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Forensic Mnemonics *** Metals *** Lead (Pb) *** As All Metals, it has Mixed action: - Local : G.I.T - Remote : Target Organs can be coded by its chemical symbol: Pb Peripheral Nerves Proximal Tubules of the Kidney blood brain bone A Target organ I always 4get is Kidney, so to remember :) The main use of Pb when came up was Water pipes.

Forensic mnemonics - metals

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A collection of menonics in forensic medicine & Toxicology (Metals) to help easily memorize important points

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Page 1: Forensic mnemonics - metals

ForensicMnemonics

***

Metals

***

Lead (Pb)

***

As All Metals, it has Mixed action:

- Local : G.I.T- Remote : Target Organs can be coded by its chemical symbol:

Pb

Peripheral Nerves

Proximal Tubules of the Kidney

blood

brain

bone

A Target organ I always 4get is Kidney, so to remember :)

The main use of Pb when came up was Water pipes.

Page 2: Forensic mnemonics - metals

So, do u remember the organ with the Largest Water channel systemin the Body?

Yes, it’s the Kidney, so don’t 4get to mention the Kidney as a targetorgan in Both Acute & Chronic Lead poisoning, producing

(Fanconi – Like syndrome) (Reveraible) ;

-Due to Proximal Tubule affection; Glucosuria, Aminoaciduria,Phosphaturia, Albumin, Blood & Casts in Urine.

***Occupational Exposure to Lead can also be coded by its Chemical

Symbol:

Pb

Plumbers

Painters

Petroleum Industry Workers (exposed to: TEL “Organo lead”)

(N.B. Tetra Ethyl Lead (TEL) is the Most LEThal & rapidly producesEncephalopathy).

battery & bullet (Missile) Industries

***

Page 3: Forensic mnemonics - metals

Special Features of PLumbism

- LOCal: GIT

Don’t 4get to talk about

3 CO

COLors

COLic

COnstipation

ColorsOral: Blue line at gingival Line (PbS)

Intestinal: Black Offensive stool (PbS)

Colic:

Paroxysmal & relieved byPressure.

Constipation:With Black offensive stool (PbS)

***Blood & Vascular System

A, B, C

Page 4: Forensic mnemonics - metals

A nemia (Microcytic Hypochromic), due to:

Haemo-lysis (++ Fragility of RBC’s _ interferes with Na\K Pump & attachesto the membrane >> ++ Fragility)

Heme-Synthesis (inhibition of several Enzymes in Heme Synthesis Pathwaythrough binding to their SH- group)

- With subsequent Compensatory Release of Immature RBC’s(Reticulocytes) Reticulocytosis.

***

Basophilic stippling (Punctate Basophilia), due to:

Inhibition of Pyridine –5- Nucleotidase (Responsible for Breakdown ofRNA) Clumping of Ribosomal RNA.

***

Circum Oral Pallor, due to VC.

***Peripheral Nerves

Lead Palsy (Wrist & Foot Drop)

PlumbuM produces

Purely Motor Peripheral Neuritis, esp. affecting Extensors.

***

Proximal Tubules of the Kidney: Fanconi-Like Syndrome.

Page 5: Forensic mnemonics - metals

***Brain:

Encephalopathy.

Esp. in Children (Immature BBB)Esp. with TEL.

***Bone:

Bone aches & Arthritic pain (Lead esp. deposits near Joints)

***

Others:

- Plumbum affects Parents

♀ Abortion (ecboilc)

♂ Sterility & Impotence

- PlumbUM affects MyocardiUM (Miocarditis)

***

Page 6: Forensic mnemonics - metals

Regarding Investigations:

- One of the important investigations in Lead poisoning, is

detection of

Amino-Levulinic Acid in urine (++ ALA, due to inhibition of ALA

Dehydratase enzyme in Heme synthesis pathway).***

Regarding TTT

PROphylaxis through:

PROmote adequate supply of Ca, Zn & Fe. (-- Pb absorption)

PROper Ventilation

PROtective clothing, Masks, gloves & boots.

PERiOdic Medical Examination of exposed workers.

***Regarding the Chelator

(BAL)

-It’s excreted in BiLe, so the chelator of choice in RenalCompromise

Page 7: Forensic mnemonics - metals

-It’s contraindicated in 4 F

- Concurrent administration or toxicity of Fe Fe-BAL Complex is

toxic.

- Favism (G6PD Deficiency) Haemolysis.

- Liver Failure (excreted in Bile).

- Fetal Gestation (Pregnancy).

***Arsenic

***

Acute ARsEniC***

As all Metals, mixed action:

Local: G.I.T

- Nausea, vomiting, colic, Diarrhea with RiCE stools

- DD : Cholera,

- To remember the points of Differentiation, ask yourself this Qu:

How To Verify it’s ChOLera or ArSENIc Toxicity ?

Page 8: Forensic mnemonics - metals

Temperature

Vomiting

COLic

ANALYsIsTenesmus

***

Remote: ArsENic

- ParENchymatous organs (Liver, Kidney & Heart)

***

Chronic Arsenic:

-Local: G.I.T: Anorexia, diarrhea Alternating with Constipation.

- Remote: As acute +

Aplastic Anemia

Skin & MM.

