Introduction

Cases of poisoning may be treated in many places, e.g. at the scene of the accident, during transport, in a
hospital. The type of care that can be given will depend on whoever makes the initial contact with the patient and
in what circumstances. Certain members of the community, such as firemen, policemen, and teachers, may
frequently be the first to be faced with poisoning cases. In rural areas, nurses and primary health care workers,
and even agronomists and veterinarians, may have to deal with poisoned persons. They all need at least some
basic training in first aid as well as in decontamination and measures for their own protection. An IPCS
handbook on this first level of response to poisoning is in preparation.1

1
Management of poisoning. A handbook for health care workers. Geneva, World Health Organization (in
preparation).
General practitioners or family doctors are often the first medically qualified persons consulted. They must be
able to give appropriate initial treatment and may need to contact their local poison information centre. Most
patients with serious poisoning, if they survive, will sooner or later reach a hospital, ideally one with a wide
range of medical facilities, including intensive care. In some places, specialized treatment services have been
established offering the best possible conditions for the management of poisoning. These services also have the
advantage of ready access to a wide range of related medical facilities.
Most cases of poisoning, however, will be treated through a country's normal health service facilities, usually at
a general hospital, far from a poison information centre and without access to a specialized clinical toxicology
unit. According to patients' needs, treatment may be given by different services within the hospital, including the
following:
* Emergency services. In practice, emergency services receive a relatively high number of poisoning cases, as
they function on a round-the-clock basis and are provided with trained personnel and basic equipment for
decontamination and life-support measures.
* Intensive care units. Intensive care units are usually well provided with highly specialized personnel and
equipment for resuscitation, life-support measures, and care of critical poisoning cases.
* General medical units. Basic medical care of non-critical poisoning cases can be provided within general
medical units in which staff have received some training in, or information on, clinical toxicology and which are
in close contact with poison information centres.
* Specialized services. Specialized services offer the advantage of well trained medical staff and appropriate
equipment for the management of poisoning cases in which specific organs or physiological functions are
affected; they include nephrology, gastroenterology, neurology, cardiology, and haematology services.
* Paediatric departments. Poisoned children are frequently treated in paediatric departments.
To be able to treat poisoned patients, general hospitals need equipment for:
*gastrointestinal, cutaneous, and ocular decontamination (e.g. equipment for gastric lavage)
*immediate, and often longer-term, life-support measures (e.g. endotracheal intubation, assisted and controlled
ventilation, parenteral fluid therapy, pharmacological treatment, cardiac pacing, defibrillation)
*continuous cardiac and circulatory monitoring (through ECGs, blood pressure measurements, etc.) and
monitoring of other vital functions
*X-ray examinations
*initial and repeated general biomedical laboratory analyses (e.g. acid-base balance, blood gases, electrolytes,
blood glucose, liver and kidney function, and coagulation)
*initial and repeated specific toxicological analyses of body fluids such as blood, urine, and stomach contents
(the choice of analyses will vary according to local patterns of poisoning)
*haemodialysis, peritoneal dialysis, haemoperfusion
*administration of appropriate antidotes (some of which may be specific to local needs and all of which should
be stored in accordance with WHO recommendations1.
In an emergency, it is essential that the relevant medical personnel at general hospitals and other health service
facilities where poisoning cases are treated have rapid access to toxicological information and experience. Here,
the poison information centre plays a key role through its telephone advice service. Ideally, centres should
circulate information to general hospitals and other health service facilities on a regular basis. This information
should be adapted to suit local needs and should include general advice on the diagnosis and management of
poisoning cases commonly expected to be treated at the particular hospital or facility, as well as information on
new developments in patient management and on new types of poisoning.
The information flow should be a two-way process. General hospitals and health science facilities should be
encouraged to maintain close contact with national and regional poison information centres and to furnish these
centres with regular reports on cases of poisoning, particularly the more unusual ones. Such reporting helps to
maintain an up-to-date national database on poisoning and is important for toxicovigilance.

