Mineral Acids and Caustic Alkalis These are called corrosive poisons. In dilute solutions they act as irritants. Mechanism Of Action Their action is mainly a local one on the tissues of the alimentary tract and to some extent on the respiratory tract. As a rule, there is no remote Systemic Action with the exception of shock. There action is characterized by : Extraction of water from the tissues. Coagulation of cellular proteins. Conversion of hemoglobin into Haematin.
1) Immediately, soon after swallowing the poison following can happened : 2) BURNING SENSATION in the mouth, throat, esophagus, stomach and abdomen followed by INTENSE THIRST, DYSPHAGIA, and VOMITING of shreddy blood stained material. 3) VOMIT may b acidic or alkaline in reaction depending upon the substance taken. 4) Signs of corrosion of mouth, lips or both. 5) The tongue is shriveled according to the nature of the corroding agent.
4) With the ingestion of a. Corrosive acids The bowels tend to be constipated and urine scanty. b. With Alkalies There may be tenesmus and frequency of stool with blood and mucus. 5) Traces of poison may also find their way into Trachea followed by Respiratory Symptoms e.g Dyspnoea is often present from oedema of glottis and is more marked in the volatile or strong fuming fluids.
Corrosive irritant if diluted. Colourless,odourless.non fuming, hygroscopic and produces coagulation necrosis of the tissues in contact. Perforation of stomach is commonest in poisoning due to sulphuric acid. Signs and Symptoms : Burning pain, Thirst, Black Vomit,detachment of corroded mucous membrane, dysphagia, chalky white teeth. Black trickle marks on lips, cheeks and chin, abdominal pain, collapse, coma and death. Fatal Dose : 10 – 15 ml Fatal period : 12 hours
Accidental Vitrolage Abortificent Succidal Vitrolage Throwing of any corrosive on a person with malicious intent. These fluids are usually thrown on the face with the object of destroying vision or causing facial disfigurement and this result in Grievous hurt. E.g Sulphuric Acid ( OIL OF VITRIOL) is most commonly employed for this purpose and hence it is called vitriolage.
1) Nitric Acid and carbolic acid are fewer times used. 2) The use of caustic soda, caustic potash, iodine and marking NUT juice has also been recorded. 3) Sulphuric acid produces severe chemical burns. They are characterized by discolouration and staining of stan and clothing ( colour changes). Brown or black in case of Sulphuric acid. Yellow in case of Nitric acid. 4) In H2SO4 vitriolage Trickle marks, Appearance of vesication And real line of demarcation and presence of chemical substance in the stains noticed.
Wash away corrosive acid with large amount of water and soap or dilute solution of NaHCO3 or KHCO3. Later a thick paste of magnesium oxides applied. skin raw surfaces can be covered by Antibiotic ointment. EYE Involved: Treatment with large amount of water followed by irrigation 1 % solution of sodium bicarbonate. Few drops of olive oil instilled into eyes. Steroids and Antibiotic containing eye drops are very helpful.
Stomach wash with soft rubber tube (Levine tube ) Give milk + egg white + melted butter. Magnesium oxide ( thick paste apply on skin ) 10 mg Morphine IM ( injection ) for pain. IV fluids Oxygen / Cortisone. Oesophageal stictures in sulphuric acid poisoning can be prevented by giving steroids.
Hydrochloric Acid (HCL) Physical and Chemical Properties: Colourless,volatile,odourless liquid has a burning sour taste. Sources: Industries,Commercial,Laboratories e.g. A normal digestive fluid of stomach. Action Locally : Corrosive, Inflammation of respiratory tract due to inhalation of fumes. Indirectly : Shock due to severe pain. Fatal Dose : 15 – 20 ml concentrated. Fatal Period : 18 – 36 hours or more.
Features : 1) Burning pain in mouth,throat, esophagus and stomach, spreading over the abdomen. 2) Erosion : 1) Of Skin Appearance : usually no erosion after a few days. 2) Of Mucous Membrane Of Mouth and Tongue: Similar as in case of skin. 3) Difficulty in Speech and Swallowing. 4) Teeth Damage 5) Eructation is present.
