DASAR-DASAR DASAR-DASAR PENATALAKSANAAN PENATALAKSANAAN

KERACUNANKERACUNAN

DASAR-DASAR DASAR-DASAR PENATALAKSANAAN PENATALAKSANAAN

KERACUNANKERACUNAN

Oleh :Siti NurdjanahSiti Nurdjanah

Diagnosis : Anamnesis Pemeriksaan Fisik, tanda-tanda

umum : Keracunan akut Kesadaran Pernafasan Tanda-tanda vital

Lab. Rutin & toksikologi

Penurunan KesadaranPenurunan Kesadaran

Tingkat I Mengantuk, tapi mudah diajak bicara

Tingkat II Sopor, dapat dibangunkan dengan rangsangan

minimal : bicara keras, lengan digoyangkan Tingkat III

Sporo-komatus bereaksi dengan rangsangan maksimal : menggosokkan kepalan tangan

Tingkat IV Koma tak bereaksi sama sekali prognosis

jelek

Pernafasan Depresi pusat pernafasan air-way

perhatikan Tekanan darah

Penurunan tekanan darah shok : dehidrasi, gangguan pusat vasomotor

Kejang-kejang Rangsangan pada SSP

Pupil & refleks Diameter pupil & reflek otot rangka tak

penting untuk diagnosis Bising usus

Penurunan kesadaran TK III : biasanya (-)TK IV : selalu (-)

Tanda-tanda lainTanda-tanda lain

Gangguan : Irama jantung Asam basa, elektrolit Kerusakan organ Gastrointestinal dll

TERAPI SUPORTIF Bebaskan jalan nafas Oksigenasi/ventilasi Terapi aritmia Perbaiki hemodinamik Hilangkan kejang Koreksi abnormalitas suhu Koreksi kelainan metabolik Hindari komplikasi sekunder

Pencegahan Terhadap Pencegahan Terhadap Absorbsi Racun Lebih LanjutAbsorbsi Racun Lebih Lanjut

Dekontaminasi Gastrointestinal Syrup ipecac untuk menginduksi muntah Bilas lambung Arang aktif Irigasi usus Pencahar Dilusi Pengeluaran melalui endoskopi atau

tindakan bedah

Dekontaminasi permukaan lain Dekontaminasi mata Dekontaminasi kulit Evakuasi racun dari rongga-rongga

tubuh

Mempercepat Eliminasi Mempercepat Eliminasi RacunRacun Multiple dose arang aktif Diuresis paksa Mengubah pH urin Chelasi Pengeluaran extracorporal

Dialisis peritoneal - Hemofiltrasi Hemodialisis - Plasmapherin Hemoperfusi - Transfusi

tukar Oxigen Hiperbarik

Penggunaan AntidotumPenggunaan Antidotum Netralisasi dengan antibodi Netralisasi dengan bahan kimia Antagonis metabolik Antagonis fisiologis

Hindari Pemaparan Ulang Pengarahan bagi orang dewasa Jauhkan dari jangkauan anak-anak Membaca cara penggunaan Rujukan Psikiatri

Terapi SuportifTerapi Suportif

A. Bebaskan jalan nafas Tidur terlentang, kepala ekstensi,

miring (bila mutah) Mulut bersihkan Pasang guedel Bila mungkin ET

B. Oksigenasi / ventilasi Tanpa alat pernafasan :

Mulut mulut Mulut hidung

Alat bantu pernafasan : Alat penghubung Balon masker Ventilator automatik Mesin pernafasan automatik

C. Terapi aritmia akibat hipoksia/ketidak seimbangan elektrolit cari causa

Bradikardia jangan segera obati, mungkin kompensasi

Akibat : hipotensi, syncope : Atropin 0.01 – 0.03 mg/Kg BB I.v. Tak berhasil : isoproterenol 1-10

mcg/menit I.v. titrasi sampai normal

Takikardia Bila tak berhubungan

hipotensi/nyeri dada observasi + obat sedatif Symptomatik induced takikardia :

prpranolol 0.01 – 0.03 mg/kg i.v. Anticholinergik induced takikardia :

physostigmine 0.01 – 0.03 mg/kg iv/neostigmin 0.01 – 0.03 mg/kg i.v.

