First Problem

Group 14
27 September 2018
Tutor: dr. Jimmy
Chief : Thurain Leo (405160222)
Secretary: Vanessa Irenea (405160129)
Notulent : Celine (405160118)
• Kania Fidelia Widjaja (405160035)
• Devin Alexander (405160054)
• Justina (405160085)
• Inggie Novania (405160086)
• Ade Mulyawan (405160125)
• Naufalia Luthfiyana (405160144)
• Anggilia Yuliani Susanti (405160174)
I Walked the Line
A 24-year-old mas was brought to the ED because of a distubance of concioussness
and vomitting. He started drinking with his friends an hour before he was taken to
the hospital. Initial physical examination: BP 100/60 mmHg, HR 60x/min, RR
15x/min (smelth like alcohol) and temp 36.5°C. Nystagmus on both eyes and needle
tracks were found. He repeatedly trying to stand up on the bed, followed by periods
of sleeping and shouting incoherently at the staffs, then falling asleep again. He also
tried several times to climb down his bed and run to the door. He was then
restained in bed with a lateral position to avoid airway obstruction in case he
vomitted. Two hours after the admission, he was found with cardiopulmonary arrest
with one of the restaint belts twined several times around his neck suggesting an
attempt of suicide. Last year he was found unconscious with half of his sleeping pill
bottle gone. His friends claimed that he also has history of multiple substances
abuse.
At the same time, a 4-year-old girl ws brought to the ED by her parents with
breathing difficulty since 3 hours ago. She accidentally drank about half a bottle of
“Gandapura” oil which was used when her father had massage at home.
Afterwards, she kept vomitting, even after her mother had giver her a drink. The
girl also became feverish and languid. No history of seizure. Physical examination:
compos mentis, agitated, HR 100x/min, RR 50x/min, temp 37.8°C. Lung
examination: vesicular, crackles +/+, wheezing -/-. Other physical examinations are
within normal. Laboratory results: Hb 12g/dL, Ht 38%, WBC 18000/µL, platelets
450000/µL, Na+ 125mEq/L, and K+ 3.1mEq/L.

Identify and discuss the problems in these cases chronologically, while considering
all possibilities!
Mind Map
FR: gg. jiwa

Riw. konsumsi Riw. konsumsi

alkohol minyak gandapura

↓ kesadaran Sesak napas, muntah,

Gejala neurologis + lesu, demam

Intoksikasi Aspirasi

Logam
Gas Zat kimia Obat berat

Karosen Psikoaktif
Organo- Non-
fosfat psikoaktif
NAPZA
Learning Issue
1. Tanda & Gejala, Diagnosis Intoksikasi
2. Algoritme Tatalaksana Intoksikasi
3. Mekanisme terjadinya Intoksikasi
4. Pemeriksaan Lanjutan Intoksikasi
5. Komplikasi dan Prognosis Intoksikasi
6. Tanda & Gejala, Diagnosis Psychotic Break
7. Algoritme Tatalaksana Psychotic Break
8. Mekanisme Terjadinya Psychotic Break
9. Komplikasi dan Prognosis Psychotic Break
Tanda & Gejala Intoksikasi
https://www.aafp.org/afp/2000/0501/p2763.html
Manifestasi Klinis – Depressants
SUBSTANSI INTOKSIKASI WITHDRAWAL
Ethanol - Slurred speech, Dizziness - Kejang, hiperaktivitas autonom (cemas,
- Gangguan koordinasi, berkeringat, facial flushing, midriasis,
Unsteady gait, Nistagmus takikardia, hipertensi ringan)
- Gangguan atensi atau memori - Tremulousness (shakes/jitters)  6 – 8 jam
- Stupor atau koma setelah penghentian
- Double vision - Gejala psikotik & perseptual  8 – 12 jam
Benzodiazepin - Somnolen, dizziness, slurred - Mirip alcohol withdrawal: cemas, iritabel,
speech, confusion insomnia, mual, muntah, tremor, berkeringat
- Ataxia, gg koordinasi & - halusinasi, disorientasi, seizure
intelektual
Barbiturat - konfusio, ataxia, slurred - Terjadi setelah 24 jam (ringan)  2 – 8 hari
speech, drowsiness, disinhibisi (berat)
- Hipotermia, hipotensi, depresi - Minor: cemas, restlessness, depresi, insomnia,
napas anorexia, mual, muntah
- Mayor: psikosis, halusinasi, delirium, kejang,
hipertermia
• Kaplan & Sadock’s synopsis of psychiatry: behavioral sciences/clinical psychiatry. 11 th Edition. New York: Wolter Kluwer, 2015.
• Tintinalli’s emergency medicine manual. 8th Edition. USA: McGraw-Hill Education, 2018.
Manifestasi Klinis – Stimulants
SUBSTANSI INTOKSIKASI WITHDRAWAL
Cocaine • Midriasis Withdrawal  disforia, appetite (^), anxiety,
Amphetamine • Agitasi iritabilitas
Ecstasy psikomotor/retardasi • Cemas, tremulousness, disforik, letargi,
• Takikardi/bradikardi fatigue
• Chills • Nightmare (+rebound raid eye movement
• Aritmia, chest pain sleep)
• Hiper/Hipotensi • Memuncak pada 2 – 4 hari dan resolved dalam
• Diskinesia 1 minggu
• Distonia • Paling serius  depresi
• Weight loss
• Mual, muntah
• Kelemahan otot
• Depresi napas
• Confusion, seizures,
koma

