Alcohol Poisoning

Aphrodisiac

An aphrodisiac is an agent or drug which is supposed to stimulate the

sexual desire or increase the libido.
Example of aphrodisiac:
Arsenic
Opium
Cannabis indica
Cocaine
Nux vomica
Alcohol etc.
Cantharides (Spanish fly)
 Introduction of Alcohol
The word alcohol appears in English in the 16th century, loaned by
French & Latin, ultimately from the Arabic (al-Kuhl, the kohl, a powder
used as eyeliner)

Arabic al-kuhl

French → alcohol (appears in English)

Kuhl was the name given to the very fine powder, which was used as an
antiseptic and eyeliner.
 Contd
Kohl is an ancient eye cosmetic. It is widely used in the Middle East,
North Africa and South Africa to darken the eyelids. Kohl goes by
numerous names
Arabic: kuhl
Hindi: kajal
Somali: kuul
Tamil: kanmai
Telegu: katuka
 Contd
Alcohol, in the commonly accepted sense of term signifies ethyl alcohol.
Pure ethyl alcohol is a transparent, colorless, volatile liquid having a
characteristic spirituous odor and a burning taste. When oxidized, it is
converted into aldehyde and acetic acid.

It is used as an antiseptic, chemical intermediate and in alcoholic drinks.

Absolute alcohol contains 99.95% alcohol. Rectified spirit contains 90% by

volume of alcohol. Industrial methylated spirit or denatured alcohol is a
mixture consisting of alcohol 95% and 5% of wood naptha (varnish)
 Percentage of alcohol in Beverages

Vodka : 60 to 65%
Ram, Liquors : 50 to 60%
Whisky, Gin, Brandi : 40 to 45%
Port, Sherry : 20%
Wine , Champagne : 10 to 15%
Beers : 4-8%
Arracks: (40-50%) it is a liquor distilled from palm, rice, sugar,
or jeggary.
 Absorption of alcohol
Alcohol is absorbed unaltered from the gastro intestinal tract, about 80% from
small intestine and 20% from the stomach. Absorption begins almost
immediately upon ingestion. Absorption is usually complete within the 1st
hour. The rate of absorption is dependent upon a number of factors of which
the presence or absence of food in the stomach and the nature of the food are
most important, the ingestion of milk and fatty foods impedes and water
facilitates its absorption. Absorption is also delayed by the presence of protein.
The maximum concentration of alcohol in blood is reached within ½ to 2
hours. Alcohol is found in the blood for about 20 hours after it is drunk.
 Metabolism
Approximately 90% of absorbed alcohol is oxidized in the liver, the
remaining 10% being exerted mainly by the kidney and the lungs.
 Excretion
Alcohol is excreted mainly by the kidneys, the sweat and the breath.

5% through urine, 5% through breath & little amount through saliva,
lacrimation, sweat gland etc.

Alcohol within blood 2-3 min, maximum conc in blood 45-90 mins.

Fatty foods, mixed foods delay absorption of alcohol.

 Medico legal aspects of alcohol
a) It is commonly used as an aphrodisiac agent
b) Most cases of poisoning are accidental or due to over indulgence
and causes of death.
c) It is stated to build nerves before performing act of violence or
crime like homicide.
d) A person may be killed by some person given mixed with alcohol to
make the smell and taste of the poison.
e) Person may be killed by influencing fatal injury or by way of
drowning after making him unconscious by giving alcoholic drink.
 Fatal dose & Fatal period

Fatal dose: 150-250ml of absolute alcohol consumed in 1 hour.

Fatal period: 12-24 hours

1 unit= 10ml of absolute alcohol.

