” Unbearable Sadness”

Rina, a 24-year-old student, was brought by her parents to the ER RSMP in an unconscious state because she tried
to commit suicide by drinking Baygon 2 hours ago. She looked shortness of breath. There are a trace of vomit and
a smell of insect poison from her mouth. According to her parents, after drinking Baygon, she groaned in pain in
her stomach accompanied by vomiting, peeing in her pants and having seizures 3 times. It was estimated that Rina
had drunk half a large bottle of Baygon.

Physical Examination:

General Appearance: GCS: E2 M5 V2, looks very sick

Vital Sign: BP : 120/80 mmHg, HR : 58 x/m, regular, RR : 28x/m, T : 37,40C

Specific Examination :

Head:

Eye: pin point pupil (+/+), ligh reflex (-/-), anemic conjungtive (-/-), sunken eyelids (-/-),

tremor eyeball (+/+).

Mouth: tremor tongue (+), a lot of saliva coming out of the corner of the mouth

Thoraks: symmetrical movement, normal vesicular, smooth wet rhonchi (+/+), wheezing (-), normal heart sound,
murmur (-).

Abdomen:

Inspection: flat

Palpation: tenderness can not be assessed

Percussion: tympani

Auscultation: increased bowel sounds

Ekstremities: cyanosis in fingertips.

Laboratory:

Blood test: Hb 13,4 g/dl; leucocyte: 9900 /mm3, Trombocyte: 225.000 mm3, LED: 13 mm/jam

Blood chemistry: Ureum 25 mg/dl, Creatinin 0,8 mg/dl, Sodium 130 mmol/l, Potassium 3,1 mmol/l
 "Kesedihan yang Tak Tertahankan"

Rina, mahasiswi berusia 24 tahun, dibawa oleh orang tuanya ke IGD RSMP dalam keadaan tidak sadarkan diri
karena mencoba bunuh diri dengan meminum Baygon 2 jam yang lalu. Dia terlihat sesak napas. Ada jejak muntah
dan bau racun serangga dari mulutnya. Menurut orang tuanya, setelah minum Baygon, dia merintih kesakitan di
perutnya disertai muntah-muntah, kencing di celana dan kejang 3 kali. Diperkirakan Rina telah meminum setengah
botol besar Baygon.

Pemeriksaan fisik:

Penampilan Umum: GCS: E2 M5 V2, terlihat sangat sakit

Tanda Vital : TD : 120/80 mmHg, HR : 58 x/m, regular, RR : 28x/m, T : 37,40C

Pemeriksaan Khusus :

Kepala:

Mata: pupil pin point (+/+), refleks ligh (-/-), anemia konjungtif (-/-), kelopak mata cekung (-/-),

bola mata gemetar (+/+).

Mulut: lidah gemetar (+), banyak air liur yang keluar dari sudut mulut

Thoraks: gerakan simetris, vesikular normal, ronki basah halus (+/+), mengi (-), bunyi jantung normal, murmur (-).

Perut:

Inspeksi: datar

Palpasi : nyeri tekan tidak dapat dinilai

Perkusi: timpani

Auskultasi : bising usus meningkat

Ekstremitas: sianosis di ujung jari.

Laboratorium:

Tes darah: Hb 13,4 g/dl; leukosit: 9900 /mm3, Trombosit: 225.000 mm3, LED: 13 mm/jam

Kimia darah: Ureum 25 mg/dl, Kreatinin 0,8 mg/dl, Natrium 130 mmol/l, Kalium 3,1 mmol/l
1. Rina, a 24-year-old student, was brought by her parents to the ER RSMP in an unconscious state because she
tried to commit suicide by drinking Baygon 2 hours ago.
a. What the meaning of Rina, a 24-year-old student, was brought by her parents to the ER RSMP in
an unconscious state because she tried to commit suicide by drinking Baygon 2 hours ago?
 Maknanya Rina mengalami keracunan insektisida yang dapat menimbulkan gejala berupa kehilangan
kesadaran akibat gangguan sistem saraf pusat. Efek sistem saraf pusat berasal dari stimulasi nikotinik
dan stimulasi muskarinik di otak. Gejala yang dilaporkan termasuk agitasi, depresi, koma, dan kejang.
(Balqis dan Hidayati, 2019)
Pada kasus ini keadaan tidak sadar terjadi karena akumulasi asetilkolin pada sistem saraf pusat yang
menyebabkan tidak sadar dan bersifat akut. Gejala timbul 30-60 menit dan mencapai maksimum dalam 2-8
jam
It means rina has insecticide poisoning, which can cause symptoms in the form of loss of
consciousness due to disorders of the central nervous system. The effects of the central nervous
system come fromnicotinic stimulation and muskarinic stimulation inbrain. Reported symptoms
include agitation,depression, coma, and seizures. (Balqis and Hidayati, 2019)
In this case, unconsciousness occurs due to the accumulation of acetylcholine in the central nervous
system which causes unconsciousness and is acute. Symptoms occur in 30-60 minutes and reach a
maximum in 2-8 hours

