CNS DEPRESSANTS

CNS DEPRESSANTS1CLASSIFICATION ETHYL ALCOHOLGENERAL ANAESTHETICSOPIOID ANALGESICSSEDATIVE HYPNOTICS2

ALCOHOL INEBRIANT POISONS PRODUCE INTOXICATIONTHAT IS Light headednessConfusionDisorientation Drowsiness

3In most case there is recovery after prolonged sleep, with some after-effects(hangover)Consisting ofHeadache Irritability LethargyNauseaAbdominal discomfort

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Alcohol-Ethyl alcoholTransparent ColorlessVolatile liquidSpirituous odorBurning taste

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Absolute alcohol contains 99.95%

Rectified spirit -90%

Denatured alcoholAlcohol95%Wood naphtha 5%

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Ethanol

sugar +yeast=ethanol by fermentation processProcess stops when 15% alcohol is formed as yeast is destroyed

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Alcoholic beveragesAre mixture of alcohol+water+small amount of congeners which are produced in fermentationFlavour is due to congeners Propyl alcoholOctyl alcoholGlycerineAldehydes

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Dimethyl and diethyl esters Acids from acetic to linoleic,ketones,trimethyl amine,allyl mercaptan etc.Total content of congeners rarely exceeds half%9

Odour may persist in tissues for several hours after all alcohol is metabolisedProof spirit-is one which at 10.5 degree celisus weighs exactly 12/13 part of equal measure of distilled waterUnder proof weaker spiritsOver proof stronger spirits

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Proof is defined as twice the % of alcohol content of the drinkExpressed in units 1 unit=8g of alcohol

11Alcohol content in beveragesVodka:60 to 65%

Rum,liquors:50 to 60%

Whisky.gin,brandy:40 to 45%

port,sherry:20%

Wine ,champagne:10 to 15%

Beers:4 to 8%12Vodka:60 to 65%

13Rum,liquors:50 to 60%

14Brandy40 to 45% of alcohol

15Beers:4 to 8%

16Whisky.gin,brandy:40 to 45%

17Safe limit of drinking to avoid liver damageMen=210g/per weekWomen=140g/per week

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Arrack

It is a liquor distilled from palm,rice,sugar or jaggery,etc.40 to 50% of alcohol For kick-is mixed with chloral hydrate and potassium bromide.19

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AbsorptionRequires no digestion prior to absorptionMouth & oesophagus-small amount absorbedStomach & small intestine- immediately 20% 80%

2110 to 20% is prevent absorption by consumption of food with alcohol.Warm alcoholic drinks- absorbed fast as they dilated the gastric capillaries.Achloryhydria or chronic gastritis have slower absorption rates.10 to 20% conc of alcohol absorbed rapid

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Dil.alcohol- empty stomach -30 to 60mins -60%90% in 60 to 90 minsWhisky and beer in blood in just 2 to 3 mins after few sipsMax.conc in blood reached within 45 to 90 minsMajority in 1 hour

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Carbonated drinks hastens absorption as the bubbles greatly increases the surface area carrying alcohol.

Food delays its absorption

Fats and protein delay more nearly for hours

Mixed meal depress max.conc in blood alcohol by half hour

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Lower and higher concentration absorbed quicklyBeer takes longer absorption time than stronger drinks .25

Drinks containing more than 40% of alcohol care absorbed more slowly Due to 1.Pyloric spasm2.Irritation of gastric mucosa and secretion of mucosa3.Reduced gastric motility.26

Habituated drinkers absorb alcohol more rapidly than abstainers,probably due to more rapid emptying time of the stomach and thus the rate of absorption .Drugs like benzine and atropine may slow the rate of absorption of alcohol by retarding the emptying time of stomach.

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Alcohol is absorbed rapidly in gastrectomy.Conc of alcohol in air is high irritation and breathing difficulty60% of alcohol inhaled can be absorbed into systemic circulation.Skin poor absorbent of alcohol28

Distribution

Some lost by diffusion into alveolar air as arterial blood passes through the lungs.In arterial blood the alcohol concentration is less due to passage through the capillary network29Adipose tissue ethanol is insoulble in fat.Red cells contains less alcohol then plasma.Plasma level of alcohol is highSerum level of alcohol is high A given intake of alcohol will prouce high level of alcohol in obese people then lean of same weight due to the aqueous compartment is smaller

30

Ethanol passes through blood brain barrier and baths neuron via the cerebral extracelluar fluid.In females the con is higher due to small aqueous compartment

31Excretion 5% ingested alcohol excreted via breath 5% in urineNegligible amount are excreted in the sweat,saliva,milk ,tears and faeces.Odour is due to excretion via skin glands.

