Group 6 Problem 4

Monday, October 19, 201
Lethally Excited
Problem 4 Emergency Medicine Block
Group 6
Faculty of Medicine
Tarumanagara University
Tutor
: dr. Eko
Leader
: Alfindra Sepalawandika405120096
Secretary : Dessy
405120170
Writer
: Rana Rick Winotho Gultom 405110011
Members : Cornelius Kevin
405110022
Wilda Mutafadillah 405110035
Josep Pandapotan405110149
Stephen Wijayanto 405110198
Amanda Juliana 405120139
Yashica Lorencia 405120155
Tiffany Anggun Prasetyo 405120158
Theffany405120198
Karin S. Felicity Siahaan 405120232
Unfamiliar Term
Methamphetamine: obat psikostimulant
Questions
1. Apa ada hubungan zat terlarang dengan keluhan?
Mengapa?
2. Apa hubungan hasil pemeriksaan urin +
methamphetamine dengan keluhan?
3. Mengapa perubahan perilaku baru terjadi 4 bulan terakhir,
padahal penggunaan obat sudah lama?
4. Bagaimana tatalaksana emergency pada pasien tersebut?
5. Apa saja obat yang dapat menstimulasi mental dan
behavior?
6. Interpretasi PF
7. Mengapa perubahan perilaku terjadi pada pasien tersebut
pada saat ditemukan?
Discussion
1. Ada, karena penggunaan zat psikoaktif
merangsang saraf simpatis timbul gejala
2. ?
3. -Karena adanya peningkatan dosis
ketergantungan efek toksik
-Penghentian obat perubahan perilaku
4. ABC, tanda vital
5. Napza, opioid, alcohol
6. TD naik
7. Karena
Review
Penyalahgunaan Obat
Jenis-jenis obat
Efek obat/manifestasi klinis
Sindrom ketergantungan
Putus obat
Pemeriksaan
Diagnosis
Tatalaksana Emergency dan Rehabilitasi

Prognosis
LO 1
Substance Abuse
Diagnostic Classification
4 major diagnostic categories in the
DSM-5
Substance Use Disorder
Substance Intoxication
Substance Withdrawal
Substance-Induced Mental Disorder
Kaplan and Sadocks Synopsis of Psychiatry 11 th Edition Chapter 20 Substance Use and Addictive
Substance Use Disorder

Results from the prolonged use of the substance
Maladaptive pattern of substance, manifested by 2 (or
more) of the following, within a 12-month period:
1. recurrent use a failure to fulfill major role obligations at
work, school, or home
2. recurrent use in situations in which it is physically hazardous
3. continued substance use despite having persistent/
recurrent social/interpersonal problems caused/exacerbated
by the effects of the substance
4. tolerance, as defined by either of the following:
A need for markedly increased amounts to achieve intoxication or

desired effect
Diminished effect with continued use of the same amount
5.Withdrawal, either of the following:

the characteristic withdrawal syndrome for the substance
the same (or a closely related) substance is taken to relieve or
avoid withdrawal symptoms
6.Taken in larger amounts/over a longer period than was

intended
7.A persistent desire/unsuccessful efforts to cut
down/control substance use
8.A great deal of time is spent to obtain the substance, use
the substance, or recover from its effects
9.Important social, occupational, or recreational activities
are given up/reduced because of substance use
10.
The substance use is continued despite knowledge of
having a persistent/recurrent physical/psychological
problem that is likely to have been caused/exacerbated by
the substance
11.
Craving/a strong desire or urge to use a specific substance
Substance Intoxication
characterized by specific signs and
symptoms resulting from recent
ingestion or exposure to the
substance
Substance Withdrawal
results from the abrupt cessation

of heavy and prolonged use of a
substance (e.g., opioid withdrawal)
Klasifikasi berdasarkan efek

