HEAVY METALS
POISONING
DR. BISHUN D. PATEL
BACKGROUND
2
Contamination
 The undesired introduction of impurities of a chemical or
microbiological nature, or of foreign matter, into or onto a
starting material, intermediate product or finished herbal
product
during
production,
sampling,
packaging
or
repackaging, storage or transport.
Cross-contamination
 The contamination of a starting material, intermediate product
or finished product with another starting material or product
during production.
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KNOWLEDGE ON HEAVY METALS
3
Arsenic
Heavy metals poisoning
Cadmium
Lead
Mercury
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DOSHAS OF DHATUS & UPADHATUS
4
Dhatus (Metals) and Upadhatus (Metalloids) have two types of
impurities
o Nija dhoshas (Inherent toxicity) :- Parada (Mercury) and Naga
(Lead), Shankhya (Arsenic)
o Bahya dhoshas (External impurities) :- Lead, tin and iron with
Mercury; Arsenic with sulphur
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HISTORICAL DISASTERS OF HEAVY METALS
5
1932 – 1952 Minamata
o Sewage containing mercury was released by Chisso’s chemicals works into
Minimata Bay in Japan. The mercury accumulated in sea foods.
o In 1952, the consumption of fish polluted with mercury, caused nearly 1000
fatalities.
1986 -11-01 Sandoz LTD. (Switzerland)
o Water used to extinguished a major fire carried fungicide containing
mercury into the upper rhine. Fish were killed over a stretch of 100 km.
1998-04 Disaster at Spanish nature reserve
o Toxic metals in water from a burst dam of a mine waste containing sulphur,
lead, copper, zinc and cadmium flow down the Rio Guadimar in southern
spain.
o Spanish nature reserve was permanently damaged after this disaster.
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HEAVY METALS TOXICITY
6
Minamata disease
Tai tai disease
Lead deposition
Heavy metals poisoning
Arsenic poisoning
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INTRODUCTION
7
 They occur near the bottom of the periodic table
 Have high densities
 Toxic in nature
 Non-degradable
Periodic table
Note: Arsenic is not actually a metal but is a semimetal i.e. its properties are
intermediate between those of metals and nonmetals.
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8
 The term heavy metals refers to any
What is heavy
metal
metallic chemical element that has
relatively high density and is toxic or
poisonous at low concentrations.
 Heavy metals are conventionally defined as
elements with metallic properties and
atomic number >20.
 The
most
contaminants
Heavy metals poisoning
common
heavy
are
Cadmium
metal
(Cd),
Chromium (Cr), Copper (Cu), Mercury
(Hg) and Lead (Pd).
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Definition
9
Heavy metal
atomic
Heavy metals poisoning
Refers to any metallic chemical element that
has a high specific gravity and high relative
mass.
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TYPES OF METALS
Heavy metals poisoning
Alkali metals
• Lithium (Li), Sodium
(Na), Potassium (K),
etc.
Alkaline earth
metals
• Magnesium (Mg),
Calcium (Ca), Barium
(Ba), etc.
Metalloids
• Boron, Silicon,
Arsenic, Antimony,
etc.
Heavy metals
• Cadmium (Cd),
Mercury (Hg), Lead
(Pb)
10
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11
Source of Heavy
Metals
Contamination
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12
Other Source of
Heavy Metals
Contamination
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DISTINGUISHING FEATURES OF HEAVY METALS
13
Conservative
pollutants
Globally
distributed
pollutants
Heavy
metal
Effectively permanent
Chemical
time bombs
Immutable
Pollutants
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BIOLOGICAL ACTIVITIES OF METALS
14
Inhibit enzymes
Inhibit synthesis of proteins
Cross membrane by passive
diffusion/pinocytosis
Target/critical organ for most of
the metals - Kidneys
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TARGET ORGAN TOXICITY OF HEAVY METALS
15
Arsenic
Liver
Hepatotoxicity
Mercury
& Lead
Brain
Neurotoxicity
Cadmium
Kidney &
Lungs
Nephrotoxicity
Pulmonotoxicity
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ARSENIC POISONING
Introduction
17
 Metallic poisons are classified as irritants.
 Ayurveda Sthavara visha (Khanija)
 Dhatu visha (Susruta )
 Apart from this, many metals have remote systemic toxicity.
 In Ayurveda, it is known as Gauripashana in Sanskrit, Shankhiya
in Hindi. It chemically is As2O3
 It is classified as Shweta, Pandu, Pitta varna
 Two types 1. white (Artificial) and red (from mine)
 Purification in Dolayantra with Cow-milk for 3 hours.
 Sp. Gravity 3.66
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Background
18
 Pure metallic arsenic was formerly thought to be non-
poisonous, as it is not soluble in digestive juice.
 Now pure arsenic dusts is believed to have toxicity.
 Many compounds of arsenic are highly toxic substances
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Arsenic Compounds
19
 White
arsenic compound (Commonly termed as
arsenic)
 Chemically it is
– Arsenous oxide
– Arsenic oxide (As2O3)
 White arsenic compounds and Potassium arsenite were
once used as medicine for intermittent fever as liquor
arsenicals or fowler’s solution
 Later as general tonic
 Its high degree of toxicity and homicidal use have imposed
restriction on its availability
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Arsenic Compounds
20
 Arsine
(AsH3): Known as arsenic hydride or arsenuretted
hydrogen is a highly toxic gas. It is an industrial poison.
 Scheele’s green (Copper arsenite) and Paris green (Aceto-
arsenite) were once used as colouring agent for various substances
including confectionery
 Orpiment (Arsenic trisulphide) and Realgar (Arsenic bisulphide)
were once used as depilatory (Hair remover), colouring pigment
and in flypaper.
 Organic
compounds
Tryparsamide,
of
Acetarsone,
arsenic
Carbarsone,
like
arsphenamine,
Stoversol
also
had
medicinal uses.
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Natural sources
 Arsenic soil
21
 Water
 Some sea fish
– Shell fish and crustaceans
– Oysters (3-10 ppm)
– Mussels and prawans (100 – 150 ppm)
 High arsenic content of soil and subsoil water of some places
are cause of endemic toxicity
 Tobacco smoke contains arsenic. Smoke of cigars (>10 ppm),
Cigarettes (50 ppm)
 Traces in beer as iron pyretes uses to prepare commercial
beer.
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Prevalence
22
 The rate of prevalence of arsenic contamination (>50 ppm) in
the following districts (Maharjan et, al., 2006);



–
Nawalparasi
5.7%,
–
Parsa
2.3%,
–
Bara
2.4%,
–
Rautahat
9.7%,
–
Rupandehi
2.1%,
–
Kapilavastu
3.9%
The highest prevalence found at Patkhouli village of
Nawalparasi (18.6%) of arsenicosis where 95.8% of tubewells is
contaminated with arsenic.
Higher in older age-groups (>50 years) of both the sexes.
Males suffered more from arsenicosis than females
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Normal values of arsenic in
biological samples
23
 Water: 0.01 mg/L
(some countries have national standard as 0.05mg/L)
 Urine: <50 μgm /L = 0.001 mg/L
 Dry Hair: <1 mg /kg
 Nail: <1.5 mg/kg
(PPM = 1 mg/kg or 1mg/L)
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Fatal dose and duration
24
 Dose 100 to 200 mg
 Duration: 12 to 48 hours
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Arsine (AsH3) Poisoning
25
 It is acolourless gas formed by the action of nascent (Freshly
generated) hydrogen on arsenic emitting a garlic like smell.
 It is produced when an acid reacts with an arsenical
compound.