Ventrikular Aritmia Ventrikular fibrilasi louter shock Ventrikular takikardi tanpa denyut

nadi precordial thump. Ventrikular takikardi dengan

denyut nadi lidokain 1-3 mg/kg iv Overdosis obat anti depresan

sodium bicarbonat 1-2 meq/kg i.v

Hemodinamik Hipotensi 200 ml Nacl iv

bolos/kristaloid isotonik lain 1-2 lt tak respon : dopamin 5-15 mg/dog/net per infus

Akibat overdosis anti depresan : sodium bicarbonat 1-2 meq /kg injeksi

Hipertensi Phentolamin 2-5 mg iv/ Sodium nitroprused 0.25 – 8ug/kg/mt iv Bila + takikardi propranolol 1-5 mg iv

E. Terapi kejang Hati-hati antikonvulsan hipotensi

cardial arrest, respiratory arrest Bila digunakan terlalu cepat

Diazepam 0.1-0.2 mg/kg iv Phenobarbitol 0.1-0.2 mg/kg iv bila

iv sulit

F. Koreksi Suhu Hipotermia selimut/cairan hangat iv,

hangatkan udara pernafasan Hipertermia tanggalkan pakaian, semprot air

suam kuku, kipasi penderita

G. Koreksi Gangguan Metabolik Sesuai sebab yang mendasari

H. Cegah komplikasi sekunder Berdasar jenis racun & reaksi yang akan timbul

Mencegah absorbsi racun lebih Mencegah absorbsi racun lebih lanjutlanjut

Dekontaminasi GIT1. Induksi mutah syrup ipecal tak

efektif setelah pemberian arang aktif K.I. :

penderita mengantuk Asam /alkali bun toksik perforasi Kerosen aspirasi Kejang

15 cc ipecal ½ gelas air 30’ emesis ulangAnak-anak 10 cc Bila tak mutah bilas lambung

2. Bilas lambung Indikasi :

< 1 jam Pend. Dgn histeri, koma, jalan

udara dilindungi K.I. :

Tertelan asam basa Minyak tanah Kejang Kelebihan cairan meningkatkan

absorbsi racun

Tehnik : Beri air 1 gelas Trendelenberg Ukur panjang pipa dari mulut lambung

tandai Gigi palsu /benda asing dimulut keluarkan Buka mulut penahan Masukkan pipa Aspirasi toksikologi 100-300 cc air hangat (37oC) dari 3 lt bilas

terakhir : 50 gr arang aktif Koma ET

3. Arang aktif Suspensi + air /pecahan botol

sus/sedotan/pipa NGT kecil 1-2 g/kg BB + 8 cc air bisa +

pemanis /perasa Bilas racun tertelan dalam lumen

usus charcool-toxin-complex.

4. Irigasi usus Pipa gastrik 0.5 lt/jam (anak)

2 lt/jam (dewasa)

Posisi duduk Cairan pembersih usus : t.d.

elektrolit & polyethirlineglikol

5. Pencahar Sorbitol 1-2 g/kg BB Mg Sulfat 30 gr

6. Dilusi/pengenceranMinum 5 ml/kg BB air/cairan jernih secepat

mungkin setelah minum toksin

7. Pengeluaran endoskopi/bedahJarang digunakan. Keracunan logam bera

lethal arsenic, besi, mercury, thalium

8. Dekontaminasi permukaan cairAir , NaCl fisiologis

Mempercepat eliminasi racun

Dosis multiple arang aktif 1 gr /kg BB setiap 2-4 jam

Diuresis paksa/mengubah pH urin Alkaline – diuresis Saline – diuresis Acid – diuresis Tak digunakan lagi

Pengeluaran racun secara extracorporal

Syarat dialisis : BM rendah Kelarutan tinggi Prot. – binding rendah Vol. Distribusi kecil Half-life panjang

Indikasi : penderita dg penurunan kesadaran cepat Kadar toksin darah lethal Gangguan detoksifikasi alami : gagal hati, ginjal

Initial management of coma

A Airway control

B Breathing

C Circulation

D Drugs (give all three) :Dextrose 50%, 50-100 mL IVThiamine, 100 mg IM or IVNaloxone, 0,45-2 mg IV1

And consider flumazenil, 0,2-0,5 mg IV2

1Repeated doses, up to 5-10 mg, may be required.2Do not give if patient has coingested a tricyclic antidepressant or other convulsant drug or has a seizure disorder.

Convulsions related to toxins or drugs requiring special

consideration.

Toxin or Drug Comment

Isoniazid (INH) Administer pyridoxine

Lithium May indicate need for hemodialysys.