• Kaplan & Sadock’s synopsis of psychiatry: behavioral sciences/clinical psychiatry. 11 th Edition. New York: Wolter Kluwer, 2015.
• Tintinalli’s emergency medicine manual. 8th Edition. USA: McGraw-Hill Education, 2018.
Manifestasi Klinis – Opioids
SUBSTANSI INTOKSIKASI WITHDRAWAL
Opioid • Perubahan perilaku • Keram otot & nyeri tulang
• Perubahan mood, • Diare
retardasi psikomotor, • Keram perut
drowsiness • Rhinorrhea
• Slurred speech • Lakrimasi
• Gangguan memori & • Piloereksi/gooseflesh
atensi • Demam
• Dilatasi pupil
• Hipertensi, takikardi, disregulasi suhu
- Morfin & Heroin  mulai 6 – 8 jam dari last
dose; puncak pd hari ke-2 & 3, persisten
hingga 6 bulan/>
- Meperidine  cepat. Puncak pd 8 – 12 jam,
berakhir hari ke 4 – 5
- Methadone  mulai 1 – 3 hari last dose,
berakhir pada 10 - 14 hari
• Kaplan & Sadock’s synopsis of psychiatry: behavioral sciences/clinical psychiatry. 11 th Edition. New York: Wolter Kluwer, 2015.
• Tintinalli’s emergency medicine manual. 8th Edition. USA: McGraw-Hill Education, 2018.
Manifestasi Klinis –
Hallucinogens
SUBSTANSI INTOKSIKASI WITHDRAWAL
Phencyclidine • Nistagmus Minim evidence unpredictable
(angel dust) • Kaku otot • Craving
• Hipersalivasi • fatigue
• Agitasi • Iritabel
• Katatonia • Kurang mampu merasakan kesenangan
Marijuana • Takikardi
• Injeksi konjungtiva
Lysergic acid • Midriasis
diethylamide • Takikardi
(LSD) • Cemas
• Muscle tension

• Kaplan & Sadock’s synopsis of psychiatry: behavioral sciences/clinical psychiatry. 11 th Edition. New York: Wolter Kluwer, 2015.
• Tintinalli’s emergency medicine manual. 8th Edition. USA: McGraw-Hill Education, 2018.
• https://adf.org.au/drug-facts/hallucinogens
Tintinalli’s emergency medicine manual. 8 th Edition. USA: McGraw-Hill Education, 2018.
 Digoxin
• a cardiac glycoside available for oral or iv use. Following oral
absorption, max serum concentration 1-3 h after ingestion. It is
approximately 25% protein bound & has a large volume of
distribution (6-7 L/kg)  primarily eliminated through the kidneys

Tintinalli’s emergency medicine

manual. 8th Edition. USA:
McGraw-Hill Education, 2018.
Rosen’s Emergency Medicine. 2017
Heavy Metal (Mercury)
• Elemental mercury exposure is most likely to occur after contact with a broken
thermometer, light bulb or other mercury spills.
• Mercury is primarily absorbed via inhalation (especially with heating or vacuuming).
• Ingestions of elemental mercury are nontoxic in those with normal GI tracts.
• Vapor exposure results in cough, fever, dyspnea, vomiting, and headache.
• Classic findings include tremor, rash, and hypertension. Inorganic mercury is used as a
disinfectant and in manufacturing.
• Ingestion of inorganic mercury results in corrosive injury to the GI tract, with vomiting,
diarrhea, abdominal pain, and GI bleeding early, followed by acute kidney injury.
• Organic mercury is found in some fungicides and pesticides and can be absorbed when
ingested.

