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FORENSIC MEDICINE & TOXICOLOGY

Enhanced Chapter-Wise Crisp Bullet Notes

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CHAPTER 1: MECHANICAL INJURIES

Q1. ROAD TRAFFIC ACCIDENTS (RTA)

1. Primary/First impact: Vehicle bumper strikes legs
   • Produces "bumper fracture" (tibia/fibula) at bumper height
   • "Tyre tread abrasion" - parallel linear abrasions
2. Secondary/Second impact: Body thrown onto bonnet/windscreen
   • Head, chest, trunk injuries
   • "Fender fracture"
3. Tertiary/Third impact: Body hits ground
   • Scattered abrasions, contusions, lacerations

• Steering wheel injuries: Chest wall contusions, rib fractures, cardiac contusion
• Dashboard injuries: Knee injuries, femur fractures, acetabular fractures
• Windscreen injuries: Dicing injuries - multiple small square lacerations on face from tempered glass (pathognomonic of RTA)
• Seatbelt injuries: Contusions/bruising in belt distribution; "Seatbelt syndrome" - transverse bruise across abdomen/chest
• Whiplash injury: Hyperextension-flexion injury of cervical spine in rear-end collision
• Airbag injuries: Abrasions to face, arms from airbag deployment

• Decapitation by wire/cable (Garrotte-type)
• Helmet protects skull but "Ring fracture" of base of skull can occur
• "Spurring of tyres" - distinctive tyre marks

1. Treat the patient (primary duty - save life)
2. Inform police (MLC - Medicolegal Case registration)
3. Preserve all clothing/evidence without cutting through injuries
4. Document injuries accurately with size, shape, nature, site
5. Issue MLC certificate/wound certificate
6. Do not alter or destroy evidence
7. Maintain secrecy - do not disclose to media/press
8. Cooperate with police investigation
9. Prepare for court testimony if required
10. If death occurs - inform police, do not disturb body, facilitate inquest/postmortem

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Q5. FIREARM INJURIES

• Smooth Bore (Shotguns): Single/double barrel; uses pellets/shots
  • Gauge = number of lead balls fitting the bore required to weigh 1 pound
• Rifled Bore: Spiral grooves inside barrel - impart spin to bullet
  • Pistol, revolver, rifle, carbine, machine gun
  • Classified by calibre (diameter of bore in inches or mm)
• By Muzzle velocity:
  • Low velocity (<600 m/s) - pistols, revolvers
  • High velocity (>600 m/s) - rifles, military weapons

• Circular/oval shape (oval if bullet strikes obliquely)
• Inverted/inturned edges (skin pushed inward)
• Abrasion collar (Graze collar): ring of abrasion around wound; caused by bullet rotating and abrading skin; width indicates angle of entry - does NOT occur at exit wound (pathognomonic of entry)
• Contusion collar/Bruising ring - bluish-red bruising around wound
• Grease/dirt collar - ring of dirt/lubricant wiped off bullet
• Singeing, blackening, tattooing - depends on range

• Larger than entry
• Irregular, stellate/lacerated
• Everted margins
• NO abrasion collar

• Temporary cavity formation; Permanent cavity; Yaw and Tumbling
• Fragmentation; KE = ½mv² - higher velocity = exponentially more energy deposited
• Bullet embolism: Rarely, bullet may travel in blood vessel

1. Brass base cap - contains primer/percussion cap
2. Powder charge - propellant (smokeless powder)
3. Wad - plastic/cardboard disc; separates powder from shot; seals gas; gives characteristic wound at intermediate range
4. Shot pellets - multiple lead balls (buckshot, birdshot)
5. Overshot card/wad - closes cartridge
6. Plastic/cardboard casing (hull)

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Q10. ABRASIONS

1. Scratches/Linear abrasions: By sharp point dragged along skin
2. Graze/Sliding/Friction abrasion: Caused by fall on rough surface; base shows parallel lines indicating direction
3. Pressure/Crushing abrasion: Due to blunt impact; may show pattern of causative weapon ("patterned abrasion")
4. Impact abrasion: Due to perpendicular blunt force impact

• Intradermal bruise: Immediate subepidermal layer; sharp defined edges; from patterned object
• Subcutaneous bruise: In subcutaneous fatty layer; blurred edges; MOST COMMON type
• Deep bruise: Deeper than subcutaneous; may take hours to 1-2 days to appear (delayed bruising)

• Age: Easily produced in children and elderly
• Sex: More common in females
• Site: More prominent at bony prominences; on loose skin (scrotum, eyelids); less on thick skin (palms/soles)
• Natural disease: Easier bruising in scurvy, hemophilia, purpura
• Complexion: More visible in fair skin

• Note: In subconjunctival haemorrhage - colour changes NOT seen

• Blood at point of impact tracks down via fascial planes and appears elsewhere
• Anterior cranial fossa fracture → Raccoon's eye (periorbital ecchymosis)
• Middle cranial fossa fracture → Battle's sign (mastoid ecchymosis)

• Caused by blows with rod/stick/whip
• Produces two parallel linear haemorrhages with normal skin in between
• Mechanism: Weapon compresses skin ridge (no vessel damage there) but marginal dermal vessels rupture due to traction