NAPZA
Golongan Depresan ( Downer )

berfungsi mengurangi aktifitas fungsional tubuh.
membuat pemakainya menjadi tenang dan bahkan
membuat tertidur bahkan tak sadarkan diri
Opioda (Morfin, Heroin, Codein), sedative (penenang),
Hipnotik (obat tidur) dan Tranquilizer (anti cemas )
Golongan Stimulan ( Upper )
merangsang fungsi tubuh dan meningkatkan kegairahan
kerja.
menbuat pemakainnya menjadi aktif, segar dan
bersemangat
Amphetamine (Shabu, Ekstasi), Kokain.
Golongan Halusinogen
menimbulkan efek halusinasi yang bersifat merubah
perasaan, pikiran dan seringkali menciptakan daya pandang
yang berbeda sehingga seluruh persaan dapat terganggu
Kanabis (ganja)
Buku Ajar Psikiatri Fakultas Kedokteran Universitas Indonesia Edisi 2 Gangguan Penggunaan Zat
NAPZA yang Sering di

Salahgunakan
1. Alkohol: semua minuman
beralkohol.
2. Opioida: heroin, morfin,
pethidin, candu.
3. Kanabinoida: Ganja, hashish.
4. Sedativa/hipnotika: obat
penenang/obat tidur.
5. Kokain: daun koka, serbuk
kokain, crack.
6. Stimulansia lain, termasuk
kafein, ectasy, dan shabu-shabu.
7. Halusinogenika: LSD,
mushroom, mescalin.
8. Tembakau (mengandung
nikotin).
9. Pelarut yang mudah menguap
seperti aseton dan lem.
Treatment and
Rehabilitation
Procedure/technique
Individual therapy
family therapy
group therapy
relapse prevention
Pharmacotherapy
Treatment of comorbidity
antipsychotic drugs and therapeutic
community principles
Stimulant-Related Disorders
Amphetamine
Stimulant
Amfetamin sulfat obat obesitas,
epilepsi, narkolepsi, depresi
Disalahgunakan siswa tahan tidak tidur,
untuk diet, meningkatkan libido
Absorbsi dan onset kerja cepat (oral 1 jam)
Cara penggunaan:
1. Amfetamin: tablet / suntikan
2. Ecstasy: digigit dengan gigi sedikit demi
sedikit kemudian ditelan
3. Shabu: uap dipanaskan melalui tabung
air dihisap melalui bibir dengan bong
plastik
Picture: http://www.cbc.ca/news/canada/british-columbia/ecstasy-crackdown-harmful-health-
Problem Fisik
Malnutrisi
defisiensi
vitamin, hilang
nafsu makan
Denyut jantung
meninggi
bahaya bagi
pengidap
penyakit KV
Gangguan
ginjal, emboli
paru, stroke
Twitching,
tetani, kejang,
koma
Penggunaan
Problem
Psikiatri
Perilaku agresif
Confusional
state, paranoid
sampai
skizofrenia
Putus zat:
lethargy,
fatigue,
exhausted,
ansietas,
gangguan tidur
Depresi berat
sampai suicide
Halusinasi
(ecstasy dan
shabu)
Problem Sosial
Tindak
kekerasan
(berkelahi)
Kecelakaan lalu
lintas
Kriminal
DSM IV-TR Criteria For Amphetamine

Intoxication
DSM IV-TR Criteria For Amphetamine

Withdrawal
Management
Prehospital management
ABC
Oxygenate
ECG monitor
Establish IV access
Treat life-threatening dysrhythmias
Seizure precautions: diazepam 5-10 mg
Antipsychotic and antianxiolytic used in short-term basis (1 st few

days)
Comorbid : depression antidepressant
Bupropion produce feelings of well being
Multiple therapeutic methods
Individual
Familial
Group psysiotherapy
Stimulant-Related Disorders
Cocaine
Obat stimulan adiktif, derivat
alkaloid.
Simpatomimetik menstimulasi
SSP & menkaskade efek fisiologis.
Penggunaan:
Inhalasi snorting efek dan
durasi 15-30 menit
Injeksi IV/subkutan efek lebih
cepat dan lebih kuat, tapi durasi
lebih singkat
Smoking durasi 5-10 menit
Metabolit bertahan di darah dan