Rita K. Cydulka,David M. Cline, O. John Ma et al. - Tintinalli's Emergency Medicine Manual 8th ed
Tintinalli’s emergency medicine manual. 8 th Edition. USA: McGraw-Hill Education, 2018.
Organophosphate
Four clinical syndromes:

ACUTE POISONING
• Most poisoned patients are symptomatic within the first 8 hours and
nearly all within the first 24 hours
• Acute organophosphate poisoning results in CNS, muscarinic,
nicotinic, and somatic motor manifestations

Rossen
Emergency
Medicine 9th
Edition
Rossen
Emergency
Medicine 9th
Edition
INTERMEDIATE SYNDROME
• May occur 1-5 days after exposure
• Clinical features include paralysis of neck flexor muscles, muscles
innervated by the cranial nerves, proximal limb muscles, and
respiratory muscles  respiratory support may be needed

CHRONIC TOXICITY
• Is seen primarily in agricultural workers with daily exposure,
manifesting as symmetrical sensorimotor axonopathy  begin
with leg cramps and progress to weaknes and paralysis, mimicking
features of the Guillain-Barre syndrome

ORGANOPHOSPATE-INDUCED DELAYED NEUROPATHY

• Characterized by cognitive dysfunction, impaired memory, mood
changes, autonomic dysfunction, and peripheral neuropathy
Rossen
Emergency
Medicine 9th
Edition
Korosene
• Inhalation: May cause headache, dizziness, drowsiness, incoordination
and euphoria. Aspiration into the lungs causes pneumonitis with
choking, cough, wheeze, breathlessness, cyanosis and fever.
• Ingestion: Often no symptoms occur but there may be nausea,
vomiting and occasionally diarrhoea.
• Ocular: This product is expected to be pH neutral but may be irritating
to the eyes causing an immediate stinging and burning sensation with
lacrimation.
• Dermal: Irritant. Drying and cracking due to defatting action. There
may be transient pain with erythema, blistering and superficial burns

Www.who.int/ipcs/emergencies/kerosene.pdf
Kriteria Diagnosis Intoksikasi Inhalan
• DSM-IV
A. Ketergantungan secara sengaja baru-baru ini atau jangka pendek, atau pajanan dosis tinggi dalam jangka pendek
inhalan yang mudah menguap (tidak termasuk gas anastetik dan vasodilator kerja singkat)
B. Perubahan psikologis atau perilaku maladaptif yg secara klinis signifikan (cth: perkelahian, penyerangan, apati, daya
nilai terganggu, fungsi sosial atau okupasional terganggu) yg timbul selama atau segera setelah, penggunaan atau
pajanan terhadap inhalan yg mudah menguap
C. Dua (atau lebih) tanda berikut, timbul selama, atau segera setelah, penggunaan.
A. Pusing
B. Nistagmus
C. Inkoordinasi
D. Bicara cadel
E. Cara berjalan tidak stabil
F. Letargi
G. Reflex terdepresi
H. Retardasi psikomotor
I. Tremor
J. Kelemahan otot menyeluruh
K. Pandangan kabur atau diplopia
L. Stupor atau koma
M. Euforia
D. Gejala tidak isebabkan kondisi umum dan tidak lebih baik diterangkan oleh gangguan mental lain
Kaplan & Sadock Buku Ajar Psikiatri Edisi 2
Gas Substance Clinical Manifestation
Smoke Inhalation • Thermal and irritant-induced laryngeal injury: cough, voice alteration, or stridor
• Soot and irritant toxins in the airways: early cough, dyspnea, and bronchospasm
• ARDS
• Deaths caused by asphyxia, airway compromise, or metabolic poisoning (eg, CO)
Hydrogen Cyanide • Odor of bitter almonds
• Tissue hypoxia  dysfunction of the heart
• CNS  coma, seizures, dysrhythmias, cardiovascular collapse
• Diffuse cellular dysfunction  elevated serum lactate concentration  metabolic acidosis
Carbon Monoxide • The “classic finding” of cherry red lips is rarely seen in living patients.
• Patients with significant poisoning may experience long-term neurological and cognitive problems