Page 9: Forensic mnemonics - metals

Peripheral Neuritis; Mainly Sensory

***

Iron

***

Acute Iron Toxicity

Condition of Poisoning:

Mainly Accidental, esp. in Children as Iron Preparations are:

- Attractive, similar to candies.

- Available at home.

Mechanism of Action:

- Local:

- GIT: Corrosive effect; may cause Hemorrhagic Necrosis &Perforation.

- To remember this Hemorrhagic action, remember that the Chief Role ofIron in the Body is incorporation in Hemoglobin of RBC’s (Blood cell

Synthesis), in contrast, when in excess, it causes (Blood Loss), HemorrhagicNecrosis.

- Remote:

- To Remember all Systems affected, Remember these actions coded by

3 P

Page 10: Forensic mnemonics - metals

Peri-portal Necrosis (Liver)

Blood Pressure (Hypotension) (Cardiovascular)

Blood PH (Metabolic Acidosis) (Metabolism)

***To Remember what causes stage I & II in acute Iron Toxicity,

Stage I.

G.i.T

- Due to irritant Corrosive effect of Iron.

***Stage II.

Apparent Recovery

- Due to Redistribution of Iron from Blood to Reticulo-

endothelial system.

***

Page 11: Forensic mnemonics - metals

N.B.

The 2 Main Toxins during our study, targeting the Liver are

Iron & Paracetamol; They share some distinct characters:

1- Both are originally handled by liver in Therapeutic doses

Iron (Stored in the Liver)Paracetamol (Metabolized in the Liver)

2- When ingested in excess, they Target it, passing Through 4stages

Note that

LIVer IV 4

The 4 Stages are in order:

I. GITII. Apparent Recovery & Altered Blood Chemistry

III. Liver Failure & Overt symptomsIV. Prognosis

See the following Table :)

N.B. Pay attention to timing of Stages in each, as a stage may beasked using the time & not the name or symptoms.

Iron (Fe) (1-6 hrs) ( 6-24 hrs) ( 12-48 hrs) ( 2-6 Wks)To remember: F is the 6th Letter, so 1st stage lasts for 6 hours,

then complete the sequence :)

Paracetamol: (1\2 – 24 hrs) (24-72 hrs) (72-96 hrs) (7-10 days)

Page 12: Forensic mnemonics - metals

dr R.M

Stage

• Stage I•G.I.T

• Stage II•Apparent

Recovery (Both)•Altered Blood

Chemistry(Paracetamol).

• Stage III• Liver Failure

• Stage IV• Prognosis

• Abdominal pain.

• Nausea, Vomiting,Hematemesis & Melena.

• Shock & Dehydrationfrom Fluid Loss.

• ـــــــــــــــــــ

• The patient appearsfalsely stable for a time.

• ـــــــــــــــــــ

• Hepatic Necrosis & Livercell failure .

• Lethargy & Coma.•(But don't 4get that iron in

addition has a corrosiveeffect & targets CVS &

Metabolism, so add:

• Recurrence of G.I.TSymptoms.

• Shock, Hypotension &Metabolic acidosis.

• ـــــــــــــــــــ• G.I.T Scarring & Narrowing

• with or withoutObstruction

(Pylorostenosis, GastricFibrosis or small bowel

stricture).

dr R.M

Iron

• Abdominal pain.

• Nausea, Vomiting,Hematemesis & Melena.

• Shock & Dehydrationfrom Fluid Loss.

• ـــــــــــــــــــ

• The patient appearsfalsely stable for a time.

• ـــــــــــــــــــ

• Hepatic Necrosis & Livercell failure .

• Lethargy & Coma.•(But don't 4get that iron in

addition has a corrosiveeffect & targets CVS &

Metabolism, so add:

• Recurrence of G.I.TSymptoms.

• Shock, Hypotension &Metabolic acidosis.

• ـــــــــــــــــــ• G.I.T Scarring & Narrowing

• with or withoutObstruction

(Pylorostenosis, GastricFibrosis or small bowel

stricture).

Paracetamol

• Malaise & Diaphoresis.

• Nausea & Vomiting.

• Drowsiness (No loss ofconsciousness)• ـــــــــــــــــــ

• Pain & Tenderness in Rt.Hypochondrium.

• Altered Liver FunctionTests.

• ـــــــــــــــــــ

• Liver failure

• (Jaundice, Coagulationdefects, encephalopathy& Altered concious level)

• ـــــــــــــــــــ

• Recovery: Resolution ofhepatic dysfunction &

complete hepaticrecovery within 3 - 6

months.

• Death: In severe casesdue to Multi-organ

failure.

dr R.M

Paracetamol

• Malaise & Diaphoresis.

• Nausea & Vomiting.

• Drowsiness (No loss ofconsciousness)• ـــــــــــــــــــ

• Pain & Tenderness in Rt.Hypochondrium.

• Altered Liver FunctionTests.

• ـــــــــــــــــــ

• Liver failure

• (Jaundice, Coagulationdefects, encephalopathy& Altered concious level)

• ـــــــــــــــــــ

• Recovery: Resolution ofhepatic dysfunction &

complete hepaticrecovery within 3 - 6

months.

• Death: In severe casesdue to Multi-organ

failure.