Terapi Definitif Keracunan Obat
Transcript of Terapi Definitif Keracunan Obat
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Dr. Nanang Sukmana, SpPD-KAISubbagian Alergi & Imunologi Klinik
Bag. Ilmu Penyakit Dalam Fakultas Kedokteran UI/RS Dr. Cipto Mangunkusumo
Jakarta
Terapi Definitif Kasus Keracunan
Obat
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The Most Common Toxic Syndromes
Anticholinergic syndromes
Sympathomimetic syndromes
Opiate, sedative or ethanol intoxication
Cholinergic syndromes
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Confusioncentral nervous system depressionweaknesssalivationlacrimationunaryfecal incontinencegastrointestinal crapingemesisdiaphoresismuscle fasciculationspulmonary edemamiosisbradycardiatachycardiaseizures
The Most Common Toxic Syndromes
Cholinergic syndromes
Common signs Common causes
Organophosphatecarbamate insecticidesphysostigmine, edrophoniumsome mushrooms
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The Most Common Toxic Syndromes
Anticholinergic syndromes
Common signs
Delirium with mumbling speech Tachycardia Dry Flushed skin Dilated pupils Myoclonus Slightly elevated temperature Urinary retention Decreased bowel sounds
(Seizure and dysrhythmias may occur in
severe cases)
AnthistamineAntiparkinson medicationAtropineSchopolamineAmantadineAntipsychitic agentsAntidepressant agentsAntispasmodic agentsMydriatic agentsSkeletal muscle relaxantssMany Plant (notably jimson weed and
Amanita muscaria)
Common causes
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The Most Common Toxic Syndromes
Sympathomimetic syndromes
Common signs Common causes
DelusionsParanoiaTachycardia (or brandycardia if the
drug is a pure alpha-adrenergic agonist)Hypertension hyperpyrexia Diaptoresis PiloerectionMydriasisHyperreflexia
(Seizures, hypotension
dysrhythmias may occur in severe cases)
Cocaineamphetaminemethamphetamine (and its derivaties 3, 4-methylenedioxyamphetamine, 3, 4- methylene-dioxymethampetamine, 3,4- methylenedioxyethamphetamine, and 2, 5-dimethoxy-4-bronmoamphetamine)over-the-counter decongestants (phenylpropanolamine, ephedrine and pseudoephedrine)In caffeine and theophyline overdoses,similar findings, except for the organic psychiatric signs, result from catecholamine release
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Comarespiratory depressionmiosishypotensionbrandycardiahypothermiapulmonary edemadecreased bowel sounds hyporeflexia needle marks
(Seizures may occur after overdoses of
some narcotic, notably propoxyphene)
The Most Common Toxic Syndromes
Opiate, sedative or ethanol intoxication
Common signs Common causes
Narcoticsbarbituratesbenzodiazepinesethchlorvynolglutethimidemethyprylonmethaqualonemeprobamateethanolclonidineguanabenz
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Penatalaksanaan Keracunan Amfetamin
Umumnya gejala yang terlihat adalah :
Agitasi
Hipertensi
Takikardi
Midriasis
Trismus
Diaporesis Sampai Gejala Berat
Hipertermi
Koagulopati
Rabdomiolisis
Aritmi
Kejang
Gagal Ginjal
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Keracunan Barbiturat
Barbiturat 1. obat hipnotik 2. sedatif
Diganti dengan benzodiazepin yang lebih aman Masih banyak digunakan untuk mengatasi kejang Beberapa tindakan anestesi
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Klasifikasi
Lama 12-24 jam Barbital 8-16 jam Natrium barbital12-24 jam Fenobarbital
PrimidonSedang 8-10 jam Alobarbital
ButobarbitalAmilobarbital
Singkat 6-8 jam Pentobarbital4-6 jam Siklobarbital
KuinalbarbitalSangat singkat 3-4 jam Heksobarbital
Tiopenton
Dosis fatal: fenobarbital 6-10 g, amobarbital dan penobarbital 2-3 g.