 It is highly toxic (250 ppm in air is toxic)
 At least 6 months exposure to arsenic above 0.05 mg/L in
water, food or air.
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Investigation
26
 Arsenic level in hair and nail above 1 mg/kg and 1.08 mg/kg
respectively and /or arsenic level in urine, above 50 μg/L.
 Presence of arsenic in urine is generally regarded as most
reliable indicator of recent or continuing exposure to arsenic.
 Skin biopsy and histopathology
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Action
27
 It causes
–
Haemolysis
–
Damage liver and kidneys
–
Depresses Central Nervous System
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Action
28
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Action
29
 Arsenic (As) has an affinity to bind sulfhydryl group (-SH) of
different proteins as different enzymes, keratins, hemoglobin etc
and accumulate in different parts of body and produce chronic
health effect.
 It crosses mitochondrial membrane and impairs oxidative
phosphorylation which inhibits ATP and NADH production then
reduces energy production causing oxidative stress and H2O2
production increase which leads to release of free radicals and
causes cell injury.
 Arsenic also inhibits non competitively alpha ketogluterate
dehydrogenase causing decreased succinyl CoA which leads to
decrease in porphyrin and heme.
 Also, it inhibits DNA synthesis and repair in mitochondria which
cause malignancy
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Signs and Symptoms
30
 Immediate effects: Not seen, however it takes at least 6 hours
or more
 Late effect
–
Nausea
–
Vomitting
–
Chill
–
Fever
–
Backache
–
Oliguria with RBCs, free hemoglobin and cast cells
–
Jaundice
–
Haemolysis leads to anemia
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Heavy metals poisoning
31
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Differential diagnosis
32
 Cholera
 Bacterial food poisoning
 Gastro-enteritis
 Chronic alcoholism
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AYURVEDA MANAGEMENT
33
 Anti-dote: Abhraka bhasma (Sataputi)
Dose: 125 mg to 250 mg with Honey, butter, milk, etc.
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Management
34
 "Prevention is better than cure" is the pillar of success in
arsenicosis mitigation.
 It includes
– Cessation of exposure to arsenic
– Administration of drugs and nutrients
– Supportive care
– Prevention of latent effects
– Counseling and education
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Cessation of exposure to
arsenic
35
– Make effort to stop drinking arsenic contaminated water or
exposure to arsenic from any other sources.
– Various options of safe drinking water like Deep tube well,
Rain water harvesting, Filtration (pond sand filtration,
household filtration: Sonofilter),
– Dug well and Pipe water supply.
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Chelating agents
36
• Chelating agents are chemical compounds that react with
metal ions to form a stable water-soluble complex.
• They are also known as chelants, chelators, or sequestering
agents.
• Chelating agents have a ring-like center which forms at least
two bonds with the metal ion allowing it to be excreted.
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Doses and Schedules for some common
drugs use in Arsenic
poisoning
37
 Dimercaprol (BAL in oil) (British antilewisite): Adult
dose:2.5-3 mg/kg 4 hourly for 2 days, then 6 hourly for 1 day
followed by bid for 10 days for arsenic levels over 50.
 DMSA (Dimercaptosuccinic acid):10 mg/kg PO 8 hourly
for 7 days followed by 10 mg/kg 12 hourly for 14 days and
repeat course 3 weeks later.
 Penicillamine: Adult dose: 25 mg/kg PO 6 hourly to
maximum 1 g/d.
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Antioxidants, vitamins and
minerals
38
 VitaminA: 50,000 I U every alternate day for 6 months.
 Vitamin E: 200mg daily for 6 months.
 Vitamin C: 500 mg daily for 6 months.
 Folic acid: 1 to 2 (500 to 1000 mcg) capsules daily for
prolonged period.
 Spirulina: 10 gm daily for 4 months.
 Selenium: 200μg/day for prolonged period.
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Supportive and symptomatic
treatment
39
 Keratolytic agents: salicylic acid in ointment base or in
Vaseline.
 Cryosurgery can be done to remove keratosis.
 Associated fungal infection should be treated with topical and
oral anti-fungal agents.
 Surgical excision can be employed in some cases.
 Retinoid may be applied topically and systemically to reduce
keratosis and to prevent malignancy.
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Prevention of latent effects and
counseling
40
 Create public awareness about health effects of arsenic toxicity
 Avoid drinking arsenic contaminated water.
 Avoid excess sunlight exposure and smoking.
 Avoid occupational exposure to arsenic.
 Avoid risk factors for cardiovascular, neurological, nephrological and
other systemic disorders etc.
 Avoid social prejudices of the disease.
 Periodic examination for early detection and management of cutaneous
malignancies.
 Steps to promote health and nutrition
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Cause of death
41
 Causes
–
Anuria
–
Uraemia
–
Convulsion
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Post mortem findings
42
 It finds
–
Severe anaemia in dead body attended immediately
–
Jaundice with fatty degeneration and focal necrosis of liver
tissue
Normal
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Steatosis
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Post mortem findings
43
 It finds
–
Kidney show tubular degeneration
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Post mortem findings
44
 It finds
–
Bronzed pigmentation of the skin
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Medico-legal aspects
45
–
Accidental poisoning occurs from industrial sources
–
Fatal exposure has been reported from inhalation of the gas
produced inside the container of the stored sea fish scrap
(Skin)
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46
WHITE ARSENIC OXIDE
ARSENIOUS OXIDE
ARSENIC TRIOXIDE (As2O3 )
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Physical properties
47
• It is available in amorphous powder or porcelain like mass.
• White arsenic is odourless and tasteless.
• It is only sparingly soluble in water.
• Though the powder is 3 ½ times heavier than water, it floats
on the surface of water.
• It is more soluble in hot water than cold water.
• Some have describes it as metalic taste.
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ABSORPTION, DISTRIBUTION
AND EXCRETION
48
• All toxic compounds of arsenic including white arsenic are
absorbed through the mucus membrane of the G.I. tract.
• Gaseous arsine and arsenical dust are absorbed through the
lungs.
• In acute intoxication, arsenic is deposited in liver, kidneys,
bones, hairs and nails, and then starts diminishing.
• However
traces remain for a long period which is
responsible for sustained toxic action
•
In bones, it is mostly from arsphenamine.
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EXCRETION
49
• Urine
• Hair
• Nails
• Due to low amount of consumption of arsenic through food
contaminated by agricultural insecticides and due to natural
content of arsenic in some food, human urine, hair and nails
may contain some amount of arsenic e.g. 10 ug%, 50 ug%
and 8 ug%, respectively.
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FATAL DOSE AND PERIOD
50
Fatal dose:
100 to 200 mg for an average adult
• Though much less dose has caused death and recovery on
the other hand has occurred after consumption of a very high
dose.
Fatal period:
• In very high dose, death may occurs within half an hour.
• Usual fatal dose, death may occur within 24 hours.
• However, it usually takes 3-7 days for death to come
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51
ACUTE POISONING
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Signs and Symptoms
52
With high dose
– Abdominal pain
– Vomiting and diarrhea followed by collapse and rapid death.
With average fatal dose, symptoms start after about ½
hours with the feeling of
– metallic taste
– Dryness and burning sensation in mouth and throat.
– Deglutination
– Severe abdominal pain and vomiting followed by severe
diarrhoea with tenesmus and rice water type stool.
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Signs and Symptoms
53
• Vomitus and stool may contain tinge of blood.
