POISONING

BAGUS RAHMAT SANTOSO, NS., M.KEP

CASE

SEORANG ANAKA LAKI-LAKI USIA 15 TAHUN DIBAWA KE

UGD. PADA TUBUH KORBAN TERCIUM BAU ALKOHOL. PADA
PEMERIKSAAN FISIK TD: 80 MMHG PALPASI, NADI: 95 BPM,
RR: 8 X/MENIT. SEBELUM MRS KORBAN MUNTAH-MUNTAH
DIRUMAH. RIWAYAT PASIEN MINUM-MINUMAN ALCOHOL
CAP GAJAH DUDUK DAN DICAMPUR MINUMAN BERENERGI
DAN LAIN-LAIN. SAAT INI KORBAN MENGALAMI PENURUNAN
KESADARAN.

WHAT SHOULD YOU DO TO BE A EMERGENCY NURSE?

INTRODUCTION

• POISONING IS CAUSED BY SWALLOWING, INJECTING,

BREATHING IN, OR OTHERWISE BEING EXPOSED TO A
HARMFUL SUBSTANCE. MOST POISONINGS OCCUR BY
ACCIDENT.

• IMMEDIATE FIRST AID IS VERY IMPORTANT IN A POISONING

EMERGENCY. THE FIRST AID YOU GIVE BEFORE GETTING
MEDICAL HELP CAN SAVE A PERSON'S LIFE.
EPIDEMIOLOGI

• POISONING IS A SIGNIFICANT GLOBAL PUBLIC HEALTH

PROBLEM.

• ACCORDING TO WHO DATA, IN 2004 AN ESTIMATED

346,000 PEOPLE DIED WORLDWIDE FROM UNINTENTIONAL
POISONING

• OF THESE DEATHS, 91% OCCURRED IN LOW- AND

MIDDLE-INCOME COUNTRIES.

• IN THE SAME YEAR, UNINTENTIONAL POISONING CAUSED

THE LOSS OF OVER 7.4 MILLION YEARS OF HEALTHY LIFE
CAUSES

• CARBON MONOXIDE GAS (FROM FURNACES, GAS

ENGINES, FIRES, SPACE HEATERS)

• CERTAIN FOODS
• CHEMICALS IN THE WORKPLACE
• DRUGS, INCLUDING OVER-THE-COUNTER AND
PRESCRIPTION MEDICINES (SUCH AS AN ASPIRIN
OVERDOSE) AND ILLICIT DRUGS SUCH AS COCAINE

• HOUSEHOLD DETERGENTS AND CLEANING PRODUCTS

• HOUSEHOLD AND OUTDOOR PLANTS (EATING TOXIC

PLANTS)

• INSECTICIDES
• PAINTS
SYMPTOMS
• ABDOMINAL PAIN • HEART PALPITATIONS
• BLUISH LIPS • IRRITABILITY
• CHEST PAIN • LOSS OF APPETITE
• CONFUSION • LOSS OF BLADDER CONTROL
• COUGH • MUSCLE TWITCHING
• DIARRHEA • NAUSEA AND VOMITING
• DIFFICULTY BREATHING OR • NUMBNESS AND TINGLING
SHORTNESS OF BREATH
• SEIZURES
• DIZZINESS
• SKIN RASH OR BURNS
• DOUBLE VISION
• STUPOR
• DROWSINESS
• UNCONSCIOUSNESS
• FEVER
• UNUSUAL BREATH ODOR
• HEADACHE
• WEAKNESS
Dose
 The amount of chemical entering the body
 This is usually given as mg of chemical/kg
of body weight = mg/kg
 The dose is dependent upon
* The environmental concentration
* The properties of the toxicant
* The frequency of exposure
* The length of exposure
* The exposure pathway
Exposure: Pathways
• Routes and Sites of Exposure
– Ingestion (Gastrointestinal Tract)
– Inhalation (Lungs)
– Dermal/Topical (Skin)
– Injection
• Intravenous, Intramuscular, Intraperitoneal

