NEUROTICS

1. NEUROTICS

2. 1) CEREBRAL : a) CNS DEPRESSANTS - e.g., Alcohol, GA, Opioid analgesics, Sedatives, Hypnotics. b) CNS STIMULANTS – e.g., CAD, Caffeine, Amphetamine, Methylphenidate. c) DELIRIANTS– Dhatura, Cannabis, Cocaine, Atropa belladona, Hyocyamus.

3. 2) SPINAL: e.g. Strychnos nux vomica, Gelsemium. 3) PERIPHERAL : e.g. Conium , Curare.

4. ALCOHOL

5. ETHYL ALCOHOL • METHYL ALCOHOL • ETHYLENE GLYCOL • ISOPROPYL ALCOHOL

6. INEBRIANTS • Inebriant –produces Intoxication • Light headedness, confusion, disorientation, drowsiness. • Prolonged sleep recovery Hangover (headache, irritability, lethargy, nausea & abdominal discomfort).

7. ETHYL ALCOHOL • C2H5OH • Transparent , colourless, volatile liquid with spirituous odor and burning taste. • Absolute Alcohol = 99.95% • Rectified Spirit = 90% • Industrial Methylated Spirit = 95%+Wood Neptha = 5% (Methyl alcohol) • Fermentation of sugar by yeast -- till (15% vol) • Beverages = Alc + Water + Congeners (0.5%) add flavour

8. “Proof spirit”– at 10.5˚C weighs exactly 12/13 part of an equal measure of D.W. • “Underproof” and “Overproof” • % of Alc content x 2 =Proof • One unit = 8 gms

9. Percentage by Volume • Vodka : 60- 65% • Rum, Liquors : 50-60% • Whisky , Gin, Brandy : 40-45% • Port, Sherry : 20% • Wine , Champagne : 10 – 15% • Beers : 5- 8%

10. Consumption = 1-2 drinks per day • Safe Limits of Alcohol =210g in men per & week 140g in women • Arrack: Liquor distilled from - palm, rice, sugar or jaggery etc. (40-50%) and may be mixed with Chloral hydrate and KBr for greater kick.

11. 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 2-3min. • Max.conc.in blood within 45-90min.(mainly1hr).

12. Factors Increasing Absorption • Carbonated drinks • Warm • Conc. = 10-20% • Absence of congeners • Without food • Gastrectomy • Drugs (which increase gastric emptying ) eg. Cimetidine, ranitidine, etc.

13. Factors Decreasing Absorption • Cold • Conc. ‹ 10% (Dilution e.g. Beer)- takes double time › 40% - Pyloric Spasm - Reduced gastric motility - Irritation of mucosa & mucus secretion

14. Food (Fat and Protein) - Fatty meal - delays by many hours . - Mixed meal -reduces max conc. by ½ • Diseases : Achlorhydria , Chronic gastritis • Drugs: (which reduce gastric emptying) eg. Aspirin, Atropine, etc.

15. 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)

16. Females have 25% higher blood alcohol conc. 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

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

18. METABOLISM • 90% is Metabolised - 90% of which is oxidised in Liver. - 10% is metabolised byCytochromeP4502E1 . Alcohol Acetaldehyde dehydrogenase (ADH) dehydrogenase AlcoholAcetaldehydeAceticacid (or NAD AcetylCoA) By- Fructose Kreb’s - Enzymes (Chronic alcoholic) cycle By – Liver damage CO2 + H2O Acetate can form – glycogen , protein ,fats and cholesterol. A Diabetic who is Ketogenic will produce fat .

19. Disappears from blood at 10-15 ml/hr (15mg/100ml/hr) • Elimination varies: 12-27mg/100ml/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)

20. 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 – criticismwith release of inhibitory tone (unrestrained behavior). • ↓Brain function ↓Vitals

21. Generalized vasodilatation (Skin) Hemorrhage • Hypnotic. • Diaphoretic Sensation of warmth Heat loss. • Tachycardia Bradycardia (at lower conc.) (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 → HDL & LDL

22. ↑ Appetite (↑salivary & gastric juice) • Carminative (Brandy) • Diuresis (d/t ↓ADH) • Spirituous liquor Heamorrhagic gastritis • Mixing of drinks ↑Gastric emptying • Fasting blood Alcohol= 0.001mg% • IN VINO VERITAS

23. Causes of Death • CNS Depression (respiratory centre) • Aspiration of vomit • Chronic effects of Alcohol.

24. ACUTE POISONING • 1) 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. • At 30mg% - impaired cognitive function , motor coordination & sensory perception. • At 50mg% - slurring of speech, unsteadiness, drowsiness, impaired reasoning & memory, decreased perception & concentration .

25. ↓Visual acuity at conc. 20mg% in abstainers 20-33mg% in moderate drinkers 40-70mg% in heavy drinkers. • Judgment & motor control : affected at 25-50mg%. • Altered time & space perception. • Pupils = Dilated. • 40-100mg% = “ALCOHOL GAZE NYSTAGMUS”. • 50-100mg% = loss of inhibitions & laughter. • 100-150mg% = slurred speech, unsteadiness & nausea.

26. Mental concentration is poor & judgment is impaired. • ↓ Attention & Recall memory. • ↓ Sensitivity to pain (at 80mg%). • ↑ Reaction time (at 50mg%). • ↑ Sexual desire & impaired performance (prolonged intercourse without ejaculation).

