INTOXICATION

Dr. Nanang Sukmana, SpPD-KAI

Divisi Alergi - Imunologi Klinik
Deptemen Ilmu Penyakit Dalam FKUI/RSCM
Jakarta

The Most Common Toxic Syndromes

Cholinergic syndromes

Anticholinergic syndromes

Sympathomimetic syndromes

Opiate, sedative or ethanol intoxication

The Most Common Toxic Syndromes

Cholinergic syndromes
Common signs
Confusion
central nervous system depression
weakness
salivation
lacrimation
unary
fecal incontinence
gastrointestinal craping
emesis
diaphoresis
muscle fasciculations
pulmonary edema
miosis
bradycardia
tachycardia
seizures

Common causes
Organophosphate
carbamate insecticides
physostigmine, edrophonium
some mushrooms

INTOXICATION

Dr. Nanang Sukmana, SpPD-KAI

Divisi Alergi - Imunologi Klinik
Deptemen Ilmu Penyakit Dalam FKUI/RSCM
Jakarta

The Most Common Toxic Syndromes

Cholinergic syndromes

Anticholinergic syndromes

Sympathomimetic syndromes

Opiate, sedative or ethanol intoxication

The Most Common Toxic Syndromes

Cholinergic syndromes
Common signs
Confusion
central nervous system depression
weakness
salivation
lacrimation
unary
fecal incontinence
gastrointestinal craping
emesis
diaphoresis
muscle fasciculations
pulmonary edema
miosis
bradycardia
tachycardia
seizures

Common causes
Organophosphate
carbamate insecticides
physostigmine, edrophonium
some mushrooms

The Most Common Toxic Syndromes

Anticholinergic syndromes
Common signs

Common causes

Delirium with mumbling speech

Tachycardia
Dry
Flushed skin
Dilated pupils
Myoclonus
Slightly elevated temperature
Urinary retention
Decreased bowel sounds
(Seizure and dysrhythmias may occur in
severe cases)

Anthistamine
Antiparkinson medication
Atropine
Schopolamine
Amantadine
Antipsychitic agents
Antidepressant agents
Antispasmodic agents
Mydriatic agents
Skeletal muscle relaxantss
Many Plant (notably jimson weed and
Amanita muscaria)

The Most Common Toxic Syndromes

Sympathomimetic syndromes
Common signs
Delusions
Paranoia
Tachycardia (or brandycardia if the
drug is a pure alpha-adrenergic agonist)
Hypertension
hyperpyrexia
Diaptoresis
Piloerection
Mydriasis
Hyperreflexia
(Seizures, hypotension
dysrhythmias may occur in severe cases)

Common causes
Cocaine
amphetamine
methamphetamine (and its derivaties 3,
4-methylenedioxyamphetamine, 3, 4methylene-dioxymethampetamine, 3,4methylenedioxyethamphetamine, and 2,
5-dimethoxy-4-bronmoamphetamine)
over-the-counter decongestants
(phenylpropanolamine, ephedrine and
pseudoephedrine)
In caffeine and theophyline
overdoses,similar findings, except for the
organic psychiatric signs, result from
catecholamine release

The Most Common Toxic Syndromes

Opiate, sedative or ethanol intoxication
Common signs
Coma
respiratory depression
miosis
hypotension
brandycardia
hypothermia
pulmonary edema
decreased bowel sounds hyporeflexia
needle marks
(Seizures may occur after overdoses of
some narcotic, notably propoxyphene)

Common causes
Narcotics
barbiturates
benzodiazepines
ethchlorvynol
glutethimide
methyprylon
methaqualone
meprobamate
ethanol
clonidine
guanabenz

Prinsip Penatalaksanaan Kasus

Keracunan

Penatalaksanaan kegawatan
Penilaian Klinis
Dekontaminasi racun
Pemberian antidotum
Terapi suportif
Observasi dan konsultasi
Rehabilitasi

Dr.Nanang Sukmana, SpPD. KAI

Keadaan Klinis Yang Perlu Mendapat

Perhatian

Koma
Kejang
Henti jantung
Henti napas
Syok
Dr.Nanang Sukmana, SpPD. KAI

MASALAH KETERGANTUNGAN OBAT

Heroin / Morfin

Extasy

Morfin

Sumber : Drug-ARM.(Awareness and Relief Movement)

PUTAUW
( diacetyl morphine )
Suatu derivat morfin dengan kekuatan 3 - 5 kali morfin
Dalam waktu 5 menit setelah suntikan dirubah
menjadi morfin
Dalam waktu 40 menit konsentrasinya (morfin)
melebihi heroin
Heroin mudah masuk ke cerebral / serebri = otak
mudah intoksikasi
Dr.Nanang Sukmana, SpPD. KAI

