ALCOHOL

INTRODUCTION
 ALCOHOL
THE TERM ALCOHOL IN POPULAR USE REFERS TO ETHYL
ALCOHOL [ ETHANOL ]

WHICH IS PRESENT IN VARIOUS FERMENTED AND DISTILLED

BEVERAGES.

ALCOHOL IS

TRANSPARENT,
COLORLESS,
VOLATILE LIQUID
HAVING A SPIRIT LIKE ODOUR
AND
BURNING TASTE.
 IT IS THE ACTIVE INGREDIENT OF MANY SOCIAL
BEVERAGES SUCH AS
WINE
BEER
WHISKEY
BRANDY
ITS APPROXIMATE %AGE IN SUCH BEVERAGES IS
BEVERAGES ALCOHOL %AGE BY DEGREES [ PROOF ]
VOLUME
RUM 42.8 75
WHISKEY / BRANDY 42.8 75
GIN 42.8/ 40.0/ 37.2 75/ 70/ 65
WINE 8-15.5 14-27
BEER 2-10.0 3.5-17.5
COUNTRY LIQUOR 11.4-45.7 20-80
 PROOF SPIRIT
THIS INDICATES A MIXTURE THAT CONTAINS

57.10 % BY VOLUME OF ABSOLUTE ALCOHOL.

OR

49.28 % BY WEIGHT OF ABSOLUTE ALCOHOL.

 PROOF STRENGTH

 IN UNITED STATES THE TERM PROOF REFERS TO

TWICE THE PERCENTAGE OF ALCOHOL BY

VOLUME.

Thus 80 proof whiskey contains 40% alcohol by volume.

 PROOF STRENGTH OF ALCOHOL

 PROOF STRENGTH OF A LIQUID IS OBTAINED BY

DIVIDING THE ALCOHOL PERCENT
[ VOLUME STRENGTH ]
BY 0.571

 PROOF / DEGREE= ALCOHOL % [VOL]

0.571
 % AGE OF ALCOHOL
 THIS IS OBTAINED BY MULTIPLYING THE PROOF
STRENGTH BY 0.571

 ALCOHOL %AGE = PROOF/ DEGREE x 0.571

 Rectified spirit contains 95% by volume of alcohol.

 Absolute alcohol the water is removed by special

technique, hence bringing it down to not more than
0.2% water.
 A SINGLE DRINK IS DEFINED AS

 12 OUNCES OF BEER.

 4 OUNCES GLASS OF WINE

 1 ¼ SHOT OF 80-PROOF ALCOHOLIC BEVERAGE.

 ARRACK
This is an eastern name for any country liquor.

It is distilled from

Coco-palm
Rice
Sugar

Its strength may be as high as that of whisky.

It is commonly fortified [to gain extra kick] with

Potassium bromide
Chloral hydrate
Dhatura
bhang
 COUNTRY LIQUOR
This although more intoxicating but will have the same
clinical effects as ethyl alcohol.

SERIOUS TOXIC EFFECTS ARE COMMON WHEN

1. The liquor is adulterated by denatured spirit which contains

methyl alcohol.

2. The so called country liquor is prepared from toxic preparations

like varnish and French polish containing methyl alcohol.

INCIDENCE OF DEATH IS QUITE COMMON WITH THIS

TYPE OF LIQUOR.
METABOLISM OF

ETHYL ALCOHOL
 METABOLISM OF ETHYL ALCOHOL
 ETHYL ALCOHOL IS RAPIDLY ABSORBED FROM
GASTROINTESTINAL TRACT.
The rate of absorption depends upon

1. Concentration of the alcohol in the fluid imbibed.

2. Presence / absence of food in the stomach.
3. Condition of stomach wall [gastrectomy, chronic
gastritis].
4. Rate of drinking.
5. Quantity of alcohol ingested.
6. Weight of the person.
7. Development of the person.
 TWO IMPORTANT FACTORS.
1. CONCENTRATION OF THE ALCOHOL

 Alcohol is absorbed more rapidly from concentrated

than from dilute solution.