Sumber :
Balqis, D. and Hidayati, I. (2019) ‘Intoksikasi Organofosfat dengan Krisis Kolinergik Akut , Gejala Peralihan dan
Polineuropati Tertunda’, J Agromedicine, 6(1), pp. 337–342.
b. What are the impact of drinking baygon?
 Minum insektisida dapat menyebabkan keracunan. dimana keracunan dapat menghasilkan efek
nikotinik dan muskarinik yang mengakibatkan munculnya manifestasi klinis yang khas yaitu sindrom
kolinergik akut, sindrom intermediet, dan OPIDPN (Balqis dan Hidayati, 2019)
Drinking insecticides can cause poisoning. where poisoning can produce nicotinic effects and
muskarinik that resulted in the emergence of typical clinical manifestations i.e. cholinergic syndrome
acute, intermediate syndrome, and OPIDPN (Balqis and Hidayati, 2019)

Sumber:
Balqis, D. and Hidayati, I. (2019) ‘Intoksikasi Organofosfat dengan Krisis Kolinergik Akut , Gejala Peralihan dan
Polineuropati Tertunda’, J Agromedicine, 6(1), pp. 337–342.
c. What is the etiologi of the unconscious state in the case?
d. What is the relationship between age and gender?
 Bunuh diri merupakan penyebab kedua tertinggi kematian pada individu berusia 15 tahun hingga 29
tahun di seluruh dunia (WHO dalam Rubrik, 2014). Bunuh diri di Amerika Serikat merupakan salah
 satu penyebab kematian pada usia 24 tahun hingga 44 tahun dan diperkirakan sebanyak 30.000 kasus
bunuh diri terjadi dalam setahun. Berdasarkan data kasus bunuh diri pada tahun 1995 - 2004 yang
dicatat oleh bagian forensik FKUI/RSCM, terdapat 771 orang laki-laki melakukan tindakan bunuh diri
dan 348 orang perempuan melakukan tindakan bunuh diri. Berdasarkan jumlah bunuh diri tersebut, 41
persen melakukan bunuh diri dengan cara gantung diri, 23 persen melakukan bunuh diri dengan cara
meminum insektisida, dan sebanyak 356 orang melakukan bunuh diri dengan meminum obat
berlebihan (Ratih dan Tobing, 2016).
Suicide is the second leading cause of death in individuals aged 15 to 29 years worldwide (WHO in
Rubric, 2014). Suicide in the United States is one of the leading causes of death between the ages of
24 and 44 and an estimated 30,000 suicides occur in a year. Based on data on suicide cases in 1995 -
2004 recorded by the forensic division of the FKUI/RSCM, there were 771 men committing suicide
and 348 women committing suicide. Based on the number of suicides, 41 percent committed suicide
by hanging themselves, 23 percent committed suicide by drinking insecticides, and as many as 356
people committed suicide by taking excessive drugs (Ratih and Tobing, 2016).