Safety level of alcohol consumed : 210ml of alcohol in men and 140ml

of alcohol in women per week are considered as safe limits for
drinking.
 Signs and symptoms
Signs and symptoms of acute alcohol poisoning:
1) Stage of excitement
2) Stage of in co-ordination
3) Stage of narcosis/coma
1. Stage of excitement:
Sense of well-being with flushing of the skin and face
Increased confidence with a certain carelessness of consequences
leading to lack of self-control
 Contd
Action, speech and emotions are less restrained due to lowering of
the inhibition normally exercised by higher centers of the brain. So ----
The person may disclose the secrets
Normal good manners are forgotten
Those who are ordinarily neat and tidy are careless in their
dress
There may be excitation of sexual desire.
Mental concentration is poor and judgement impairs
Blood alcohol level is between 50-150 mg/100 ml of blood
 Contd

2. Stage of incoordination

Sense of perceptions and skilled movements are affected (blood

alcohol level is between 150-250 mg/100 ml of blood)

Alteration in the conduct of the individual according to the dictates of

his inherent desires and emotions. He may be morose, gay, irritable,
garrulous, argumentative, quarrelsome, sleepy and so on
 Contd
The reaction times are somewhat lengthened and certain clumsiness and
incoordination is observed in the finer and more skilled movements, as
evidenced by slight alteration in speech and in the finer finger movements

State of confusion and dulling of perception

Muscular in coordination with staggering gait

Slurred and incoherent speech

Blurred vision

Stupor-pupils dilated, reaction to light is sluggish

 Contd
3. Stage of narcosis
The patient gradually passes into unconsciousness and coma with ----
Slow stertorous breathing
Commonly paralysis of the respiratory centre
Full rapid pulse which later become slow and small
Pupils contracted but stimulation viz, slapping, pinching etc. causes them to
dilate but when subject is left alone pupils will return to their original position
(McEwan’s sign)
Temperature subnormal
Blood alcohol level is between 300-400 mg/100 ml of blood
Death usually occurs due to asphyxia resulting from respiratory paralysis
 Treatment
Gastric lavage: stomach wash is recommended within 3 hours of last intake or
even after 3 hours if the stomach is distended with ill digested food and alcohol.
Plain warm water or sodium bi carbonate solution may be used

30-60 ml liquid paraffin is left in the stomach to act as a demulcent

Respiration is safe guarded by cleaning the air passage and giving O2 inhalation

Patient should be covered by warm blankets to maintain the body temperature

 Contd
If the above does not seem to improve the condition of the patient
then, analeptic like Nikethamide is given

If analeptic does not work then 50 ml of 50% dextrose is given slowly I/V
injection along with 15 units insulin subcutaneously