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Metabolism

90% of alcohol absorbed in oxidised in liver 10% is excreted

liver33

34Acetate is oxidised into co2 and water in krebs cycleDiabetic who is ketogenic will produce fat from alcohol , because he cannot use the sugar.Enzymes can be increased by regulary use of alcoholic beverages and alcohol decrease may be doubled

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OXIDATION

Alcohol is not stored in tissuesDisappears from blood fairly uniform rate of about 10 to 15ml per hourThis is equivalent of about 15mg 100mlLarger doses are lost faster.Chronic alcoholics are able to metabolise alcohol faster -40 to 50 mg/100ml /hr36

BECAUSE DUE TO INCREASE IN LIVER ENZYMETHUS THEY DEVELOP LIVER DAMAGE.Later due to liver damage alcohol metabolism is depressed.Due to which the remain intoxicated for hours after a few drinks.10% of alcohol which is metabolised is deposited in tissues as lipids in form of neytral fat and cholesterol.

37ACTIONTraces of ethyl alcohol are found in all persons.Endogenous alcohol Normal metabolismBacterial activity in git38

Well known stimulantSelective depressant especially of higher nervous centres which it inhibits.Ethanol depress reticular activating systemFrontal lobes sensitive to low concentration(mood changes)Followed by occipital lobe (visual disturbances)

39Cerebellum loss of coordination

Lower concentration-depression of more specialised and sensitive cells of cerebral cortex(centres regulating conduct,judgement,self criticism)

40Increasing concentration depresses more brain function.Finally vital centres in mid brain and medulla are depressed death from cardio respiratory failure.

41Causes generalised vasodialation ,especially in skin.Not true aphrodisiacHynotic and diaphorecticCreates sensation of warmth ,but increases heat lossLow concentration heart rate increasedMore than 300mg % -bradycardia

42Moderate stimulates appetite as it promotes salivation and secretion of gastric juiceStronger beverages the reverse actionLittle brandy carminative actionDiuresis occurs secondary to inhibition of ADHRelease from posterior pituitary.

43Spiritous liquors on emptying the stomach can cause severe ,even haemorrhagic gastritis.It has toxic effect on almost every organ system.Due to effect of metabolite acetaldehyde or to redox potential of cells but the mechanism is not known clearly

44

All the neuro transmitter system are affected ,no specific receptors

45It has synergistic effect with other sedative-hypnotic agents.15 to 30g /day consumption increases the concentration of hdl and decreases ldl.It has favourable effects on haemostatic factors such plasma fibrinogen ,fibrinolytic activity and platelet adhesiveness.46MIXING OF DRINKS-greater intoxicationThan the amount consumed. Due to presence or formation of substances which affect the rate of emptying of stomach,with more rapid absorption of alcohol.

47Roman saying IN VINO VERITAS which means IN WINE THERE IS TRUTHThe real personality of individual often will be revealed when he is intoxicated.

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Cause of death

Direct depressive effects upon brain stem mediated via the respiratory centreAspiration of vomitDeath due to acute overdoses not commonChronic effects of alcohol are common.493 phases

There are three phases of intoxicationStage of excitementStage of incoordinationStage of coma50Stage of excitement

First a feeling of wellbeing and certain slight excitation.Actions ,speech and emotions are less controlled due to lowering of inhibition normally exercised by higher centre of the brain Increased confidence and lack of self control constant feature of alcoholic poisoning.51Mental concentration is poor and judgement impaired.Attention is impairedRecall memory is often disturbed52Disclose secrets.Good manners are forgottenThe neat and orderly are careless in their dressBlood alcohol concentration of 30mg% impairment of cognitive function,motor coordination and sensory perception occur

5350 mg % - slurring of speech,unsteadiness,drowsiness,impaired reasoning and memory ,reduced perception and decreased concentration occur.Alcohol reduces visual in conc as low as 20mg% in abstainers 20 to 30mg% in moderate drinkers40 to 70 mg %in heavy drinkers