1. Split laceration: Blunt force at bony prominence; "incised-looking" laceration; seen at scalp, forehead, shin
2. Stretch laceration: Overstretching of skin; seen in run-over injuries, compound fractures
3. Avulsion laceration: Tangential/shearing force; leads to Flaying, Degloving, Amputation
4. Tear laceration: Object hits and skin pulled back (e.g., car door handle)
5. Cut laceration: Heavy cutting weapon (axe, chopper); underlying bone fracture also occurs

• Sites: Front of forearm, outer upper arm, front of chest/abdomen, outer thighs
• Features: Incised, multiple, superficial, parallel; clothes usually NOT cut
• MLI: To make false charges of assault; convert simple to grievous injury; allege rape; avoid duties

• Tentative, superficial cuts before final decisive cut in suicide
• Multiple, parallel, superficial; on accessible parts
• Sites: Front of wrist, front of elbow, front and sides of neck
• Indicates deeper at beginning, superficial at end

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SKULL FRACTURES

1. Linear fracture - most common; thin line; no displacement
2. Comminuted fracture - multiple fragments
3. Depressed fracture - bone pushed inward
4. Pond fracture - circular dent; ping-pong fracture; in infants/children/forceps delivery; outer table fractures, inner table intact
5. Gutter fracture - groove by tangential bullet
6. Perforating fracture
7. Basilar fracture
8. Sutural fracture

• Divides entire base of skull into two parts
• Fracture of middle cranial fossa
• Seen in motorcyclists

• Depressed fracture where shape of depression corresponds to striking surface of weapon
• Helps identify weapon; shows how violence was applied

• Bleeding between dura and arachnoid (subdural space)
• Vessels: Rupture of bridging/communicating veins; dural venous sinus tears
• Site: Fronto-temporal; preserves contours of cerebral convolutions
• Types: Acute (<3 days), Subacute (4-21 days), Chronic (>3 weeks - seen in infants and elderly)
• CT scan: Concavo-convex opacity
• MLI: In battered baby syndrome - SDH is the MOST CONSISTENT feature

• Artefact (NOT a vital phenomenon) - seen in skull exposed to tremendous heat
• Resembles extradural haematoma (EDH)
• Features: Soft friable clot, light chocolate brown, sickle shaped, honeycomb; bilateral; parieto-temporal
• Contains up to 120 mL blood; eggshell fracture present; crosses suture lines (unlike EDH)

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BURNS (GB)

• 1st degree: Superficial; epidermal only; extremely painful (nerve endings intact)
• 3rd degree: Painless - nerve endings destroyed (Wilson's burns distinction)

• For children: Lund & Browder chart (head proportionately larger)
• MLI: >33% TBSA - poor prognosis; Parkland formula for fluid resuscitation

1. Hypovolemic shock (within 24-48 hrs) - loss of fluid and protein
2. Acute oedema of glottis - from inhaled irritant smoke/hot gases
3. Sepsis after 4-5 days - Pseudomonas, Staphylococcus, UTI
4. Bronchopneumonia
5. Gangrene, tetanus, anaemia
6. Oesophageal stricture (chemical burns)

• Central crater with peripherally raised margins; chalky white; floor pale
• Mild hyperaemia of adjacent intact skin
• Metallization: Deposition of metallic ions into skin (detected by Acro-Reaction test); only at entry wounds
• Microscopic: Epidermal separation; palisading of nuclei; nuclear streaming; coagulative necrosis
• MLI: Presence of Joule burns NOT itself proof of electrocution EXCEPT for zone of hyperaemia

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CHAPTER 2: ASPHYXIAL DEATHS

Q3 & Q15. DROWNING

1. Typical/Wet drowning (85-90%): Water aspirated into lungs; most common
2. Dry drowning (10-15%): Laryngeal spasm; asphyxia without aspiration; lungs dry at autopsy
3. Secondary/Delayed drowning: Symptoms appear hours after apparent recovery (surfactant damage)
4. Immersion syndrome (Hydrocution): Sudden cardiac arrest/vagal inhibition due to cold water - no water aspirated; seen in alcoholics
5. Salt water drowning: Hypertonic - draws fluid from blood → haemoconcentration; death faster (5-6 min)
6. Fresh water drowning: Hypotonic - absorbed rapidly → haemodilution, haemolysis, VF; death in 3-4 min (faster)

• Diatom Test: Diatoms in bone marrow = confirmatory of AM drowning
• Gettler's Test:
  • Fresh water: Left heart Cl⁻ < Right heart Cl⁻
  • Salt water: Left heart Cl⁻ > Right heart Cl⁻
  • Normal difference <10 mg% (>10 mg% significant)

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ASPHYXIA

1. Stage of Dyspnoea (0-1 min): Increased RR; rise in BP and HR; cyanosis
2. Stage of Convulsions (1-2 min): CO₂ acts on brain; convulsions/loss of consciousness; petechiae form; sphincters relax
3. Stage of Exhaustion (2-3 min): Respiratory efforts decrease; BP falls
4. Stage of Apnoea (3-5 min): Cessation of respiration; heart continues briefly; death

• Cyanosis
• Petechiae (Tardieu spots) - subconjunctival, facial, pleura, pericardium
• Congestion
• Fluidity of blood (dark, liquid)
• Right heart engorgement
• Pulmonary oedema