• Abdomen is tender
• Dehydration resulting low BP
• Oliguria
• Exhaustation
• Albuminaria
• Pain in limbs
• Muscular weakness
• Sign of collapse with cold extremities
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Myocardial depression
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Signs and Symptoms
54
• Development of white streaks at
the growing part of the nails
(Mee’s lines)
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LABORATORY INVESTIGATIONS
55
• In living being
– Urine
– Stool
– Blood
– Hair
– Nail
• From dead bodies
– Bone
– Liver
– Kidneys
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LABORATORY INVESTIGATIONS
56
• Urine: Excretion of 100ug or more/day is indicative of
poisoning. Positive within 6 hours of poisoning and
continues to be positive for about 2 weeks. Urine
coproporphyline test is also positive.
• Stool: within some hours of poisoning, stool examination
shows presence of arsenic and blood.
• Blood: Premature RBC & WBC in peripheral circulation
• Hair: More than 75 ug/dl is suggestive of poisoning.
• Nail: More than 100 ug/dl of arsenic in nail is suggestive of
poisoning.
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LABORATORY INVESTIGATIONS
57
In case of dead bodies
– Bone: Arsenic remains present for a long time.
– Liver and Kidneys: Show presence of arsenic
• In case of death, Histopathologic examination
–
Myocardium shows round cell infiltration.
– Cloudy swelling of liver and kidney.
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TREATMENT
58
1.
Stomach wash with Luke warm water.
2. Emesis
3. If possible, substituted by stomach wash with freshly
prepared ferric oxide (45ml of ferric chloride soln. with 15
gm of magnesium oxide).
4. 15 gm of ferric oxide is used with a glass full of water to
wash the stomach.
5. It should not be left in stomach for long.
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TREATMENT
59
1.
Lewisite (C2H2AsCl3) is an organoarsenic compound. It was once
manufactured in the U.S., Japan, Germany and the Soviet Union
for use as a chemical weapon, acting as a vesicant and lung
irritant.
2.
Anti-dote is B.A.L. (British Anti-lewisite) or Dimercaprol (3
mg/kg body weight in a 10% solution of 20% benzyl benzoate in
refined peanut oil, given deep intramuscularly 4 hourly for first
two days and then twice daily for 7 days.
3.
Purgative (Magnesium sulphate; 5-10 gm in 250 ml water) for
unabsorbed poison from intestine
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TREATMENT
60
1.
Electrolytes in Ringer’s solution, IV
2.
Protection of liver providing carbohydrate, vitamins, proteins
and amino acids
3.
Adequate rest for some days
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Cause of Death
61
1.
Dehydration with circulatory collapse
2.
Potassium and other electrolyte loss
3.
Hepatic failure
4.
Toxic encephalopathy
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62
CHRONIC ARSENIC
POISONING
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Introduction
63
•
Chronic arsenic poisoning may occur in industrial or
agricultural exposures, due to use of contaminated food or
drink for examples Sea food, subsoil water in some area.
•
Prolonged use of an arsenical preparation as medicines.
•
Chronic signs may also be apparent after some time of
recovery from an acute poisoning episode.
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Signs and symptoms
64
Non-specific symptoms are
–
Easy fatiguability
–
Malaise
–
Lack of interest and concentration
–
Pain in joints
–
Constipation or loose motion
–
Loss of weight
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Signs and symptoms
65
Specific symptoms are
•
Muscular weakness
•
Changes in keratin tissue
•
Abnormal pigmentation of skin
–
Initially brownish pigmentation (Milk rose complexion) of
skin around the neck, shoulders and temples.
–
Virtually all around the body
•
Dark brown of the skin of of the palms and soles with
thickening
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Signs and symptoms
66
•
No mucus membrane pigmentation (Contrary to addison’s
disease).
•
Hyperkeratosis (Palms and soles)
•
Occasionally leads to epithelioma
•
Ulceration of nasal mucosa
•
Alopecia
•
Liver damage with damage and pruritus
•
Damage of the kidneys may give clinical features of
Albuminuria.
•
Neurogenic (Cramping pain, weakness and muscle wasting).
•
Bone marrow aplasia
•
Mee’s line
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Laboratory Investigations
67
•
Should be done during acute poisoning
•
In chronic poisoning
–
24 hours urine collection after a diagnostic dose of BAL
–
Quantitative estimation is not possible because of irregular
excretion of arsenic.
–
Examination of hair, nails
–
In case of death, bone
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Treatment
68
•
The source of poisoning should be identified and further
exposure should be avoided.
•
British Anti-lewisite (BAL) or Pencillamine (Cuprimine;
100 mg/kg/day PO divided q6hr x5 days, Endpoint 24
hours urinary arsenic <50 mcg/L) should be administered
in the recommended dose.
•
Supportive treatment for protection of liver, kidneys and
neurogenic functions
•
Nutrients like vitamins, minerals adequate in food.
•
Epithelioma needs special attention.
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Postmortem findings
69
•
Acute poisoning; emaciation
•
Early Rigor mortis (before 2 hours)
•
Decomposition sets in late (Antibacterial action of arsenic
and dehydration)
•
Stain of blood (tinged vomitus and faeces matter on the
body and clothes)
•
Mucus membrane may be irritated.
•
Oesophageal mucus membrane is inflamed.
•
Stomach wall is swollen and soft, inner surface inflamed,
haemorrhagic and ulcerted.
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Postmortem findings
70
•
Stomach contains blood, mucus shreds and thick mucus
often mixed with arsenic powder.
•
Intestinal mucosa shows inflammation, swelling with
occasional haemorrhagic points
•
Lung are congested and oedematous
•
Liver and kidneys may show degenerative changes.
•
Bone marrow aplasia
•
Mees line in nails.
•
Yellowish discoloration occurs in stomach and surrounding
tissues as it forms arsenic sulphide (from H2S)
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Postmortem findings
71
Externally in chronic cases,
–
Emaciation
–
Pigmentation
–
Keratosis or epithelioma
–
Alopecia
–
Mees line
–
Wasting of muscle
–
Jaundice
–
Ulceration
–
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Postmortem findings
72
Internally in chronic cases,
–
Degenerative changes in Liver, Kidneys, and muscles.
Dead body recovered from graves;
–
Soluble arsenic salts in the body.
–
Insoluble arsenic salts in the soil.
–
In case of high concentration, soluble arsenic salt percolates in
soil.
–
In case of high concentration in soil, insoluble arsenic salt
percolates in the body.
–
Decomposed death body, soluble arsenic salts found more than
the sides an upper of the graves
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Medico legal aspects
73
•
Homicidal
•
Suicidal
•
Accidental
•
Criminal abortion (Abortifacient agent)
•
Improve complexion
(Dark to milk rose complexion)
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Cause of Death
74
•
Damage of liver, kidneys
•
Toxic encephalopathy
•
Intercurrent infections
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Difference between Acute arsenic poisoning
and Cholera/Gastro-enteritis
SN
Points
75
Arsenic poisoning
Cholera/Gastro-enteritis
1.
Vomiting and
purging
Purging follow vomiting
Vomiting follow purging
2.
Vomitus
Contains mucus and blood
No such thing
3.
Stool
Like rice water, may contains
blood
Like rice water; does not
contain blood, passed in jet
4.
Burning pain in
throat
Present
Absent
5.
Tenesmus and
burning pain at
anus
Present, related with motion
Absent
6.
Motive
circumstances
Homicidal, rarely accidental
No such thing
7.
Epidemiology
Restricted to an individual or a
family or a group sharing same
food
Sporadic or endemic
8.
Lab investigation
Detects arsenic
Vibrio cholerae (Culture)
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76
LEAD POISONING
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Introduction
77
•
It is blackish, shining on cut edges, odourless metal
•
Lead is not an essential constituent of our body.
•
However it is always present in our body due to various
factors like its extensive use and easy absorption in the
body in various forms.