54Affects the judgement and motor control when BAC of 25 to 50mg% Strong light is needed for distinguish objectsDimly lighted object may not be distinguishedIt alters time and space preception.Pupils are dilated55Between 50 to 100 mg% -loss of inhibition ,loquaciousness and laughter occurs.Slurred speech ,unsteadiness and nausea are between 100 to 150mg%.When jerking movements is in the direction of gaze and independent of position of the head- it is known as alcohol gaze nystagmus and appears at blood level of 40 to 100mg%56Emotions are affectedIt increases the desire for sex but it impairs the performance at 50 to 150mg% of blood alcohol57Stage of incoordinationAt 150 to 250mg/100ml the sense of perception and skilled movements are affected.Loss of control over the higher centres causes alteration in conduct .Carefree,cheerful,ill tempered ,irritable,excitable,quarrelsome,sleeply .58Clumsiness and incoordination of movements which are skilled onesAlteration in speechNausea and vomiting Breath smells of alcoholFace flused,pulse rapidSense of touch,taste,smell and hearing are diminished.Temperature subnormalHeart rate increased

59Stage of comaMotor and sensory cells are deeply affectedSpeech thick and slurring , coordination is markedly affectedGiddy,stagger and possibly fallPerson passes into state of coma with stertorous breathing.Pulse is rapid and temperature subnormal.60Pupils are contracted but stimulation of the person e,g by pincing or slapping ,cause them to dilate with slow return Mc EWAN SIGN.With recovery coma lightens into deep sleepRecovery -8 to 10hrsWake up with depression,nausea ,abdominal discomfort,irritability,lethargy and severe headache.

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Munich beer heartIn which cardiac dilation and hypertrophy is seen due to excessive and prolonged beer drinking. MICTURITION SYNCOPE A condition which occurs usually after heavy beer drinking .when the person rises from bed in the middle of night to pass urine ,he loses consciousness during the act of urination,probably due to sudden upright posture

62If coma continues more than 5hrs condition is going to worseDeath due to asphyxia,respiratory paralysis ,may occur in shock.Mostly death occurs not due to high blood level but after it have damaged the vital organs.63Acute intoxication death BAC of less than 400mg%In person with chronic diseases Arteriosclerotic heart Pulmonary emphysemaChronic lung diseasesHypoxia severe condition64Prolonged coma leads to hypoxic brain damage and death with BAC low.As the alcohol might be oxdised and excreted.65Fatal dose -150 to 250ml of absolute alcohol/one hrFatal period -12 to 24hrTolerance to alcohol it is aquired and may be lost by those out of practice

66Consent of examinationConsent of the detained person for medical examination is necessary.If the person is unconscious or not fit for consent ,the doctor called by police should not disclose to police any information he has obtained during examintion but should wait to get the consent of the patient when he regains consciousness,or in fit condition to be asked67TREATMENTEvacuation of stomach and gastric lavage with an alkaline solution Patient must be kept warm Congestion of the brain ice berg should be applied to head.One litre of normal saline with 10%glucose,100mg thiamine and 15 units of insulin are useful.

68If coma deepens ,nerve stimulants such as caffeine and strychnine should be used and artificial respiration,if there is difficulty in breathing .Inhalation of oxygen is of great useHaemodialysis or peritoneal dialysis is very useful.69POSTMORTEM APPEARANCESOn opening the cavities of the body ,alcoholic odour is frequently notedAcute inflammation of stomach with a coating of mucus is commonly found.The brain ,liver and lungs are congested and the smell of alcohol in the viscera may be noted.70Blood-fluid and darkOedema and congestion of brain Meninges and cloudy swelling of parenchymatous organs are seen

71CHRONIC POISONINGAlcohol addicts withdrawal symptoms,if they doResults in impaired social or occupational functioningChronic alcoholics are those who have reached a state of more or less irreversible somatic or brain changes caused by alcohol.72Patient suffers from

NauseaVomitingAnorexiaDiarrhoeaJaundiceTremors of tongue and handsInsomniaLoss of memoryImpaired power of judgementHypoproteinaemiaGeneral anasarcaSymptoms of peripheral neuritis and dementia occur in last stageSuddenly they die from coma

73Postmortem appearancesSigns of malnutrition may be present

Gastric mucous membrane is deep reddish-brown with patches of congestion or effusion and is hypertropied.

