dr Shahrul Rahman, Sp.

PD
Departemen Ilmu Penyakit Dalam
Fakultas Kedokteran
Universitas Muhammadiyah Sumatera Utara

Acute exposure is a single contact that

lasts for seconds, minutes or hours, or

several exposures over about a day or
less. Chronic exposure is contact that
lasts for many days, months or years.
A poison may get into the body
through ingestion, inhalation (gas,
vapors, dust, fumes, smoke, spray),
skin contact (pesticides), or injection
(bites and stings, drug injection

History taking
What poison was ingested.
Time since ingestion.
Total amount of poison ingested.
Route of exposure.
Progression of signs and symptoms since

ingestion.
Family history of epilepsy, mental sub
normality, bleeding disorder.
Whether the patient is receiving other
medications which may interact with the
poison.

General Management
1. PREVENT FURTHER POISONING
2. KEEP PATIENT ALIVE
3. ANTIDOTE S AND ANTAGONIST

PREVENT FURTHER POISONING

The patient should be separated from the

source of poison immediately

Removal of contaminated clothings
Cleaning of skin and mucous membrane
Gastric lavage are important
Vomiting may be induced
The mouth must be at a lower level than the
larynx

KEEP PATIENT ALIVE

Management of coma
Management of shock
Management of respiratory failure
Good appropriate nursing management

ANTIDOTES AND ANTAGONISTS

The term Universal antidote implies an

emetic agent
Less than 2% instances of poisoning is there a
spesific pharmacological antidotes
Very few poisons will be antagonised in vivo

Initial resuscitation
stabilization

Includes airway- proper positioning head tilt

and chin lift, suction of secretions from

oropharynx, falling back of tongue is
prevented by suitable airway tube.
Breathing- oxygen via a mask, when
gag/cough reflects is absent- ET tube
inserted. if necessary positive pressure
ventilation with ABG monitoring, respiratory
stimulants for severe respiratory
depression.
Circulation- proper IV access, maintenance
of fluid & electrolyte balance, IV drugs for
treatment.

Gastric Lavage. If the vomiting does

not occur quickly, gastric lavage

should be done promptly to remove
the poison. In a symptomatic but alert
patient with minor ingestion, activated
charcoal alone by mouth is sufficient
for gastrointestinal decontamination

Insecticides
1. Phenolic substance, e.g. Dinitrophenol

This causes anxiety, tachycardia,

arrhythmias, pyrexia, perspiration and
mucosal burns
Treatment : Intensive supportive therapy
Ice packs
Sedation

2. Organophosphorus, e.g.
Parathion,
Malathion
This cause restlessness, fibrillary twitches,
fits, colic, salivation, hypotension, unconscious.
Mild Poisoning

INSECTICIDE POISONING
Cause :
Suicide
Homicide
Accident due to :
No

follow direction use

Not known (children)
Route of poisons :
Airway (inhalation
Skin (contact)
GI Tract
Umar Zein

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The most common insecticides that cause

poisoning are:
- Organophosphate and Carbamat
- Chlorinated Hydrocarbon
Organophosphat dan Carbamat.
organophosphat groups :

Highly toxicity :
-Octamethyl pyro phospharamide (OMPA)
- Tetraethyl pyrophosphate (TEPP)
- Diisoprophylfluorophosphate (DFP)
- Sulfo tetraethyl pyrophosphate (Sulfo TEEP)
- Parathion
- Phosphamidon

Moderate Toxicity :
- Dichlovos
- Quinalphos
- Fenthion
- Diazinon
- Fenitrothion

Low Toxicity :
- Malathion
- Temephos

Carbamat groups :
Highly toxicity :Aldicarb, Apocarb, Carbofuran.
Moderate toxicity : Carbaryl, Primicarb,
Propoxur
Low toxicity : Metam sodium