Ron Walls et al. - Rosen's Emergency Medicine_ Concepts and Clinical Practice 9th ed

. Rita K. Cydulka,David M. Cline, O. John Ma et al. - Tintinalli's Emergency Medicine Manual 7th ed
Kriteria diagnosis DSM-IV-TR
intoksikasi kanabis
• Penggunaan kanabis baru-baru ini,
• Perubahan psikologis atau perilaku maladaptive yang secara klinis signifikan (cth:
koordinasi motoric terganggu, euphoria, ansietas, sensasi waktu melambat, daya nilai
terganggu, penarikan social) yang timbul selama atau segera setelah penggunaan
kanabis
• Dua (atau lebih) tanda berikut timbul dalam waktu 2 jam setelah penggunaan kanabis
a. injeksi konjungtiva
b. peningkatan nafsu makan
c. mulut kering
d. takikardi
• Gejala tidak disebabkan suatu kondisi medis umum dan tidak lebih baik diterangkan
oleh gangguan mental lain
Ron Walls et al. - Rosen's Emergency Medicine_ Concepts and Clinical Practice 9th ed
Algoritme Tatalaksana
Intoksikasi
 Treatment:
ABCDEFGH
A : airway
B : breathing
C : circulatory
D : decontamination
E : elimination
F : focused therapy
GH : getting help
Rita K. Cydulka,David M. Cline, O. John Ma et al. - Tintinalli's Emergency Medicine Manual 8th ed

Rita K. Cydulka,David M. Cline, O.

John Ma et al. - Tintinalli's Emergency
Medicine Manual 8th ed

Sherman, S. C., et al. 2014. Clinical

Emergency Medicine. E-book Mc Graw Hill
Lange™, United State
Rita K. Cydulka,David M. Cline, O. John Ma et al. - Tintinalli's Emergency Medicine Manual 8th ed
Rita K. Cydulka,David M. Cline, O. John Ma et al. - Tintinalli's Emergency Medicine Manual 7th ed
Acetaminophen

Clinical Emergency Medicine Lange 2014

Management of Organophosphorus Poisoning
Department of Clinical Pharmacology, Department of Emergency and General Practice, Maharajgunj Medical Campus, Institute of Medicine, Tribhuvan
University, Kathmandu, Nepal.
 Heavy Metal
Lead Arsenic