Liver is congested,fatty infiltration,enlarged and weight may exceed 2kg

74Cirrhosis occurs Kidneys show granular degeneration Heart is dilated and shows fatty degeneration ,patchy fibrosis.

75Treatment

Disulfiram-single dose daily 250mgIt is reduced gradually untill 0.125 to 0.25g is reached which should be continued untill the patient has been conditioned to accept adequate follow-up therapy.Antabuse inhibits the biotransformation of ethanol beyond the acetaldehyde stage.

76Ethyl alcohol is metabolised by the liver as two step processAntabuse partially blocks reaction 2,leading to acculumation of acetaldehyde in blood and tissues and causes unpleasant symptomsFlushing ,palpitation,anxiety,sweating,headache,abdominal cramps,nausea and vomiting due to which the patient dislikes alcohol.

77Citrated calcium carbimide 50mg.tablet once a day can be used with less side effects.Chlorpromazine 25 to 50mg every 4 to 6 hours is also usefulClonidine 60 to 180mg/hr i.vchlormethiazole78Conditioned reflex treatmentIt consists of giving alcoholic beverages to the patient in surroundings that affect his visual and olfactory senses.With a backdrop of bottles of various alcoholic beverages the patient is given various types of liquor ,togather with drugs that will cause immediate and acute nausea and vomiting .79After 5 to 8 daily treatments,symptoms are brought on simply by sight of a bottle and the patient begins mentally to associate his painful sickness with alcohol.Hypnosis and psychotherapy also useful80Alcoholics anonymousInternational organisation which has branches throughout india.The addicts who are desirous to give up alcohol narrate their bad experiences to other alcoholics through group meetings,letters,press and other media.The organisation functions on self-supporting basis through contribution from the membranes.

81Drunkenness

Drunkenness is a condition produced in a person who has taken alcohol in a quantity sufficient to cause him to lose control of faculties to such an extent ,that he is unable to execute safely ,in the occupation in which he was engaged at particular time 82Clinical diagnosisSame amount-different person-different effects-same circumstances.Mentally unstable ,epileptics and those who have suffered cerebral trauma show excessive reaction for small amounts.83Model scheme of medical examinationThe scheme of examination of an alleged alcoholic has been suggested by special committee of british medical association THE DRINKING DRIVER1965Medical examiners record should note the DATEand TIME at beginning and at the end of the examination.84(1) Exclusion of Injuries and Pathological States:The following conditions which simulate alcoholic intoxication should be excluded :(a)Severe head injuries,(b) Metabolic disorders, e.g.hypoglycemia,diabetic pre-coma, uremia,hyperthyroidism.(c) Neurological conditions,e.g. disseminated sclerosis,intracranial tumors,Parkinson's disease, epilepsy, acute aural vertigo,(d) Drugs: Insulin, barbiturates, antihistamines,morphine, atropine, hyoscine..Drugs capable of producing sedation or depression of the nervous system (antihistaminic, tranquillizers), will simulate or enhance the effects of alcohol,(e) Certain preexisting psychological disorders, e.g. hypomania,general paresis,(f) High fever,(g) Exposure to CO.

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(2) History: Enquire whether he suffersfrom any disease or disability and whether he is under medical treatment.(3) General Behavior:(a) General manners and behavior,(b) State of dress: Presence of slobber on mouth or clothing; presence, character and color of any vomit, soiling of clothes by excretions,(c) Speech: Note the type, e.g.is it thick, slurred or over-precise? Slight blurring of certain consonants is one of the earliest signs of in coordination of the muscles of the tongue and lips. Certain test phrases may be used to bring out thisdifficulty in speech, such as 'British Constitution', West Register Street,Truly Rural',etc.A sober person will say that he is not good at such phrases; the semi-intoxicated person will often insist on getting them correctly,(d) Self-control.: Note whether he is able to control himself in response to the demands made on him by the examiner.

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(4) Memory and Mental Alertness:The memory of the person for recent events, and his appreciation of time can be judged by asking suitable questions about his movements during the preceding few hours, and the details of his accident if any. A few very simple sums of addition or subtraction may be asked.