Status
Imunologi
Kognitif

Putus Obat

Endokarditis
Infektif

Overdosis
Adiksi

Kehamilan

HIV

Dispepsia

HCV
Kel. hematologi

Pneumonia
drug abuse

Infeksi : Kulit
SSP

Emboli paru

Adverse effect of Mood-Altering on pregnancy and the newborn

Drug

Spontaneous Premature Perinatal Neonatal Fetal Distress Congenital

Abnormality
Abortion
Delivery Mortability Withdrawal

Amphetamines
Barbiturates
Sedative
Tranquilizers

Heroin

+
+

+
+

+
+

+
+

++

Mekanisme Kerja Opiat di Otak pada Pengguna

Morfin

Endorphin
(endogen morfin)
Reseptor
Opiat
1

2
Nalokson

POLA ENDORPHIN DI SSP

MCI / SAKIT HEBAT

TRAUMA
Morfin

Endorphin

SAKIT KANKER

Alur Tatalaksana Intoksikasi Opium

Intoksikasi golongan opiat

-Aloanamnesa
-Riwayat pemakaian obat
-Bekas suntikan (Needle track sign)
-Pemeriksaan urin

Trias intoksikasi opiat

-Depresi napas
-Pupil pin-point
-Kesadaran menurun

Suport sistem pernapasan & sirkulasi

Intravenous nalokson (lihat protokol)

Observasi/pengawasan tanda vital &

dipuasakan selama 6 jam

Penatalaksanaan Overdosis Opioid

70% pengguna narkoba melalui suntikan (Injection Drug User / IDU),

Gejala klinis
Penurunan kesadaran disertai salah satu dari:

1. Frekuensi pernapasan < 12 kali/menit

2. Pupil miosis (seringkali pin-point).

3. Adanya riwayat pemakaian morfin/heroin/ terdapat needle
track sign

Tindakan
Penanganan kegawatan
Bebaskan jalan nafas
Berikan oksigen 100% sesuai kebutuhan
Pasang infus D5% emergensi atau NaCl 0,9%; cairan koloid bila
diperlukan
Pemberian antidotum naloxone (1)
1. Tanpa hipoventilasi : Dosis awal diberikan 0,4 mg iv.
2. Dengan hipoventilasi : Dosis awal diberikan 1-2 mg iv.
3. Bila tidak ada respon dalam 5 menit ,diberikan nalokson 1-2 mg iv
hingga timbul respon perbaikan kesadaran dan hilangnya depresi
pernapasan, dilatasi pupil atau telah mencapai dosis maksimal
10 mg. Bila tetap tidak ada respons lapor konsulen Tim Narkoba.

Pemberian antidotum naloxone (2)

4. Efek nalokson berkurang 2040 menit dan pasien dapat jatuh
kedalam keadaan overdosis kembali, sehingga perlu pemantauan
ketat tanda-tanda penurunan kesadaran, pernapasan dan
perubahan pada pupil serta tanda vital lainnya selama 24 jam.
Untuk pencegahan dapat diberikan drip nalokson satu ampul
dalam 500 cc D5% atau NaCl 0,9% diberikan dalam 4 6 jam.
5. Simpan sampel urin untuk pemeriksaan opioid urin dan lakukan
foto toraks.
6. Pertimbangkan pemasangan ETT ( endotracheal tube ) bila :
Pernapasan tidak adekuat
Oksigenasi kurang meski ventilasi cukup
Hipoventilasi menetap setelah pemberian nalokson ke 2.
7. Pasien dipuasakan untuk menghindari aspirasi akibat spasme
pilorik

Ecstasy (Ekstasi)
Komposisi spesifik :
1. MDMA (3,4-methylenedioxymethamphetamine)= Ecstasy
2. MDEA (3,4-methylenedioxyethamphetamine)= Eve
3. 2 CB (4-bromo-2,5-methoxyphenylethylamine)
4. Bromo-DMA (4-bromo-2,5-dimethoxyamphetamine)
= Bromo STP = DOB
Nama populer umum (street name) :
DOB : Golden eagle, LSD 25, Tile, 100X, Bromo STP
MDA : Harmony, Love drug, Speed for lovers
MDMA : Adam, Ecstasy, Essence
2 CB : Eve, Spectrum
Dr.Nanang Sukmana, SpPD. KAI

Keracunan Amfetamin
Umumnya gejala yang terlihat adalah :
Agitasi

Koagulopati

Hipertensi

Rabdomiolisis

Takikardi

Aritmi

Midriasis

Kejang

Trismus

Gagal Ginjal

Diaporesis Sampai Gejala Berat

Hipertermi

Daun Cocaine
Sumber : Drug-ARM.(Awareness and Relief Movement)