Mercury

Rita K. Cydulka,David M. Cline, O. John Ma et al. - Tintinalli's Emergency Medicine Manual 8th ed
Rita K. Cydulka,David M. Cline, O. John Ma et al. - Tintinalli's Emergency Medicine Manual 8th ed
http://www.emed.ie/Toxicology/CO.php
Mekanisme terjadinya
Intoksikasi
 Acetaminophen
In therapeutic doses  metabolized by
conjugation with glucuronide + sulfate into
nontoxic metabolites (urine)
<5% is oxidized by CYP2E1 to a highly
cytotoxic metabolic intermediary, N-acetyl-
p-benzoquinoneimine (NAPQI)
Overdoses glutathione depleted NAPQI
covalently binds to cellular proteins, producing
https://www.aafp.org/afp/2000/0501/p2763.html hepatocellular necrosis
Acute ingestion of > 150–200 mg/kg (children) or 7 g
total (adults)
highly toxic metabolite is produced in the liver
Toxicity is likely to occur after a minimum acute
ingestion of 140 mg/kg, or about 10 g in an adult
Ron Walls et al. - Rosen's Emergency Medicine_ Concepts and Clinical Practice 9th ed
 Organophosphate
• The primary mechanism of action of • Once AChE has been
organophosphate pesticides is
inhibition of acetylcholinesterase
(AChE).
• AChE is an enzyme that degrades
the neurotransmitter acetylcholine
(ACh) into choline and acetic acid.
• ACh is found in the central and
peripheral nervous system,
neuromuscular junctions, and red
blood cells (RBCs).
• Organophosphates inactivate AChE
by phosphorelation.
inactivated, ACh
accumulates throughout
the nervous system,
resulting in
overstimulation of
muscarinic and nicotinic
receptors.
• Although most patients
rapidly become
symptomatic, the onset
and severity of symptoms
depend on the specific
compound, amount, route
of exposure, and rate of
metabolic degradation.
Current Medical Diagnosis & Treatment 2017
Ron Walls et al. - Rosen's Emergency Medicine_ Concepts and Clinical Practice 9th ed
Pemeriksaan Lanjutan
Intoksikasi
Ron Walls et al. - Rosen's Emergency Medicine_ Concepts and Clinical Practice 9th ed
Ron Walls et al. - Rosen's Emergency Medicine_ Concepts and Clinical Practice 9th ed
Ron Walls et al. - Rosen's Emergency Medicine_ Concepts and Clinical Practice 9th ed Core Psychiatry, 3rd ed
Ron Walls et al. - Rosen's Emergency Medicine_ Concepts and Clinical Practice 9th ed
Komplikasi dan Prognosis
Intoksikasi
Opiate
Prognosis
• Naloxone-responsive injection drug users with presumed
heroin intoxication can be safely discharged 1 to 2 hours
after administration of naloxone if they have independent
mobility, oxygen saturation on room air >92%, respiratory
rate >10 breaths/min, pulse rate >50 beats/min, normal
temperature, and a Glasgow coma scale score of 15.
• In cases of exposure to opioids other than heroin, an
observation period of 4 to 6 hours in the ED is
recommended after the last naloxone administration.
• In long-acting opioid overdose, observation should be
extended for a minimum of 8 hours
• Moderate to severely symptomatic patients usually require
hospital admission to monitored settings and may require
continued administration of naloxone
Core Psychiatry, 3rd edition
 Delirium Tremens (Alcohol
Withdrawal)

Management
Benzodiazepine
• Lorazepam IV 1 – 4 mg tiap 5
– 15 mnt atau IM 1 – 4 mg
tiap 30 – 60 mnt s/d ps
tenang
• Diazepam 5 mg IV tiap 5 – 10
mnt (bs s/d 4x) jk blm efektif
jadikan 20 mg
Haloperidol IV u/ pengganti
Benzo
Tiamin 100 mg IV
Ron Walls et al. - Rosen's Emergency Medicine_ Concepts and Clinical Practice 9th ed
Mg Sulfat 2 g IV
Tanda & Gejala Psychotic
Break
Psychotic Break

Sumber: Kaplan & Sadocks Synopsis of Psychiatry, 11 th ed.

Tatalaksana Psychotic
Break
Assessment 2. Identifikasi pasien dengan ide atau rencana bunuh diri
1. Safety pd ps violent: 3. Evaluasi medis psikiatri
• Jaga jarak yg aman dari pasien
• Hindari kontak mata yg berlebihan
• Jaga postur dan suara tetap tenang dan menghargai pasien
• Jangan ada yg menghalangi jalan keluar
• Ruang pemeriksaan harus tenang, nyaman dan tidak ada benda
berbahaya
• Jk pasien tidak bisa dikendalikan sehingga membahayakan diri
sendiri atau org lain, maka perlu dilakukan fiksasi (restrain):
• Beritahu pasien dan keluarga bahwa fiksasi dilakukan u/
kebaikan pasien
• Dilakukan oleh 5 orang: 1 leader dan 4 orang memfiksasi
tiap ekstremitas
• Kepala sedikit dielevasi u/ mencegah aspirasi
• Monitor kondisi pasien min tiap 30 menit
• Jika kondisi pasien sudah membaik, fiksasi boleh
dilepaskan satu per satu

Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 7th ed. 2011

Gray, S.W. Competency-based Assessments in Mental Health Practice. 2011.
Sumber: Kaplan & Sadocks Synopsis of Psychiatry, 15th ed.
Sumber: Kaplan & Sadocks Synopsis of Psychiatry, 15th ed.
Kesimpulan
• Kami telah mempelajari
intoksikasi dan withdrawal gas,
zat kimia, obat, dan logam berat,
serta delirium dan psychotic
break
Saran
• Pasien 1 dilakukan RJP untuk
henti jantung dan napas, serta
diberikan antidot untuk alkohol
(etanol)
• Pasien 2 dilakukan resusitasi
cairan dengan elektrolit