Introduction to Neurotics (Alcohol)
- 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.
- SPINAL :
- e.g. Strychnos nux vomica, Gelsemium.
- PERIPHERAL :
- e.g. Conium , Curare.
- Inebriant —produces Intoxication
- Light headedness, confusion, disorientation, drowsiness.
- Prolonged sleep -> recovery -> gam Hangover (headache, irritability, lethargy, nausea & abdominal discomfort).
- 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
- 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)
- 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
- Conc.= 10-20%
- Habituated drinkers
Factors Decreasing Absorption
- 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)
- More :
- Alveolar air (diffusion)
- Water content
- Less :
- 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
- All routes.
- 10% is excreted.
- 5% – Breath
- 5% – Urine
- Traces- Sweat, saliva, milk, tear and feaces.
- Skin glands -> Odour
- 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)
- 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)
- 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
- Decreased Brain function -> deceased Vitals
- Generalized vasodilatation (Skin) -> Hemorrhage
- 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
- STAGE OF SOBRIETY (0-50mg%)
- At 30mg% – impaired cognitive function ,
motor coordination & sensory perception.
- At 30mg% – impaired cognitive function ,
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).
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.
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
- Recovers from deep sleep in 8 – 10 hrs
- Wakes with acute depression nausea, abd. discomfort, irritability, lethargy and headache.
- at 400Ing%
- below 400mg% in chr. debilitating disease severe arteriosclerotic heart disease pulmonary emphysema chronic lung disease with hypoxia.
Low blood alc. levels seen in —
- Prolong coma causing hypoxic brain damage
- Prolong survival after heavy drinking.
150 — 250 ml of Absolute alc. consumed in 1 hr
Fatal period :
- Tolerance : is acquired, lost by out of practice d/t- tissue sensitivity or rate of absorption restricted by liver damage
- Evacuation of stomach & bowel with Gastric Lavage.
- Keep warm
- 1 ltr. N.S. with 10% Glucose, 100 mg Thiamine and 15 units of insulin
- Nerve stimulants (Caffeine)
- 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.
- 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
- 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.
- Citrated calcium carbamide 50 mg OD
- Chlorpromazine 25-50 mg 6 héurly
- Clonidine 60-180 mg/hr iv
- NMDA receptor blockers
- Thiamine supplements
Other Forensic Notes :-
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