• Typical Effectiveness of Route of

Exposure
iv > inhale > ip > im > ingest > topical
KOMPLIKASI
• KERACUNAN ZAT PADAT
1. OBAT SALISILAT: PERDARAHAN, EDEMA PARU,
DEPRESI PERNAPASAN, NEKROSIS TUBULAR AKUT

2. MAKANAN: DEHIDRASI, GANGGUAN KESADARAN

• KERACUNAN GAS:
1. CARBON MONOLSIDA: EDEMA PARU, DEPRESI
PERNAPASAN, SYOK, COMA

2. TOKSIT IRITAN: EDEMA PARU

3. HIDROKARBON: DEPRESI PERNAPASAN
KOMPLIKASI
• KERACUNAN ZAT CAIR
 ALKOHOL
1. PERDARAHAN LAMBUNG DAN USUS
2. KERUSAKAN GINJAL DENGAN ZAT GULA DALAM KENCING
3. KERUSAKAN HATI (LIVER)
4. KEGAGALAN JANTUNG
5. OEDEMA PARU-PARU (PARU-PARU BERISI AIR)
6. PEMBENTUKAN METHEMOGLOBINE (OLEH AMLY ALKOHOL)
 METIL ALKOHOL: KEJANG, SYOK, KOMA
FIRST AID
1. SEEK IMMEDIATE MEDICAL HELP.
2. FOR POISONING BY SWALLOWING:
• PERIKSA DAN MONITOR JALAN NAFAS PASIEN, POLA NAFAS,
DAN SIRKULASI. JIKA DIPERLUKAN, BERIKAN RESCUE
BREATHING ATAU CPR

• PASTIKAN KORBAN TERSEBUT KERACUNAN. CARI TANDA-

TANDA SEPERTI BAU MULUT, IRITASI DISEKITAR MULUT, SESAK
NAFAS, MUNTAH, BAU YANG TIDAK BIASA, JIKA
MEMUNGKINKAN IDENTIFIKASI RACUNNYA

• DO NOT MAKE A PERSON THROW UP UNLESS TOLD TO DO

SO BY POISON CONTROL OR A HEALTH CARE PROFESSIONAL.
FIRST AID CONTINUE
• JIKA PASIEN MUNTAH, BEBASKAN JALAN NAFAS, AMBIL
SAMPEL VOMITING  IDENTIFIKASI KERACUNAN.

• IF THE PERSON STARTS HAVING CONVULSIONS,

GIVE CONVULSION FIRST AID.

• PASTIKAN PASIEN DALAM KEADAAN NYAMAN DAN

MIRINGKAN KEARAH KIRI

• IF THE POISON HAS SPILLED ON THE PERSON'S CLOTHES,

REMOVE THE CLOTHING AND FLUSH THE SKIN WITH WATER.
FIRST AID CONTINUE
3. FOR INHALATION POISONING:
• CALL FOR EMERGENCY HELP. NEVER ATTEMPT TO
RESCUE A PERSON WITHOUT NOTIFYING OTHERS FIRST.

• IF IT IS SAFE TO DO SO, RESCUE THE PERSON FROM THE

DANGER OF THE GAS, FUMES, OR SMOKE. OPEN
WINDOWS AND DOORS TO REMOVE THE FUMES.

• TAKE SEVERAL DEEP BREATHS OF FRESH AIR, AND THEN

HOLD YOUR BREATH AS YOU GO IN. HOLD A WET
CLOTH OVER YOUR NOSE AND MOUTH.

• DO NOT LIGHT A MATCH OR USE A LIGHTER BECAUSE

SOME GASES CAN CATCH FIRE.
FIRST AID CONTINUE

• AFTER RESCUING THE PERSON FROM DANGER, CHECK

AND MONITOR THE PERSON'S AIRWAY, BREATHING, AND
PULSE. IF NECESSARY, BEGIN RESCUE BREATHING AND
CPR.
• IF NECESSARY, PERFORM FIRST AID FOR EYE INJURIES OR
CONVULSION FIRST AID.

