordination is affected — giddy, stagger & falls.
    • Pulse = rapid, Temp =Subnormal
    • Pupils = contracted, Dilate on pinching or slapping, with slow return (Mc Ewan Sign).
    • Micturition Syncope :
      • At night
      • Loses consciousness d/t upright posture
    • Munich Beer Heart :
      • Cardiac dilation and hypertrophy
    • Hang over:
      • Recovers from deep sleep in 8 – 10 hrs
      • Wakes with acute depression nausea, abd. discomfort, irritability, lethargy and headache.
  5. Death
    • at 400Ing%
    • below 400mg% in chr. debilitating disease severe arteriosclerotic heart disease pulmonary emphysema chronic lung disease with hypoxia.
  6. Low blood alc. levels seen in
    • Prolong coma causing hypoxic brain damage
    • Prolong survival after heavy drinking.
  7. Fatal Dose:
    150 — 250 ml of Absolute alc. consumed in 1 hr
  8. Fatal period :
    12-24 hrs
  9. Tolerance : is acquired, lost by out of practice d/t- tissue sensitivity or rate of absorption restricted by liver damage

Treatment

  1. Evacuation of stomach & bowel with Gastric Lavage.
  2. Keep warm
  3. 1 ltr. N.S. with 10% Glucose, 100 mg Thiamine and 15 units of insulin
  4. Nerve stimulants (Caffeine)
  5. Oxygen
  6. Dialysis — Hemo or Peritoneal

Post mortem appearance

  • Alcoholic odour in cavities
  • Stomach – Acute inflammation with coating of mucus
  • Brain, Liver & Lungs = congested with smell of alc.
  • Blood= fluid and dark
  • Brain & Meninges = Oedematous & congested
  • Cloudy swelling in parenchymatous organs
  • Sign of malnutrition present.
  • The GI mucosa is reddish brown and congested.
  • Liver is congested and enlarged with weight approximately 2kg . The surface is pale and greasy .
  • Later cirrhosis develops and liver becomes smaller and contracted with weight 800-1200gm.
  • Kidneys show granular degeneration
  • Heart shows fatty degeneration and patchy fibrosis.
  • Central pontine myelinosis with a low salt vitreous electrolyte pattern.

Chronic poisoning

  • Syn- Alcohol addiction, chronic alcoholism, Ethanolism.
  • Addicts are the people who cannot stop drinking for long or develops withdrawal symptoms if they stop drinking.
  • Barbiturate-alcohol type dependence
  • They suffer from nausea ,vomiting , anorexia ,diarrhoea , jaundice ,tremors of the tongue , and hands ,loss of memory , impairment of judgment , coma ,death

Conditions seen in Chronic poisoning

  • Alcoholic Brain syndrome
  • Alcoholic epilepsy
  • Alcoholic paranoia
  • Alcoholic polyneuritis
  • Battered alcoholic syndrome
  • Beriberi heart
  • Cirrhosis; AST:ALT >2.0
  • Delirium tremens- acute episode of delirium precipitated by alcohol withdrawal
  • Korsakoff’s psychosis
  • wernicke’s encephalopathy
  • Mallory-Weiss syndrome
  • Mania a potu
  • Marchiafava-Bignami Syndrome
  • Pancreatitis

Treatment

  1. Disulfiram 250mg OD .
    • It inhibits aldehyde dehydrogenase.
    • It causes accumulation of aldehyde in blood and tissues .
    • Aldehyde causes unpleasant symptoms such as flushing , palpitation , anxiety ,sweating , nausea, vomiting ,abdominal cramps ,due to which patient dislikes alcohol.
    • Disulfiram like reaction is caused by metronidazole.
  2. Citrated calcium carbamide 50 mg OD
  3. Chlorpromazine 25-50 mg 6 héurly
  4. Clonidine 60-180 mg/hr iv
  5. Chlormethiazole
  6. Baclofen
  7. NMDA receptor blockers
  8. Thiamine supplements

Other Forensic Notes :-

Sexual Offences

Identification By Trace elements

Spinal & Peripheral Nerve Poisons

Opium & its Derivatives

Cardiac Poisons

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