6) Thirst Present. 7) Vomiting and Vomitus Reaction : Strongly present. 8) Altered blood : Present 9) Tenesmus : May be Present 10) Tenderness over Abdomen : Present 11) Stiffness of Abdomen : May be due to distension of stomach. 12) Perforation or rupture of Stomach : uncommon 13) Urination : Suppressed. 14) Nature of Stool : Mucus with altered blood may be present. 15) Cause of Death : Shock,Laryngeal spasm,pulmonary oedewr due to tickling of acid or vomitus or inhalation of vapour of the acid.
1) Here there may not be much corrosion of the skin. There my be damage of the skin over these areas with brownish parchmentisation.The mucous membranes of the mouth and tongue show reddish brown corrosion. Similar changes may be seen on the inner surface of esophagus. 2) The stomach is soft, swollen with congestion desquamation,haemorrhagic points and ulceration of the inner surface. It contains altered blood with mucous shreds.
3) Perforation is uncommon. 4) The upper part of the small intestine shows signs of Irritation. 5) In case if vapours are inhaled, there occurs congestion of the respiratory tract with the congestion and oedema of the lungs. Similarly if vomits is inhaled same findings appear.
In all these cases, I. Stomach with contents. II. A loop of upper part of small intestine. III. Half of the liver. IV. Half of each kidney in 1 container. V. Corroded areas of skin in other container. VI. Acid stained clothes are preserved separately. Preservatives Viscera and skin are preserved in absolute alcohol or rectified spirit, clothes are sent without any preservation.
Inflammatory reaction first : 4 – 7 days Granulation Stage : Fibroplasias and formation of collagen starts. 2 nd and 3 rd Week : Tissues become weak. Third Stage (Cicatrisation Stage) : Formation of scar tissue which increases the chances of perforation. Their action is characterized by : I. Extraction of water from tissues. II. Coagulation of cellular proteins III. Conversion of hemoglobin into haematin.
Diagnosis Radiology I. Acute Stage :1 – 10 days in peeding perforations. II. Sub. Acute Stage : 11 – 16 days. Atony,dilation and rigidity of the antrum and pylorus seen. III. Chronic Stage : Stenosis and contraction of the antrum and pylorus occurs. Chest and abdominal X-rays and routine Laboratory testing should be obtained to evaluate for Aspiration, perforation and organ dysfunction. Endoscopy : performed for getting better results 12 – 24 hours e.g. to check perforation
Treatment 1. Weak acid : carbonated beverage or citrus juice. 2. Base Antacid. 3. Do not perform gastric levag,it increases the chances of perforation. 4. Do not give any orally for 2-3 days after water milk,water electrolytes shafted be green. 5. Broad spectrum Antibiotics. 6. For Esophageal stictures and gastric outlets : obstruction may require subsequent dilatation or surgical reconstruction.
Treatment(CONT…) 6) Laprotomy is required for patients with gastric perforations and peritonitis. 7) Skin lesions need to be washed with soap and water followed by the application o some ointment. 8) Eye involvement needs irrigation with water or normal saline, also refer to ophthalmologist.
i. Accidental Poisoning : Commonly found in many house hold agents e.g drain detergents, drain openers. ii. Accidental Ingestion : The intestine accidently warms the unintentional taken of his mistake causing him to spit of the acid which dribbles out on his chin and some stains on his clothes. Further more attempts to wipe the burning stuff from the lips may result in spreading it over the surrounding area and cheeks etc.
Medicolegal Aspects(CONT…) III. Succidal Poisoning : in intentional swallowing of the acid, intense pain may result in spluttering and staining of the mouth,chin, and clothing. IV. Homicidal Poisoning : homocidal victims are usually incapable infants or intoxicated persons. V. An acute exposure to the vapours in the industries may lead to death due to Respiratory distress. VI. Prolonged exposure to the vapours of the agent in the industries may lead to Respiratory copmlications.