• IF THE PERSON VOMITS, CLEAR THE PERSON'S AIRWAY.

WRAP A CLOTH AROUND YOUR FINGERS BEFORE
CLEANING OUT THE MOUTH AND THROAT.

• EVEN IF THE PERSON SEEMS PERFECTLY FINE, GET

MEDICAL HELP.
MANAGEMENT IN ED

1. RESUSITASI DAN STABILISASI  ABC

2. EVALUASI KLINIS DAN DIFINITIF DIAGNOSA

3. DEKONTAMINASI

4. ANTIDOTUM

5. PERAWATAN SUPORTIF
EVALUASI KLINIS DAN
DEFINITIF DIAGNOSA.
ANAMNESA :
- BAGAIMANA RACUN MASUK TUBUH :
- JUMLAH RACUN YANG MASUK.
- SUDAH BERAPA LAMA KONTAK.
- PERTOLONGAN PERTAMA YANG SUDAH
DIBERIKAN.
- PROFIL PSYKOLOGI PENDERITA.
- GEJALA YANG TELAH DIALAMI PENDERITA.
 Common Physical Signs in Toxicology
Physical signs Likely Causative agent

Coma; drowsiness Alcohol, antidepressants, antihistamines, antipsychotics, barbiturates and

other sedatives, narcotics, salicylates
Breath odour Alcoholic breath: Ethanol
Smell of garlic: Arsenic, organophosphates, phosphorus
Odour of bitter almonds: Cyanides
Smell of acetone: Isopropanol, nail polish remover, salicylates
Pungent odour: Ethchlorvynol
Fragrance of violets: Turpentinne
Smell of oil of Wintergreen: Methylsalicylate liniment
Pearl-like odour: Chloral hydrate
Miscellaneous typical odours: Ammonia, kerosene, petrol, petroleum
distillates, phenol
Eyes
Pupils:
Constricted (miosis) Mushrooms (muscarinic properties), narcotics, organophosphates
Dilated (mydriasis) Amphetamines, antihistamines, atropine, barbiturates, cocaine, glutethamide,
lysergic acid Diethylamide (LSD), methanol, opiate withdrawal, tricyclic
antidepressants
Nystagmus Barbiturates, PCP, phenytoin, sedatives
Visual disturbance Botulism, digoxin, methanol, organophosphates
Visual hallucinations Alcohol, cocaine, LSD, mescaline, PCP 9/1/2018
Mouth:
Dry Amphetamines, antihistamines, atropine, narcotics
Salivation Arsenic, corrosives, mercury, mushrooms, organophosphates, strychnine.

Gum discoloration Lead, other heavy metals

Respiration:
Rate increased Amphetamines, barbiturates (early effect), methanol, petroleum distillates,
(>20/min) salicylates
Rate decreased Alcohol, barbiturates (late effect), narcotics
(<10/min)
Respiratory paralysis Botulism, organophosphates
Wheezing/pulmonary Narcotics, organophosphates, petroleum distillates
oedema

Heart Rate:
Bradycardia Digitalis, narcotics, sedatives
Tachycardia Alcohol, amphetamines, atropine, cocaine, salicylates
Gastro-intestinal:
Abdominal Colic Arsenic, heavy metals, lead, mushrooms, narcotic withdrawal,
organophosphates
Constipation Lead, narcotics
Diarrhoea Arsenic, boric acid, iron, mushrooms, organophosphates
Vomiting (sometimes Boric acid, caffeine, corrosives, heavy metals, phenol, salicylates,
bloody) theophylline
Skin:
Bullae Barbiturates, carbon monoxide
Cyanosis Carbon monoxide, nitrites, strychnine
Jaundice Arsenic, carbon tetrachloride, castor bean, mushroom
(delayed effect), paracetamol (delayed effect)
Needle marks Amphetamines, narcotics, PCP
Purpura Salicylates, snake bites, spider bites
Redness and Alcohol, antihistamines, atropine, boric acid, carbon
flushing of skin monoxide, cyanide
Sweatiness Amphetaminess, barbiturates, cocaine, LSD,
mushrooms, organophosphates
Neuromuscular:
Fasciculations/ Alcohol, amphetamines, antihistamines, barbiturate
convulsions withdrawal, chlorinated hydrocarbons, cyanide, isoniazid,
lead, methaquolone, organophosphates, phenothiazines,
plants (a number of), salicylates, strychnine, tricyclic
antidepressants
Paralysis Botulism, heavy metals
Ataxia Alcohol, barbiturates, bromides, hallucinogens, heavy metals,
organic solvents, phenytoin
DEKONTAMINASI