2. PRESENCE OF FOOD IN STOMACH.

 Fats and proteins retard the absorption, milk

being very effective for this purpose.
 CONCENTRATION OF ALCOHOL
FOLLOWING ABSORPTION

 the concentration of alcohol in blood reaches a maximum

in about 45-90 minutes after ingestion.

THE CONCENTRATION OF ALCOHOL IN VARIOUS TISSUES

AFTER EQUILIBRIUM IS ESTABLISHED AS FOLLOWS.

 BLOOD IS TAKEN AS 1
 BRAIN 1.17
 PLASMA 1.16
 URINE 1.33
 VITREOUS AND BILE 1.12
 LIVER 0.91
 BLOOD CLOT 0.77
 METABOLISM [CONTD]

approximately 90% of the absorbed alcohol is oxidized in the liver.


remaining 10% being excreted mainly by kidney and lungs.

 NORMAL BODY METABOLISM OF ALCOHOL IN AN HOUR

IS

 ½ fluid ounce of absolute alcohol.

 One fluid ounce of whisky. [ one drink ]

 12 ounces of beer.

IF THE INTAKE EXCEEDS THIS QUANTITY THE SUBJECT MANIFESTS

SIGNS AND SYMPTOMS OF DRUNKENNESS UNLESS TOLERANCE HAS
BEEN DEVELOPED.
 TIME ESTIMATION SINCE INTAKE
THE AVERAGE FALL OF THE ALCOHOL
CONCENTRATION IS AROUND

15-18 mg ethanol per 100 ml of blood per hour.

[ 15-18 mg / 100 ml / hour ]

HENCE IT IS POSSIBLE TO CALCULATE

 how long after a given dose body will be alcohol free.

 Blood alcohol concentration a few hours before the

blood analysis.
 ALCOHOL CONCENTRATION
CONCENTRATION OF ALCOHOL IN BLOOD VARIES
CONTINUOUSLY.

First increasing during the period of absorption.

Then decreasing on account of metabolism.

SINCE GLOMERULAR FILTRATION RATE HAS CONCENTRATION

SIMILAR TO THAT OF PLASMA

A given sample will reflect the average blood alcohol concentration

during the time the urine has accumulated in the urinary bladder.

As the bladder may contained urine before taking alcohol , it is

necessary to empty the bladder and use a second sample collected
within 30-60 minutes for any such test
 ACUTE

ETHYL ALCOHOL

POISONING
 ETHYL ALCOHOL POISONING
 ethyl alcohol depresses the central nervous
system irregularly in descending order from
cortex to medulla.
 It first depresses the higher centres which control

judgment and behavior. [ stage of excitement-

blood alcohol 30-100 mg% ]
 Then it depresses the motor centres [ stage of

incoordination -blood alcohol 100-300 mg% ]

 Finally the vital centres in the medulla are

depressed [ stage of narcosis-blood alcohol over

300 mg% ]
 The breath smells alcohol throughout.
 Ethyl poisoning [ contd ]
 EFFECTS APPEAR EARLY IN THOSE WHO ARE

 mentally or physically fatigued

 Epileptics
 Head injury patients
 Already intoxicated with barbiturates or other CNS
depressants.

THE STATUTORY LIMIT FOR A CHARGE OF DRUNKEN

DRIVING IS

 0.08-010% in USA.
 0.08% in Canada and Britain.
 0.15% in India.
STAGES OF ETHYL ALCOHOL
POISONING

STAGE OF EXCITEMENT.

STAGE OF INCOORDINATION.

STAGE OF NARCOSIS.
 STAGE OF EXCITEMENT
THIS IS A FEELING OF WELL BEING AND PLEASURE
RESULTING FROM INHIBITION OF THE HIGHER CENTRES.

THE PERSON

 converses well.
 Laughs and smiles readily.

 Or may become angry easily.

 May disclose secrets easily.