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CHAPTER 3: POST-MORTEM CHANGES

1. Irreversible cessation of brain, respiration, circulation
2. Facial pallor
3. Changes in the eye

1. Algor mortis
2. Livor mortis (PM staining)
3. Rigor mortis
4. Primary flaccidity of muscles
5. Loss of elasticity of skin

1. Mummification
2. Adipocere
3. Decomposition/Putrefaction

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LIVOR MORTIS (GB)

• Onset: 30 minutes
• Well developed: 4 hours
• Completely develops: 6 hours
• Fixation: 8-12 hours

• Supine: Back of head, chest, legs (except pressure areas)
• Prone: Front of face, chest, abdomen
• Hanging: Lower forearms and legs (glove & stocking)
• Drowning in stagnant water: Face, upper chest

1. Sign of death
2. Helps estimate TSD
3. Determines position of body after death
4. Determination of cause of death
5. May be mistaken for bruise

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RIGOR MORTIS

• Starts: 1-2 hours after death
• Takes 12 hours to develop (complete)
• Persists for next 12 hours
• Vanishes in next 12 hours
• Total duration: approximately 24-36 hours
• Mechanism: ATP depletion → actin-myosin cross-bridges cannot break → muscles fixed in contracted state
• Nysten's Law: Jaw → neck → trunk → upper limbs → lower limbs (cervicofrontal)

1. Heat stiffening
2. Cold stiffening
3. Cadaveric spasm
4. Gas stiffening

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PUTREFACTION

• 12-24 hrs: Greenish discolouration of right iliac fossa
• 36-48 hrs: Marbling AND skin slippage
• 48-72 hrs: Peeling of skin

• 72 hrs: Loosening of hair

• Months: Skeletonisation
• Casper's Dictum: 1 week in air = 2 weeks in water = 8 weeks in earth
• Adipocere: Starts 3 days after death; takes 3-6 months to complete
• Mummification: 3 months - 6 months after death

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PMI ESTIMATION - BIOCHEMICAL MARKERS (GB)

• 18-36 hrs: Flies lay eggs
• 12-24 hrs: Eggs hatch into maggots/larvae
• 4-5 days: Maggots develop into pupae
• 8-12 days: Pupae into adult flies
• Lice die within 3-6 days after death

• Blood: Potassium and magnesium RISE; sodium and chloride FALL
• CSF: Potassium, creatine, uric acid INCREASE; glucose DECREASES
• Vitreous humour: Potassium, magnesium, urea, creatinine INCREASE

• Eyeball: Flaccid due to fall in IOP (10 to 0 mmHg) within 4-6 hrs
• Tache noire: Dark brown-black deposit on sclera; triangular with apex toward canthus; within 3-6 hrs
• Cornea: Hazy and opaque at 6-8 hrs

• Stomach contents: Full with undigested food = death within 2-4 hrs of last meal
• Intestinal contents: Feces in pelvic colon suggests death at night; empty suggests death after morning evacuation
• Urinary bladder: Full bladder in morning = may have died before usual rising time
• Facial hair growth: Estimate survival time from time of last shave

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CHAPTER 4: SEXUAL OFFENCES

• Vaginal swab (high/low) - spermatozoa, seminal fluid, DNA
• Cervical swab - sperm motility, acid phosphatase
• Anal swab (if anal assault); Oral swab (if oral assault)
• Blood - DNA, toxicology (DFSA drugs)
• Urine - toxicology (GHB, Rohypnol)
• Fingernail scrapings, pubic hair combing, clothing, bite mark swabs

• Motile: Up to 6-12 hours
• Non-motile: Up to 72-120 hours (5 days)
• Seminal stains: Weeks on fabric
• Two-finger test: Medically unjustified; banned by Supreme Court - must NOT be performed

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REPRODUCTIVE HEALTH (GB)

• False positive (sinks in stillborn): Putrefaction gas; artificial respiration
• False negative (float in liveborn): Neonatal atelectasis, premature, pneumonia, prolonged pressure

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CHAPTER 5: GENERAL TOXICOLOGY

1. Corrosives: Strong acids (HCl, HNO₃, H₂SO₄; oxalic, carbolic acid); Strong alkalis (NaOH, KOH, NH₄OH); Metallic salts
2. Irritants: Inorganic (metallic: As, Pb, Hg, Cu; nonmetallic: phosphorus, iodine); Organic (plants: Abrus precatorius, castor; animals: snakes, scorpions); Mechanical (powdered glass, diamond dust)
3. Neurotics: Cerebral (Somniferous - opium; Inebriants - alcohol; Deliriants - dhatura, cocaine, cannabis); Spinal (strychnine); Peripheral (curare)
4. Cardiac: Digitalis, Oleander, Aconite, HCN
5. Asphyxiants: CO, H₂S, CO₂
6. Miscellaneous: Agrochemicals (OPC, AlPhos, Paraquat, Thallium); Drugs of dependence; Petroleum products; Food poisoning