1
The International Pharmacopoeia, Third edition. Vol. 2, Quality specifications. Geneva, World Health
Organization, 1981.
The training of medical personnel in relevant aspects of toxicology for their work in managing poisoned patients
is another important task for the poison information centre. For this purpose, it is essential that the centre itself is
closely involved in the management of poisoning cases.
Some countries have found it valuable to have one or more specialized clinical toxicology units where the most
important cases of poisoning in a region are treated. In some cases an intensive care unit is associated with, or
forms part of, a clinical toxicology unit. The latter would normally be associated with a national or regional
poison information centre.
Clinical toxicology units
Roles and functions
While general clinical wards and various specialized services that treat both poison victims and other types of
patient are potential participants in poison control programmes, clinical toxicology units deal exclusively with
the management of poisoning. These independent specialized units may have three principal functions besides
patient management, namely toxicovigilance, education, and research. Locating a poison information service and
analytical facilities in the same department or building as a clinical toxicology unit is an advantage and may be
of benefit to patients. However, where there is no common location, highly reliable communications between the
unit, the information service, and the laboratory are essential in order to establish a partnership between them in
the diagnosis and management of poisoning.
Ideally, a specialized clinical toxicology unit should be part of national or regional medical facilities for the
management and treatment of poisoning. It provides for:
*optimal treatment of poisoned patients
*identification of the effects of chemicals and natural toxins on health
*evaluation of the cause-effect relationship in a case of poisoning
*assessment of new developments in clinical and analytical methods of diagnosis and in treatment
*development of specific therapeutic management
*appropriate follow-up and surveillance of cases for identification and assessment of sequelae, and
*study of the circumstances of the poisoning and predisposing factors (data can then be used for planning
preventive action).
Clinical toxicology units should record data on poisoning cases and toxicological consultations in a standardized
format, preferably compatible with that used by poison information centres. Full case data, including follow-up,
should be recorded.
Location and facilities
The minimum requirements for setting up a clinical unit for the treatment of acute poisoning are:1
*availability of methods, equipment, and areas for the resuscitation, decontamination, and initial management of
poisoning cases
*good communication links with a poison information centre
*well established protocols for the treatment of common cases of acute poisoning
*availability of antidotes for immediate use, in quantities appropriate to the frequency of the main forms of
poisoning (see Section 7)
*laboratory facilities for standard biological analyses and for toxicological screening (see Section 4)
*availability of emergency transport for patients
*an emergency plan for dealing with disasters and major chemical accidents.

1
See also Table 1.
There should be sufficient space for all levels of patient care, and for the activities of the staff on duty, including
administration, small conferences, education activities, and storage of clinical records.
Consideration should also be given to such practical matters as a comfortable rest area, personal hygiene
facilities, parking space, and the provision of food and beverages round the clock for duty staff.
-subheader_en
Staff
Initially, the staff may consist of emergency-room physicians to provide resuscitation and first aid, plus
paediatricians, anaesthetists, and intensive-care staff to look after severely poisoned patients. However, in
developing countries or in newly established clinical units, there may be a shortage of sufficiently well qualified
medical personnel, in which case medical officers or adequately trained paramedical personnel have an
important part to play in the initial evaluation, transfer, and referral of poisoning cases. They should be capable,
for example, of recognizing a case of, poisoning, of identifying the main toxic syndromes (e.g. anticholinergic,
cholinergic, opioid), and especially of recognizing situations that require the immediate application of life-saving
measures.
Ideally, therefore, the staff should consist of:
*The medical director of the clinical toxicology service, who should be qualified to:
-organize the care of poisoned patients, both directly and through case consultation
-implement, review, and update protocols for the evaluation and treatment of poisoning cases
-supervise staff performance
-promote toxicological research
-identify those programmes or agencies that might provide funding for research or the further development of
the service.
*Trained specialist(s) in clinical toxicology with practical experience and, ideally, with a professional
qualification.
*Physician(s) with competence in the care of critically ill patients.
*Psychiatrist(s).
*Advisers from other medical disciplines, e.g. pharmacology, and from non-medical areas of interest.
*Social workers.
*Supporting paramedical staff (e.g. nurses, medical officers).
*Administrative staff and record-keepers.
Training
While the need for clinical toxicology services is becoming increasingly obvious, the growing demand for
adequate, trained personnel is not being met. Physicians from countries with no appropriate facilities should be
sent for training in toxicology to established centres where poisoned patients are treated. The objective in each
case should be for the trainee to obtain experience of every aspect of the work of a centre, so as to be able to
initiate or develop poison control activities in his or her own country. It is important for trainees to know the
problems and special "risk profiles" associated with poisoning in their own countries before starting their
courses.
Physicians from developing countries where facilities for training in some aspects of clinical toxicology are
available could be trained in their own countries if appropriate programmes were organized, with visiting experts
invited to teach those subjects for which training facilities are lacking. Alternatively, trainees could be sent to
centres abroad to supplement or enlarge experience gained at home.
A training programme for clinical toxicologists should include education in the theoretical aspects of human
toxicology, preparation for a dissertation, and teaching activities. Trainees should also gain experience of work
in:
*a poison information centre (including training in preparing documents, collecting information, replying to
enquiries, recording case data, and follow-up of cases);
*a clinical toxicology unit, emergency department, or intensive care unit where poisoned patients are treated;
and
*a toxicological laboratory, where a practical understanding of sampling and analytical methods and of the
medical interpretation of the results of analyses is provided.
There should also be opportunities to attend or participate in seminars, courses, lectures, conferences, and
meetings within and outside the centre.
This training programme would be expected to take two years and should be undertaken preferably by
physicians with some experience in related disciplines and some knowledge of chemistry, biochemistry,
statistics, epidemiology, pharmacology, and information technology. It should cover all the main areas of
toxicology in general, while stressing those in which local cases or risks of poisoning are frequent or severe. The
basic contents of such a training programme are indicated in Table 2.
Although the basic professional training of clinical staff is supplemented by experience obtained in the course of
their work, the rapid development of toxicology makes continuing education and updating of knowledge a
professional and ethical responsibility. Means of achieving this include the reading of scientific literature,
participation in local, regional, and national seminars, meetings, and workshops, or attendance at training
courses of several days' or weeks' duration. The continued updating of expertise can be stimulated by, for
example, making participation in scientific meetings a condition of certification. In the USA, where professional
certification is controlled by the American Board of Medical Toxicology, the American Board of Veterinary
Toxicology, and the American Board of Toxicology, evidence of active interest in new developments is
necessary in order to maintain expert status in toxicology. This system not only encourages continuing education
but also contributes to career advancement by boosting professional status.
Nurses and paramedical personnel working in clinical units where cases of poisoning are treated should also be
given special training in toxicology. This is especially important in countries where qualified physicians are
scarce or are overwhelmed by crowded emergency rooms and outpatient consultations.
Nurses, paramedical personnel, and clinical officers will need a concise and more practical training course than
that given to physicians, perhaps based on the training programme on clinical toxicology outlined in Table 2. For
example, the principles of quick clinical diagnosis, first-aid measures, decontamination techniques, and
recognition of life-threatening symptoms are of primary importance. Other more theoretical aspects of
toxicology may be omitted altogether or considered only briefly.
Recommendations
Clinical toxicology is still not acknowledged as a separate medical discipline in most countries. Its full
acceptance as such by medical schools and the public health service is therefore desirable, and the importance of
active collaboration among scientists and professionals in this area has now been internationally recognized.
Every effort must be made to ensure that the relevant human resources are developed as quickly and effectively
as possible. Measures to harmonize approaches to clinical toxicology throughout the world and to coordinate the
work of international organizations and other international bodies in this area should be reinforced.
At the national level, the following measures should be taken to support and promote clinical toxicology:
*Clinical toxicology services should be established wherever the need for them is identified.
*The discipline of clinical toxicology should be given official recognition, as should the trained professionals
who may be already working in this field.
*Academic institutions should be encouraged to develop clinical toxicology as a discipline in its own right, e.g.
by establishing a department within a teaching hospital with an intensive care unit, outpatient clinic, laboratory
for toxicological analysis, etc. This would be a step towards the institution of an academic career structure for
clinical toxicologists.
Additional, internationally coordinated measures that would be useful in promoting clinical toxicology include
the establishment of:
*mechanisms for ensuring unimpeded communication and exchange information and experience
*collaborative research projects on clinical toxicology
*international collaboration in establishing protocols for the treatment of poisoned patients and for the
evaluation of antidotes
*international mechanisms for ensuring the adequate availability of antidotes and early warning of toxic hazards
*appropriate international educational programmes and exchanges.