Sumber :
Ratih, AA Sagung Weni Kumala dan Tobing, David Hizkia. 2016. KONSEP DIRI PADA PELAKU
PERCOBAAN BUNUH DIRI PRIA USIA DEWASA MUDA DI BALI. Denpasar: Jurnal Psikologi Udayana.
e. What are the ingredients contained in insecticides / baygon?
 Organafosfat dan karbamat. Gugus Organafosfat adalah dichorvos atau dichlorovynil dimethyl
phosphate (DDVP). Dan bahan aktif Carbamate adalah Propuxur yang merupakan jenis insektisida
pembunuh serangga. Kandungan senyawa kimia yang terdapat pada obat nyamuk selain berupa
propuxur dan dichlorvos, senyawa lain yaitu pyrethroids, tranfluthrin, dellatherine.
Ifo:
1) Insektisida untuk dipakai dalam pertanian
a) Tolly (Malathion) parathion
b) Basudin diazinon
c) Phosdrin systox
2) Insektisida untuk Keperluan tumah tangga
a) Baygon (DDVP+Propoxur)
b) Starvox (DDVP+allethrin)
c) Sheltox (DDVP+Pyrethroid)
Organaphosphate dan carbamates. The Organaphosphate group isdichorvos or dichlorovynil dimethyl
phosphate (DDVP). And the active ingredient Carbamate is Propuxur which is a type of insecticide
insect killer. Compound content chemicals found in mosquito repellent other than in the form of
propuxur and dichlorvos, other compounds, namely pyrethroids, tranfluthrin, dellatherine.
Sumber :
Khasanah, Heti Rais, dkk. 2017. Jangka Waktu Penggunaan Obat Nyamuk Bakar Terhadap Kadar Enzim
Cholinester Pada Usia Subur di Desa Sidosari Sukaraja Kabupaten Seluma. Journal Of Nursing and Public
Health. Vol. 5(1): 1-5.
f. What is the mechanism of unconscious in the case?
g. How is the first aid in the case?
a) Penanganan Keracunan Pestisida
Setiap orang yang pekerjaannya sering berhubungan dengan pestisida seperti petani, buruh penyemprot
dan Iain-lain harus mengenali gejala dan tanda keracunan pestisida dengan baik. Tindakan pencegahan
lebih baik dilakukan untuk menghindari keracunan. Setiap orang yang berhubungan dengan pestisida
harus memperhatikan hal-hal berikut:
1) Kenali gejala dan tanda keracunan pestisida dan pestisida yang sering digunakan.
2) Jika diduga keracunan, korban segera dibawa ke rumah sakit atau dokter terdekat.
3) Identifikasi pestisida yang memapari korban, berikan informasi ini pada rumah sakit atau dokter
yang merawat.
4) Bawa label kemasan pestisida tersebut. Pada label tertulis informasi pertolongan pertama
penanganan korban.
5) Tindakan darurat dapat dilakukan sampai pertolongan datang atau korban dibawa ke rumah sakit.
a. Handling of Pesticide Poisoning
1. Everyone whose work is often related to pesticides such as farmers, spray workers and others must
recognize the symptoms and signs of pesticide poisoning well. Precautions are better taken to avoid
poisoning. Everyone who comes into contact with pesticides should pay attention to the following:
2. Recognize the symptoms and signs of pesticide poisoning and frequently used pesticides.
3. If poisoning is suspected, the victim is immediately taken to the nearest hospital or doctor.
4. Identify the pesticide that exposed the victim, provide this information to the hospital or treating
doctor.
5. Bring the pesticide packaging label. On the label is written information on first aid handling of
victims.
6. Emergency measures can be taken until help arrives or the victim is taken to the hospital.
b) Pertolongan Pertama yang Dilakukan
1) Hentikan paparan dengan memindahkan korban dan sumber paparan, lepaskan pakaian korban dan
cuci/mandikan korban.
2) Jika terjadi kesulitan pernafasan maka korban diberi pernafasan buatan. Korban diinstruksikan agar
tetap tenang. Dampak serius tidak terjadi segera, ada waktu untuk menolong korban
 3) Korban segera dibawa ke rumah sakit atau dokter terdekat. Berikan informasi tentang pestisida yang
memapari korban dengan membawa label kemasan pestisida
4) Keluarga seharusnya diberi pengetahuan/penyuluhan tentang pesticida sehingga jika terjadi
keracunan maka keluarga dapat memberikan pertolongan pertama
b. First Aid Performed
1. Stop exposure by removing victim and source of exposure, removing victim's clothes and
washing/bathing victim.
2. If there is difficulty breathing, the victim is given artificial respiration. The victim was instructed to
remain calm. Serious impact does not happen immediately, there is time to help victims
3. The victim is immediately taken to the nearest hospital or doctor. Provide information about
pesticides exposed to victims by carrying pesticide packaging labels
4. Families should be given knowledge/counseling about pesticides so that if poisoning occurs, the
family can provide first aid
Sumber :
Raini, Mariana. 2017. TOKSIKOLOGI PESTISIDA DAN PENANGANAN AKIBAT KERACUNAN
PESTISIDA. Media Litbang Kesehatan. Vol. 17(3): 10-18
h. What are the classifications of poisoning?
i. What are the factors that cause a person to commit suicide?

