Dasar-dasar Penatalaksanaan Keracunan
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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.