In gross intoxication antibiotic cover should be given

In case of acute intoxication of chronic alcoholics, vitamin B complex

therapy with vitamin B1 and B6 is given and normal intake of balance diet
is gradually restored
 Post mortem findings
1. The cloths are generally in a disorderly/torn condition
2. Clothes stain due to vomit or blood may be present
3. Face and conjunctiva may be congested
4. Rigor mortis may last unusually long
5. Putrefaction is said to be retarded
6. Alcoholic odour is perceptible in stomach, lungs and brain, unless
putrefaction has set in
7. The mucous membrane of the stomach may be red, intensely
congested and inflamed
8. Liver, lung and brain are usually congested
 Hazards of alcohol/complication
Pancreatitis (not common in
Drunkenness
Bangladesh)
Vehicular accident Malnutrition
Fall from height Gastric and peptic ulcer
Electrocution Delirium tremens
Drowning Korsakoff’s psychosis
Burning Saturday night paralysis
Choking (café coronary) Alcoholic paranaia
Cirrhosis of liver Alcoholic epilepsy
Cardiomyopathy Wernick’s disease
Mallory-weiss syndrome Alcoholic blackout
 Chronic alcohol
poisoning/alcoholism/alcohol addict
Alcohol addicts are people who can’t stop drinking for long or who
experience withdrawal symptoms, if they do
It is characterized by-
Loss of appetite
Nausea, vomiting especially in the morning
Diarrhoea
Jaundice
Tremor of the tongue and hands
Insomnia
 Contd
Loss of memory
Impaired power of judgement
Hypoproteinema
Dropsy
General anasarca (generalized oedema)
Symptoms of peripheral neuritis and dementia
Sudden death may occur from coma
 Treatment of alcoholism
Antabuse (disulfiram) is administered in doses of 0.25 to 0.5 gm. A single daily dose
of 0.5 gm. Is usually adequate—to be continued for 5 to 7 days, the doses is
gradually reduced so that an adequate daily dose of 0.125 to 0.25 gm. Is reached,
which should be continued until the patient has been conditioned to accept
adequate follow up therapy.
Antabuse inhibits the metabolism of alcohol at the acetyldehyde stage, and
ultimately helps the patient to abstain himself from the habit of taking alcohol.
Usually this drug does not cause any discomfort, but when a small quantity of alcohol
is taken at the same time, the two combine and cause unpleasant symptoms like
flushing, palpitation, throbbing, headache, nausea and vomiting, sweating, chest
pain, vertigo and hypotension due to increase in the concentration of acetaldehyde
in the body. All these unpleasant symptoms make the addict acquire a distaste for
alcohol, which may last several days
 Contd
Citrated calcium carbimide (temposil) 50 mg tablet once a day will
sensitise an individual to alcohol, the side effects are less than
antabuse
Sulfonylureas may also produce similar effect
Chlopromamazine 25 to 50 mg every 4 to 6 hours is also useful
Clonidine 60 to 180 mg/day
Chlormethiazole
A well balanced diet with large doses of multivitamin tablets for a
prolonged period
A complete psychiatric examination and necessary treatment
 Post mortem appearances of alcoholism
1. Gastric mucous membrane shows a deep reddish brown color with
patches of congestion
2. Liver is either enlarged or cirrhosed and contracted. It shows a fatty
infiltration.
3. Kidney shows granular degeneration
4. Heart is dilated and show fatty degeneration
 Hang over
With recovery, the coma gradually lightens into a deep sleep, and the
patient usually recovers in 8 to 18 hours, and wakes up with acute
depression, nausea, abdominal discomfort, irritability, lethargy and
severe headache.
 Drunkenness
Definition: It is the condition produced in a person who has taken
alcohol in a quantity sufficient to cause him to lose control of his
faculties to such an extent that he is unable to execute safely, the
occupation in which he was engaged at the particular time
Or, excessive amount consumption of alcohol that leads to
a) Lose his control over mental faculties
b) Unable to perform duties
c) He may be dangerous for himself or others.
Blood level is 150-250mg/dl.
 Contd
Medicolegal Importance:
Drunkenness is not an offence by itself. It may be an offence only when
it is accompanied by some act which causes danger to the life and
property of the individual or some other. Thus a person may be charged
with being drunk.
Diagnosis of drunkenness:
Alcoholic smell or breathing
General manner or behaviors ---- excited, talkative, hilarious
Dress ----- disarranged, soiled by vomiting or excretion
Speech ---- slurred and incoherent
 Contd
Self-control ----- lost
Memory ---- lost or confusion
Hand writing ---- It takes time
Pulse ---- rapid, full or bounding
Conjunctiva ---- congested
Gait ----staggery gait.
Unable to button his clothes
Unable to walk along a straight line
Laboratory examination ----
The concentration of alcohol in blood, urine, saliva→
increased
 Opinion for drunkenness

Report should be done based on physical examination & laboratory

findings any one of following way-

a) He/she hasn’t consumed alcohol

b) He/she has consumed alcohol but not under the influence of it

c) He/she has consumed alcohol & is under its influence.

 Delirium tremens
It is a psychic disorder involving hallucination of sight, hearing, touch found
in habitual and excessive users of alcoholic beverage.

It results from the long continued action of alcohol on the brain

Precipitating factors
1) Temporary excess of alcohol
2) Sudden withdrawal of alcohol
3) Shock following an injury such as fracture of bone
4) Acute infection such as pneumonia, influenza etc
Medico legal importance of drunkenness &
delirium tremens
Drunkenness can be an offence & made punishable if it causes
harm/damage to property or person but in case of

Delirium tremens never an offence because during this state he/she

considered to mentally unsound & person is not responsible for his act.
 Contd
Korsakoff’s psychosis

Pronounced memory disorder, associated with polyneuritis resulting from chronic

alcoholism is known as Korsakoff’s psychosis.