(5)Handwriting:The examinees should be asked to copy a few lines from a newspaper or book. A note should be made of:(a) The time taken,(b) Repetition or omission of words,letters, or lines,(c) Ability to read his own writing. Both the original and the copy should be retained. The examinees should be asked to sign his name.The signature can be compared with that on his driving license if any.

(6) Pulse:The resting pulse should be taken at the beginning and at the end of the examination.The pulse is rapid and is usually full and bounding. A slight increase in B.P. may occur, often in the systolic level.87(7) Temperature:The surface temperature is usually raised.

(8) Skin:Note whether skin is dry, moist,flushed or pale.Skin is warm, dry and flushed in drunkenness.

(9) Mouth:(a) Record the general state of mouth, teeth and tongue, noting whether the tongue is dry, furred or bitten,(b) The smell of the breath should be recorded

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(10) Eyes:(a) General appearance :(1) Whether the lids are swollen or red, and whether the conjunctiva are congested.(2) The color of the eyes, and abnormalities.(b) Visual acuity: Any gross defect should be noted.(c) Intrinsic muscles:(1) Pupils: Equal or unequal, dilated or contracted or abnormal in any way(usually dilated in early stages, but may becontracted in later stages or coma).(2) Reaction to light : Note whether the action is brisk, slow or absent. They may become unequal, equalizing againin response to light, and dilate again slowly even if the light continues to be directed into the eyes.89(d) Extrinsic muscles:Convergence: Test the degree of ability to follow a finger in all normal directions and to converge the eyes normallyon a near object.

(2) Strabismus : Note whether it is present.

(3) Nystagmus : The presence of fine lateral nystagmus may indicate alcoholic intoxication. Nystagmus may be produced by fatigue, emotion or postural hypotension.

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(11) Ears:Examine for (a) Gross impairment of hearing, (b) Abnormality of the drums.

(12) Gait:The integrity of the nervous and muscular system is tested for the coordination of fine and gross movements, e.g. balance, gait and speech. The examinees should be asked to walk across the room and note:

Manner of walking: Is it straight, irregular, over precise, unsteady, or with feet wide apart?

(b) Reaction time to a direction to turn: Does the examinees turn at once or continue for one or two steps before obeying?

(c) Manner of turning : Does the examinees keep his balance, lurch forward, or reel to one side? Does he correct any mistake in a normal or exaggerated way? It is undesirable to ask the examinees to walk along a straight line drawn on the floor.91(13)Stance :Note whether the examinees can stand with his eyes closed and heels together without swaying.

(14) Muscular Coordination :Ask the examinees to perform the following tests:Placing finger to nose,

(b) Placing finger to finger,

(c) Picking up medium-sized objects from the floor,

(d) Lighting a cigarette with a match,

(e) Unbuttoning and rebuttoning coat.

(f) Lifting two objects, such as tumblers from the table, and replacing them side by side on the table.

The examiner should not ask the examinees to perform any act which he could not perform easily himself. He should also appreciate the difficulty involved for some people in apparently simple movements, such as picking up small objects from the floor. A chronic alcoholic when sober may not be able to perform tests for coordination as well as when he has actually consumed alcohol.

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(15) Reflexes :Knee and ankle reflexes should be tested which are delayed or sluggish.Plantar reflex may be extensor or flexor.

(16)Pulmonary, Cardiovascular and Alimentary Systems:The heart, lungs and abdomen should be examined, and the blood pressure taken to establish the presence or absence of disease.

(17) Tests:Some of the following objective tests are useful; flicker fusion test, measurements of tremor during standing, oscillations during forced imbalance, pupillary reflex time, speed of spinal reflexes, presence of random ocular movements with closed eye, nerve conduction speed, complex reaction time, delayed auditory feedback, positional nystagmus, glare recovery test, color difference threshold, etc.93(18) Laboratory Investigations:The degree of intoxication can be estimated by the concentration of alcohol in the blood, urine, breath, or saliva. In fatal accidents with partial body destruction, muscle or the fluid in the eye can be analyzed. Vitreous humour and urine are protected from putrefactive processes for a longer period of time and do not contain much glucose. Blood is the most suitable and the most direct evidence of the concentration of alcohol in the brain.