•
Contrary to many other pure metals, pure metallic lead is
absorbed through the GI tract, being soluble in the gastric
juice.
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Contd…
•
Atomic number 82
•
Atomic weight = 207.22
•
Sp. Gravity = 11.3
•
Melting point = 326 °C
•
Boiling point = 1525 °C
•
Sanskrit name Naga
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78
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Compounds
•
Galena (Pb sulphide)
•
Cerrusite (PbCO3)
•
Anglesite (PbSO4)
•
Matlockite (PbClF)
•
Litharge (PbO)
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79
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Impured Lead (In Ayurveda)
80
•
Poliguria
•
Jaundice
•
Emaciation
•
Skin diseases
•
Leucoderma
•
Joints pain
•
Paralysis
•
Muscular weakness in limbs
Heavy metals poisoning
14-Feb-21
Detoxification
•
81
Melted lead is drown in Nirgundi (Vitex negundo) bark
juice for 7 times
•
Lime water for 7 times
•
Cow urine, Cow ghee, Honey for 3-7 times
Heavy metals poisoning
14-Feb-21
Compounds drugs
82
•
Jwaradi rasa
•
Tribanga
•
Rasa manikya
•
Yogeshwor rasa
Heavy metals poisoning
14-Feb-21
Classification
83
A. Ayurvedic view
–
Sthavara (Khanija) visha
–
Dhatu visha (Susruta)
–
Putiloha (Rasashastra)
B. Modern science
–
Inorganic irritant
–
Metallic poison
Heavy metals poisoning
14-Feb-21
Common uses
84
Lead has extensive uses in
–
Industries
–
Agricultural
–
Commerce and
–
Domestic purposes
–
It was used in water pipes
–
It is used in tin food container, batteries, paints, hair dyes,
cosmetics (vermilion), petrol, glass blowing, surface of
ceramic articles.
Heavy metals poisoning
14-Feb-21
Absorption, Distribution and
Excretion
85
•
Most of the lead compounds are soluble in gastric juice
and are thus absorbed through G.I. tract.
•
Lead dust and fume are well absorbed through the
respiratory tract.
•
Lead tetraoxide (Vermilion), some other dyes, and
cosmetics and tetra-ethyl lead are absorbed through the
skin.
•
Lead acetate is soluble in water and is easly absorbed
when swallowed, though it is more injurious locally.
Heavy metals poisoning
14-Feb-21
Distribution
86
•
Lead is a cumulative poison.
•
Its rate of excretion being less than absorption.
•
In chronic exposure, it deposits in tissues, mostly in
bones, and also in liver and kidneys.
•
If death does not occur after a large dose, then a good part
of the absorbed lead is deposited in these tissues.
Heavy metals poisoning
14-Feb-21
Excretion
87
•
It is mostly excreted through urine, though the rate of
excretion is very low.
•
It is also slightly excreted through bile.
•
To a small extent it is also excreted through nails.
Heavy metals poisoning
14-Feb-21
88
ACUTE POISONING
Heavy metals poisoning
14-Feb-21
Fatal dose 89and period
•
Fatal dose:
20 gm of lead acetate
30 gm of lead carbonate
•
Fatal period:
In severe cases death may occur
within 24 hours
•
Ordinarily fatal period may extend to 2-3 days.
Heavy metals poisoning
14-Feb-21
Signs and Symptoms
90
•
An astringent metallic taste in mouth and a burning pain in
the throat comes quickly in case of ingestion of lead acetate.
•
In any case, there are abdominal pain and vomiting
•
The vomitus containing curdy white lead chloride.
•
There are cramps in the abdomen
•
Loose motion
•
Stool is dark due to lead sulphide
•
It causes thirst, dehydration
•
Sign of collapse
•
Death due to Circulatory failure
Heavy metals poisoning
14-Feb-21
Treatment
91
•
In acute cases,
–
Treatment consists of removal of unabsorbed poison from
G.I. tract.
–
Removal of absorbed poison and symptomatic treatment.
–
To remove lead from stomach, emesis may be tried first,
followed by washing of the stomach with magnesium or
sodium sulphate.
–
These form highly insoluble lead sulphate preventing its
absorption.
–
For removal from GI tract, Magnesium or Sodium sulphate
is given in purgative dose form.
Heavy metals poisoning
14-Feb-21
Contd…
92
•
Calcium gluconate (2 gm IV relieves abdominal colic and also
helps deposition of some lead in bones and combat the acute crisis.
•
Atropine may be necessary in case of acute abdominal colic.
•
Cal. Bisodium EDTA (Ethylenediaminetetraacetic acid) is
given by slow IV infusion in a dose of 10-15 mg/kg body weight,
twice in the first day.
•
If the therapy is tolerated well then, it is repeated in the same dose
for the next four days
•
If necessary, the same regimen may be followed after a gap of five
days.
•
Peritoneal dialysis is also recommended in renal failure
Heavy metals poisoning
14-Feb-21
Contd…
93
•
Patients sensitive to EDTA, BAL can be used.
•
BAL can excrete circulatory lead but not lead deposited on
bones.
•
In some cases both are preferred combined therapy of
EDTA and BAL
•
EDTA is not very effective if given subcutaneously or
intramuscularly.
•
Penicillamine is in a way better than EDTA in the sense that
is less toxic.
•
It is given in usual doses.
Heavy metals poisoning
14-Feb-21
Postmortem findings
94
Externally
–
Body emaciated
–
Rigor motis occurs early.
Internally
–
GI tract irritation
–
Stomach wall is swollen
–
Mucus membrane is extremely congested, often greyish in
colour.
–
Presence of curdy whitish lead chloride.
–
The length of the intestine is inflammed.
Heavy metals poisoning
14-Feb-21
95
CHRONIC LEAD POISONING
Heavy metals poisoning
14-Feb-21
Introduction
96
•
Lead is a cumulative poison and as exposure to lead is
rather inevitable, particularly in the urban, semi-urban and
industrial areas.
•
Some amount of lead is being constantly absorbed and
remains accumulated in the body.
•
When the level of the accumulated lead exceeds the
threshold level, features of chronic lead poisoning appear.
•
As a matter of fact, incidents of chronic lead poisoning is far
more than the incidents of acute poisoning.
Heavy metals poisoning
14-Feb-21
Source of chronic lead poisoning
•
97
Industrial environment due to inhalation of lead
dust or lead vapour arising from;
–
Burning paints
–
Battery
–
Glass blowing
–
Polishing
–
Enamel factories
– Tetra ethyl lead in gasoline's
–
Cosmetics
– Smouldering
–
Dye
–
Colour factories
–
Drinking
water
supplied
through leaded pipe
Heavy metals poisoning
– Food preserved in food continer
– Insecticides
– Prolonged use of vermilion
14-Feb-21
Historical aspects
98
•
Lead water pipes and food containers (Bowls, etc) were
popularly used as elites of the ancient Roman Empire.
•
It is one of the cause of disintegration and destruction of the
Roman culture.
•
Members of the upper class of Roman society suffered from
various physical and mental disabilities and their women in
addition suffered from sterility due to chronic lead toxicity.
Heavy metals poisoning
14-Feb-21
Signs and Symptoms
99
•
Facial pallor: It is earliest signs of lead poisoning
•
Anaemia:
1.
Lead impaires synthesis of haeme from porphyrin and
porphyrin from delta-amino levulinic acid.
2. Increased fragibility of RBCs
•
Retinal stippling: Greyish glistering lead particles in
retina.
•
Burtonian line: Bluish discolouration of gingival line
•
Colicky pain: Generalised spasmodic pain in abd.