urin hingga 10 hari
Rosens Emergency Medicine 7

Kaplan and Sadocks Synopsis of Psychiatry 11 Edition Chapter 20 Substance Use and Addictive D
th
Rosens Emergency Medicine 7th Editi
Comorbidity
Diagnostic
Criteria
DSM IV-TR Criteria For Cocaine Intoxication
DSM IV-TR Criteria for Cocaine

Withdrawal
Management
Prehospital management:
ABCs
Respiratory Support
Oxygenate
ECG monitor
Establish IV access
Treat life-threatening dysrhythmias
Seizure precautions: diazepam 5-10 mg
Treatment : symptomatic
Agitation benzodiazepin or antipsychotic
Somatic system beta blockers
Adverse Effects
Nasal congestion; serious inflammation, swelling,
bleeding, and ulceration of the nasal mucosa
Long-term use perforation of the nasal septa
Freebasing and smoking crack damage the
bronchial passages and the lungs
IV use infection, embolisms, and the transmission
of human immunodeficiency virus (HIV)
Minor neurological complications: acute dystonia,
tics, and migraine-like headaches
Major complications cerebrovascular, epileptic, and
cardiac
Cannabis-Related
Disorder
= ganja canabis sativa

Efek psikoaktif tetrahidrokanabinol
(THC) depresan SSP
halusinogenik
Bentuk canabis yang
disalahgunakan:
Marijuana (daun/bunga yang dikeringkan)

Harshis (resin THC)
Minyak harshis
Epidemiologi:
Indonesia minimal 2-3 juta
Di AS 5 juta orang menggunakan ganja
sepekan sekali
https://www.msu.edu/~hertlerg/THCbrain.jpg
DSM IV-TR Criteria For Cannabis

Intoxication
Efek Ganja
Dosis normal :
Timbul setelah 2-3 jam setelah merokok ganja
Rileks
Awal pemakaian merangsang napsu makan
Daya ingat hilang atau berkurang
Mata merah
Hipotensi
Dosis besar :
Efek spt diatas, intensitas >> + dingin, kelelahan,
halusinasi, gelisah, paranoid, panik, euphoria
Menyebabkan kematian
Suicide
Infeksi berat
Tindak kekerasan (kecelakaan lalu lintas)
Efek Jangka Panjang

Fisik
Psikiatri
Sosial
Ggn saluran pernapasan

Fungsi otak
Susah belajar
(infeksi): sinusitis,
menurun:
Kenakalan
bronkhitis
gangguan
remaja
Ggn hormon: gangguan
memori dan
Hancurnya
hormon reproduksi
konsentrasi
performa
sehingga gairah seks
akademik/ kerja
Ggn sistem saraf:
menurun, menstruasi
psikosis
hilang
tidak teratur, jumlah
(halusinasi,
pekerjaan
sperma menurun
delusi, paranoid) Gangguan
hingga
menggunakan
Fetal damage bagi wanita
hamil
skizofrenia
kendaraan dan
Mengandung agen
Ansietas, panik
alat mesin
kanker: kanker paru,
sampai reaksi
Terlibat
ispa, pencernaan, leher,
bingung
masalah hukum
dan kepala
Sindrom
amotivasional
Gangguan saraf: sakit
kepala, gangguan fungsi
terlihat fisik
koordinasi motorik
lemah, halusinasi
Emfisema
Depresi berat,
Gangguan
kardiovaskular
bisa suicide
Buku
Ajar Psikiatri
Fakultas Kedokteran Universitas
Indonesia Edisi 2 Gangguan Penggunaan Zat
Tatalaksana
Umum:
Oksigen
Kalau cardiac arrest: adrenalin 0,3 cc
Hipotensi: NaCl IV
Koma: Bersihkan mata dan mulut secara reguler,
pastikan mata tetap basah, pastikan elektrolit tetap
seimbang, Natrium bikarbonat 50 cc IV
Kejang: diazepam 10 mg IV
Diuresis: furosemid
Spesifik:
Diazepam 10-30mg PO/parenteral
Chlordiazepoxyde 10-25 mg PO
Kalau diperlukan, ulangi setelah 30 menit-1 jam
Alcohol-Related Disorder
Sumber energi potensial, 1 g menghasilkan 9 kkal
Penggunaan tidak terkontrol dapat menimbulkan :
Ketergantungan
Pola makan tidak teratur
Peradangan dan pendarahan usus
Kekurangan vitamin
Kekebalan tubuh menurun
Hepatitis
Kerusakan otak, tangan dan kaki gemetar
Denyut jantung tidak teratur
Bahaya meningkat bila yang diminum alkohol illegal/untuk