The disadvantages are: (1) it may be difficult to collect from an uncooperative person, (2) consent of the person is necessary, (3) substances like acetone, ether, paraldehyde, etc. when present in the blood are estimated as alcohol.94URINE : Urine has about 25% more water than an equal volume of blood, so its concentration of alcohol would be about 25% higher than in blood collected at the same time. As the urine is secreted, its water will have essentially the same alcohol concentration as the water of the blood passing through the kidney. If the bladder contains urine before drinking began, urine secreted during or after the period will be diluted with the alcohol-free urine. If the bladder was empty when drinking began, urine secreted after some time will reflect the blood concentration of alcohol at that time. In order to compare the urine and blood, a ratio of 1.3:1.0 is usually accepted when urine and blood are in equilibrium.

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Analysis of two urine samples are required. The first sample should be taken as soon as possible following the incident, the bladder being completely emptied. The second sample should be taken 25 to 30 minutes later. The concentration of alcohol in the second specimen reflects the blood alcohol level during the inter-specimen interval. The difference in the alcohol concentrations in the two samples indicates whether the subject was in the absorptive phase, at its peak, or, in the elimination phase. Multiplication of alcohol concentration in the second urine specimen by 0.75 (based on a bio urine alcohol ratio of 1:1.35) gives an approximate value of the blood alcohol level, during the time that this specimen was being secreted.96The disadvantages of urine examination are: (1) A time lag before equilibrium between blood and urine is reached; the maximum concentration is reached about twenty to twenty-five minutes later than in blood.

(2) The urine alcohol concentration at any given time after the maximum concentration in blood has been reached will be higher by twenty to thirty percent than in the blood, because the specimen of urine examined will have been secreted from the blood at some earlier period.

(3) Alcohol may pass through the lining of the bladder in either direction both in life and after death, depending on the relative concentration of alcohol in blood and urine.97

Collection of Blood:Spirit must not be used for cleaning the skin, and the syringe must be free from any trace of alcohol. The skin is cleaned with a solution of 1:1000 mercuric chloride or washed with soap and water. Blood samples should be preserved by the addition of hundred mg. of sodium fluoride for ten ml., followed by thorough shaking. This prevents loss of alcohol by glycolysis and bacterial action. Such samples will maintain alcohol concentration for several weeks ,even at room temperature. Hundred mg. of phenyl mercuric nitrate or sodium azide can also be used, as a preservative for 10 ml of blood or urine.98PrecautionsScrew capped glass bottle of universal size is used

Container should be tightly clamped

Sealed to prevent loss of alcohol by evaporation and labelled with name and date ,time of taking the specimens

Rubber stopper should be avoided ,because they may contaminate the sample with oxidisable substances.

It must be refrigerated if not sent to lab but not froze it

Which will cause cells to lyse

When blood is kept in a refrigerator ,formation of oxidisible substances is not significant.

Analysis is best made within a week

Serum or plasma alcohol concentration is 12 to 20% higher than that of whole blood.99

COLLECTION OF POSTMORTEM SAMPLES

TEMPERATE CLIMATES-postmortem blood alcohol determinations are completely valid for 36hrs after death.Blood best place to be obtained is from femoral or iliac veins or from axillary veins.Jugular vein is not suitable as it may be contaminated by reflux from the upper thoraxIf the concentration of alcohol is same in all these samples the exposure is extraneous ,because bacterial and chemical decomposition does not occur at exactly the same rate all over the body.Free blood in the pleural or pericardial cavities should not be used as false high results may be obtained due to gastric alcohol diffusion after death.Embalmed bodies alcohol can be estimated either in vitreous or muscle.Erroneous result can be obtained due to haemolysis ,clot formation ,postmortem diffusion from other body fluids and tissues ,not properly preserved sample ,and putrefactionFalse blood alcohol levels in excess of 0.1 mg% may be produced if autopsy blood samples are stored at room temperature for more than a week

100Widmark formula for bloodSize,sex,type of alcohol consumed . formulaA=PRCA-WEIGHT OF ALCOHOL IN g in the bodyP- is the body weight in kgC-is the concentration of alcohol in blood in mg per kgR- is a constant0.6-men 0.5 women

For urine analysisA=3/4 PRQQ-ALCOHOL CONCENTRATION IN mg per kg

101Methods used for determining blood alcoholBasic principal: reduction of potassium bichromate by test substance1.Kozelka and hine test is a macro-method.2.Cavett test is a micro-method.Many procedures are there but gas chromatography in a specificity can be ascertained

Test:in a test tube place one ml of unknown solution +one ml of acetic acid+one drop of sulphuric acid and heat gently for one minute .=strong fruity odour is positive.