Heavy metals poisoning
14-Feb-21
Contd…
100
•
Constipation: It is common feature and usually precedes
colic.
•
Lead palsy: It occurs due to degeneration of nerve and
atrophy of muscles which may be result of interference with
the phosphocreatine metabolism at the muscular level. It
starts with numbness, hyperesthesia, fibrillation, tremor, and
cramps in the muscles. Ultimately there may be wrist drop and
foot drop due to paralysis of extensor muscles of wrist and
of anterior tibial muscles respectively. There may be
paralysis of deltoid, biceps, occular muscles and
intrinsic muscles of the fingers and toes.
Heavy metals poisoning
14-Feb-21
Contd…
101
•
Lead palsy
Heavy metals poisoning
14-Feb-21
Contd…
102
•
Lead encephalopathy: Frequently encountered in children.
•
Due to inactivation of monoamine oxidase by combining of
lead with the Sulfhydryl (SH) radical of the enzymes.
•
Change in personality
•
Restlessness
•
Fatiguability
•
Mental dullness
•
Convulsion
•
Delirium
•
Coma
Heavy metals poisoning
14-Feb-21
Contd…
103
•
Optic atrophy: Blindness due to optic nerve atrophy
•
Lead osteopathy: Calcium and Vit. D promotes lead
deposition on bones. It causes abnormal bone development.
•
Reproductive system: Sterility of both male and female.
Birth of physically and mentally handicapped child is
possible. Menstrual irregularities, abortion in female. Loss
of libido in male.
•
Circulatory
arteriosclerosis,
cardiopathy.
Heavy metals poisoning
system:
Arterial
hypertension
degeneration
and
such
hypertensive
14-Feb-21
Contd…
104
•
Kidneys: Chronic interstitial nephritis
•
Liver: Acute or chronic degeneration
•
Peripheral nerves:
–
Anterior horn cells degeneration and demyelination leading
to peripheral neuritis.
–
Meningo-encephalitis
•
Hair: Alopecia
Heavy metals poisoning
14-Feb-21
Lab investigations
105
•
Blood: < 50 ug/dl
•
Urine: < 250 ug/L
•
Stool: < 0.5 mg/dl
•
X-ray examination: X-ray of ends of long bones will show
higher density beyond the epiphysis.
Heavy metals poisoning
14-Feb-21
Treatment
106
Prophylaxis:
–
Precautionary steps to prevent toxicity in the workers of the
industries.
–
Inhalation of lead dust may be prevented by moistening of
machineries.
–
Proper ventillation and use of masks.
–
Regular medical check up of workers.
–
Change the place of work regularly.
Heavy metals poisoning
14-Feb-21
CONTD…
107
–
All the sources of lead should be prevented
–
Avoidance of toys and lead pencils
Heavy metals poisoning
14-Feb-21
CURATIVE
108
–
Cal bisodium EDTA (30-40 mg/kg body weight, given one
hourly infusion, twice a day for 5 days and repeated after a
gap of 3-5 days for a similar courses.
–
Pencillamine (500 mg 4 times a day given in place of
EDTA).
–
Dimercaprol is useful for excretion of lead from circulation
but cannot from de-lead the bones and other tissue.
–
Sod. Iodide or Pot. Iodide; 1-2 gm thrice helps to
remove lead from bones.
Heavy metals poisoning
14-Feb-21
CURATIVE
109
–
Sodium or potassium citrate helps excretion of the lead in
circulation.
–
For severe colic, 0.5-1 mg of atropine slphate and/or hot
compression on the abdomen is helpful.
–
Ma. Sulphate as purgative
–
Surgical decompression of the skull in lead encephalopathy in
children.
–
Sod. or pot. bicarbonate should be preferred, calcium diet and
vit.D should be restricted.
Heavy metals poisoning
14-Feb-21
Contd…
110
–
In chronic lead poisoning, Calcium gluconate, lactate or
milk intake for a few days helps to shift lead from blood to
bones.
Heavy metals poisoning
14-Feb-21
Death
111
–
Encephalopathy
–
Liver/kidneys damage
–
Circulatory failure
–
Inter-current infection
Heavy metals poisoning
14-Feb-21
Post mortem findings
112
Externally
–
Emaciated body
–
Blue lining in gum
–
Internally
–
Kidneys: Interstitial nephritis
–
Degenerative changes in tissues and organs
–
Blood vessels: Arteriosclerotic changes
–
Bone marrow: Decrease in fats,
and increase in erythroblasts and leucoblasts
Heavy metals poisoning
14-Feb-21
Heavy metals poisoning
113
14-Feb-21
Post mortem findings
114
Internally
–
Muscles: Fibrotic myositis
–
Testis: Degeneration of germinal epithelium
–
Stomach & Intestine: Ulceration and hemorrhagic
changes
–
Anterior horn cells: Demyelination and degeneration,
and meningo-encephalitis
Heavy metals poisoning
14-Feb-21
Medico-legals aspects
115
•
Acute poisoning with lead is uncommon.
•
The victims are usually children who chew substances
painted with lead paints.
•
Chronic poisoning is very common.
•
Accidental
•
Homicidal
•
Suicidal
•
Cattle poisoning
•
Criminal abortion
Heavy metals poisoning
14-Feb-21
116
MERCURY POISONING
Heavy metals poisoning
14-Feb-21
PARADA IN AYURVEDA
117
•
Atomic number 80
•
Atomic weight = 200.6
•
Sp. Gravity = 13.56
•
Freezing = 36 °C
•
Boiling point = 357.25 °C
•
Sanskrit name = Rasa, Rasendra (Best among rasa and uparasa),
Suta (Rejuvenating agent)
•
English Quick silver
Heavy metals poisoning
14-Feb-21
CLASSIFICATION
118
A. Ayurvedic view
–
Sthavara (Khanija) visha
–
Dhatu visha (Susruta)
B. Modern science
–
Inorganic irritant
–
Metallic poison
Heavy metals poisoning
14-Feb-21
Compounds
119
• /;k'ik, Mercuric chloride (HgCl2)
• /;sk"{/ Mercurious chloride (Hg2Cl2)
•
Mercuric cyanide Hg(CN)2
•
Mercuric oxide (HgO)
•
Mercuric sulphide (HgS2)
Heavy metals poisoning
14-Feb-21
RESULT OF PURIFICATION
120
Impurities
Before Purification
(PPM)
After Purification
(PPM)
Iron
4.7800
2.5760
Copper
4.5840
2.6520
Zinc
1.2280
0.2800
Silver
0.304
0.044
Tin
3.7560
1.6090
Cadmium
2.0534
0.1330
Lead
2.3400
0.9036
Arsenic
2.6500
1.0146
Heavy metals poisoning
14-Feb-21
Types of impurities
121
1. Naisargika dosha
i.
Visha
ii.
BAhni
iii. Mala
2. Yogika dosha
i.
Naga
ii.
Banga
Heavy metals poisoning
3. Kanchuka dosha
i. ParpatI
ii. PAtanI
iii. BhedI
iv. DrAvI
v. MalakArI
vi. AndhakArI
vii. DhvankshI
14-Feb-21
KANCHUKA DOSHA
122
1. Bhedi (tearing)
2. Dravi (liquefying)
3. Malakad (causing impurities)
4. Dhvanksi (causing darkness of skin)
5. Patanakari (rupturing)
6. Parpatika (producing scales on skin)
7. Andhakari (causing blindness)
Heavy metals poisoning
14-Feb-21
EIGHT DOSHAS OF PARADA
123
1. Visha (Poison) causes death
2. Vahni (Unduly heaviness) causes Hotness (SantApa)
3. Mala (endogenius, exogenius waste like excretea) causes
Emesis, syncope
4. Chapalya (instability, fickle nature) causes sterility
5. Giri (Minerals) causes vesicles, blisters, etc.
6. Naga (Lead) causes wounds, ulcer, etc.
7. Banga (Tin) causes skin diseases
8. Asahyagni (intolerance to heat) causes passion, affection, etc.
Heavy metals poisoning
14-Feb-21
DETOXIFICATION
124
1.