 May behave in an obscene manner or talk in vulgar

language.
 Sexual desire may be aroused.
 STAGE OF INCOORDINATION

THERE IS INCOORDINATION OF

 thought
 speech
 Action

MANIFESTED BY

 impaired judgment
 confusion
 slurred speech
 staggering gait

THE DRUNK PERSON MAY

 Suffer from hiccups

 May be untidy in appearance
 STAGE OF INCOORDINATION [ CONTD ]
THE PERSON MAY DEPICT INHERENT EMOTIONS LIKE

 Remorse
 Euphoria
 Irritability

SIGN AND SYMPTOMS

 Nausea
 Vomiting
 Dilated pupils

IMPAIRED JUDGMENT MAY LEAD TO MOST OFFENCES LIKE

 Accidents
 Sexual excesses
 Violence
 crime
 STAGE OF NARCOSIS
 The patient passes on to deep sleep and responds only
to strong stimuli.
 Pulse is rapid.
 Temperature subnormal.
 Breathing is stertorous.

MACEWAN SIGN

 Pupils may be contracted.

 However on pinching the neck or face, they dilate initially

and slowly return to their original size.

 This sign is helpful to differentiate alcoholic coma from

other comatose conditions.
STAGE OF NARCOSIS [ contd ]
If this stage lasts for more than 12 hours
Death may ensue from paralysis of

Cardiac centre respiratory centre

Or

Later from effects of pulmonary edema.

 ACUTE ALCOHOLISM
 Death from acute alcoholism is not common.
 Recovery occurs with acute depression and

gastrointestinal irritation, which continues for 24

hours or longer.

Hang-over

Headache is also present as a hang-over effect,

which is caused by cerebral edema.
 hang-over means a temporary state of

indisposition usually following recovery from

drunkenness.
 CLINICAL
MANIFESTATIONS
 BLOOD ALCOHOL LEVEL AND CLINICAL
MANIFESTATIONS
PERCENT MG % EFFECT

LESS THAN 0.03% LESS THAN 30 NOT NOTICEABLE

0.03-0.05 30-50 SELECTIVE IMPAIRMENT

0.05-0.10 50-100 SLIGHT IMPAIRMENT

0.10-0.15 100-150 UNDER THE INFLUENCE

0.15-0.20 150-200 DRUNK

0.20-0.30 200-300 VERY DRUNK

0.30-0.35 300-350 STUPOR TO COMA

OVER 0.35 OVER 350 COMATOSE TO DEATH

 CLINICAL MANIFESTATIONS
 SELECTIVE IMPAIRMENT.
 Increase in reaction time.
 Impairment of complex skills. [ driving ]
 Detectable only on detailed examination.

 SLIGHT IMPAIRMENT.
 Flushed face.
 Dilated / sluggish pupils.
 Euphoria.
 Loss of restraint.

 UNDER THE INFLUENCE.

 Face flushed.
 Dilated and sluggish pupils.
 Euphoria.
 Loss of restraint.
 Test errors.
 Stagger on sudden turning.
 CLINICAL MANIFESTATIONS
 DRUNK
 Face flushed.
 Dilated/ sluggish/ inactive pupils.
 Clouding of intellect.
 Incoordination of thought, speech, and action.
 Staggering gait with reeling and lurching while making sudden turns.

 VERY DRUNK
 Flushed or pale face.
 Pupils inactive dilated [ may be contracted.]
 Mental confusion.
 Marked incoordination of thought, speech, and action.
 Staggering, reeling gait with tendency to lurch and fall.
 Vomiting.
 Amnesia.

 SPECIAL NOTE.
 These manifestations appear in persons who are not regular and excessive drinkers.
 Recovery has been recorded after blood alcohol levels of 780 mg% and above.
 FATAL DOSE

FATAL PERIOD

CAUSE OF DEATH
 FATAL DOSE FATAL PERIOD

 THIS DEPENDS ON THE  USUALLY IT IS

 Age.  12-24 HOURS
 Habit of the person.
 Strength of the liquor  ALTHOUGH DEATH
taken. MAY BE DELAYED FOR
 Death usually occurs from  5-6 DAYS
large dose taken in short
period.