102BREATH : breath analysis machine operte on the principle that alcohol absorbs radiation in the infrared light absorbed by a vapour is proportional to the concentration of the alcohol in that vapour.60 to 100 ml of breath is received into dry ballon and analysed by drunkotester, drunkometer, intoximeter, alcometer, alcotest or breathalyserThe end portion of prolonged forced expiration gives correct results .The concentration of alcohol in deep lung air is dependant on conc in arterial blood.2100 to 2300ml of alveolar air contains the same amount of alcohol as one ml of blood.

103Factors that can upset the breath testSternuous hyperventilation Violent physical exercise Emesis Regurgitation of stomach contentsEructation or belching and drinking of liquor within few minutes of the time of the performance of the test .False value is obtained in these conditions

104Saliva-mouth should be thoroughly washed with water and about 5ml of saliva collected in test tube containing 10mg of sodium fluoride

Vitreous- at equilibrium for every unit of alcohol in blood ,there are 1.2 units of alcohol in vitreous ,as it has a high water content .

During the absorptive phase of alcohol ,vitreous alcohol levels are lower than the blood.

Vitreous alcohol lags behind blood alcohol by 1 to 2 hours

It does not change after death due to putrefaction. Henry s law when volatile chemical is dissolved in a liquid and is brought to equilibrium with air ,there is a fixed ratio between the concentration of volatile compound in air and its concentration in the liquid and the ratio is constant at given temperature.Temperature is 37c that is exhaled air temperature

105Diagnosis-

Extreme cases no problem

Marginal cases problem

usual Signs of drunkenness

Strong odourLoss of selfcontrolUnsteady gaitVacant lookCongested eyesDilated pupilsDry lipsIn creased pulse rateUnsteady and thick voice Talks at random Lack of perception of passage of time.

106DETERMINATION OF BLOOD ALCOHOL HELPS: the concentration of alcohol circulating in the bodyThis can be attempted only after equilibrium between the blood and tissues has been attained which helps the court in testing reliabity of statement of accusedTo assits in conforming Enable to accept clinical diagnosisHelps to judge the non medical witness

107Medical terminologyUnder the influence means that due to drinking alcohol,a person has lost his clearness of mind and self control.Loss of judgement140mg%- intoxicated to the point where they cannot deal with unusual ,emergency or noncustomary problems

108Below 10mg:sober20 to 70mg%:drinking80 to 100mg%:under the influence150 to 300mg%:drunk or intoxicated400mg% and above :coma and death109Under the influenceSymptomsFlushed faceDilated and sluggish pupilsEuphoriaLoss of restraintThickness of speechCarelessness and recklessnessIncoordination Stagger on sudden

DrunkFlushed face Dilated and inactive pupilsRapid movement of eyes Unstable moodLoss of restraintClouding of intellectThickness of speech IncoordinationStaggering gait with reeling and lurching when asked to make sudden turns

110Very drunk

Mental confusionGross incoordinationSlurred speechStaggeringReeling gaitTendency to lurch and fallVomiting

ComaRapid pulseSubnormal temperaturestertorous breathingContracted pupils

111Hazards of alcoholChild abuse,domestic violence,suicidePersonal riskDeathPneumonia VomitChokingLowers resistances effect on hypoxiaMay fall downHead injuryDrownedElectrical shockPoisonedAccidentsSaturaday night paralysis

112Alcoholic palimpsests or blackoutLoss of memory of a period during a drinking spell or in some cases ,inability to recall what happened over period of days.The person may cause a criminal act and may not remember it when they recover113Alcohol and traffic accidentsDriving ability 1/ conc of alcohol in bloodIncreases reaction timeIncreases false confidenceImpairs concentrationDulls judgementDegrades muscular coordinationDecreases visual and auditory acuity

114Below 50%- no risk in drivingAt 50%- control of speed ,sensorimotor coordination ,braking is impaired.Boldness increases and impulses alsoAt60%-risk of accident is higherAs mg% increases risk also increases