antiseptik
Umumnya mengandung metanol yang dapat menimbulkan kebutaan
Kombinasi + AINS meningkatkan iritasi lambung yang besar

Kombinasi + psikotropik meningkatkan terjadinya depresi
INTOKSIKASI
Euforia
Cadel
Nistagmus
Ataksia
Bradikardi
Hipotensi
Kejang
Koma
KEADAAN PUTUS
ALKOHOL
Halusinasi
Ilusi
Kejang
Delirium Tremens
Gemetar
Keluhan GIT
Muka merah
Mata merah
Hipertensi
Gangguan Fisik
Mulai dari radang hati
sampai kanker hati
Gastritis
Ulkus peptikum
Pneumonia
Gangguan vaskuler
dan jantung
Defisiensi vitamin
Fetal alcohol
syndrome
Gangguan mental
Depresi hingga
skizofrenia
Gangguan lain
Kecelakaan lalu
lintas
Perkelahian
Problem domestik
Tindak kekerasan
Management
Prehospital management:
ABCs
Respiratory support
Oxygenate
Establish IV access
Administer 100 mg thiamine IV
ECG monitor
Check glucose level
Administer D50W, if hypoglycemic
Opioid-Related Disorder
Etiology:
Psychosocial factors
Biological & Genetic Factor
Psychodynamic theory
Route of administrations
Opium : smoked
Heroin : smoked, Injected
IV or SC
Some others : oral
Adverse effects
Transmission of Hepatitis
and HIV
Idiosyncratic reaction
Kaplan and Sadocks Synopsis of
DSM IV-TR Criteria For Opioid

Intoxication
Naloxon:
Administer 0,8mg
Naloxone IV, wait 15
mins
If no response, give
1,6mg Naloxone, wait
15 mins
If no response, give
3,2mg Naloxone,
suspect other
diagnosis
If success, continue
Naloxone at
0,4mg/hour IV
Kaplanconsider
and Sadocks Synopsis of
Always
DSM IV-TR Criteria For Opioid Withdrawal
Treatment
Medically supervised withdrawal and detoxification
Opioid agents for treating Opioid withdrawal
Methadone : supress withdrawal syndrome, dose 20120mg/day, once-daily
Other : levomethadyl (no longer used) &
Buprenorphine
Opioid antagonist : Naloxone, Naltrexone

Psychotherapy
Therapeutic communities
Education and Needle Exchange
Narcortic Anonymous
Sedative-, Hypnotic-, or AnxiolyticRelated Disorders

Benzodiazepin
Diazepam (Valium)
Flunitrazepam (Rohypnol)
Barbiturat
Secobarbital (Seconal)
Barbiturat-like substances
Methaqualone (Quaalude)
Meprobamate (Miltown)
Sedative-, Hypnotic-, or Anxiolytic-Related