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1. Inform police in ALL cases (government MO) - private practitioner must inform only in homicidal poisoning
2. If doctor does not inform police - punishable under Sec. 176 IPC
3. Note preliminary particulars of patient
4. Take proper history (suicidal/homicidal/accidental)
5. Inform senior doctor
6. Collect evidence: gastric lavage, food, vomitus, blood, urine, faeces; preserve and send to FSL - Failure to preserve evidence: Punishable under Sec. 201 IPC
7. Prepare MLC report with consent
8. If patient about to die: arrange Dying Declaration
9. If patient dies: Do NOT issue death certificate; send body for PM
10. Opinion on nature of poison: Only after FSL report

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Q2. ORGANOPHOSPHORUS (OPC) POISONING

• Alkyl phosphates: HETP, OMPA, TEPP, Malathion (Mnemonic: HOT MALA)
• Aryl Phosphates: Diazinon (Tik-20), Chlorthion, Parathion (Mnemonic: DCP)

• Muscarinic: Salivation, Lacrimation, Urination, Defecation, GI cramps, Emesis, Bradycardia, Bronchospasm, Miosis, Sweating
• Nicotinic: Muscle fasciculations, Weakness, Mydriasis, Tachycardia
• CNS: Anxiety, Depression, Restlessness, Seizures, Coma

• AChE level in RBCs and plasma - decreased
• Symptoms occur when >50% of cholinesterase inhibited
• Liquid gas chromatography - to detect OPC in blood
• P-nitrophenol test - in case of parathion poisoning

1. Remove from exposure; decontaminate (remove clothing, wash skin with soap and water)
2. ABC stabilisation
3. Atropine: 2-4 mg IV, repeat every 5 minutes until atropinisation (dry secretions, HR >80) - titrate to dry secretions, NOT pupil size
4. Pralidoxime (PAM): 1-2 g IV over 15-30 min, then infusion; only within 24-48 hrs; relieves nicotinic features; contraindicated in carbamate poisoning (GB)
5. Diacetyl monoxime (DAM) also used as AChE reactivator (GB)
6. Benzodiazepines for seizures
7. Avoid succinylcholine, morphine, barbiturates, phenothiazines

• External: Smell of kerosene from nostrils and mouth; signs of asphyxia; blood-tinged froth
• Internal: GIT congested; lungs congested and oedematous; brain congested

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Q16. ARSENIC POISONING

• GI: Metallic/garlic odour; nausea, vomiting (profuse, projectile, dark brown); rice water diarrhoea (like cholera); colicky abdominal pain; tenesmus
• Systemic: Dehydration, circulatory collapse; oliguria/anuria; haematuria; muscle cramps; haemolysis
• CVS (GB): Hypotension, ARDS, weak pulse, sunken eyes, arrhythmias
• Skin (GB): Delayed loss of hair, skin eruptions

• Mees' lines (Aldrich-Mees' lines) - white transverse lines on nails
• Arsenical keratosis (palmar/plantar)
• Rain-drop pigmentation
• Alopecia, golden hair (GB)
• Peripheral neuropathy - glove-stocking distribution
• Black foot disease: Vasospasm and thrombosis leading to gangrene (GB)
• Bone marrow depression, pancytopenia (GB)

• Urine arsenic: >50 µg/L in 24 hrs = indicative; toxic >200 µg/L
• Blood arsenic: 0.9 µg/dL
• Hair arsenic: 75 µg%
• Nail arsenic: 100 µg%
• Tests: Reinsch test, Marsh test, Gutzeit test, AAS, NAA

1. Gastric lavage with 1:5000 KMnO₄ (GB)
2. BAL (Dimercaprol): 3 mg/kg IM 4-hourly for 2 days; then 6-hourly for 4 days; then 12-hourly (GB)
3. Whole bowel irrigation (GB)
4. Purgatives (GB)
5. IV fluids, sodium bicarbonate to correct shock
6. Hemodialysis if renal failure
7. DMSA (succimer) - oral chelation; safer alternative
8. D-Penicillamine - mild/chronic cases

• External: Sunken eyeballs; rigor mortis appears early; delayed putrefaction; emaciated
• Internal: Ulceration of mouth/pharynx/oesophagus; stomach mucosa red velvety; lungs, liver congested; heart - subendocardial petechial haemorrhages

• Homicide common: cheap, colourless, odourless, tasteless, easily obtainable; symptoms simulate cholera; gradual onset
• Suicide rare; accidental from well water or improper medicinal use
• Used on abortion sticks; may be used as cattle poison

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CHAPTER 5B: ADDITIONAL POISONS (GB)

CYANIDE (HCN) POISONING

1. Cyanide inhibits cytochrome oxidase (Complex IV)
2. Blocks final step of oxidative phosphorylation → prevents ATP formation
3. Arrest in aerobic respiration → histotoxic hypoxia
4. Blood saturated with O₂ but tissues cannot utilise it
5. Conversion of pyruvate into lactate → lactic acidosis

• HCN: 50-60 mg
• NaCN/KCN: 200-300 mg

• HCN: 2-10 minutes
• NaCN/KCN: 30 minutes

• GIT: Burning taste, throat constriction, numbness, salivation, froth at mouth
• CNS: Headache, vertigo, dizziness, coma, anxiety
• CVS: Initially hypertension + reflex bradycardia; later hypotension + reflex tachycardia
• RS: Initially tachypnoea; later respiratory depression; smell of bitter almond in breath
• Eyes: Prominent; pupils dilated