What happens when a patient shows up at the emergency room

exhibiting signs and symptoms of poisoning? The attending physician
in the ER may not immediately know what type of toxin the patient
was exposed to. Exposure to toxic compounds — what we tend to call
poisoning — may be due to a variety of agents: pharmaceutical drugs,
illegal drugs, or even environmental toxins. Poisoning may occur for
many different reasons: intentional harm (suicide), deliberate misuse
(recreational drug abuse), accidental use (such as ingestions by small
children exploring their environment), or by a prescribed dose that
causes a toxic reaction.
[I]t is useful to know the established
guidelines for treatment that the doctor may
follow in order to arrive at the best possible
outcome.
Poison Control Centers estimate approximately two million exposures
to toxins per year; this may be an underestimate of actual exposures,
since not all are reported to officials. Some antidotes exist for certain
drugs, but if the patient's symptoms are not clear-cut, it is often
necessary, and quite possible, to treat the patient with basic supportive
care such as IV fluids or vasopressors. Given how relatively common
poisoning is, it is useful to know the established guidelines for
treatment that the doctor may follow in order to arrive at the best
possible outcome. Some of these are described below.

First Steps
Physicians generally evaluate the patient right off the bat for certain
basic body functions. Some assessments include the degree to which
airways are open or closed, the rate and depth of breathing, and
circulation (heart rate, blood pressure, etc.). If the patient appears to
have been exposed to a toxin externally (i.e., via the skin), then
measures are taken immediately to decontaminate the skin of the toxic
substance.