115In india the limit of bac

30mg%-first offence Rs.2000 or 6 months imprisonment or both Second or subsequent offence-Rs3000 or imprisonment up to 2 years or both

116Alcohol withdrawl

Symptoms appear 12 to 48hrs after reduction in alcohol intakeTremors of hands,tongue and eyelids Nausea and vomitingMalaise and weaknessHypertensionTachycardia,sweatingAnxiety,depressed mood ,irritabilityTransient hallucinations and illusionsHeadache and insomniaDelirium tremens

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118Treatment

20 mg of CHLORDIAZEPOXIDE or 100mg of diazepam are given 4times a dayPATHOLOGY1.DELIRIUM TREMENS 72 to 96 hrs after the last drinkTEMPORARY EXCESSSUDDEN WITHDRAWLSHOCK AFTER INJURY ,FRACTUREACUTE INFECTION-PNEUMONIA,INFLUENZA,ERYSIPELAS119

Alcoholic polyneuritisWeaknessPain in extremitiesWrist and foot dropUnsteady gaitLoss of deep reflexes and tenderness of muscles of arm and leg

120Alcoholic paranoiaFixed delusions no hallucinationsDeeply suspicious of the motives and action of their family members

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Acute alcoholic hallucinosisPersistent hallucination develop within 48hr after cessationHallucination by be visual or audioContent will be unpleasant and disturbingLasts for several weeks and months122

Alcoholic epilepsy Seizures occur a day or more after termination of drinking sessionSometimes during drinking itself it may occur

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WERNICKES EPILEPSYLESIONS IN HYPOTHALAMUS,MIDBRAIN,CEREBELLUMVIT B1 DEFICIENCY124

WERNICKES ENCEPHALOPATHY SYMPTOMSDisturbances of consciousness, drowsiness, amnesia, peripheral neuropathy, nystagmus, ataxia, delirium and stupor.If untreated 80% of cases progress to next chronic stage KORSAKOFF PSYCHOSIS125KORSAKOFF PSYCHOSISIMPAIRMENT OF anterogade and retrograde memoryDisorientation in timeInability to learn new information and confabulation126

Cardiac dysrhythmias Tachyrhythmias due to high adrenergic nervous system activity which may cause sudden death.127MARCHIAFAVAS SYNDROMEDegeneration of corpus callosum

Mallory weiss syndromeRupture of oesophagus with mediastinitis

MalnuritionGastric and peptic ulcerCirrhosisMyocarditisPancreatitisMental illness

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Alcoholic and Criminal behaviourit is not due to infulence but due to the repression of inhibitory influences that prevents in sober person to commited a crimedue excitement and stimulation of the brain at high peak

129suppressed feelings of aggression and hostility are released,the drinker goes into the state of artificial display of braverysuicides and homicidesslows the reaction of the victimnot able to protect himselfcauses dilation small injury may lead congestion of blood vessels dur to prolonged bleeding

130CHRONIC LIVER DISEASES IMPAIRS CLOTTINGDIE FROM INHALATION OF VOMIT OR BLOOD DUE TO INJURYSECTION 510 IPC-MISCONDUCT IN PUBLIC-IMPRISONMENT FOR 24HRS

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ALCOHOL AND SUDDEN DEATHEFFECT ON MYOCARDIUM AND PRODUCES ARRHYTHMIASCardiopulmonary arrest- intoxicated struggle-dies.no anatomical causes for deathCatecholamines+alcohol=cardiac arrhythmia=deathCardiopulmonary arrest contributed by alcohol during violent struggleIntoxicated person beaten in face=death cns depression and diffuse axonal injury from beating132Alcohol after deathDiffuses through the stomach wall into pleural fluid,pericardinal fluid,blood and tissuesHigher level means it was the level during livingTrauma subdural clots and blood level of concentration will be same in case of fatal injurySevere internal injury gastric contents may collect in thoracic cavity so diffusion possibity is high No loss occurs by evapourationPutrefaction-alcohol level is destroyed .analysis of brain gives best results.

133Endogenous alcohol due to bacterial activity occurs by fermentation of carbohydrates and proteins .e.coil.Longer interval after death .higher temperture more production of alcohol0.2% -putrefaction alcohol0.2% above alcohol consumptionBlood,organs but not in urine and vitreous humour it is not due to putrefaction.134