1. DEKONTAMINASI KULIT DAN MATA  BILAS

DENGAN AIR MENGALIR SELAMA 10-15 MENIT

2. DEKOMTAMINASI PERNAFASAN  HIGH FLOW

OKSIGEN 100% WITH NRM

3. DEKONTAMINASI GIT  DILUSI/PENGENCERAN,

EMESIS, GASTRIC LAVAGE, ELIMINASI
MENGGUNAKAN CARCOAL
DECONTAMINATION
HOSPITAL TREATMENT

• ACTIVATED CHARCOAL – IS SOMETIMES USED TO TREAT

SOMEONE WHO'S BEEN POISONED; THE CHARCOAL BINDS
TO THE POISON AND STOPS IT BEING FURTHER ABSORBED
INTO THE BLOOD

• ANTIDOTES – THESE ARE SUBSTANCES THAT EITHER PREVENT

THE POISON FROM WORKING OR REVERSE ITS EFFECTS

• SEDATIVES – MAY BE GIVEN IF THE PERSON IS AGITATED

• A VENTILATOR (BREATHING MACHINE) – MAY BE USED IF
THE PERSON STOPS BREATHING

• ANTI-EPILEPTIC MEDICINE – MAY BE USED IF THE PERSON

HAS SEIZURES (FITS)
NURSING CARE IN ED
1. MAINTAIN AN OPEN AIRWAY.
2. LAKUKAN FOCUSED HISTORY AND PHYSICAL EXAM
3. TERMASUK SAMPLE HISTORY.  USE GLOVED HANDS TO
CAREFULLY REMOVE ANY PILLS, TABLETS, OR FRAGMENTS FROM
THE PATIENT’S MOUTH.

4. VITAL SIGNS.
5. MENGENCERKAN RACUN DENGAN AIR ATAU SUSU SESUAI
INDIKASI

6. TRANSPORT THE PATIENT WITH ALL CONTAINERS, BOTTLES, AND

LABELS FROM THE SUBSTANCES.

7. PERFORM ONGOING ASSESSMENT EN ROUTE.

NURSING CARE FOR INHALED POISONING

• REMOVE THE PATIENT TO A SAFE AREA. DETECT AND TREAT

IMMEDIATELY LIFE-THREATENING PROBLEMS IN THE INITIAL
ASSESSMENT. EVALUATE THE NEED FOR PROMPT
TRANSPORT FOR CRITICAL PATIENTS.

• PERFORM A FOCUSED HISTORY AND PHYSICAL EXAM ,

INCLUDING SAMPLE HISTORY AND VITAL SIGNS.

• ADMINISTER HIGH CONCENTRATION OXYGEN.

• TRANSPORT THE PATIENT WITH ALL CONTAINERS, BOTTLES,

AND LABELS FROM THE SUBSTANCE.

• PERFORM ONGOING ASSESSMENT EN ROUTE.

NURSING CARE FOR ABSORBED
POISONING
1. DETECT AND TREAT IMMEDIATELY LIFE-THREATENING PROBLEMS IN THE INITIAL
ASSESSMENT. EVALUATE THE NEED FOR PROMPT TRANSPORT FOR CRITICAL
PATIENTS.