Looking for Clues

Once basic body functions have been deemed stable, the doctor may
be able to determine what class of toxin is responsible for the
poisoning. One method is to look at pupil size, which can be enlarged
in response to certain toxins, or constricted in response to others. Skin
texture — wet/moist skin vs. dry, flushed skin — can also be a signal
as to what type of toxic substance has been ingested. Patients who are
showing clear signs of altered mental status are given a test to
determine glucose level, since this is the brain's only nourishment. If
the glucose level is low, then doctors will give the patient an IV drip
of fluid containing dextrose, a sugar solution.

Electrocardiogams (ECG or EKG) are performed on all patients who

exhibit exposure to toxic compounds, as they may be good indicators
of the type of toxin involved. For example, a specific change in the
pattern of the ECG can indicate the presence of tricyclic
antidepressants. Doctors can then treat the patient accordingly and do
a repeat ECG to monitor the patient's progress and recovery.

Low Blood Pressure and Poisoning

While many people may be familiar with the risks of hypertension in
everyday life, hypotension "or low blood pressure" is a common
symptom in poisoned patients and can result from a variety of factors,
including dehydration or anaphylaxis (severe allergic reaction). In
cases of hypotension, doctors will begin a specific type of IV drip and
monitor the patient closely. If the patient does not respond to the IV, a
vasopressor "a compound that constricts the blood vessels to increase
blood pressure" should be administered. It is important for the
physician to keep in mind that the patient may be on prescription
antidepressants, which would determine what type of vasopressor is
administered.

Decontaminating the Digestive Tract

If the patient has overdosed orally, such as in the case of a medication
or drug abuse the doctor will need to evaluate and likely treat the
gastrointestinal (GI) tract specifically with one of three methods. The
theory goes that the less of the poisonous compound the patient is
exposed to, the better. In other words, the effect of the toxin increases
with the level of exposure, so it is almost always a good idea to
decrease the level of exposure to the GI tract, if possible. There are a
few ways for the medical team to do this: administering activated
charcoal, orogastric lavage (a.k.a., stomach pumping), and whole
bowel irrigation. There are risks and benefits to each method and
some controversy exists as to whether each method is useful in the
clinical setting.
The hope is that the poisonous substance will
be siphoned out of the GI system before it is
absorbed and causes further toxicity.
Pumping the Stomach
This method, also known as orogastric lavage, is not so common,
mainly because it is invasive and associated with a handful of
complications. These include aspiration (taking liquid into the lungs)
and esophageal perforation (tearing of the esophagus). The method
can, however, be used effectively if the patient has very recently
ingested a life-threatening substance. It is done by passing an
orogastric tube (via the mouth) into the stomach; liquid is then
administered to the patient's stomach in small quantities and sucked
back out through the tube. The hope is that the poisonous substance
will be siphoned out of the GI system before it is absorbed and causes
further toxicity. Studies have shown mixed results for the method's
effectiveness, but it is still used in specific situations.

Administering Activated Charcoal

This method is the most common used in treating poisoned patients.
The charcoal itself is prepared so that its surface area is at a
maximum, which increases the amount of toxin it can absorb. It is
usually given to the patient either by mouth or by nasogastric tube,
which is passed through the nose to reach the stomach. The success of
the process depends on the drug involved and the amount of charcoal
that is administered. Optimum absorption has been shown to occur
when charcoal is given within one hour of the patient's overdose.
However, it has been shown to work after one hour as well, and is
considered a fairly effective method of treating oral overdose.

Whole Bowel Irrigation

This is a straightforward, mechanical washout. A large volume of an
electrolyte solution is administered through the mouth at a rapid rate
until the rectal effluent is clear, in order to mechanically flush out any
toxic substances and therefore decrease absorption through the GI
tract. No controlled clinical studies have indicated a great benefit to
whole bowel irrigation, and there are some complications that can
evolve as a result of the treatment. But it is used under specific
circumstances, such as when the ingested substance is not absorbed
well by activated charcoal or in cases of intentionally ingested packets
of drugs (i.e., by people who are known as body-packers).

Though the three methods of gastrointestinal decontamination

mentioned above have sometimes not been shown to be of significant
benefit in clinical studies, it is important to realize just how difficult
studying these mechanisms is. For example, there are some animal
and human volunteer studies out there, but these usually involve very
small doses of a toxic substance — doses which may not reflect the
situation of the real-life poisoned patient. Furthermore, the actual
poisoned patient may ingest more than one toxic substance, each of
which might have a different method of action on the body. But each
of the three GI decontamination methods has specific benefits and ER
doctors will use each one under different circumstances, depending on
the specific situation of the patient he or she is treating at the moment.