27. 2)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. • ↓ Sense of touch, taste, smell & hearing.

28. 3) 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).

29. 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.

30. Death - at 400mg% - 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.

31. Fatal Dose : 150 – 250 ml of Absolute alc. consumed in 1 hr • Fatal period : 12-24 hrs • Tolerance : is acquired, lost by out of practice d/t- tissue sensitivity or rate of absorption restricted by liver damage

32. Treatment • 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 and Strychnine) • Oxygen • Dialysis – Hemo or Peritoneal

33. 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

34. Chronic poisoning • Addicts are the people who cannot stop drinking for long or develops withdrawal symptoms if they stop drinking. • It results in impaired social or occupational functioning. • They suffer from nausea, vomiting, anorexia , diarrhoea , jaundice, tremors of the tongue and hands, loss of memory, impairment of judgment, coma, death.

35. Post mortem appearance • 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.

36. Treatment 1. Disulfiram250mg OD . • It inhibits aldehydedehydrogenase. • It causes accumulation of aldehyde in blood and tissues . • Aldehyde causes unpleasantsymptoms such as flushing , palpitation , anxiety ,sweating , nausea , vomiting ,abdominal cramps ,due to which patient dislikes alcohol. • Disulfiram like reaction is caused by metronidazole.

37. 2. Citrated calcium carbamide -50 mg OD • 3. Chlorpromazine -25-50 mg 6 hourly • 4. Clonidine : 60-180 mg/hr iv • 5. Chlormethiazole

38. Drunkenness • The state of an individual whose mind is affected by the consumption of alcohol. • Drunkenness is a consequence of drinking intoxicating liquors to such an extent as to alter the normal condition of an individual and significantly reduce his capacity for rational action and conduct. It can be asserted as a defence in civil and criminal actions in which the state of mind of the defendant is an essential element to be established in order to obtain legal relief.

39. Medical examination of Drunkenness • Exclusion of injuries and pathological state 1.Severe head injury 2.Metabolic disorder 3.Neurological condition 4.Drugs like insulin, barbiturate, morphine 5.Pre-existing psychological disorder like hypomania 6.High fever 7.Exposure to CO

40. Medical examination of Drunkenness B. History C. General behaviour- 1.general manner 2.state of dress 3.speech 4.self control D. Memory and mental alertness E. Hand writing F. Pulse - usually rapid, full and bounding

41. G. Temperature-raised H. Skin-dry I. Mouth J. Eyes- 1.General appearance-lid swollen and red 2.Visual activity-reduced 3.Intrinsic muscle-pupil (equal or unequal dilate or contracted, reaction to light (may be unequal, brisk slow and absent) 4.Extrinsic muscle- test for convergence, strabismus, and nystagmus.

42. K. Ears- examine for any impairment L. Gait-examine for manner of walking, reaction time to a direction to turn, manner of turning, M. Stance-whether the examinee can understand with his eye closed and heel together (Romberg'ssign) N. Muscle incordination-finger nose test O. Reflexes-test for knee and ankle reflex P. Pulmonary, cardiac and alimentary system-general examinations for presence or absence of any disease.

43. Laboratory Investigation-A. Urine • Conc. of alcohol is 25% higher than in blood collected in same time. • First sample should be taken as soon as possible while second sample should be taken 25 to 30 minutes later. • Multiplication of alcohol concentration in the second urine specimen by 0.75 gives an approximate value of blood alcohol level, during the time that this specimen was being secreted.

44. B. Collection of blood • Spirit must not be used for cleaning the skin, and syringe must be free from any traces of alcohol. • Skin should be cleaned with a solution of 1:1000 mercuricchloride or washed with soap and water. • Blood sample should be preserved by addition of 100 mg. of sodiumfluoride and 30 mg. potassiumoxalate for 10ml.followed by shaking. this prevent loss of alcohol by glycolysis and bacterial action. • Collection of post-mortem sample-the best place to obtain blood is from femoral or iliac veins or axillary veins. • In embalmed bodies alcohol can be estimated either in muscle or vitreous.

45. Widmark’s formula a= prc • a=weight of alcohol in gm.in the body • p=body wt in kg • r=constant (0.68 for men and 0.55 for women) • c= concentrationof alcohol in blood (in mg. per kg.) For urine analysis the formula is – a = 3/4 prq • q is alcohol concentration ( mg. per kg.) in urine

46. Methods of determining blood alcohol • Kozelka and Hine – Macro-method • Cavetttest – Micro test Other techniques : • Direct injection gas chromatography • Enzyme- spectrophotometric assay • Oxidation techniques

47. C.Breath • Breath analyser machines operate on the principle that alcohol absorbs radiation in the infrared region. • Concentration of alcohol in deep lung air dependent on concentration in arterial blood.2100-2300ml of alveolar air contains same amount of alcohol as one ml. of blood (Henry’s law)

48. 60 – 100 ml of breath • Drunkotester, drunkometer, intoximeter, alcometer, alcotest, or breathalyser. • Residual alcohol disappears from mouth in 20 minutes. • Test should be repeated after 20 minutes.

49. D.Saliva Mouth should be thoroughly washed with water and about 5 ml of saliva collected in a test tube containing 10 mg. of sodium fluoride.

50. E. Vitreous At equilibrium for every unit of alcohol in blood there are 1.2 unit of alcohol in vitreous, as it has high water content