Mechanism of action of organophosphat &

carbamat

Inhibition

of asetylcholinesterase

asetylcholine

Parasymphatic activity
Neuromuscular Activity
Alteration of CNS

Symptoms & Signs

1. Parasymphatic activity

( Muscarinic effect) :
Hypersalivation,

hypersecretion of

bronchial.
Sweating
Hyperperistaltic nausea, vomiting,
diarrhea
Pinpoint pupil (myosis)
Bradycardia
Bronchospasm
Incontinence urine and faecal

Neuromuskular stimulation :
- Twitching - Convulsion
Muscles weakness
Paralysis
Resp.muscles
Alteration of CNS :
Death

Confusion
Psychosis
Coma
Convulsion
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Management :
General :
Gastric lavage (if less than 4 hours)
Oxygen with Mechanical Ventilation
IVFD Ringer Lactate / NaCl
Body cleansing
Charcoal active : 1 gr / kg BW
Specific :
Antidote : Atropine ( Sulphas Atropine / SA)

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Tidak sadar : 16 ampul (4 mg) iv 8 ampul (2 m

per 30 menit sampai sadar

Sadar : 8 ampul (2 mg) iv 2 ampul (0.5 mg)/30 m

sampai atropinisasi
Atropinisasi : 1 ampul (0.25 mg)/4 jam selama 24

Atropinisation :
Mydriasis, dry skin, dry mouth, flushing and
warm,
tachycardia
Maintenance Dose.
0,5 mg / 30 minutes or 1 hour or 2 hour or 4
hour (depend on you need)
NB :
Contra indication SA : cyanosis --> VF
Maximal Dose : 50 mg / 24 hours.
1 amp SA = 0,25 mg

Obat lain yang diberikan setelah

atropinisasi:
Diazepam : 5 - 10 mg IV
Pralidoksim :
Dosis

- Inisial : 2 gr IV
- Maintenance : 8 mg/kgBB/jam selama

24 j

Obidoksim :
Dosis : - Inisial : 250 mg / IV
- Maintenance : 0,5 mg/kgBB/jam selama
24 j
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Organo Klorin
Jenisnya :
Toksisitas tinggi :

- Toksisitas rendah :

Aldrin

- Ethylan
-

Endrin

Hexachlorbenzene
Dieldrin
Endosulfan

- Methoxychlor

Toksisitas sedang :

- Chlordane
- Heptaklor
- Lindane
Toxaphene

- DDT
- Kepone
- Minex

Tanda &Gejala Klinis

Gelisah, gemetar, lemah
Sakit kepala, vertigo
Kesadaran menurun (delirium, koma)
Kejang, paralisis --> apnu
Takikardia, vibrilasi ventrikel
Takipnu, sianosis, edema paru.
Kalau tertelan : muntah, diare, sakit perut
Kalau terinhalasi : hidung / tenggorokan

terasa
spt terbakar
Kalau kena mata : iritasi, spt terbakar
Kalau kena kulit : iritasi, bintik-bintik merah

Keracunan kronis :
Sakit kepala, insomnia, gangguan jiwa, sulit
konsentrasi, depressi, twitching, kejang,
gangg. spermatogenesis, Ca
Penatalaksanaan:
Bersihkan kulit dan mata.
Bila tertelan : rangsang muntah, kumbah

lambung dan beri arang aktif.

Bila kejang : Diazepam 10 mg IV
Antidotum : tidak ada.
Phenobarbital 100-200 mg/ hari selama
beberapa hari - 2 minggu untuk :
Mempercepat metabolisme organoklorin
Mengurangi keluhan

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BOTULISMUS
Definisi : adalah suatu bentuk keracunan

akibat memakan makanan yang mengandung

toksin botulin yang dihasilkan oleh
Clostridium
botulinum.
Etiologi : Clostiridium botulinum
menghasilkan endotoksin /
neurotoksin
tdd 7 strain : A-G
yg paling sering : A,B,E
Spora : -mati pd temp.1200C selama 30 mnt
-tahan temp 1000C beberapa jam pada
Toksin : rusak pd - temp.1000C selama 1 mnt
- temp 800C selama 20 mnt

Pertumbuhan di hambat oleh Nitrat.

