Problem 5

Emergency Medicine Block

Frudensia Kristiana
405110031
Group 10

Diagnosis Multiaxial
(PPDJ III)

Daftar Kategori Diagnosis

F0 : Gangguan Mental Organik, Termasuk Gangguan Mental

Simtomatik
F1 : Gangguan Mental dan Perilaku Akibat Penggunaan Zat Psikoaktif
F10 : Gangguan mental dan perilaku akibat
F11 : Gangguan mental dan perilaku akibat
F12 : Gangguan mental dan perilaku akibat
F13 : Gangguan mental dan perilaku akibat

hipnotika
F14 : Gangguan mental dan perilaku akibat
F15 : Gangguan mental dan perilaku akibat
termasuk kafein
F16 : Gangguan mental dan perilaku akibat
F17 : Gangguan mental dan perilaku akibat
F18 : Gangguan mental dan perilaku akibat
mudah menguap
F19 : Gangguan mental dan perilaku akibat
dan penggunaan zat psikoaktif lainnya

penggunaan
penggunaan
penggunaan
penggunaan

alkohol
opioida
kanabinoida
sedativa atau

penggunaan kokain
penggunaan stimulansia lain
penggunaan halusinogenika
penggunaan tembakau
penggunaan pelarut yang
penggunaan zat multipel

F2 : Skizofrenia, Gangguan Skizotipal dan Gangguan

Waham
F3 : Gangguan Suasana Perasaan
F4 : Gangguan Neurotik, Gangguan Somatoform dan
Gangguan yang berkaitan dengan Stres
F5 : Sindrom Perilaku yang Berhubungan dengan
Gangguan Fisiologis dan Faktor Fisik
F6 : Gangguan Kepribadian dan Perilaku Masa Dewasa
F7 : Retardasi Mental
F8 : Gangguan Perkembangan Psikologis
F9 : Gangguan Perilaku dan Emosional dengan Onset
Biasanya pada Masa Kanak dan Remaja

Diagnosis Multiaksial
Tujuan dari diagnosis multiaksial :
Mencakup informasi yang komperhensif

(gangguan jiwa, kondisi medik umum, masalah

psikososial dan lingkungan, taraf fungsi secara
global), sehingga dapat membantu dalam
perencanaan terapi dan memperkirakann
outcome atau prognosis.

Axis I
Gangguan Klinis (F00-09, F10-29, F20-29, F30-39, F40-

48, F50-59, F62-68, F80-89, F90-98, F99)

Kondisi Lain yang Menjadi Focus Perhatian Klinis
(tidak ada diagnosis Z03.2, diagnosis tertunda R69)

Axis II
Gangguan Kepribadian (F60-61, gambaran kepribadian

maladaptive, mekanisme defensi maladaptif)

Retardasi Mental (F70-79)
(tidak ada diagnosis Z03.2, diagnosis tertunda R46.8)

Axis III
Kondisi Medik Umum

Axis IV
Masalah Psikososial dan Lingkungan

(keluarga, lingkungan social, pendidikan,

pekerjaan, perumahan, ekonomi, akses
pelayanan kesehatan, hukum, psikososial)

Axis V

Axis V
Penilaian Fungsi Secara Global (Global Assesment of Functioning = GAF Scale)
100-91

gejala tidak ada, fungsi max, tidak ada masalah yang tidak
tertanggulangi
90-81
gejala min, fungsi baik, cukup puas, tidak lebih dari masalah harian
biasa
80-71
gejala sementara dan dapat diatasi, disabilitas ringan dalam social
70-61
bbrp gejala ringan & menetap, disabilitas ringan dlm fungsi, scr
umum baik
60-51
gejala dan disabilitas sedang
50-41
gejala dan disabilitas berat
40-31
bbrp disabilitas dlm hubungan dgn realita & komunikasi, disabilitas
berat
dlm beberapa fungsi
30-21
disabilitas berat dlm komunikasi & daya nilai, tdk mampu berfungsi
dlm hampir semua bidang
20-11
bahaya mencederai diri/orang lain, disabilitas sangat berat dlm
komunikasi & mengurus diri
10-01
persisten dan lebih serius
0
informasi tidak adekuat

Drug abuse

Common Drugs of Abuse

Opioid

Opioid Effect

http://www.ncbi.nlm.nih.gov/bookshelf/picrender.fcgi?
book=hssamhsatip&part=A45799&blobname=tip54a2fig.jpg

Hallucionogen

Cocaine

Cannabis

How to Use?
Smoked euphoric effects in minutes,
Peak : 30 minutes,
Lasts : 2-4 hours,
Motor & cognitive effect : 5-12 hours

Orally brownies, cakes. 2-3 times dose to

achieve same effect as smoked.