2. PERFORM A FOCUSED HISTORY AND PHYSICAL EXAM , INCLUDING SAMPLE

HISTORY AND VITAL SIGNS. THIS INCLUDES REMOVING CONTAMINATED
CLOTHING WHILE PROTECTING ONESELF FROM CONTAMINATION.

3. REMOVE THE POISON BY DOING ONE OF THE FOLLOWING:

a. POWDER: BRUSH OFF PATIENT.
b. LIQUIDS: IRRIGATE WITH CLEAN WATER FOR AT LEAST 20 MINUTES AS
NEEDED.

c. EYES: IRRIGATE WITH CLEAN WATER FOR AT LEAST 20 MINUTES AS NEEDED.

4. TRANSPORT THE PATIENT WITH ALL CONTAINERS, BOTTLES, AND LABELS FROM
THE SUBSTANCE.

5. PERFORM ONGOING ASSESSMENT EN ROUTE.

ANTIDOTUM

Antidote poisoning Treatment regime

N-Acetylcystein Paracetamol 1. Iv NAC 150 mg/kg
dlm 200 ml D5%
diatas 30min.
Diikuti
2. 1v NAC 50 mg/kg
dlm 500 ml D 5%
diatas 4 jam
diikuti
3. Iv NAC 100 mg/kg
dlm 1L
D5%diatas 16 jam
ATROPINE 1. Organophosphat 1-2 mg per 5 menit
2. Nerve agents sampai sekresi
3. Carbamat bronchial berkurang
4. Muscarinic agent NB: ukuran pupil
bukan tujuan akhir
terapi
ETHANOL 1. Methanol 1. Iv 7.5 ml/kg dari
2. Ethylene glycol 10% Ethanol,
dilanjutkan
2. 1v 1-2 ml/kg dari
10 % ethanol
untuk
mempertahankan
serum ethanol
pada 100mg/dl
Naloxone 1. Opioad 1. Iv 0.4 -2 mg
2. Clonidine diatas 5 menit
diikuti dengan
2. Iv 0.4 -0.8
mg/jam

Sodium Bicarbonat 1. Severe 1. Iv 1-2 mEq/jam

metabolic bolus diikuti
acidosis akibat 2. Infusion untuk
salicylat, mempertahanka
methanol, n pH darah
ethylene glycol 7.45- 7.5 dan
2. Tricyclic pH urine 7.5-8
antidepresssant
MANAGEMEN SPESIFIK PADA KERACUNAN
ORGANOPHOSPHATE TOXICITY
TANDA DAN GEJALA

TANDA GEJALA KERACUNAN ORGANOPHOSPHATE TERBAGI MENJADI 3

KATEGORI :

1. MUSCARINIC EFFECTS
• CARDIOVASKULER  BRADYCARDIA, HYPOTENSION
• RESPIRATORY  BRONCHOSPASM, COUGH, SEVERE RESPIRATORY DISTRESS
• GASTROINTESTINAL - HYPERSALIVATION, NAUSEA AND VOMITING,
ABDOMINAL PAIN, DIARRHEA, FECAL INCONTINENCE

• GENITOURINARY – INCONTINENCE
• OCULAR - BLURRED VISION, MIOSIS
• GLANDS - INCREASED LACRIMATION, DIAPHORESIS
2. NICOTINIC EFFECTS  MUSCLE FASCICULATIONS,
CRAMPING, WEAKNESS, AND DIAPHRAGMATIC FAILURE

3. CNS EFFECTS
 ANXIETY
 EMOTIONAL LABILITY
 RESTLESSNESS
 CONFUSION
 ATAXIA
 TREMORS
 SEIZURES
 COMA
TREATMENT

1. AIRWAY CONTROL  ABC DAN INTUBASI JIKA PERLU

2. PEMASANGAN IV LINE  MULTIPLE MEDICATION DAN BGA
3. KOLABORASI PEMBERIAN ATROPINE DAN GLYCOPYRROLATE
UNTUK MUSCARINIC EFFECT
4. MONITORING ECG  PADA OP POISONING BISA
MENYEBABKAN TORSADES DE POINTES  MAGNESIUM SULFATE
5. DECONTAMIINASI  GASTRIC LAVAGE DAN PENGGUNAAN
CARCOAL
6. APABILA KEJANG  KOLABORASI PEMBERIAN DIAZEPAM
7. PERAWATAN SUPORTIF DI ICU
DEXTROMETHORPHAN OVERDOSE
SYMPTOMS