Coke
Charlie
Snow

Euphoria = perasaan senang yang berlebihan

Stress / gelisah hilang
Aktif / atraktif
Membangkitkan gairah

Daun Ganja

Sumber : Drug-ARM.(Awareness and Relief Movement)

Mariyuana /
Cannabis

Perasaan senang
Ramah
Berperilaku diluar karakter
Berperilaku lucu

Perkiraan waktu deteksi dalam urin

beberapa jenis obat
Jenis obat
Amfetamin
Barbiturat
Benzidiazepin
Kokain
Kodein
Heroin
Methadone
Morpin

Lamanya waktu bisa dideteksi

2 hari
1 hari (short acting)
3 minggu (long acting)
3 hari
2 - 4 hari
2 hari
1 - 2 hari
3 hari
2 - 5 hari

Dr.Nanang Sukmana, SpPD. KAI

Makanan yang
tercemar

Summary of Bacterial Food Poisoning

Organism

Incubation
Period

Mechanism

Bacillus cereus

1-6 h (emesis)
8-16 h (diarrhea)

Toxins produced in food and

patient

Clostridium perfringens

6-16 h

Toxins produced in food and

patient

Eschericia coli

12-72 h

Toxins produced in patient

Listeria monocytogenes

9-32

Invasive

Salmonella

12-36 h

Invasive

Shigella

1-7 d

Invasive

Staphylococcus aureus

1-6 h

Toxins performed in food;

heat resistant

Vibrio parahemolyticus

8-30 h

Invasive and toxin produced

in patient

Penatalaksanaan Keracunan Parasetamol

Gambaran Klinis

Keracunan parasetamol dapat terjadi jika anak menelan > 150

mg/kg atau seorang dewasa menelan 150 mg/kg atau 7,5 gr
atau lebih
Stadium I (0-24 jam)
Stadium II (24-48 jam)
Stadium III (72-96 jam)
Stadium IV (7-10 hari)

Antidotum / Terapi spesifik

Dewasa
N-asetilsistem
N-asetilsistem merupakan antidotum terpilih
a)

Kerjanya sebagai subsitusi glutation

b) Meningkatkan sintesa glutation

c)

Meningkatkan konjungsi sulfat pada parasetamol

 Kemasan ampul 10 ml 10% (mengandung 100 mg/ml)

1 gram atau ampul 10ml 20% (mengandung 200 mg/ml)

Indikasi

Pasien yang menelan parasetamol < 24 jam (dapat diberian

sampai 72 jam setelah penelanan
N-asetilsistein diberikan secara intra vena atau per oral. Jika
diberikan per oral dapat menyebabkan mual dan muntah

Dosis dan cara pemberian

Secara perinfus :
Bolus 150 mg/kg BB dalam 200 ml dextrose 5% secara
perlahan selama 15 menit, dilanjutkan 50 mg/kg BB dalam 500
ml dextrose 5% selama 4 jam, kemudian 100 mg/kg BB dalam
1000 ml dextrose 5% secara perlahan melalui intravena selama
16 jam berikutnya.
Jika perlu N asetilsistein diberikan dalam NaCL fisiologis
(catatan: kestabilan N asetilsistein dalam NaCL 0,9% kurang
dari 24 jam)

 Secara peroral atau melalui pipa nasogastrik

Dosis awal 140 mg/kg BB. 4 jam, jam kemudian berilah
dosis pemeliharaan 70 mg/kg BB setiap 4 jam
sebanyak 17 dosis,

Keracunan Salisilat
Penggunaan
A. Asam asetil salisilat secara luas dipergunakan untuk
mengobati nyeri panas, flu, peradangan tulang dan otot seperti
artritis.
B. Kolin salisilat gel atau cairan dioleskan pada gusi anak-anak
untuk mengobati sakit gigi.
C. Metil salisilat dibuat dalam bentuk linimen dan salep yang
diberikan diatas kulit untuk mengobati nyeri dalam tulang dan
rematik.
D. Asam salisilat digunakan dalam bentuk bubuk, lotion atau
salep untuk mengobati penyakit kulit.

Dosis toksis salisilat menstimulasi pusat

pernapasan menyebabkan alkalosis pernapasan.