 FATAL DOSE.
 0.35 % [350 mg%] and
above, concentration of
blood alcohol is usually
sufficient to cause death.
 CAUSE OF DEATH
 DEATH IS DUE TO DEPRESSION OF THE RESPIRATORY
CENTRE.

 ALCOHOL MAY BE LETHAL AT RELATIVELY LOWER

BLOOD LEVELS WHEN

Combined with other central nervous system

depressants, such as
Barbiturates
Carbon monoxide
Morphine

Or in the presence of
some natural heart or lung disease.
ALCOHOL
AND
DRIVING
 ALCOHOLIC INTOXICATION AND DRIVING.

A MOTOR VEHICLE IS A COMPLICATED PIECE OF MACHINERY,

HANDLING OF WHICH REQUIRES
 skill,
 dexterity,
 and mental acuity.
 All of these are selectively reduced, even eliminated by alcohol.

 Thus an individual may be intoxicated to the point of being unable

to operate an automobile safely while appearing sober.

RESEARCH SHOWS THAT A DRIVER’S ABILITY IS ADVERSELY

AFFECTED

 with a blood alcohol count of 0.03-0.05 % [ or sometimes even

less].
 which means consumption of only two beers in about an hour.
 ALCOHOLIC INTOXICATION AND DRIVING.
 ALCOHOL CAUSES
 faulty depth perception.
 Poor peripheral vision.
 Distorted color vision.
 Reduced night vision.

 EXAMPLE 1
 When a drunk driver is exposed to glare of head lights of an
oncoming vehicle.
 It can take 2-8 seconds to adapt to the dark conditions.
 As compared to 1 second required by a normal individual.

 EXAMPLE 2
 An alcoholic impaired driver’s ability to judge the distance may also
be reduced.
 Making it difficult to change lanes.
 Or to determine whether car is approaching, moving away, or
standing still.
 HANGOVER PHASE AND DRIVING.
 DRIVING ABILITY IS GENERALLY IMPAIRED EVEN IN THE HANGOVER
PHASE DUE TO AFTER AFFECTS OF ALCOHOL ON

 Judgment.
 Perception.
 Reaction time.
 Coordination.

AN INCREASE OF ONE TENTH OF A SECOND IN REACTION TIME

means

THAT A CAR TRAVELLING AT 80 KM/ HOUR

needs

AN ADDITIONAL 2.2 METRES OF ROAD TO PULL UP.

TREATMENT
OF
ETHANOL
POISONING.
 TREATMENT
GASTRIC LAVAGE
The stomach should be lavaged with care with
5 % solution of sodium bicarbonate in warm water.

GENERAL MEASURES
The patient should be kept warm.

HYPOGLYCEMIA
Isotonic solution with 5 % glucose [preferably fructose] may be
required.

INCREASED INTRACRANIAL PRESSURE.

This often occurs and is to be treated with
Saline purges
and
Intravenous hypertonic glucose solution
 TREATMENT

RESPIRATORY DEPRESSION

Artificial respiration may be required along with oxygen inhalation.

SERIOUS LIFE THREATENING EMERGENGENCY MAY NEED

peritoneal dialysis

Haemodialysis
POST –MORTEM
APPEARANCE
 POST MORTEM APPEARANCE
 CLOTHES.
 Torn and disorderly.
 Stained with blood and vomitus.

 MISCELLANEOUS.
 Tongue may be furred.
 Rigor mortis lasts longer.
 Bruises are found on various parts of the body.
 Other injuries may be present.

 ON OPENING UP THE BODY.

 Odour of alcoholic beverages is often evident.
 Blood is fluid and dark.
 POST MORTEM APPEARANCE

BRAIN
 is slightly edematous.
 Shrinkage of the cerebral cortex [grey mater] is common in chronic alcoholics.
 In individuals who sustain head injury with subdural / epidural hemorrhage and
survive for hours to days
THE ANALYSIS OF THE BLOO CLOT MAY REVEAL INITIAL BLOOD
ALCOHOL LEVEL AT THE TIME OF INJURY.