Amphetamine

DSM IV-TR CRITERIA FOR

AMPHETAMINE INTOXICATION

Kaplan and Sadocks Synopsis of

DSM IV-TR CRITERIA FOR

AMPHETAMINE WITHDRAWAL

Kaplan and Sadocks Synopsis of

Hypnotics, Sedatives,
Anxiolytics

Intoxication and Withdrawal

Kaplan and Sadocks Pocket Handbook of Clinical

Treatment of Benzodiazepine
Withdrawal

Alcohol

DSM-IV-TR Diagnostic Criteria for

Alcohol Withdrawal
A. Cessation of (or reduction in) alcohol use that has been heavy
and prolonged
B. Two (or more) of the following, developing within several
hours to a few days after Criterion A:
1. autonomic hyperactivity (e.g., sweating or pulse rate
greater than 100)
2. increased hand tremor
3. insomnia
4. nausea/vomiting
5. transient visual, tactile, or auditory hallucinations or
illusions
6. psychomotor agitation
7. anxiety
8. grand mal seizures
C. The symptoms in Criterion B cause clinically significant
distress or impairment in social, occupational, or other
important areas of functioning
D. The symptoms are not due to a general medical condition and
are not better accounted for by another mental disorder

Nicotine

Caffeine

Withdrawal Symptoms
Headache (often described as
being gradual in development
and diffuse, and sometimes
throbbing and severe)
Fatigue -- (e.g., fatigue,
tiredness, lethargy, sluggishness)
Sleepiness/drowsiness -- (e.g.,
sleepy, drowsy, yawning)
Difficulty concentrating -(e.g., muzzy)
Work difficulty -- (e.g.,
decreased motivation for
tasks/work)
Irritability -- (e.g., irritable,
cross, miserable, decreased wellbeing/contentedness)
Depression -- (e.g., depressed
mood)
Anxiety -- (e.g., anxious,
nervous)
Flu-like symptoms -- (e.g.,
nausea/vomiting, muscle

Intoxications
nervousness (anxiety),
restlessness,
excitement,
insomnia,
rambling flow of thought and
speech,
gastrointestinal upse
tremors,
tachycardia,
diuresis,
muscle twitching,
periods of inexhaustibility, and
psychomotor agitation.
In addition, there have been
reports of patients with caffeine
intoxication having fever,
irritability, tremors, sensory
disturbances, tachypnea, and
headaches. High dose caffeine
toxicity is very rarely fatal.
However, caffeine can be lethal at

Psychiatry Emergency

DSM - IV
Recent ingestion
Behavior changes (e.g. aggression)
Slurred speech
Coordination
Unsteady gait
Nystagmus
Attention or memory
Stupor or coma

Support Vital Signs

Measure vital signs frequently
Address life-threatening problems ABCs

Of Emergency Care
No medication until are sure they are
needed

Airway and Breathing

Assure adequate ventilation
Straighten head (if no neck injury)
Remove obstructions in mouth
If needed intubate
Use respirator (~12 breaths/min)

Circulation
Maintain adequate blood pressure
Start IV line
Use large-gauge needle
Use a slow drip until know if need fluids

Specific Drugs : Antidotes

Opioids naloxone
Monitor possible opioid abstinence syndrome

BDZ flumazenil
Monitor possible seizures & intracran press

Atropine-like drugs physostigmine

Barbiturates No antidote
Forced diuresis & alkalinization of urine

GEOMETRICAL HALUCCINATION

Brain Involvement

Heroin
Heroin enters the brain, converted to

morphine, binds to opioid receptors

(located in brain, body,brainstem) affects
perception of pain, and alter breathing, BP,
HR, arousal, etc
Regular heroin use tolerance
decreased physiological and
psychological effect of drug more heroin
needed to reach the same intensity of
effect