• BREATHING PROBLEMS -- SLOW • HALLUCINATIONS

AND LABORED
• HIGH OR LOW BLOOD PRESSURE
BREATHING, SHALLOW
BREATHING, NO BREATHING • MUSCLE SPASTICITY (TWITCHES)
• BLUISH-COLORED FINGERNAILS • NAUSEA
AND LIPS
• RAISED BODY TEMPERATURE
• BLURRED VISION (HYPERTHERMIA)
• COMA • RAPID HEARTBEAT
• CONSTIPATION • SPASMS OF THE STOMACH AND
INTESTINES
• CONVULSIONS (SEIZURES)
• VOMITING
• DROWSINESS
• DIZZINESS
BEFORE CALLING EMERGENCY

DETERMINE THE FOLLOWING INFORMATION:

• PATIENT'S AGE, WEIGHT, AND CONDITION
• NAME OF PRODUCT (AS WELL AS THE INGREDIENTS AND
STRENGTH, IF KNOWN)

• TIME IT WAS SWALLOWED

• AMOUNT SWALLOWED
• IF THE MEDICINE WAS PRESCRIBED FOR THE PATIENT
ED MANAGEMENT

• ACTIVATED CHARCOAL
• BREATHING SUPPORT, INCLUDING A TUBE THROUGH
THE MOUTH AND BREATHING MACHINE (VENTILATOR)

• EKG (HEART TRACING)

• FLUIDS THROUGH A VEIN (BY IV)
• LAXATIVE
• MEDICATION TO REVERSE THE EFFECT OF THE
NARCOTIC IN THE DRUG AND TREAT OTHER SYMPTOMS

• TUBE THROUGH THE MOUTH INTO THE STOMACH TO

EMPTY THE STOMACH (GASTRIC LAVAGE)
ETHANOL OVERDOSE
SYMPTOMS

• NAUSEA, VOMITING, ABDOMINAL PAIN

• HYPOGLYCAEMIA
• ATAXIA, LETHARGY, COMA, CONVULSIONS
• RESPIRATORY DEPRESSION
• HYPOTHERMIA
• HYPOKALAEMIA, METABOLIC ACIDOSIS
• BREATH ALCOHOL IF POSSIBLE
PREHOSPITAL CARE

• REMOVE ANY CONTAINERS NEAR PATIENT

• CHEK BLOOD GLUCOSE
• AMANKAN ABC BILA PASIEN PENURUNAN
KESADARAN
ED MANAGEMENT
1. INITIAL TREATMENT SHOULD FOCUS ON THE AIRWAY, BREATHING,
AND CIRCULATION
2. CAREFUL MONITORING
3. PREVENTION OF BREATHING OR CHOKING PROBLEMS
4. OXYGEN THERAPY
5. FLUIDS GIVEN THROUGH A VEIN (INTRAVENOUSLY) TO PREVENT
DEHYDRATION
6. USE OF VITAMINS AND GLUCOSE TO HELP PREVENT SERIOUS
COMPLICATIONS OF ALCOHOL POISONING
7. GIVE ANTIDOTE  Iv 7.5 ml/kg dari 10% Ethanol,
kemudian dilanjutkan 1v 1-2 ml/kg dari 10 %
ethanol untuk mempertahankan serum ethanol
pada 100mg/dl
8. Perawatan Supportif  ICU
PERAWATAN SUPORTIF

- Biasanya di ICU atau Ruang khusus

- Suportif pada Airway, Breathing,
Circulation
- Toxin eleminasi.