VITREOUS.
 Vitreous analysis will reveal alcohol level in all the cases.
 POST MORTEM APPEARANCE

 GASTROINTESTINAL TRACT FINDINGS

 Edema of the larynx.

 Café coronary. [ bolus of food obstructing the larynx.]
 Fatty liver.
 Acute hemorrhagic pancreatitis.
 Stomach shows signs of alcoholic gastritis to a varying degree.
 Mucus membrane of the small intestine is edematous but not ulcerated.
[ a differentiating point from infective death like salmonella infection where
ulcerations are present.]
 CHEMICAL EXAMINATION
VISCERA SENT FOR THE CHEMICAL ANALYSIS ARE

Stomach and its contents.

Small intestine.

Piece of liver, spleen, kidney.

Vitreous fluid.

Cerebrospinal fluid.

Blood collected from a peripheral vein.

MEDICOLEGAL
ASPECTS
 MEDICOLEGAL ASPECTS

POISONING BY ALCOHOL
Although it is comparatively common but death directly due to its ingestion occurs
in a far smaller number of cases.

LIABILITY TO FATAL COMPLICATIONS MAY OCCUR SUCH AS

Head injuries.
Serious bleeding from trivial injuries.
Café coronary leading to suffocation.
Drowning.

A STRONG RELATIONSHIP EXISTS BETWEEN ALCOHOL, CRIME, AND

VIOLENCE.
 CHRONIC ALCOHOLISM
THIS IS A COMMON CAUSE OF

Sexual jealousy crimes, especially those of a homicidal nature.

CONTRIBUTORY NEGLIGENCE

A passenger who accepts a lift from the driver of a

motor vehicle whom he knows from to be drunk accepts
the risk of contributory negligence in the event of an
accident.
 CHRONIC
ALCOHOLISM
 ALCOHOL ADDICTION
This results from the continued use of alcohol.

IT IS CHARACTERISED BY GRADUAL DETERIORATION OF

Physical health.
Moral values.
Mental intellect.

Also known as ALCOHOLIC DEMENTIA.

PHYSICAL DETERIORATION
THIS IS MANIFESTED BY

Lack of personal hygiene.

Loss of appetite.
Chronic gastroenteritis.
Wasting.
Peripheral neuropathies.
Impotence.
Sterility.
Fatty changes in liver and heart.
 HEPATOTOXICITY OF ALCOHOL

ALCOHOL IS A HEPATOTOXIC POISON.

Cirrhosis of liver is common.

A useful index of liver damage is level of enzyme

GAMMA -GLUTAMYL TRANSPEPTIDASE,

in the serum,
the normal level being less than 36 units.
 MORAL DTERIORATION

This manifests as crimes which the addict commits to get the

drink.

Mental degeneration results in dementia.

The person may hit the family members and have an

aggressive attitude.
THREE COMMON CLINICAL SYNDROMES
RESULT FROM CHRONIC ALCOHOLISM

DELERIUM TREMENS

KORSAKOFF’S PSYCHOSIS.

ACUTE HALLUCINOSIS.
 DELERIUM TREMENS
This is a state of excitement with hallucinosis which lasts
3-4 days.

THIS RESULTS FROM.

 Unusual bout of drinking.

 Sudden withdrawal of alcohol.

 Acute infection, e.g. pneumonia or influenza.

 Shock from injury e.g. fracture of bone.

 Exposure to cold.
 DELERIUM TREMENS
THIS IS CHARACTERIZED BY

Acute attack of insanity in which the main symptoms are

 Sleeplessness.
 Marked tremors.
 Excitement.
 Fear.
 Visual and Auditory hallucinations.

The person may seek escape from his terrifying new world by suicide.

 The person is often violent with a homicidal tendency.

 The person is considered insane for the time being and not held
responsible for his actions.