National Institute on Drug Abus

National Institute on Drug Abus

Marijuana / Cannabis
Enters brain stimulate

dopamine release
euphoria
Impairs brain ability to form
new memory and shift focus.
Binding to receptor in
cerebelum and basal ganglia
impairs coordination and
balance
Large dose acute
psychosis (hallucinations and
delusions), the cause
remains unknown

National Institute on Drug Abus

LSD
Disrupting interaction of nerve cells and

neurotransmitter serotonin impairs

control of behavioral, perceptual, and
regulatory systems, including mood,
hunger, body temperature, sexual
behavior, muscle control, and sensory
perception
Impairs glutamate receptors impairs
perception of pain, responses to the
environment, and learning and memory.

National Institute on Drug Abus

Amphetamine
Binds to serotonin transporter prolonged

serotonin signal
Enters serotonergic neurons release
more serotonin
Serotonin is a neurotransmitter that plays
an important role in the regulation of mood,
sleep, pain, appetite, and other behaviors.

National Institute on Drug Abus

Metamphetamine
Increases the release and block the

reuptake of dopamine euphoria

Chronic abuse reduced motor skills and
impaired verbal learning, severe structural
and functional changes in areas of the
brain associated with emotion and memory
cognitive and emotional problems

National Institute on Drug Abus

Sedatives, Hypnotics,
Anxiolytics
Binds to GABAA receptors increase

affinity to GABA increase the flow of

chloride ions thorugh the channel into the
neuron
GABA stimulation results less chloride influ
than was caused by GABA stimulation
before benzodiazepine administrations
tolerance and dependence

Kaplan and Sadocks Synopsis of

Ecstasy
Binds to serotonin transporter prolonged

serotonin signal
Enters serotonergic neurons release
more serotonin
Lesser effect in dopamine
After drugs use : confusion, depression,
sleep problems, drug craving, and severe
anxiety
Chronic : impairs cognitive ability

National Institute on Drug Abus

Alcohol
No single molecular targets
Effects on membranes of neurons
Short term : increasing fluidity of the

membranes
Long term : membranes become rigi

Harrisons Principle of Internal Medicine 18th Ed

Kaplan and Sadocks Synopsis of

Alcohols Affect on the Brain

Alcoholism shrinks the brain

Diagnosis

Physical examination
General appearance
General neglect with poor nutritional state suggests

a lifestyle that has become totally concerned with

drugs, ignoring personal hygiene, food or clothing,
etc
Marked weight loss is particularly seen with chronic
use of stimulants such as amphetamines
Scars over head may indicate injuries sustained
during convulsions, usually in the course of sedative
hypnotic withdrawal
Gait
Unsteady gait (ataxia)

Eyes
Watering eyes occur during opiate withdrawal.
Pin-point pupils suggests the recent

administration of opiates.
Dilated pupils occurs in opiate withdrawal, and
which also occur following the use of
amphetamine, cocaine, hallucinogens (LSD), and
anticholinergic drugs (in some OTC drugs).
Nystagmus is indicative of intoxication with
sedative hypnotics
Red eye (dilatation of conjunctival blood vessels)
usually due to cannabis or volatile solvents abuse

Nose
Congestion of nasal mucosa (lining of the

nose) occurs if drugs have been snorted.

Nasal septum ulceration or perforation
occurs when cocaine or heroin is snorted.
Runny nose (rhinorhoea) is due to opiate
withdrawal, or due to constant sniffing.
Red, spotty rash around the nose and mouth
is due to solvent sniffing

Mouth
Dental caries is frequently found in opiate

dependent users (due to poor dental hygiene

and predilection for sweet food).
Loss of several teeth may occur in the course
of convulsions during sedative hypnotic
withdrawal.
Breath odour may indicate solvents or
alcohol abuse.