Disorders
Benzodiazepin
Tablet (nitrazepam, flunitrazepam,

flurazepam, bromazepam, diazepam)
Suntikan mengganggu diazepam
Sebab kematian:
Kecelakaan
Infeksi sistemik
Depresi berat sampai suicide
Dehidrasi, malnutrisi
Problem Fisik Problem

Psikiatri
Suntikan:
Perilaku agresif
abses, infeksi terutama saat
sistemik,
intoksinasi
Ansietas, panik,
hepatitis,
HIV/aids
confusional
Gangguan GI
state
Gangguan
Withdrawal
neurologik
state perilaku
Malnutrisi
agresif &
violence
Problem
Sosial
Menggangg
u interaksi
rumah
tangga &
lingkungan
masyarakat
Finansial
terganggu
Kaplan and Sadocks Synopsis of Psychiatry 10 th Ed
Benzodiazepine Discontinuation
Syndrome
Management
LO 2
Psychotic Break
Psychotic Break
Psikosis: Kehilangan Reality Testing of
Ability dan gangguan pada fungsi mental
Terjadi ketika seseorang mengalami suatu
episode psikosis primer akut
Faktor resiko genetik, mutasi genetik
22q11 (skizofrenia)
Symptoms halusinasi, delusi
Penyebab Kondisi psikologis, kondisi
medis, zat-zat (penyalahgunaan obat dan
alcohol)
Disorders
Diagnosis dan Tatalaksana

Pemeriksaan:
Anamnesis, tes darah (elektrolit,
infeksi dan hormon), skrining obat,
MRI
Tatalaksana:
Obat antipsikotik
Psikologis cognitive behavioural
therapy, family therapy, self-help
groups
http://www.nhs.uk/Conditions/Psychosis/Pages/Treatment.a
Kesimpulan dan Saran

Kesimpulan
Kemungkinan pasien mengalami intoksikasi
obat stimulant (metamfetamin) DSM IV
perubahan perilaku dan tanda gejala
Saran
Tatalaksana ABC, oksigenasi, monitor EKG, IV
access, mengobati disritmia yang mengancam
(jika ada), dapat mencegah kejang dengan
memberikan diazepam 5-10 mg, kemudian
pasien ditatalaksana untuk mengobati
ketergantungan obat-obatannya

Group 6 Problem 4

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Monday, October 19, 201

Tatalaksana Emergency dan Rehabilitasi

Substance Use Disorder

A need for markedly increased amounts to achieve intoxication or

5.Withdrawal, either of the following:

6.Taken in larger amounts/over a longer period than was

results from the abrupt cessation

Klasifikasi berdasarkan efek

Golongan Depresan ( Downer )

NAPZA yang Sering di

DSM IV-TR Criteria For Amphetamine

DSM IV-TR Criteria For Amphetamine

Antipsychotic and antianxiolytic used in short-term basis (1 st few

Metabolit bertahan di darah dan

Rosens Emergency Medicine 7

Rosens Emergency Medicine 7th Editi

DSM IV-TR Criteria For Cocaine Intoxication

DSM IV-TR Criteria for Cocaine

= ganja canabis sativa

Marijuana (daun/bunga yang dikeringkan)

DSM IV-TR Criteria For Cannabis

Efek Jangka Panjang

Ggn saluran pernapasan

Bahaya meningkat bila yang diminum alkohol illegal/untuk

Kombinasi + AINS meningkatkan iritasi lambung yang besar

DSM IV-TR Criteria For Opioid

Kaplan and Sadocks Synopsis of

DSM IV-TR Criteria For Opioid Withdrawal

Kaplan and Sadocks Synopsis of

Opioid antagonist : Naloxone, Naltrexone

Sedative-, Hypnotic-, or AnxiolyticRelated Disorders

Sedative-, Hypnotic-, or Anxiolytic-Related

Tablet (nitrazepam, flunitrazepam,

Problem Fisik Problem

Kaplan and Sadocks Synopsis of

Kaplan and Sadocks Synopsis of

Diagnosis dan Tatalaksana

Kesimpulan dan Saran

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