1. ABC; assisted ventilation, 100% O₂; cardiac monitoring
2. Decontaminate: Remove from source; remove clothing; flush skin
3. Gastric lavage: 5-10% sodium thiosulphate solution; followed by potassium carbonate (forms inert Prussian blue)
4. Antidotal kit (3 steps):
   • Step 1: Amyl nitrite pearl - inhale 30 secs every minute
   • Step 2: Sodium nitrite 300 mg IV slowly
   • Step 3: Sodium thiosulphate 12.5 g IV over 10-20 min
5. Hydroxycobalamine (Vitamin B₁₂) IV - binds cyanide → cyanocobalamine
6. Dicobalt EDTA

• PM staining: BRIGHT RED (not cherry red like CO - important differentiator)
• Smell of bitter almonds on opening body cavity
• Oral/perioral erosions
• Lungs congested and oedematous
• Bitter almonds contain amygdalin (cyanogenic glycoside) → enzymatic hydrolysis in GIT → releases HCN

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BARBITURATE POISONING (GB)

• CNS depression: Drowsiness, delirium, excitement, hallucinations, ataxia; coma with positive Babinski sign; loss of reflexes
• RS: Rapid/shallow or slow/laboured breathing (respiratory centre depressed)
• CVS: Decreased cardiac output → hypotensive shock, cyanosis, bradycardia
• GIT: Absence of bowel sounds in comatose (BAD prognosis)
• Renal: Scanty urine, contains albumin and sugar
• Skin: BARBITURATE BLISTERS (characteristic)
• Temperature: Decreased (hypothermia); fever if bronchopneumonia

1. ABC
2. Gastric lavage with 1:1000 KMnO₄ + activated charcoal
3. Forced Alkaline Diuresis: Sodium bicarbonate in 5% dextrose IV
4. Antibiotics to prevent bronchopneumonia
5. Scandinavian method (combination of 1+2+3+4)
6. Hemodialysis; Exchange transfusion
7. Supportive care

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SULPHURIC ACID POISONING (GB)

• Oropharyngeal burns (blackening); pain in throat and epigastrium
• Violent cough, dyspnoea, glottic oedema
• Teeth become CHALKY WHITE (characteristic)
• Intense thirst, scanty urine; swollen lips and tongue
• Abdomen: Tender, distended; constipation and tenesmus

• Neurogenic shock; Perforation of stomach; Peritonitis; Septicaemia; Glottic oedema and asphyxia; Oesophageal stricture; Renal failure

1. ABC; tracheostomy if glottic oedema
2. Gastric lavage: CONTRAINDICATED
3. Milk/water immediately to neutralise acid
4. Avoid sodium bicarbonate (CO₂ production causes perforation risk)
5. Steroids to prevent inflammation
6. IV antibiotics if perforation
7. Morphine for pain

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METHYL ALCOHOL POISONING (GB)

• GIT: Nausea, vomiting, cramps, alcohol odour, dehydration
• Eyes: Fixed and dilated pupils; photophobia; blurred/"snowfield vision"; scotoma; blindness due to optic neuritis/atrophy
• CNS: Headache, dizziness, restlessness, hypothermia, delirium, coma; convulsions (terminal)
• Renal: Acidosis, strongly acidic urine, scant urine

1. Gastric lavage with sodium bicarbonate solution
2. Sodium bicarbonate 4-hourly orally to treat acidosis
3. Ethanol as competitive antagonist: 0.8-1 ml/kg orally of 95% ethanol OR 10 ml/kg IV of 10% ethanol in D5W
4. Antidote: 4-methylpyrazole (Fomepizole) - competitive inhibitor of alcohol dehydrogenase; blocks formation of formaldehyde and formic acid
5. Calcium folinate IV, thiamine, pyridoxine
6. Cover eyes to protect from light
7. Hemodialysis in severe poisoning

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PHENOL (CARBOLIC ACID) POISONING (GB)

• Eyes: Pupils constricted
• Skin: Cold and clammy; local: white painless eschar (damage to nerve endings → tingling → numbness)
• GIT: Burning, tingling then anaesthesia; diarrhoea; abdominal pain; vomiting RARE
• CNS depression: Headache, giddiness
• Kidneys: Renal failure
• CVS: Rapid, feeble, irregular pulse; coma
• Carboluria: Urine scanty, suppressed with GREENISH HUE (appears after 36-48 hrs of ingestion) - characteristic

• External: Corrosion of mouth, tongue, chin; smell of phenol
• Internal: Brown leathery stomach (hardening of mucosa); haemorrhagic nephritis

1. ABC
2. Gastric lavage with water + charcoal + OLIVE OIL (only corrosive acid where gastric lavage is indicated)
3. Normal saline with sodium bicarbonate IV
4. Hemodialysis if renal failure

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GENERAL PRINCIPLES OF TREATMENT IN POISONING (GB)

• Injected: Remove sting (bee/wasp); tourniquet/ice; treat anaphylaxis
• Contact: Remove clothes; wash with soap and water
• Inhaled: Remove to fresh air; O₂ supplementation
• Ingested: Gastric lavage (Ewald tube or Boas tube)