What's the Toxic Substance? Testing for

Drugs in the System
Blood Serum Test
While many blood and urine tests for toxic substances can be costly
and time-consuming without a specific indication to request one, there
is one blood serum test that is routinely done after a patient comes in
for suicidal ingestion. This test is for acetaminophen, the active
ingredient in Tylenol®. Because the drug is so common in
households, many people do not even think of it as a potentially
harmful drug — and if it is not viewed as a potentially harmful drug, it
may not be reported to doctors as an ingested substance.
There are also some real limitations to urine
drug screens.
Approximately 1 in 500 patients who go to the ER for intentionally
ingesting toxic substances (in attempts to do self-harm) will also have
potentially toxic acetaminophen levels, even though they do not report
that acetaminophen has been ingested. This is difficult for doctors in
the ER because a patient can have toxic levels of acetaminophen in the
body while having no or non-specific symptoms. If treated early
enough, the prognosis is excellent. Doctors may also request blood
serum tests if he or she feels there is a likelihood that certain other
drugs are involved; these include salicylates (found in aspirin and
other pain medications), lithium (a mineral used to treat bipolar
disorder), and methanol.

Urine Screen
Unlike the blood serum test, which can directly measure the presence
of a specific substance in the body, the urine screen may not be a
terribly effective tool because results can only be interpreted as
positive or negative for a certain substance. Among the drugs included
in these screens are amphetamines, cannabinoids, cocaine, and
opioids. However, if positive results are found in this kind of drug
screen, they rarely change the management or outcome of a patient's
treatment.

There are also some real limitations to urine drug screens. For one
thing, they are not comprehensive, only testing for a small range of
certain chemicals, so negative screens don't exclude all possible drug
exposures. Also, positive screens can result long after symptoms from
the drug have passed. Therefore the presence of the drug in the urine
may not actually be responsible for the current condition. This
unfortunate effect is one that may often mislead doctors to attribute a
patient's symptoms to a specific drug, when actually a different (and
non-drug-related) diagnosis should be made. For example, a patient's
altered mental state might be attributed to a drug when in fact, it is
actually related to an underlying meningitis. However, drug screening
is still beneficial in cases of suspected malicious poisoning or to
confirm the presence of certain substances in suspected child abuse or
neglect.

Seizures
Some drugs may cause seizures. Since the stability of our bodies
depends on the balance of excitatory and inhibitory neurotransmitters,
if this delicate balance is upset by drug intake, then seizures can occur.
For example, drugs that either decrease the production of GABA (the
brain's most popular inhibitory neurotransmitter) or that interfere with
GABA's receptors in the brain can cause seizures. Additionally, if a
drug interferes with the neurotransmitter adenosine, which is a
naturally occurring anticonvulsant, then severe and protracted seizures
can occur. This can happen after very large ingestions of one of the
most popular legal drugs, caffeine. Whatever the cause of the seizure,
doctors usually treat seizures with a benzodiazepine, a common
anticonvulsant.

Hyperthermia
Hyperthermia is a fairly common result of a variety of drugs; it is
defined as the core body temperature being above 39°C or 102.2°F.
Some of the culprits include cocaine exposure and alcohol withdrawal,
as well as neuroleptic malignant syndrome and serotonin syndrome.

Neuroleptic malignant syndrome is potentially life-threating. It may

cause hyperthermia, along with altered mental status and motor
movement problems such as rigid muscles and tremors. The disorder
typically occurs in response to a sudden drop in the level of the
common neurotransmitter dopamine — this can happen either with the
addition of medications that block the dopamine receptor or in the
withdrawal of medications that mimic the actions of dopamine (which
are used in the treatment of Parkinson's disease).

Serotonin syndrome is another that may cause hyperthermia and

occurs when there is too much serotonin stimulating specific varieties
of serotonin receptors. This can happen in response to high levels of
common antidepressants in the body, like monoamine oxidase
inhibitors (MAOIs) or selective serotonin reuptake inhibitors (SSRIs),
cocaine, MDMA (ecstasy), or even some antibiotics. Like neuroleptic
malignant syndrome, there are multiple symptoms other than
hyperthermia that can occur (e.g., muscle rigidity, tremors, altered
mental status, to name a few), and it can therefore be tricky for the
physician to diagnose. However, clonus — involuntary muscle
contractions — is the primary means of identifying serotonin
syndrome.

Whatever the root of the drug-induced hyperthermia, doctors will

generally employ the same series of treatments: rapid cooling,
hydration through an IV drip, and removal of the drug from the
system. It may be necessary to sedate the patient in these cases,
because muscle rigidity and general agitation can prevent effective
cooling of the body temperature.

Conclusion
Clearly patients who have been exposed to toxic compounds can show
a variety of symptoms, depending on the type of drug involved and the
amount of drug taken in. There are some antidotes that exist for
certain drugs, but doctors always begin by adhering to some of the
basic treatment principles described in this article. Often doctors will
consult with their local Poison Control Centers, in order to make
absolutely sure that they are treating the patient in the most effective
way possible.