Pathogenesis :
Keracunan terjadi melalui berbagai cara :

1. Termakan makanan yang mengandung toksin

botulin (makanan basi, diasapi, peragian)
diabsorbsi, terutama di lambung &
usus halus bagian atas
Absorbsi di bagian bawah usus halus &
kolon : lambat.
2. Wound botulism:
C. botulinum masuk melalui luka / suntikan
subkutan (ok tdk tepat) berkembang biak
menghasilkan toksin.
Masa inkubasi : 4 - 14 hari
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Effek dari toksin botulinum :

Antikolinergik (parasimpatolitik) : menghambat

pelepasan asetil kolin

Tidak menembus sawar darah otak.
Dosos toksik : 0,05 mikrogram.

Gejala klinik:
Dimulai stlh 12-36 jam (bisa 8 hari) termakan

toksin.
Makin cepat makin berat.
Mual, muntah, lemah, vertigo.
Mulut/tenggorokan terasa kering ; sakit
menelan.
Mata : kabur, diplopia.
Otot (termasuk otot pernafasan) lemah

apnu
kematian

Pemeriksaan Fisik:

Kesadaran : normal sampai somnolen

Mata : ptosis, midriasis, refleks pupil

melemah
Mulut : mukosa & lidah kering
Paru : obstruksi jln nafas, infeksi sekunder.
Abdomen : distensi, peristaltik
lemah/hilang
V. urinaria : retensi urin
EKG : gangguan irama jantung

Diagnosa :
Ada riwayat memakan makanan tercemar
Ada gejala/tanda klinis :

Laboratorium :
Mendeteksi toksin pada makanan, muntahan,

tinja

---- lama pemeriksaan :24 jam

Diagnosa Banding:
Miastenia gravis
Guillain Barre Syndrome
Poliomielitis akut
Stroke
Keracunan atropin (Belladona)

Infant Botulismus:
tjd pd bayi 1 mgg- 6 bulan
terutama yang diberi madu
Gejala : Hipotonia

Sulit menelan
Takikardia

Penatalaksanaan :
Perbaiki jalan nafas:
Kalau

tjd obstruksi : - trakeostomi

- resp.
mekanik

Cleansing enema.
Bersihkan luka ( Wound Botulisme)
Antitoksin : Trivalent (ABE) antitoksin botulin

diberikan secara IV.

Hati-hati anafilaktik --- Test dulu

Antibiotik : Penisilin, Amoksilin, Ampisilin

Prognosa:

Angka kematian tinggi :

Strain

A : 60 - 70 %
Strain B : 10 - 30 %
Strain E : 30 - 50 %
Makin

dini diagnosa ditegakkan :

Makin baik prognosa.

Kerosene
Poisoning

Clinical Presentation
1. Pharynx, esophagus, gastric and small intestine
irritation burning sensation in mouth, throat
esophagus and mucosa ulcers
2. Ventricle fibrillation rare
3. CNS : somnolent or coma, rapidly after ingestion
4. Bronchopneumonia
5. Inhalation sign: euphoria like alcohol intoxication
6. Severe Intoxication : albuminuria
Asphyxia Death

Management
# Induction of emesis absolute contraindicated
# Adrenalin contraindicated
# Dont give Alcohol & Mineral oil
# True therapy :
1. Supportive
2. Oxygen
3. Intravenous fluid line
4. Antibiotic for prophylaxis
5. CNS symptoms caffeine

Intoksikasi

OPIAT

Effects of Opiate Administration and Opiate Withdrawal

Opiate Administration

Opiate Withdrawal

Hypothermia
Decrease in blood pressure
Peripheral vasodilation, skin flushed and warm
Miosis (pupillary constriction)
Drying of secretions
Constipation
Respiratory depression
Antitusive
Decreased sex drive
Relaxation
Analgesia
Euphoria