Saturday night paralysis:

It is a condition that occurs in the stage of narcosis or coma in acute alcohol

poisoning. A worker who has received his salary at a week end (Saturday) goes on
drinking while in a drunken state; he may assume an abnormal posture with
hanging of one or both arms over a chair. This results in presence on radial nerve
leading to paralysis of one or both arms. This is called Saturday night paralysis.
 Contd

Alcoholic blackout:

It means temporary loss of memory after alcohol drinking. It is a late

manifestation of alcoholism. Loss of memory of the drinking period or
in some cases over a period of days following drinking alcohol is called
alcoholic blackout. The blackout or amnesia may be fragmented or
total. In the later case amnesia may be permanent.
 Contd
Alcoholic anonymous:

This is an organisation without having a formal body, place and other

formalities of an association. The addicts (alcohol) from all over the
world who are desirous to give up alcohol, narrates their bad
experiences to other alcoholics through letters, press and other media,
which act favorably for re-addiction.
 Methyl alcohol
Also known as wood alcohol/methanol/French polish/denatured spirit

Pure methyl alcohol is colorless, volatile liquid, with an odor, similar to

ethyl alcohol and has a burning taste

Composition: contains 3 ingredients ----

90% ethyl alcohol
9.5% wood naptha
0.5% crude pyridine
Or, ethyl alcohol 95% and wood naptha 5%
 Contd
Use:
 Certain home-made beverages
 Antifreeze
 Paint removers and
 Varnish
Signs and symptoms:
These are same as ethyl alcohol, but the metabolized products of methyl
alcohol namely formaldehyde and formic acid has specific action on optic
nerve producing optic neuritis and atrophy resulting in permanent blindness
Death occurs due to respiratory failure
 Contd
Eye findings: methanol produces formaldehyde & formic acid which
directly act on optic nerve cuaese;
Photophobia
Snowfield vision or misty vision
Central & peripheral scotoma
Optic neuritis
Optic nerve atrophy & blindness.
Methanol also causes toxic effects to kidney & produces acidic urine.
 Contd
Fatal dose: 60 to 200ml
Fatal period: 24 to 36 hours
However, in many cases, death occurs as late as in the 4th or 5th day
Treatment:
1. Gastric lavage with 5% sodium bi carbonate solution
2. Antidote is ethyl alcohol 50% in a dose of daily 0.75 to 1ml per kg body weight for 3 to 4 days
(it is preferably given intravenously as 10% solution of starting with a loading dose of around
500ml given as infusion). It acts by the affinity for combining with alcohol dehydrogenase
enzyme, thereby, blocking the metabolism of methyl alcohol. I/V infusion is continued till
blood methanol falls below 25mg% oral administration of ethanol is not desirable
3. Correction of acidosis
4. Eye care --- protect from bright light
5. Symptomatic treatment
 Post mortem findings
1) Most of the findings are that of ethanol poisoning

2) Prominent cyanosis of upper part of the body

3) Lungs show oedema, emphysema and desquamation of alveolar

epithelium

4) Toxic damage of liver and kidney

5) Eyes may show retinal edema or optic atrophy

 Viva
Q. Why methyl alcohol is dangerous than ethyl alcohol?
It has cumulative effect.
It produces formaldehyde which is 33 times more toxic than ethyl
alcohol
 It has direct toxic effect to eye & kidney.
Q. What is the antidote of methyl alcohol poisoning & explain it.
Ethyl alcohol is used as competitive antagonist. here it blocks the
formation of formaldehyde & allows the methyl alcohol to be
excreted unmetabolised.
Q. Which stage of alcohol poisoning is more important medicolegally?
2nd stage or stage of In co-ordination.
Identification:
Clear glass bottle with stopper containing transparent, colorless,
volatile, having a characteristic spirituous odor and burning taste- so it
is the specimen of alcohol

Medico legally what type of poison it is?

Accidental poison.