Pada keracunan berat terjadi metabolik asidosis,

kehilangan cairan dan elektrolit. Keracunan pada
sistim saraf pusat ditandai dengan telinga

berdenging, pendengaran hilang

Dosis Toksis:
A. Penelanan akut 50-200 mg/kg .
B. Intoksikasi kronik dapat terjadi pada penelanan
100 mg/kg/hari selama 2 hari atau lebih.
Gambaran Klinis
A. Penelanan akut
B. Keracunan kronik

Penatalaksanaan
1. Stabilisasi

2. Dekontaminasi
- Dekontaminasi gastrointestinal
- Aspirasi dan kumbah lambung

- Arang aktif
- Katartik
3. Maningkatkan eliminasi
4. Antidotum: tidak ada
5. Terapi selanjutnya

Penatalaksanaan(2)
Arang aktif : Dosis tunggal 1 gram/kg
(dewasa 30-100 gr dan anak-anak: 15-30 gr)

Cara pemberian : dicampur rata dengan perbandingan

5-10 gr arang aktif dengan 100-200 ml air sehingga
seperti bubur kental. Dewasa 10 gr dan anak-anak 5 gr
tiap 20 menit.
Bilas usus (whole bowel irrigation) dilakukan pada
body packer 1-2 L/jam sampai bersih

3. Terapi suportif

Keracunan Masal
Fase Informasi
-Jenis makanaan/jumlah makanan
-Jumlah korban
-Keluhan yg ditemukan
Panitia Pelaksana

Tim Medis
-Besar masalah
-Jenis bahan

-Perawatan awal
-Observasi/rujukan

Internal :
SDM/obat/transportasi/
RS rujukan
Eksternal : Kerjasama
lintas sektor dgn
DinKes setempat

Antidotes commonly used within the first hour of treatment of a patient

with an overdose
Toxin
Opiated

Antidote
Naloxone

Dose and Comments

Starting dose 2 mg. More may be needed for
overdoses of some synthetic narcotics; less
may be used in addicts to avoid precipitating
withdrawal symptoms.

Methanol, ethylene
glycol

Ethanol

Loading dose 10 ml of 10% solution per

kilogram per hour Double maintenance dose
should be used during dialysis. Titrate to a
blood ethanol level of 22 mmol per liter
(100 mg per deciliter)

Anticholinergic
agents

Physostigmine

1 to 2 mg intravenously. Over 5 minutes. Used

only for severe delirium. May be usedful to
treat seizures or tachydysrhythmias, but
strong clinical evidence is lacking

Organophosphate or
carbamate isecticides

Atropine

Test doses 2 mg intravenously. Repeat in

larger incremants until drying of pulmonary
secretions occurs

Antidotes commonly used within the first hour of treatment of a patient

with an overdose (2)
Toxin

Antidote

Dose and Comments

Isoniazid, hydrazine Phyridoxine Give in gram-per-gram equivalent doses to what was
ingested. If amount ingested is unknow, start with 5
monomethylhylhydg intravenously. An overdose of pyridoxine may
razine (in gyromitra
cause neuropathy
species mushrooms)
Beta-bloker

Glucagon

Tricyclic anti
depressants

Bicarbonate 1 to 2 mmol perkilogram introvenously for

substantial cardiac condition delay or entricular
dysrhythmias. Titrate to response and arterial pH.

Digitalis, glycosides

Digoxinspecific
antibody
fregment

Starting dose 5 to 10 mg intravenously. Titrate to

response (normalization of signs). Maintanance
dose of 2 to 10 mg per hour may be used

Equimolar to ingestion the number of milligrams of

digoxin ingested divided by 0.6 is the number of
vials required. If amount ingested is unknow and the
patient has life-threatening dysrhythythmias give 10
to 20 vials intravenously. If serum digoxin
concentration is know, the number of vials to
administer =
concentration (in ng/ml) X 5.5 X weight in kg
600

Antidotes commonly used within the first hour of treatment of a patient

with an overdose (3)
Toxin

Antidote

Dose and Comments

Benzodiazepines

Flumazenil

0.2 mg over 30 seconds. If there is no response

after 30 seconds. Give 0.3 mg over 30 second. If
there is no response after 30 seconds. Give 0.5 mg
over 30 second at 1 minutes intervals up to a total
dose of 3 mg. Should not be given if the patient
shows of signs of serious overdose from
coingstion of tricyclic antideprssant or was talking
benzodiazepines for control of siezured

Calcium-channel
blockers, hydro
fluoric acid
fluorides

Calcium

1 gr calcium chloride given over 5 minutes by

intravenous infusion with continous cardiac
monitoring. May be repeated often in life
threatening situations, but the serum calsium level
should be monitored after the third dose

Social / Environmental
Risk Factors
Behavioral / Psychological
Risk Factors
Organ Systems

Risk Factors
Cellular
Risk Factors
Molecular
Risk Factors