1. Forced alkaline diuresis: Sodium bicarbonate - for acidic drugs (salicylate, barbiturate)
2. Forced acid diuresis: Ammonium chloride - for alkaline drugs (amphetamines, quinine, TCA)
3. Haemodialysis (Mnemonic LABS): Lithium, Alcohol, Barbiturates, Salicylates
4. Haemoperfusion: Blood through activated charcoal filter - for caffeine, barbiturates, mushroom
5. Whole bowel irrigation
6. Diaphoretics

1. Corrosive poisoning (acids, alkalis) - risk of perforation
2. Petroleum products/hydrocarbons - risk of aspiration
3. Convulsions (unless airway protected with ETT)
4. Loss of consciousness (unless airway protected)
5. Strychnine poisoning

6. 4-6 hrs after ingestion

7. Oesophageal pathology (stricture, varices)

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CHAPTER 6: GASEOUS POISONS

H₂S POISONING

• Cyanosis; greenish/black discolouration of viscera (H₂S + Hb → sulphmethaemoglobin)
• Pulmonary oedema; frothy fluid in airways; petechiae
• Smell of rotten eggs on opening body; faster putrefaction

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CHAPTER 7: SNAKE BITE

• Venom: Neurotoxic (alpha/beta-bungarotoxin)
• Bites at night; minimal local signs
• Descending paralysis: Ptosis, diplopia, dysphagia, dysarthria → respiratory failure
• NO coagulopathy
• Mnemonic (GB): 5Ds + 2Ps - Dyspnea, Dysphonia, Dysarthria, Diplopia, Dysphagia + Ptosis, Paralysis

• Venom: Vasculotoxic + Cytotoxic
• Local: Severe pain, massive swelling, blistering, skin necrosis, haemorrhagic bullae
• "Bilateral parotid swelling" - 'viper head' (GB)
• Systemic: DIC; Bilateral Renal Cortical Necrosis (BRCN - Russell's viper specific)

1. Place a few ml of venous blood in clean, dry glass tube
2. Leave undisturbed 20 min at room temperature
3. Tip the tube once
4. Blood still unclotted and runs out = incoagulable blood = viperine envenomation
5. Normal 20 WBCT excludes Viperidae species

• Do's: Immobilise limb; Remove rings/jewellery; Pressure immobilisation (for elapid bites only); Wash bite with soap and water (GB); Cover with clean dry dressing (GB)
• Don'ts: Do NOT incise and suck; Do NOT tourniquet; Do NOT electric shocks; Do NOT ice; Do NOT drink alcohol as painkiller (GB); Do NOT take aspirin/ibuprofen (GB)

• 80-100 mL serum diluted in 200-500 mL isotonic saline
• Recommended initial dose: 8-10 vials slow IV over 1 hour

• Fluid resuscitation with NS, Ringer's, FFP; Dopamine for hypotension
• Fresh blood/FFP/platelets for coagulopathy; Haemodialysis for ARF
• Surgical excision for gangrene prevention

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CHAPTER 8: INORGANIC POISONS

ALUMINIUM PHOSPHIDE (ALP) POISONING

• Garlic/phosphine odour (DISTINCTIVE)
• GI: Nausea, vomiting, abdominal pain; burning in mouth/throat/stomach
• CVS: Hypotension, bradycardia, arrhythmias (MAIN CAUSE OF DEATH), toxic myocarditis
• Pulmonary oedema (frothy blood-stained sputum), ARDS
• CNS: Restlessness, seizures, coma
• Metabolic acidosis, lactic acidosis

1. Inhalation: Remove from source to open area
2. ABC
3. Gastric lavage with 1:10000 KMnO₄ + activated charcoal; Antacids and liquid paraffin
4. IV fluids for hydration and renal perfusion; Dialysis if renal failure
5. Treatment of shock: IV fluids, Hydrocortisone, Low-dose dopamine, ECMO (GB)
6. Treatment of metabolic acidosis: IV NaHCO₃; if fails → haemodialysis
7. Treatment of arrhythmias: IV MgSO₄ for hypomagnesaemia and arrhythmias (GB)
8. Antiarrhythmic agents
9. No specific antidote - Avoid oils (increase absorption)

• Gastric content in airtight container (phosphine is volatile)
• Blood, urine, liver, kidney, lung
• Transport in ice; container must be airtight

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CHAPTER 9: VEGETABLE POISONS

DATURA POISONING

• Fatal dose: 80-120 seeds; Stupefying dose: 40-60 seeds (GB)

1. Dryness of mouth
2. Dysphagia - difficulty swallowing
3. Dysarthria - difficulty talking
4. Dilatation of cutaneous blood vessels (flushing)
5. Dry hot skin (hyperthermia/fever)
6. Drunken gait
7. Diplopia (due to mydriasis)
8. Drowsiness
9. Delirium, hallucinations, pill-rolling movements, pulls imaginary threads from clothes
10. Dysuria due to urinary retention

1. Mydriatic test: Drop of suspected specimen in rabbit's eye → dilation of pupils
2. Pilocarpine test: Instil 2-3 drops of 1% pilocarpine in patient's eye - if NO constriction → Datura poisoning
3. Atropine detected by Radioimmunoassay