Poisoning both accidental and intentional is a significant contributor to mortality and morbidity
throughout the world. According to WHO, 3 million acute poisoning cases with 2, 20,000 deaths occur
annually, these 90% of fatal poisoning occur in developing countries particularly among agricultural
workers1 . Agriculture is backbone of India and about 70% of population who lives in villages occupation
is farming. In India suicidal, homicidalpoisoning are more common compared to Western countries due
to easily Review Article International Ayurvedic Medical Journal ISSN:2320 5091 The article deals with
the duties of registered medical practitioner (RMP) to make the profession efficient as well as legal. One
should have knowledge in offering immediate first aid i.e. having priority in life saving and thereafter the
procedural Criminal l order to avoid negligent death. The doctor attending the patient has to fulfill his
duties, first as a medical professional then as a medico legal hospitals has to notify cases of homicidal
poisoning to police and every case of poisoning has to be notified in case of government hospitals.
exhibits as evidence so that the analysis of material may be done which may be helpful investigating
officer for further perusal of the case. respect to every case of poisoning and death certificate should
not be issued unless post mortem has done to rule out the cause of death. Keywords: Duties, Poisoning,
Imprisonment, Preservation and IPC sections. DUTIES AND LAWS RELATED TO MEDICAL PRACTITIONERS
IN CASE OF POISONING: A PEER REVIEW Kulkarni Siddhanand S2 ., Pali Neeraj Kumar3 , Hingmire N. S
Dept. of AgadtantraAvumVidhiVaidyaka, YashwantAyu. College P.G.T & R. C, Kodoli, Kolhapur,
Maharshtra, India Dept. of RachanaSharir (Anatomy), YashwantAyu. College P.G.T. & R.C. Kodoli,
Kolhapur, Maharshtra, India Poisoning both accidental and intentional is a significant contributor to
mortality and morbidity throughout the world. According to WHO, 3 million acute poisoning cases with
2, 20,000 deaths occur annually, out of these 90% of fatal poisoning occur in eloping countries
particularly among Agriculture is backbone of India and about 70% of population who lives in villages,
their main farming. In India suicidal, homicidalpoisoning are more common when countries due to easily
availability of poisonous weak laws for governing on availability. commonest cause of poisoning in India
being agriculture based econom illiteracy, mental conditions availability of highly toxic pesticides
Accidental poisoning is also more common due to various animal bites mostly by snakes and scorpions
and greater use of chemicals and pesticides for agro industries and domestic purposes.In India, the
common poisons are insecticides1 , pesticides such as organo phosphorous1 , chlorinated hydro
carbons1 , Aluminum phosphate Review Article International Ayurvedic Medical Journal ISSN:2320 5091
ABSTRACT deals with the duties of registered medical practitioner (RMP) to make the profession
efficient as well as legal. One should have knowledge in offering immediate first aid i.e. having priority in
life saving and thereafter the procedural Criminal law should be allowed to operate in order to avoid
negligent death. The doctor attending the patient has to fulfill his duties, first as a then as a medico legal
professional. The attending doctor in private s of homicidal poisoning to police and every case of
poisoning has to be notified in case of government hospitals. Later preservation and collection so that
the analysis of material may be done which may be helpful investigating officer for further perusal of the
case. Detailed written records should be made with respect to every case of poisoning and death
certificate should not be issued unless post mortem has done to rule out the cause of death. , Poisoning,
Imprisonment, Preservation and IPC sections. DUTIES AND LAWS RELATED TO MEDICAL PRACTITIONERS
IN CASE OF Hingmire N. S4 Dept. of AgadtantraAvumVidhiVaidyaka, YashwantAyu. College P.G.T & R. C,
Kodoli, P.G.T. & R.C. Kodoli, Kolhapur, substances and governing on availability. The commonest cause
of poisoning in India being agriculture based economy, poverty, illiteracy, mental conditions and easily
oxic pesticides1 . also more common due to various animal bites mostly by snakes and greater use of
chemicals and pesticides for agro industries and In India, the common pesticides such as , chlorinated
hydro , Aluminum phosphate1 , snake bites Review Article International Ayurvedic Medical Journal
ISSN:2320 5091 deals with the duties of registered medical practitioner (RMP) to make the profession
efficient as well as legal. One should have knowledge in offering immediate first aid i.e. having aw
should be allowed to operate in order to avoid negligent death. The doctor attending the patient has to
fulfill his duties, first as a The attending doctor in private s of homicidal poisoning to police and every
case of poisoning has to and collection of biological so that the analysis of material may be done which
may be helpful to the Detailed written records should be made with respect to every case of poisoning
and death certificate should not be issued unless post mortem P. Manoj Kumar Et; All: Duties and Laws
Related To Medical Practitioners In Case Of Poisoning: A Peer Review 454 www.iamj.in IAMJ: Volume 2;
Issue 4; July- August- 2014 and scorpion bites. So whenever a victim of poisoning is brought to a medical
practitioner, even though it is a medico-legal case, the prime responsibility of a doctor “to save the life
of patient”2 , second informing to police and it should not be left. MATERIAL AND METHODS: The
commandments to be followed by all the doctors in cases of suicidal, homicidal and accidental poisoning
includes both medical and medico legal duties. Medical duties includes3 1. Diagnosis of suspected
poisoning 2. Treatment of suspected poisoning 3. Secrecy 4. Timely referral Medico legal duties
includes3 1. Collection of evidence 2. Preservation of evidence 3. Legal case register Acute poisoning
forms one of the commonest causes of emergency hospital admissions. Pattern of poisoning in a region
depends upon variety of factors such as, availability of poisons, socio economic status of people,
illiteracy, religious and cultural influences. Following points must be kept in mind while treating these
cases at clinic level or hospital: 1. As the cases of poisoning are brought to the nearest available hospital,
a registered medical practitioner who is in Govt. service has no right to refuse a poisoning case but a
private medical practitioner has right to refuse but not in life threatening situation under code of ethics4
. 2. The first and the foremost are the care and treatment of the patient2,4, without wasting any time
the doctor should try to save the life of the patient by efficiently treating him. 3. On mere suspicion he
should never give a verbal or a written opinion until and unless he is sure about the case from 
Symptomology2  The history of the patient2  Toxic analysis 4. Take the details of the patient i.e. age,
sex, address; date, time, identification marks etc5 . 5. It is compulsory to make a written record of all the
findings and treatment administered6 as it is useful in a suspicious case of poisoning if it is petitioned in
the court of law. 6. If death occurs while giving treatment, a medical practitioner must remember that
“he is protected against any harm done in good faith to a patient without consent of a person in an
emergency situation ethically as well as legally as per Section IPC 92”7 . 7. A Govt. medical practitioner
should inform all the cases of poisoning which include homicidal, suicidal and accidental8 and a private
medical practitioner must inform mainly homicidal cases8 but to be on safe side, should inform all the
cases to police officer or magistrate under section Cr.P.C 395,6,9 and are punishable if not informed. 8.
Under section IPC 1765,6,9, a medical practitioner is punished with an imprisonment of one month or
fine up to 1000/- rupees or both, if a case of poisoning is not informed to police. 9. Under section IPC
1935,6,9, a medical practitioner is punished with an imprisonment of 7 years if he/she is not P. Manoj
Kumar Et; All: Duties and Laws Related To Medical Practitioners In Case Of Poisoning: A Peer Review 455
www.iamj.in IAMJ: Volume 2; Issue 4; July- August- 2014 giving details about the poisoning case i.e.;
giving false information. 10. In case of suspected homicidal poisoning, it is advisable to consult another
practitioner, preferable a senior.A doctor should take every precaution in suspected poisoning to
prevent the possibility of further administration of poison to the patient directly or indirectly by eatables
brought by friends/attendant’s and no one can obtain access to his medicines except the nursing
staff10. 11. Two well trained nurses may be employed with instructions that nothing should be given to
him by anyone except by either of the nurses10. 12. In every case of suspected poisoning a medical
practitioner whether in private practice or Govt. must preserve all the evidence such as vomited matter,
first stomach wash contents and samples of blood, urine and feces passed in his presence which likely to
contain poison in a separate wide mouthed glass bottles with glass stoppers tightly fitted5,6,10. They
are properly labeled with name of patient, material preserved, date and time of collection and are send
to forensic lab for further examination3 . 13. Under section IPC 2015,6,7,deliberateomission to collect
and preserve the evidence, a medical practitioner is awarded punishment up to 7 years imprisonment.
14. Recording of dying declaration is necessitated by calling magistrate and the doctor should declare
that the patient is ofCompos mentis (of sound mind). If the patient’s condition is serious and there is no
time to call a magistrate, the doctor himself should take the dying declaration in the presence of two
witnesses10,11. 15. Death certificate should not be issued in the case of poisoning unless and until
postmortem is done for ruling out the cause6,8. 16. In case of food poisoning originating from public
eatery (functions, canteen, hotel etc.), public health authorities must be notified6,10. 17. Records and
documents properly kept can become defense shields for the doctor in the court of law. 18. Records of
poisonous cases are preserved for a time bound of 3 years12. DISCUSSION: Due to agricultural based
economy, poverty, illiteracy, weak laws in availability, and mental conditions,the cases of poisoning are
more common in India. As most of the cases of poisoning are acute, immediate emergency management
should be done. A registered medical practitioner is required to observe certain prescribed rules of the
conduct contained in Code of medical ethics while performing his duties. The registered medical
practitioner while performing his duties i.e. treating the patient and he does with intention to save the
life of the patient and in some cases if he forgets/tries to give false information, not informing to police,
hiding the cause of death he is legally efficient for awarding the punishment because the intension with
which any act is committed is an important element in law. Last but not least every registered medical
practitioner shouldn’t forget his duties; if he /she do, they are liable to fall under misconduct and are
punishable by law. CONCLUSION: The doctor in cases of poisoning shouldnot refuse to treat the case
due to fear oflegality. P. Manoj Kumar Et; All: Duties and Laws Related To Medical Practitioners In Case
Of Poisoning: A Peer Review 456 www.iamj.in IAMJ: Volume 2; Issue 4; July- August- 2014 He should
treat the patient efficientlyand adhere to the other legal duties likeproper collection of the exhibits
foranalysis, reporting the matter to police officeror magistrate where required, recording ofdying
declaration if needed, handing over thedead body if the person dies topolice for furtherinvestigation in
the event of death withoutissuing death certificate. By performing hisduties both clinical and legal, the
doctor notonly helps the patient but also helps himself bynot omitting his duties. REFERENCES 1. K. S.
Narayan reddy. The essentials of