Medicolegal Aspects(CONT…) VII. In case of Fatal Poisoning Cases : By these acids, no trace of poisons may be discoverable in viscera. The quantity of free acid present,specially important in HCL poisoning as this acid is contained uncombined with bases in the gastric juice to the extent of about 0.2% or more. VIII. Sometimes disposal of the dead body may be affected by throwing the dead body into the acid with an attempt to dissolve the body of the victim as was practised by John George Haigh so called Acid Bath Murder.
Corrosive irritant if diluted. Nitric acid is a powerful oxidizing agent. Signs and Symptoms: Burning pain,thirst,yellow colouration of mucous membrane and teeth,yellow brown vomitus,tender and distended abdomen, oligurea,shock,choking,lacrimation, dyspnoea and cough are due to INHALATION. Fatal Dose :15-20 ml Fatal Period : 18 hours.
Xanthoproteic Reaction Xanthoproteic reaction occurs with ingestion of nitric acid. Nitric Acid is a powerful oxidizing agent and reacts with organic matter ( protein) to produce tri nitro phenol liberating nitrogen mono oxide is called Xanthoproteic Reaction.
Treatment o Stomach wash (with soft rubber tube) o Give milk – Magnesium oxide – Egg white o Melted Butter o 10 mg Morphine (pain relieft) o IV Fluids ( ice Sucking ) o Cortisone (for treatment of shock and to prevent oesophageal stictures) Medicolegal Points o Accidental o Succidal o Abortificiental / Vitriolage
Postmortem Appearances There may be signs of corrosion and partial destruction of the parts with which the poison has been in contact. Externally : The lips may be burnt and trickle marks may be found running from the mouth to the chin, neck,chest. Internally : they vary in extent from localised patches to extensive AREAS particularly in stomach. Stomach Perforation is common with sulphuric acid. Irritation of Respiratory tract is found in case of volatile poisons e.g nitric acid,HCL.
Medicolegal Aspects Attempted succide with corrosives is not seen now owing largely due to the use of other less painful substances like barbiturates and synthetic narcotics and organophosphate compounds. Corrosives are rarely used for homocide owing to their painful action. Corrosives usually thrown on the face out of jealousy or in fits of rage, called vitriolage. They cause severe injury even death from accidental spilling.
Collapse from shock sets in with a. Cold clammy skin, sunken eyes, dilated pupil. b. Pale anxious face c. Rapid feeble pulse and sighing respirations. Consciousness is usually retained until near the end. Death : death may result from primary shock, suffocation,due to oedema of glottis or perforation of stomach. If quantity of poison swallowed is small, death may be delayed until Hypostatic pneumonia develops. Patient may be recover and death may be later due to complications. e.g Sticture of oesophagus with resulting emaciation and malnutrition. The sites likely to be affected by local contact.
Treatment Stomach tubes and emetics are contraindicated. 1) Soft stomach tube (Levine Tube) can be pass with case within about an hour of ingestion of poison to prevent serious caustic burns of the stomach walll followed by ulceration,cautraction and stricture. If an acid has been taken alkaline carbonates are contraindicated because they liberate CO2 which may distend and rupture a damaged stomach. 2) Weak alkalis and plenty of water or neutralizing agents such as milk and egg albumin should be given.
Treatment(CONT…) 3) In case of Alkali : A weak acid such as vinegar (acetic acid) will neutralize its effects. 4) 10 mg Morphine IM injection for relieving pain. 5) ICE CUBES to suck to relieve thurst and bring effects. 6) IV Fluids to combat fluid loss. 7) Corticosteroids : for shock treatment and to prevent oesophageal sticture. 8) Tracheostomy may be necessary if there is acute oedema of the glottis. 9) Melted Butter 10) Magnesium Oxide ( along with general treatment of poisoning)