1. ABC; Gastric lavage with KMnO₄ or tannic acid (GB); Activated charcoal
2. Physostigmine 0.5-2 mg slow IV; dose (GB): 0.5-1 mg slow IV over 5 min with ECG monitoring; repeat 20 min if needed
3. Purgatives and colonic lavage (GB)
4. Short-acting barbiturates for delirium (GB)
5. IV Diazepam for seizures; Cold/tepid sponging for hyperthermia
6. Dark quiet room; Catheterisation for urinary retention

• "Rail-road poison" - used by criminals as stupefying agent for robbery, rape
• Resists putrefaction
• Used as adulterant in country liquor to enhance kick effect
• Used in Chinese herbal medicines to treat asthma

• External: Signs of asphyxia
• Internal: GIT - inflamed mucosa containing seeds and fragments; Lungs, brain, other viscera - oedematous and congested

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CHAPTER 10: NARCOTIC POISONS

OPIUM POISONING

• Toxic triad: Coma + Miosis + Respiratory depression

1. Stage of Excitement: Euphoria, well-being, freedom from anxiety, talkativeness, laughter, hallucinations, flushed face, red eyes, rapid HR
2. Stage of Stupor: Headache, nausea, vomiting, weakness, heaviness, drowsiness, contracted pupils, cyanosed face/lips
3. Stage of Narcosis/Coma: Deep coma; muscles flaccid; absent reflexes; congested conjunctiva; pin-point non-reacting pupils; hypotension; hypothermia; weak pulse; slow stertorous respiration

1. ABC - airway critical
2. Stomach wash with 1:5000 KMnO₄ (GB)
3. Activated charcoal - method of choice for decontamination
4. Enema with 30 g sodium sulphate twice daily (GB)
5. Whole bowel irrigation in body packers (GB)
6. Naloxone: 0.4-2 mg IV/IM; repeat every 2-3 min; max 10 mg; short half-life (30-90 min) - may need infusion

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SHORT NOTES - FORENSIC PSYCHIATRY

McNaghten's Rules / IPC Sec 84:

• History (GB): In 1843, Daniel McNaughton shot Mr. Edward Drummond (PM Peel's secretary) believing persecution by Tory Party; suffered paranoid delusions; acquitted on insanity ground
• Rules: At time of act, due to disease of mind, person:
  1. did NOT know nature and quality of the act, OR
  2. did NOT know it was wrong
• IPC Sec 84: "Nothing is an offence which is done by a person who, at the time of doing it, by reason of unsoundness of mind, is incapable of knowing the nature of the act or what he is doing is either wrong or contrary to law"

• Legal test of insanity = "Right or Wrong" test
• Requirements: Evidence of mental disease; must exist at time of crime; degree must prevent understanding act is wrong

• Organic mental disorders: Delirium, dementia
• Psychoactive substance use disorders: Acute intoxication, withdrawal
• Schizophrenia and delusional disorders
• Mood disorders: Manic, depressive, bipolar
• Neurotic and somatoform disorders: Anxiety, phobia, OCD
• Adult personality disorders; Mental retardation; Developmental disorders

• False interpretation of external object which HAS real existence (vs hallucination - no external stimulus)
• Types: Universal (same for all, e.g., rail tracks appearing to converge) and Personal (differ per individual)
• Sane person can correct illusions; insane continues to believe even when real facts pointed out

• UK defence to murder; reduces to manslaughter (culpable homicide) if established
• Requires: Abnormality of mental functioning; from recognised medical condition; substantially impaired ability to understand conduct/form rational judgment/exercise self-control; provides explanation for killing

• Definition: Morbid and irrational fear in presence of stimulus; person tries to avoid situation
• Agoraphobia: Morbid fear of places from which escape is difficult (crowd, market)
• Social phobia: Fear of socially demanding situations (stage fear, public speaking)
• Specific/Simple phobia: MOST COMMON; e.g., claustrophobia, hydrophobia, zoophobia

• Person can make advance directive for treatment/care
• Decriminalized attempt to commit suicide
• Rights: Right to access mental healthcare; right to information; right to dignity; right to confidentiality
• Child <3 years of woman receiving treatment should NOT be separated from her
• Supported admission: Minor (age <18 yrs) - any such admission must be informed to board within 72 hrs
• Independent admission: Person ≥18 yrs
• Treatments PROHIBITED:
  • Direct ECT without muscle relaxants/anaesthesia
  • ECT for minors without board permission
  • Psychosurgery without permission
  • Sterilization as treatment for mental illness

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MEDICAL JURISPRUDENCE

• Definition: Lack of reasonable care and skills on part of doctor that resulted in injury/death
• Components (4D's) (GB):
  1. Duty of doctor
  2. Dereliction of duty
  3. Damage to patient
  4. Direct causation

1. No duty owed to patient
2. Res judicata: Matter already decided by court; cannot be tried again
3. Contributory negligence: Patient also found negligent
4. Therapeutic misadventure: Damage from drug/procedure (hypersensitivity to penicillin); doctor not liable
5. Limitation: Case must be filed within 2 years from date of alleged negligence
6. Error of judgement: Doctor's wrong decision - not liable for negligence
7. Products liability: Defective drug/instrument from manufacturer - manufacturer held responsible
8. Informed consent for the act