“Clinical forensic medicine”—a term now commonly used to refer to that branch of medicine involving
an interaction among the law, the judiciary, and the police, and usually concerning living persons—is
emerging as a specialty in its own right. There have been enormous developments in the subject in the
last decade, with an increasing amount of published research that needs to be brought together in a
handbook, such as A Physician’s Guide to Clinical Forensic Medicine. The role of the health care
professional in this field must be independent, professional, courteous, and nonjudgemental, as well as
well-trained and informed. This is essential for the care of victims and suspects, for the criminal justice
system, and for society as a whole. As we enter the 21st century it is important that health care
professionals are “forensically aware.” Inadequate or incorrect diagnosis of a wound, for example, may
have an effect on the clinical management of an individual, as well as a significant influence on any
subsequent criminal investigation and court proceedings. A death in police custody resulting from failure
to identify a vulnerable individual is an avoidable tragedy. Although training in clinical forensic medicine
at the undergraduate level is variable, once qualified, every doctor will have contact with legal matters
to a varying degree. A Physician’s Guide to Clinical Forensic Medicine concentrates on the clinical
aspects of forensic medicine, as opposed to the pathological, by endeavoring to look at issues from
fundamental principles, including recent research developments where appropriate. This volume is
written primarily for physicians and nurses working in the field of clinical forensic medicine—forensic
medical examiners, police surgeons, accident and emergency room physicians, pediatricians,
gynecologists, and forensic and psychiatric nurses—but such other health care professionals as social
workers and the police will also find the contents of use. The history and development of clinical
forensic medicine worldwide is outlined, with special focus being accorded the variable standards of
care for detainees and victims. Because there are currently no international standards of training or
practice, we have discussed fundamental principles of consent, confidentiality, note-keeping, and
attendance at court. The primary clinical forensic assessment of complainants and those suspected of
sexual assault should only be conducted by those doctors and nurses