General methods
2. Specific methods
Heavy metals poisoning
14-Feb-21
General methods
125
1.
Rub mercury with equal amount of lime and add water.
2. Filter it with double layered cloth.
3. Put in kharala along with peeled garlic (Equal amount)
and half rock salt (saindhava lavana)
4. Then rub upto blackening of paste, and then wash and
store.
Heavy metals poisoning
14-Feb-21
SPECIFIC PURIFICATION
126
1. Visha (Poison):
–
Rub Mercury with Triphala or Chitraka root powder for 3 to 6
hours.
2. Vahni/Giri (Undully heaviness):
–
Rub Mercury with Trikatu for 3 to 6 hours.
3. Mala (Indogenous or exogenous excreta)
–
Rub Mercury with Amlatasatvaka powder or Ghee kumari juice
for 3 to 6 hours
Heavy metals poisoning
14-Feb-21
CONTD…
127
4. Chapalya (instability, fickle nature):
–
Rub Mercury with Krishna Datura beej powder or Panchanga
for 3 to 6 hours.
5. NAga (Lead):
–
Rub Mercury with Soot (Grihadhum) and Brick powder,
Haridra powder and dust or minutely cut wool all together for 3
to 6 hours.
Heavy metals poisoning
14-Feb-21
CONTD…
128
6. Banga dosha (Tin):
–
Rub Mercury with Indrayana, Ankola and Haridra powder for 3
to 6 hours.
7. Agnidosha
–
Rub Mercury with Chitraka moola powder or Triphala powder
for 3 to 6 hours.
8. Asahyagni dosha (intolerance to heat):
–
Rub Mercury with Gokshura powder or paste for 3 to 6 hours.
Heavy metals poisoning
14-Feb-21
ASHTADASH SANSKAR
129
Parada is briefly used for two purposes;
1. Deha-vandha (Medicine, body rejuvenation) and
2. Loh-vandha
(Occult,
Alchemical
and
Spiritual
upliftment).
First eight are recommended for Deh-vandha (medicinal
purposes) while the remaining ten steps, which are obscure
and have occult overtones, are used only for purifying
mercury in such a way that it can transform vulgar metals
into gold (Loh-vandha).
Heavy metals poisoning
14-Feb-21
DEHA-VANDHA SANSKAR
130
The
first
eight
steps
to
preapre
Parada
for
Dehvandha (consumption as medicine, rasayana) comprise of:
1. Svedana (steam, or make Parada seat)
2. Mardana (rubbing or massaging Parada)
3. Murchana (swooning or making Parada faint)
4. Utthapana (upliftment or elevation of Parada; installing upward
direction into Parada)
5. Patana (sublimation of Parada, installing downward direction
into Parada)
6. Bodhana /Rodhana (awakening of Parada, educating Parada)
7. Niyamana (restraining or disciplining Parada to have control
over its movements)
8. Deepana (stimulation, energizing or potentiating Parada)
Heavy metals poisoning
14-Feb-21
LOHA-VADHA SANSKAR
131
The remaining 10 sanskaras (treatments) which are speciffically used
for Loh-vadha (alchemical , spiritual and occult purposes) are as
follows.
1. Grasa (swallowing)
2. Garbhadruti (internal liquefication)
3. Bahirdruti (external liquefication)
4. Charana (movement)
5. Jarana (amalgamation)
6. Ranjana (dyeing)
7. Sarana (pushing)
8. Kramana (leaping)
9. Vedha (trans mentation)
10. Sevana (application)
Heavy metals poisoning
14-Feb-21
COMPOUNDS DRUGS
132
1.
Rasa parpati
2. Rasasidura
3. Makardwaja
4. Rasakarpura
5. Mugdharasa
6. Tribhuvan kirti rasa
7. Arogyavardhani vati
8. Hema garbha
Heavy metals poisoning
14-Feb-21
INTRODUCTION
133
•
It is colourless but has a burning, metallic taste.
•
Mercuric chloride or corrosive sublimate is available as
colourless prismatic crystals or as crystalline powder.
•
Pure metallic mercury is a heavy, silvery, non-adhesive
liquid which is not absorbed as such through GI
tract, being insoluble in gastric juice.
•
Mercury is volatile at room temperature and the
vapour may be absorbed by way of inhalation.
•
Forceful rubbing of the metallic mercury may
result in mild degree absorption through the skin.
Heavy metals poisoning
14-Feb-21
SOURCES
134
•
Poisonous
compounds
of
mercury
and
their
sources
•
Consumption of living stocks, fed with seeds preserved with
mercurial compounds, have caused mass poisoning.
•
Many Mercury is methylated under sea water and certain
sea fish particularly sword fish is rich in methyl mercury,
prolonged excessive use of which may cause chronic
mercurial poisoning.
•
Mercuric chloride is soluble in gastric juice, is absorbed
through GI tract and is highly toxic.
Heavy metals poisoning
14-Feb-21
USES
135
Mercuric chloride is used in
–
Medicine
–
Laboratories
–
Preservative
–
Industries.
•
Mercuric cyanide is used in medicine and mercuric oxide and
mercuric sulphate are used in industries
•
Mercuric sulphide, used as vermilion, is not absorbed through the
skin and is as such non-poisonous.
•
Mercurous chloride or calomel is used as purgative as it is nontoxic for human consumption in therapeutic dose.
Heavy metals poisoning
14-Feb-21
Contd…
136
•
Many of the organic mercurial compounds are toxic for human
consumption.
•
Mercurial compounds are toxic for human consumption.
Mercurial diuretics (Mersalyl) may damage the kidneys. When
given I.V., mercurial diuretics may cause anaphylaxis in sensitive
persons.
•
Alkylmercuric compounds like phenyl mercuric acetate are used
for preservation of seeds as fungicidal agents and are toxic to
human beings.
Heavy metals poisoning
14-Feb-21
ABSORPTION, FATE AND
DISTRIBUTION
137
Absorption:
•
Mercuric chloride and some other mercurial salts being
soluble in the gastric juice are readily absorbed through the
GI tract.
Vapour of mercury and soluble mercury salts are also
well absorbed through
–
Respiratory tract,
–
Vagina (Douche) and
–
Urinary bladder (mercurial antiseptic washing agent)
Heavy metals poisoning
14-Feb-21
ABSORPTION
138
•
Microscopic particles of mercury and calomel (which is not
absorbed through GI tract) are absorbed through skin, via
sebaceous glands.
•
Skin ointment of mercury, when used for a long period, may
cause chronic poisoning.
Heavy metals poisoning
14-Feb-21
FATE AND DISTRIBUTION
139
•
After absorption, mercury gets deposited in all tissues of the
body, particularly in liver, kidneys, spleen and bones.
•
When
absorbed
by
way
of
inhalation,
maximum
concentration occurs in the brain tissue.
•
In the kidneys, it is found in the tubules, where it may stay
for upto 3 months but it is not deposited in the glomerulli.
Heavy metals poisoning
14-Feb-21
DISTRIBUTION
140
•
In toxic deaths, the concentration in liver may go as high as
1 mg per 100 gm, and the concentration in kidneys up to 2
mg per 100 gm.