Skin
Gooseflesh (pilo-erection) indicates opiate

withdrawal.
Profuse sweating indicates withdrawal from
sedative-hypnotics and alcohol.
Scars of abscesses over anywhere of the
body
Needle puncture marks in the skin overlying
the veins of injection
Pigmentation of the skin over the veins
(tracking) due to repeated injection

Neuromuscular system
Tremor and muscle twitching are signs of

opiate withdrawal.
Severe wasting of the muscle occurs when
drug like pethidine is repeatedly injected.
Further examination
Examination of cardiovascular system,

respiratory system, abdomen, lymphatic

system and neuromuscular system requires
referral to medical practitioners with
experience in addiction

Laboratory Examination
Drug test lab management include:
Screening test
See the presence / absence of the substance /
metabolite
Knowing the type of substance / metabolite

contained
Setting presence / absence complications
due to drug use

Laboratory method for screening drugs and his

metobolit must have the following requirements:

Sensitivity and specificity high sensitive:
Being able to detect presence or absence of

substance metabolite types of drugs in urine

SPECIFIC
Tools / reagents are able to identify the type of

drug that is in the urine. The method meets the

two conditions are:
EIA (enzyme immunoassay) and Imunokromatografi

Moreover both methods have a common simple

technique for screening

The advantage of using imunokromatografi

techniques:
Easy to do
Fast results (3-10 minutes)
Specific (standards National Institute of Drug

Abuse NIDA, now SAMHSA)

Sensitivity up to 99.7%

Base
Saturation competition IgG anti-drug
containing enzyme substrate (antibodies)
with enzyme drug in urine samples to be
screened (antigen)
This test is a qualitative

Result
Urine sample (+)
Saturation occurs, meaning that Ig G anti-

drug containing enzymes can not bind to the

enzyme of the drugs examined.
No color change.
Urine sample (-)
Saturation does not occur, it means Ig G anti-

drug containing enzyme could bind to full or

part by enzymes of the drug were examined.
It changes color.

Single Detection of Drugs and

Metabolites
Only detect one type of drug
TEST STRIP / STICK
Allow samples and reagents at room

temperature.
Reagents opened shortly before done
Dip tesstrip into the urine sample. Do not
exceed the maximum limit sign on the strip
Read the results of the first 3-5 minutes and
3-5 minutes both

Test Card
Let the samples and reagents at room
temperature.
Reagents opened shortly before done
Put 3-5 drops of urine samples in the sample

zone
Read the results of the first 3-5 minutes and
3-5 minutes both

3-6 Drug Detection and Metabolites

Being able to detect 3-6 types of drugs as

well as
Prepare reagents and urine samples
Dip the strip into 6 parts into the urine

sample.
Results read after 5-10 minutes

Interpretation of Results
Positive
Forming a pink line on the zone C, showed drug
levels above the threshold value
Negative
There are two pink lines on zone T (test) zone
and C (control)
It could mean:
No drug substances in the urine
Levels below the threshold (cut off point) that can

be detected by the test tool if dubious confirmation

Confirmatory Test for Drugs

Mass chromatografi (MS) sensitive

(higher sensitivity for measuring the

intensity of the ion substances)
Gas chromatografi (GS) specific (able to
differentiate various types of substances
through ion intensity level, the barriers of
time and form)

Investigations
X-ray
CT-scan
EKG

Complication
Infection HIV, hepatitis, and tuberculosis
Tracks," visible puncture scars, are caused

by repeated injection.
Scarring of the veins may lead to swelling.
Using veins and inject directly into the first
layer of skin, known as "skin-popping.
cellulitus (infection into connective tissue)
and abscess.
Criminal activity.

Prognosis
60% exposure to toxins can be treated and

removed
10% admitted to ICU
Non toxic exposure or light can often be
sent home
Psychiatric consultation if there is an
attempt to commit suicide

DD
Opioid
Hypoglycemia
Hypoxia
Intracerebral
hemorrage
Alcohol intoxication
Hepatic
encephalophaty
Hypothermia
Hyponatremia
seizures

Barbiturat
Alcohol intoxication
Benzodiazepin intoxication
Sepsis
seizures

DD
Benzodiazepins
Alcohol intoxication
Barbiturat
intoxication
Hypoglycemia
Meningitis
Sepsis

Halusinogen
Delirium
Skizofren
Head injury
Meningitis
Sepsis