who have acquired specialist knowledge, skills, and attitudes during both theoretical and practical
training. All doctors should be able to accurately describe and record injuries, although the correct
interpretation requires considerable skill and expertise, especially in the field of nonaccidental injury in
children, where a multidisciplinary approach is required. Avoidance of a death in police custody is a
priority, as is the assessment of fitness-to-be-detained, which must include information on a detainee’s
general medical problems, as well as the identification of high-risk individuals, i.e., mental health and
substance misuse problems. Deaths in custody include rapid unexplained death occurring during
restraint and/or during excited delirium. The recent introduction of chemical crowd-control agents
means that health professionals also need to be aware of the effects of the common agents, as well as
the appropriate treatments. Custodial interrogation is an essential part of criminal investigations.
However, in recent years there have been a number of well-publicized miscarriages of justice in which
the conviction depended on admissions made during interviews that were subsequently shown to be
untrue. Recently, a working medical definition of fitness-to-be-interviewed has been developed, and it is
now essential that detainees be assessed to determine whether they are at risk to provide unreliable
information. The increase in substance abuse means that detainees in police custody are often now
seen exhibiting the complications of drug intoxication and withdrawal, medical conditions that need to
be managed appropriately in the custodial environment. Furthermore, in the chapter on traffic
medicine, not only are medical aspects of fitness-to-drive covered, but also provided is detailed
information on the effects of alcohol and drugs on driving, as well as an assessment of impairment to
drive. In the appendices of A Physician’s Guide to Clinical Forensic Medicine, the relevant ethical
documents relating to police, nurses, and doctors are brought together, along with alcohol assessment
questionnaires, the mini-mental state examination, and the role of appropriate adults; the management
of head-injured detainees, including advice for the police; the Glasgow Coma Scale, and an example of a
head injury warning card; guidance notes on US and UK statutory provisions governing access to health
records; an alcohol/drugs impairment assessment form, along with a table outlining the peak effect,
half-life, duration of action, and times for detection of common drugs.