Hyperthermia
Increase in blood pressure
Piloerection (gooseflesh), chillines
Mydriasis (pupillary dilation)
Lacrimation, rhinorrhea
Diarrhea
Yawning, panting
Sneezing
Spontaneous ejaculations and orgasms
Restlessness, insomnia
Pain and irritability
Depression

Source.From Jaffe (1985) and Jaffe and Martin (1985)

Bila pemberian morfin dihentikan secara tiba-tiba maka

akan menimbulkan gejala :
-

Craving (mendambakan obat)

Gelisah, mudah tersinggung dan lekas marah
Peningkatan kepekaan terhadap rangsang nyeri
Mual, muntah
Piloereksi (bulu roma berdiri)
Disforia (suasana hati tidak nyaman)
Dilatasi pupil
Berkeringat
Takikardia
Nyeri otot
Kejang otot (kram)
Diare
Hipertensi
Demam
Menguap

Heroin yang disuntikkan sendiri

Heroin yang disuntikkan saling bergantian

Over dosis Heroin, menemui ajal dgn mengeluarkan buih

dari mulut

DIAGNOSIS
INTOKSIKASI
Trias:

Pinpoint
Depresi napas
Penurunan kesadaran (sampai kom

Bekas suntikan (needle track sign)

Pemeriksaan kualitatif urin

Penatalaksanaan
Kegawatan
A (Airways) bebaskan jalan napas dari
sumbatan bahan muntahan, lendir, gigi palsu, dll.
Bila perlu dengan perubahan posisi dan
oropharyngeal airway dan alat penghisap lendir.
B (Breathing) jaga agar pernapasan sebaik
mungkin dan bila memang diperlukan dapat
dengan alat respirator.
C (Circulation) tekanan darah dan volume cairan
harus dipertahankan secukupnya dengan
pemberian cairan. Bila terjadi henti jantung
lakukan RJP (Resusitasi Jantung Paru).

Protokol Penanganan Overdosis Opiat

B. Pemberian antidotum nalokson :
Tanpa hipoventilasi: Dosis awal diberikan 0,4 mg iv
(pelan-pelan atau diencerkan)
Dengan hipoventilasi: Dosis awal diberikan 1-2 mg iv
(pelan-pelan atau diencerkan)
Bila tidak ada respon diberikan nalokson 1-2 mg iv
tiap 5-10 menit hingga timbul respon atau mencapai
dosis maksimal 10 mg

Protokol Penanganan Overdosis Opiat

Efek nalokson berkurang 2040 menit dan pasien dapat jatuh

kedalam keadaan overdosis kembali, sehingga perlu pemantauan
ketat tanda-tanda penurunan kesadaran, pernapasan dan
perubahan pada pupil serta tanda vital lainnya selama 24 jam.
Untuk pencegahan dapat diberikan drip nalokson satu ampul
dalam 500 cc D5% atau NaCl 0,9% diberikan dalam 4 6 jam.
Simpan sampel urin untuk pemeriksaan opiat urin dan
lakukan foto toraks.

Protokol Penanganan Overdosis Opiat

Pertimbangkan pemasangan ETT (endotracheal tube) bila :
A. Pernapasan tidak adekuat setelah pemberian nalokson
yang optimal.
B. Oksigenasi kurang meski ventilasi cukup
C. Hipoventilasi menetap setelah 3 jam pemberian nalokson
yang optimal.
Pasien dipuasakan 6 jam untuk menghindari aspirasi
akibat spasme pilorik

Hipotensi diberikan cairan IV yang adekuat,

dapat dipertimbangkan pemberian dopamin
dengan dosis
2 - 5 mcg/Kg BB/menit dan dapat ditritasi bila
diperlukan.

Terima Kasih