•
With injection of mercurial diuretics it may contain 2 mg,
and 3mg per 100 gm of liver and kidneys respectively.
•
Organic mercurial compound passes placental
barrier very easily and the foetus may have more
concentration of methyl mercury than the mother.
Heavy metals poisoning
14-Feb-21
MECHANISM OF ACTION
141
Heavy metals poisoning
14-Feb-21
DEPOSITION
142
• End
part
of
the
proximal
convoluted tubules, loop of henle
and distal convulated tubules are
the sites of deposition in the
kidneys.
• Though
mercury
is
not
a
constituent of the body, it may be
found in trace quantity in tissues
(5 ug to 50 ug per 100 gm, more
in kidneys and less in liver).
Heavy metals poisoning
14-Feb-21
EXCRETION
143
•
Mercury is mainly excreted through the kidneys, liver (bile)
and large intestine, though other body secretions also may
show the presence of mercury in very trace amount.
Heavy metals poisoning
14-Feb-21
144
Acute poisoning
Heavy metals poisoning
14-Feb-21
FATAL DOSE AND PERIOD
145
Fatal dose: 0.5 gm to 4 gm of mercuric chloride is the normal
range of the fatal dose.
Fatal period: Death may occur usually between 12 hours to 7
days.
–
Chance of recovery is high after about 7 days.
–
With IV injection of mercurial diuretics anaphylaxis may
cause very rapid death.
Heavy metals poisoning
14-Feb-21
SIGNS AND SYMPTOMS
146
•
After swallowing, there are signs and symptoms of corrosion
and irritation with burning pain and metallic taste in the
mouth.
•
There are difficulty in deglutination and feeling of
constriction in the throat, pain and tenderness in the body
with vomiting.
•
The vomitus contains mucus and altered blood and shreds
of gastric mucosa.
•
The mucosa of the mouth, tongue and gum appears greyish
white and is necrosed.
Heavy metals poisoning
14-Feb-21
CONTD…
147
•
With development of renal damage there are oliguria,
albuminuria, and haematuria.
•
After a day, there will be blood stained loose stool with
presence of necrosed mucus shreds from the colon.
•
Renal damage leads to oedema.
•
Subsequently, more generalized symptoms start with loss of
appetite, headache, tremor, fatigue, ataxia, deafness,
scotoma, emotional instability, loss of memory.
•
Death may also occur due to depression of heart, hepatitis,
colitis and starvation.
Heavy metals poisoning
14-Feb-21
CONTD…
148
•
ATAXIA
abnormal
a
group
signs
of
and
symptoms.
•
Symptoms due to phenyl
mercuric acetate may be
restricted to CNS.
•
SCOTOMA a partial loss of
vision or blind spot in an
otherwise normal visual field
Heavy metals poisoning
14-Feb-21
DIFFERENTIAL DIAGNOSIS
149
 Heavy metal poisoning e.g. Lead, Arsenic, Copper
 Kawasaki disease (Mucocutaneous lymph node syndrome)
 Scarlet fever
Heavy metals poisoning
14-Feb-21
DIFFERENTIAL DIAGNOSIS
150
 Heavy metal poisoning e.g. Lead, Arsenic, Copper
 Kawasaki disease (Mucucutaneous lymph node syndrome)
 Scarlet fever
Heavy metals poisoning
14-Feb-21
AYRVEDIC TREATMENT
151
•
Decoction of Triphala for gargle
•
Mahagandhaka rasayana 500mg tab x twice a day
•
Parpatadharishta or Sarivadhyarishta 30 ml x BD
Heavy metals poisoning
14-Feb-21
TREATMENT
152
•
Proteinous substance like egg albumin, milk,
gelatin
should
be
given
along
with
other
demulcents so that, the protein will combine with
the mercury compound and the demulcent agents
will protect the wall of the stomach from the
corrosive action of mercuric chloride, if it has been
ingested.
Heavy metals poisoning
14-Feb-21
CONTD…
153
•
Then emetics should be given or stomach should be washed
out with tube.
•
Luke-warm sodium bicarbonate (2-4 tablets containig
625mg per tablet in 100 ml water) solution or ipecacuana
syrup (15 to 30ml or 1 to 2 tablespoonfuls, followed
immediately by 240 mL; one full glass in adult, and 15 ml or
1 tsf with 120 ml of water) may be chosen for emesis.
•
Na. citrate or bicarbonate, if given orally, may also be
helpful.
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Treatment
154
•
High colonic wash is recommended to free the colon from
the poison.
•
For absorbed part of the poison, BAL (100 mg/kg/day PO
divided q6hr x 5 days) or pencillamine (D-pencillamine or
N-acetyle-DL-pencillamine; 500 mg 4 times a day) in usual
doses may be given.
•
100 ml of 50% sodium sulphate solution may be given IV,
to help anuria.
•
Peritoneal or haemodialysis helps excretion of the
absorbed poison quite effectively, in acute cases of renal
failure.
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POST MORTEM FINDINGS
155
Externally
•
In cases of death due to acute poisoning, the body may look
emaciated due to loss of body fluid by way of vomiting and
purging.
•
In hypertensive persons, there may be inflammatory skin
lesions due to contact with mercuric chloride.
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CONTD…
156
Internally,
•
Mucus membrane of mouth, including tongue and gum and
that of esophagus appear necrotic.
•
The stomach is swollen with evidence of desquamation
(Peeling, exfoliation), haemorrhage and ulceration.
•
Necrosis of the mucus membrane of intestine with
ulceration at places are quite common.
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POST MORTEM FINDINGS
157
• Liver tissue shows central necrosis.
• There may be necrosis of the myocardium
• In chronic poisoning further changes are noticed.
• Kidneys
are swollen with lower nephrosis (Nephrotic
syndrome).
• Serum albumin decreases with change in albumin-globulin
ratio (A:G is 1.5 -2.5:1).
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158
Chronic poisoning
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SIGNS AND SYMPTOMS
159
•
There is a constant metallic taste in the mouth with signs of
gingivitis, glossitis, salivation, loosening of teeth with blue
line in the gum.
•
There are loss of weight, anaemia and lymphocytosis,
constipation or diarrhoea, increased urination, jaundice and
restricted field of vision with damage of the retina
(Scotoma).
•
Repeated local contact may cause dermatitis.
Heavy metals poisoning
14-Feb-21
CONTD…
•
160
Acrodynia occurs due to absorbed poison, with redness, swelling,
vesiculation and desquamation of palm, fingers, soles and toes.
•
a disease of infants and young children that is an allergic reaction
to mercury, is characterized by dusky pink discoloration of hands
and feet with local swelling and intense itching, and is
accompanied by insomnia, irritability, and sensitivity to light
called also erythredema, pink disease, Swift's disease.
Heavy metals poisoning
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CONTD…
161
•
Mercuriolentis may develop with deposition of mercury in
lens capsule.
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14-Feb-21
Contd…
162
• There is tremor of hands (Hatter’s shake) and tongue, exaggerated
reflex, unsteady gait which is more like that due to pyramidal tact
lesion.
• There may be mercurial erethism (Insomnia, anxiety, irritability,
fatiquability).
• There is also a personality change.
• In chronic poisoning the daily urinary excretion may be over 300 ug.
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163
• Chronic mercury poisoning may cause amyotropic lateral
sclerosis (ALS) like condition.
• ALS is a group of rare neurological diseases that mainly
involve the nerve cells (neurons) responsible for controlling
voluntary muscle movement.
• Motor neurons are nerve cells that extend from the brain to
the spinal cord and to muscles throughout the body.
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TREATMENT
164
•
In
chronic
poisoning
cases,
dimercaprol
(BAL)
or
pencillamine should be given.