2. She looked shortness of breath. There are a trace of vomit and a smell of insect poison from her mouth.
a. What is the etiologi of shortness of breath and vomit due to drinking baygon?
b. How is mechanism of looked shortness of breath in the case?
c. How is mechanism of vomit in the case?

3. According to her parents, after drinking Baygon, she groaned in pain in her stomach accompanied by
vomiting, peeing in her pants and having seizures 3 times.
a. What is the meaning according to her parents, after drinking Baygon, she groaned in pain in her
stomach accompanied by vomiting, peeing in her pants and having seizures 3 times?
b. How is mechanism of groaned in pain in her stomach accompanied by vomiting, peeing in her pants
and having seizures 3 times?
c. What is the impact of seizures 3 times?
d. How are the main complaints and additional complaints related?
e. What is the probability of disease in this case??
f. What is the etiologi of vomiting, peeing in her pants and having seizures 3 times?
4. It was estimated that Rina had drunk half a large bottle of Baygon.
a. What is the meaning it was estimated that Rina had drunk half a large bottle of Baygon?
b. What are the types of insecticides?
c. How much amount of insecticide can be compensated by the body?
d. What are the clinical manifestations of insecticide poisoning?

5. Physical Examination:

General Appearance: GCS: E2 M5 V2, looks very sick

Vital Sign: BP : 120/80 mmHg, HR : 58 x/m, regular, RR : 28x/m, T : 37,40C

Specific Examination :

Head:

Eye: pin point pupil (+/+), ligh reflex (-/-), anemic conjungtive (-/-), sunken eyelids (-/-),

tremor eyeball (+/+).

Mouth: tremor tongue (+), a lot of saliva coming out of the corner of the mouth

Thoraks: symmetrical movement, normal vesicular, smooth wet rhonchi (+/+), wheezing (-), normal heart
sound, murmur (-).

Abdomen:

Inspection: flat

Palpation: tenderness can not be assessed

Percussion: tympani

Auscultation: increased bowel sounds

Ekstremities: cyanosis in fingertips.

a. How is the interpretation of physical examination?

b. How is the mechanism of abnormal physical examination?

6. Laboratory:

Blood test: Hb 13,4 g/dl; leucocyte: 9900 /mm3, Trombocyte: 225.000 mm3, LED: 13 mm/jam
 Blood chemistry: Ureum 25 mg/dl, Creatinin 0,8 mg/dl, Sodium 130 mmol/l, Potassium 3,1 mmol/l

a. How is the interpretation of laboratory examination?

No In the case Normal rate Interpretation

Blood test:
1 Hb 13,4 g/dl; 12-14 gr/dl Normal
2 leucocyte: 9900 /mm3, 5000-10.000 mm3 Normal
3 Trombocyte: 225.000 mm3, 150.000-450.000/ mm3 Normal
4 LED: 13 mm/jam 0-20 mm/jam Normal
Blood chemistry:
1 Ureum 25 mg/dl, 20-40 mg/dl Normal
2 Creatinin 0,8 mg/dl, 0,6-1,2 gr/dl Normal
3 Sodium 130 mmol/l, 135-145 mmol/l Hiponatremi
4 Potassium 3,1 mmol/l 3,5-5,0 mmol/l Hipokalemi

b. How is the mechanism of abnormal laboratory examination?