Organophosphates Administer pralidoxime (2-PAM) and atropine

StrychnineC”onvulsions are actually spinally mediated muscle spasms and usually require neuromuscular paralysis

TheophyllineConvulsions indicate need for hemodialysis or charcoal hemoperfusion

Tricyclic antidepressant

Hyperthermia and cardiotoxicity are common complicationss of repeated convulsions; paralyze early with neuromuscular blockers to reduce muscular hyperactivity

Some toxic agents for which there are specific antidotes

Toxic Agent Specific Antidote

Acetaminophen Acetylcysteine

Anticholinergics (eg, atropine) Physostigmine

Anticholinesterases (eg, organophosphate pesticides)

Atropine and pralidoxime (2-PAM)

Benzodiazepines Flumazenil

Carbon monoxide Oxygen

Cyanide Sodium nitrite, sodium thiosulfate

Digitalis glycosides Digoxin-Specific fab antibodies

Heavy metals (eg, lead, mercury, iron) and arsenic

Specific chelating agents

Isoniazid Pyridoxine (vitamin B6)

Methanol, ethylene glycol Ethanol (ethyl alcohol)Or fomepizole (4-methylprazole)

Opoids Naloxone, nalmefene

Snake venom Specific antivenin

Recommended use of hemodialysis (HD) and hemoperfusion (HP) in Recommended use of hemodialysis (HD) and hemoperfusion (HP) in poisoningpoisoning

Poison Procedure1 indications2

Carbamazepine HP Seizures, severe cardiotoxicity

Ethylene glycol HD Acidosis, serum level > 50 mg/dl

Lithium HDSevere symptoms; level >4 meq/L more than 12 hours after last dose

Methanol HD Acidosis, serum level >50 mg/dl

Phenobarbital HPIntractable hypertension, acidosis despite maximal supportive care

Salicylate HDSevere acidosis, CNS symptoms, level > 100 mg/dl (acute overdose) or >60 mg/dl (chronic intoxication)

Theophylline HP or HDSerum level >90-100 mg/L (acute) or seizures and serum level >40-60 mg/L (chronic)

Valproic acid HDSerum level > 900-1000 mg?L or deep coma, severe acidosis

1Contac a regional poison control center or a clinical toxicologist before undertaking these procedure

Example of common drugs screened for in blood and urine in a reference toxicology laboratory

BloodAcetaminophenAlcoholsBarbituratesBenzodiazepinesCarbamazepineCarisoprolol

EthchlorvynolGlutethimideMeprobamidePhenytoinSalicylates

UrineAcetaminophenAlcoholsAmphetaminesBarbituratesChlorpheniramineCocaineCodeineDextromethorphanDiphenhydraminelidocaine

MepperidineMeprobamateMethadoneMorphinePentazocinePhencyclidinePhenothiazinesPropoxypheneSalicylatesTricyclic antidepressants

Examples of common drugs screened in blood and urine in a reference toxicology laboratory

Drug or Toxin Treatment

Acetaminophen Specific antidote (acetylcysteine) based on serum level

Carbon monoxide

High carboxythemoglobin level indicates need for 100% oxygen, consideration of hyperbaric oxygen

Carbamazepine High level may indicate need for hemoperfusion or hemodialysis

Digoxin On basis of serum digoxin level and severity of clinical presentasion, treatment with Fab antibody fragments (Digibind) may be indicated.

Ethanol Low serum level may suggest nonalcoholic cause of coma (eg, trauma, other drugs, other alcohols). Serum ethanol may also be useful in monitorring ethanol therapy for metathol or ethylene glycol poisoning.

Iron Level may indicate need for chelation with deferoxamine

Lithium Serum levels can guide decision to institute hemodialysis

Methanol, ethylene glycol

Acidosis, high levels indicate need for hemodialysis, therapy with ethanol or fomepizole.

Methemoglobin Methemoglobinemia can be treated with methylene blue intravenously.

Salicylates High level may indicate need for hemodialysis, alkaline diuresis

Theophylline Immediate hemodialysis or hemoperfusion may be indicated based on serum level

Valproic acid Elevated levels may indicate need to consider hemodialysis.

Common corrosive agents

Category and Examples Injury Caused

Concentrated alkaliesClinitest tabletsDrain cleanersIndustrial-strength ammoniaLyeOven cleaners

Penetrating liquefactionNecrosis

Concentrate acidsPool disinfectantsToilet bowl cleaners

Coagulation necrosis

Weaker clening agentsCationic detergents (diswaher detergents)Household ammoniaHousehold bleach

Superficial burns and irritation; deep burns (rare)

OtherHydrofluoric acid

Penetration, delayed, destructive injury

Reproduced, with permission, from Saunders CE, Ho MT (editors): Current Emergency Diagnosis & Treatment, 4th ed. Originally piublished by Appleton &

lange Copyright © 1992 by The McGraw-Hill Companies, Inc.