•
General health should be restored and oral hygiene should
be maintained.
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14-Feb-21
CAUSES OF DEATH
165
•
Renal failure
•
Hepatitis
•
Colitis
•
Intercurrent infections
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POST MORTEM FINDINGS
166
•
Apart from gingivitis, glossitis, colitis, necrosis of liver and
kidney, certain specific changes occur in the tubules of the
kidney
•
The tubular cells degenerate, to start with, flattened cells
gradually changing to cuboidal.
•
A syncytial (Fusion of cells, and multinucleated conditions)
pattern develops in the cells.
•
There is calcification of the necrosed tubular cells.
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MEDICOLEGAL FINDINGS
167
•
Suicidal
•
Homocidal
•
Accidental (mercurial vapors)
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14-Feb-21
168
COPPER POISONING
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14-Feb-21
TAMRA IN AYURVEDA
169
•
Atomic number = 29
•
Atomic weight = 63.54
•
Sp. Gravity = 8.95 to 9
•
Melting point = 1084°C
•
Boiling point = 2310 °C
•
Sanskrit name = Nepaleeya, Mlecchha
•
English anme = Copper
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CLASSIFICATION
170
A. Ayurvedic view
–
Sthavara (Khanija) visha
–
Dhatu visha (Susruta)
B. Modern science
–
Inorganic irritant
–
Metallic poison
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14-Feb-21
COMPOUNDS
171
•
Copper glance or Chalcocite (Cu2H)
•
Svarnamakshika (Copper pyrrite or Chalco pyrrite
•
Melacite (Cu2CO3. Cu2(OH)2)
•
Azurite (2Cu2CO3. Cu2(OH)2)
•
Cuprite (Cu2O)
Heavy metals poisoning
14-Feb-21
EIGHT POISONOUS172EFFECT OF TAMRA
Eight Visha doshas (Poisonous effect) of Copper as
follow;
•
Bhrama (Delirium)
•
Murchha (Syncope)
•
VidAha (Burning sensation)
•
Sveda (Sweating)
•
Kleda (Wetness of body or moisture in the body)
•
Vanti (Emetic)
•
Aruchi (Anorexia)
•
ChitasantAapa (Uneasiness, discomfort)
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PURIFICATION/DETOXIFICATION
173
1.
Common purification (Sodhana)
2. Specific purification (Sodhana)
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COMMON PURIFICATION
(SODHANA)
174
–
Heated copper is dipped into oil, takra, Cowurine, ArnAla,
and Kulath decotion seven time in every one consecutively.
–
It purifies all the impurities in the metal.
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SPECIFIC PURIFICATION
(SODHANA)
175
1.
Paste rock salt with Citrus juice or latex of calotropis on
Copper, and then heat it to red hot and deep in Kanji
(Acetic acid) for 7 -8 times.
2. Paste rock salt with Citrus juice or latex of calotropis on
Copper, and then heat it to red hot and deep in Juice of
Vitex negundo for 7 -8 times.
3. Boil dust of copper in cow urine in Dolayantra for 3 hours.
Heavy metals poisoning
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INTRODUCTION
176
 Pure metallic copper is not poisonous.
 Copper is soluble in water or liquid with pH less than 5.5.
 Hence food with pH less than 5.5 stored in copper utensils
or cooked in copper vessels will cause poisoning.
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14-Feb-21
SOURCES
177
Copper and its chemical compounds are used in
– Industries,
– Commercial centers,
– Fungicide,
– Pesticides
– Household appliances
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COMMON TOXIC COMPOUNDS
178
 Copper subacetate (Verdegris)
 Copper sulphate (Blue vitriol)
 Copper chloride
 In fact, many compounds of copper, after ingestion, may
get dissolved in the gastric juice, forming copper chloride.
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FATAL DOSE AND PERIOD
179
• Fatal dose: Copper subacetate (15 gm)
Copper sulphate (30 gm)
• Fatal period: Usually more than a day, may be upto 10-12
days.
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NORMAL DOSE
180
 Rasaratnasamuchya = 4 Rati
 In practice = ½ to 1 Rati
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SIGNS AND SYMPTOMS
181
• There are nausea, vomiting with greenish blue vomitus
which turns deep blue if treated with ammonia, diarrhoea,
abdominal pain, urinary suppression, haematuria, jaundice
due to damage of the liver.
• Paralysis of limbs, increased fragibilty of the RBCs, shock
and respiratory distress due to haemolysis, anaemia with
increased leukocyte count, coma.
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CONTD…
182
• In chronic poisoning cases, there are GI tract disturbance,
unhealthy gum with blue lining, jaundice, muscular
weakness, paralysis of limbs.
• Hair contains copper.
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Heavy metals poisoning
183
14-Feb-21
BLUE LINE IN GUM
184
• Copper
Heavy metals poisoning
14-Feb-21
TREATMENT IN AYURVEDA
185
• Drink coriander leaves juice or decoction with Crystal sugar
for 3 days.
• Grind Munivrihi (Hygroryza aristata Nees) with crystal
sugar and drink.
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TREATMENT
186
• Stomach wash with 1% Potassium ferrocyanide solution (2
gm in 200 ml water)
• Castor oil 15 ml for purgative at day time.
• For absorbed part of the poison, BAL (100 mg/kg/day PO
divided q6hr x 5 days) or pencillamine (D-pencillamine or
N-acetyle-DL-pencillamine; 500 mg 4 times a day) in usual
doses may be given.
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14-Feb-21
POSTMORTEM FINDINGS
187
Externally
• There are not many external signs on the dead body in
acute poisoning cases.
• The mucus membrane of mouth and tongue may have
bluish or greenish blue tinge.
Internally
• Discoloration present in the mucus membrane of the
esophagus and stomach.
• Congestion in mucus membrane of the stomach.
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14-Feb-21
POSTMORTEM FINDINGS
188
Internally
• Congested stomach with desquamation and haemorrhagic
spots.
• Mild to moderate irritation in upper part of mucus
membrane of intestine.
• Degenerative changes in liver and proximal tubules of the
kidneys.
Heavy metals poisoning
14-Feb-21
POSTMORTEM FINDINGS
189
Chronic poisoning
Internally
• Muscular atrophy
• Unhealthy gum with bluish green lining
• Varying degree of degeneration in liver and kidneys.
• In inhalation of copper vapor, there is signs of chronic
pneumonitis.
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14-Feb-21
Medicolegals aspects
• Suicidal
190
• Accidental
• Chronic poisoning occurs in industries or laboratories and
from commercial sources.
• Chronic poisoning also occurs in industrial and domestic
environment due to constant use of copper utensil or
consumption of vegetables treated with copper sulphate
solution as preservatives or colouring agent.
• Homicidal
• Cattle poisoning
Heavy metals poisoning
14-Feb-21
ACCEPTABLE MAXIMUM LIMIT
191
Countries
Cd
Pb
As
Hg
Canada
0.3 ppm
10 ppm
5 ppm
0.2 ppm
EU
1 ppm
4 ppm
2 ppm
0.2 ppm
India
0.3 ppm
10 ppm
3 ppm
1 ppm
China
1 ppm
10 ppm
2 ppm
0.5 ppm
20 ppm
5 ppm
0.5 ppm
10 ppm
0.3 ppm
0.5 ppm
20 ppm
5 ppm
0.5 ppm
5 ppm
0.3 ppm
0.3 ppm
1 ppm
0.5 ppm
Singapore
Philippines
0.3 ppm
Tanzania
USA
Australia
Heavy metals poisoning
0.2 ppm
0.1 ppm
0.2 ppm
14-Feb-21