7. How to diagnose ?
8. What is differential diagnosis ?

9. What is supporting examination?

1. Pengukuran ChE (Cholinestrase) sel darah merah dan plasma
 Keracunan akut ; Ringan (40-70%), sedang (20-40%), Berat (<20%)
  Keracunan berat : bila kadar AchE menurun sampai 25%-50% setiap individu yang berhubungan dengan
insektisida ini harus segera disingkirkan dan baru diijinkan bekerja kembali kadar AchE telah meningkat
>75% (Normal).
2. Analisis Gas Darah
1) Measurement of ChE (Cholinestrase) of red blood cells and plasma
 Acute poisoning; Mild (40-70%), moderate (20-40%), Severe (<20%)
 Severe poisoning: if the AchE level decreases to 25%-50% every individual who is in contact with this
insecticide must be removed immediately and then allowed to work again the AchE level has increased
>75% (Normal).
2) Blood Gas Analysis
10. What is working diagnosis?
 Intoksikasi Insektisida golongan karbamat
11. How is treatment of this case?
Primary Survey:
 Airway : bebaskan jalan nafas dari corpus alienum
 Breathing : Terapi Oksigen
 Circulation : follow vital sign dan infus kristaloid dan dextrose 5% IV gtt 15-20 gtt/menit
Secondary Survey:
 Kubah lambung
 Antidotum : Sulfas Atropin
 Atrofin Sulfat (SA), kerjanya menghambat efek akumulasi AKh pada tempat penumpukan
 Awalnya Sulfas Atropin bolus IV 2 mg
 Selanjutnya Sulfas Atropin bolus IV 0,5 mg tiap 5 menit sampai timbul gejala atropinisasi (lidah kering,
pupil midriasis, flushing)
 Bila gejala atropinisasi tercapai interval diperpanjang pada menit 15’-30’-60’
 Selanjutnya diperpanjang dengan interval 2-4-6-8-12 jam, SA dihentikan minimal setelah 2 x 24 jam
pemberian
12. What is complication?
 Kejang
 Koma
 Kematian
 Gagal ginjal akut akibat dehidrasi
 Henti jantung (Cardiac arrest) dari asetil kolin yang terakumulasi menyebabkan gangguan pada saraf
parasimpatis post ganglionik, sehingga SA node dan AV node terganggu.
 Seizure
  Comma
 Death
 Acute kidney failure due to dehydration
 Cardiac arrest from accumulating acetyl choline causes disruption of the postganglionic
parasympathetic nerves, so that the SA node and AV node are disrupted.
13. What is Prognosis?
Vitam: Dubia ad bonam
Functionam : Dubia ad malam
Sanationam : Duba ad bonam
14. What is KDU?
3B. Gawat darurat

Lulusan dokter mampu membuat diagnosis klinik dan memberikan terapi pendahuluan pada keadaan gawat
darurat demi menyelamatkan nyawa atau mencegah keparahan dan/atau kecacatan pada pasien. Lulusan dokter
mampu menentukan rujukan yang paling tepat bagi penanganan pasien selanjutnya. Lulusan dokter juga
mampu menindaklanjuti sesudah kembali dari rujukan.

3B. Emergency

Doctoral graduates are able to make clinical diagnoses and provide preliminary therapy in emergency
situations to save lives or prevent patient severity and/or disability. Doctor graduates are able to determine the
most appropriate referral for the next patient treatment. Doctor graduates are also able to follow up after
returning from a referral.

15. What is NNI?

 An-nisa:29
Wahai orang-orang yang beriman! Janganlah kamu saling memakan harta sesamamu dengan jalan yang batil
(tidak benar), kecuali dalam perdagangan yang berlaku atas dasar suka sama suka di antara kamu. Dan
janganlah kamu membunuh dirimu. Sungguh, Allah Maha Penyayang kepadamu.
 Riw. Hadist siapa yang membunuh dirinya dengan sesuatu di dunia maka dia disiksa oleh alat tersebut
pada hari kiamat
 Barangsiapa membunuh dirinya dengan besi maka besinya akan berada di tangannya dia akan tinggal di
nerka jahanam selama-lamanya

Hypotesis
Rina, a 24-year-old in unconscious, shortness of breath, vomiting, peeing in her pants and having seizures because
of the possibility of having insecticide poisoning as a result of an attempted suicide.
Consept

FR (suicide attempt)

Drink Baygon

Enter and absorbed in the

gastrointestinal tract

widely distributed to
tissues

insecticide poisoning

unconscious, shortness of breath, vomiting,

peeing in her pants and having seizures