• Temporary: Doctor not allowed to practise for specified period
• Permanent ("Professional Death Sentence"): Permanent removal; doctor cannot practise for whole life
• Given for: Adultery, addiction to drugs, alcoholism, criminal abortion, female feticide
• Appeal: To Central Health Ministry within 30 days → forwarded to NMC

• 1986: CPA introduced; 1992: Medical services covered; 2019: New Act replaced 1986 Act
• E-filing of complaints; Mediation provisions
• No lawyer required; No court fee; Fast-track courts
• Limitation: 2 years from date of cause of action

• Defined under Sec. 45 IEA
• Can draw conclusions on facts observed by himself or others
• Can express opinion on observations made by others
• Can volunteer information; highly responsible for comments

• Definition: Any question suggesting the answer the person putting it wishes to receive; answered Yes/No
• NOT allowed in Examination-in-Chief and Re-examination
• Allowed in cross-examination
• Allowed in examination-in-chief ONLY if:
  1. Witness declared hostile by court
  2. Court gives permission

• Fee paid to witness in CIVIL cases at time of serving summons to meet expenses
• In criminal cases: No conduct money; witness must attend in interest of State; Government pays TA/DA

• "New intervening act" - independent event after accused's act that caused/contributed to consequence
• Breaks causal chain between accused's action and liability
• Defence for accused to prove liability is limited/non-existent

• Examination of accused by medical practitioner at request of police officer (not below rank of sub-inspector)
• Includes: Blood, bloodstains, semen, swabs, sputum, sweat, hair, fingernail clippings, DNA profiling
• Female accused: Examined only by or under supervision of female doctor

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IDENTIFICATION

• Loops (65-70%): Ulnar loop; Radial loop
• Whorls (30-35%): Concentric circles; require 2 triradii
• Arches (5% - LEAST COMMON): Plain arch (no triradius); Tented arch (one triradius)

• Used when only skull available; face destroyed; mass disaster
• Dacosta's method, Glaister's method (radiographic), video superimposition (most common modern method)

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TOXICOLOGY SHORT NOTES

• Burtonian Line: Blue-black line at gingival margin; pathognomonic of chronic lead poisoning; formed by Lead + H₂S → Lead sulphide

• Burton's line; Basophilic stippling of RBCs; Microcytic anaemia
• Peripheral neuropathy: WRIST DROP (radial nerve palsy), foot drop
• Encephalopathy (children); Lead colic; Lead lines on X-ray of long bones
• Treatment: CaNa₂EDTA, DMSA (succimer), BAL

• Toxin: Clostridium botulinum (Type A most lethal)
• Mechanism: Botulinum toxin cleaves SNARE proteins → blocks ACh release at NMJ → descending flaccid paralysis
• Features: Descending paralysis starting with cranial nerves (diplopia, dysphagia, dysarthria) → limbs → respiratory; NO fever, NO sensory loss; constipation
• vs Guillain-Barré: No sensory deficit in botulism; DESCENDING vs ascending
• Treatment: Botulinum antitoxin (trivalent ABE); ventilation

• Active principle: THC (Δ⁹-Tetrahydrocannabinol)

1. Thiamine 100 mg IV - BEFORE glucose (to prevent Wernicke's in alcoholics)
2. Dextrose 50% - 50 ml IV (hypoglycaemia)
3. Naloxone 0.4-2 mg IV - opioid overdose
4. Flumazenil 0.2 mg IV - benzodiazepine overdose (cautiously - may precipitate seizures)
5. O₂ - all unconscious patients

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FORENSIC PATHOLOGY & AUTOPSY

1. Virchow's method: Each organ removed separately
2. Ghon's method (en bloc): Organs removed in blocks
3. Letulle's method (en masse): All organs removed as single mass, then separated
4. Rokitansky's method: Organs removed in situ, examined on their beds

• Use saturated SALT SOLUTION (NOT formalin or spirit - destroys volatile poisons/drugs)
• Preserve: Stomach + contents; Small intestine; Liver (500 g); Kidney; Urine; Blood (100 ml); Vitreous humour; Brain (500 g); Bone marrow (chronic metal poisoning)

• Virtual Autopsy: Non-invasive PM using CT/MRI - preserves body integrity; permanent digital record; 3D reconstruction; detects gas emboli; but cannot replace standard autopsy
• Negative Autopsy: No anatomical cause found - occurs in: arrhythmia, vagal inhibition, drug/toxin death, electrocution, anaphylaxis, dry drowning
• Cafe Coronary: Sudden death from choking on food (meat bolus) while eating; mimics MI; Heimlich manoeuvre
• Burking: Simultaneous compression of chest + mouth/nose closure; named after William Burke (1828); no external signs of violence; signs of asphyxia only
• Battered Baby Syndrome: Multiple injuries at different healing stages in child <3 years; Typical: Posterior rib fractures; metaphyseal fractures; skull fractures; subdural haematoma (shaken baby); retinal haemorrhages; bruises in unusual sites; SDH is MOST CONSISTENT feature

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KEY DIFFERENTIATIONS (GB)

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KEY LEGAL SECTIONS (QUICK REFERENCE)

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