Lama kejaDosis terapi
Nama generik Nama dagang
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Gambaran Klinis
Efek utama dari intoksikasi barbiturat
Depresi sistem susunan saraf pusat
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Social / Environmental
Risk Factors
Behavioral / Psychological
Risk Factors
Organ Systems
Risk Factors
Cellular
Risk Factors
Molecular
Risk Factors
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Yang Terjadi PadaPenyalahgunaan NAPZA
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The Opium Poppy
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Gambaran NAPZA di RSCM
1998 : 62 kasus overdosis1999 : 203 kasus overdosis
Overdosis putaw (opiat) 166 (82%) Overdosis shabu-shabu (amfetamin)
37 (18%) Laki-laki 172. Perempuan 31 Meninggal 11 orang
Dari catatan medik Unit Gawat Darurat (Dr. Nanang Sukmana,dkk)
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RS. IM = 743 (dari 1997 - 1999)
RS. AG = 1120 (Oktober 1997 - 1999)
RS.MMA = 251 (selama 1 tahun)
RS. TH = 286 (Jan.1999 - Des.1999)
Pengguna NAPZA yang dirawat di berbagai RS. Swasta
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= Heroin / Morfin
= Extasy
MASALAH KETERGANTUNGAN OBATMASALAH KETERGANTUNGAN OBAT
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Perasaan senang Ramah Berperilaku diluar karakter Berperilaku lucu
= Mariyuana /Cannabis
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Daun Ganja Sumber : Drug-ARM.(Awareness and Relief Movement)
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Daun Ganja
Sumber : Drug-ARM.(Awareness and Relief Movement)
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Komposisi spesifik :1. MDMA (3,4-methylenedioxymethamphetamine)= Ecstasy2. MDEA (3,4-methylenedioxyethamphetamine)= Eve3. 2 CB (4-bromo-2,5-methoxyphenylethylamine)4. Bromo-DMA (4-bromo-2,5-dimethoxyamphetamine) = Bromo “STP” = DOB
Nama populer umum (street name) :DOB : Golden eagle, LSD 25, Tile, 100X, Bromo STPMDA : Harmony, Love drug, Speed for loversMDMA : Adam, Ecstasy, Essence2 CB : Eve, Spectrum
Range of toxicity untuk MDMA : 50 - 150 mg
Ecstasy (Ekstasi)
Dr.Nanang Sukmana, SpPD. KAI
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Suatu derivat morfin dengan kekuatan 3 - 5 kali morfin
Dalam waktu 5 menit setelah suntikan dirubah
menjadi morfin
Dalam waktu 40 menit konsentrasinya (morfin)
melebihi heroin
Heroin mudah masuk ke cerebral / serebri = otak
mudah intoksikasi
( diacetyl morphine )
Dr.Nanang Sukmana, SpPD. KAI
PUTAUW
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= CokeCharlieSnow
Euphoria = perasaan senang yang berlebihan Stress / gelisah hilang Aktif / atraktif Membangkitkan gairah
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Daun Cocaine
Sumber : Drug-ARM.(Awareness and Relief Movement)
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Bubuk cocaineBubuk cocaine
Sumber : Drug-ARM.(Awareness and Relief Movement)
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Morfin
Sumber : Drug-ARM.(Awareness and Relief Movement)
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Alat Hisap Opiat (Pipa Rokok)
Sumber : Drug-ARM.(Awareness and Relief Movement)
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Morfin
Sumber : Drug-ARM.(Awareness and Relief Movement)
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Heroin
Sumber : Drug-ARM.(Awareness and Relief Movement)
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Alat Hisap Cocaine (Pipa)
Sumber : Drug-ARM.(Awareness and Relief Movement)
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Rute (Pemakai Heroin)
Smoking Snorting Sniffing
Injeksi bawah kulit (skin popping)
IV (intra vena)
Dr.Nanang Sukmana, SpPD. KAI
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Street Names for Heroin
BingBoy JiveBrownCaballoChivoCrapDead on ArrivalDopeDoo DooDuke
DynamiteEstuffanFoolish PleasureFunkHHombreHorseJiveJunkLa Bamba
MudScatShitSkagSmackSugarSweet JesusTango and Cash
Dr.Nanang Sukmana, SpPD. KAI
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Mekanisme Kerja Endorphin di Otak dalam keadaan Normal
Endorphin(endogen morfin)
1 2
ReseptorOpiat
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Mekanisme Kerja Opiat di Otak pada Pengguna
Nalokson
Endorphin(endogen morfin)
1 2
ReseptorOpiat
Morfin
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PneumoniaHCV / HIV
PEMAKAI SEHAT
Kelompok risiko tinggi
Emergensi
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Status Imunologi
Putus Obat
Overdosis
Adiksi
HIV
Pneumonia drug abuse
Endokarditis Infektif
Kel. hematologiHCV
Infeksi : Kulit
SSP
Kehamilan
Kognitif
Dispepsia
Emboli paru
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Infeksi
Imunitas
Paparan kuman
CD4 CD8
NK
LAK (Lymphokine Activated Killer) IL2 stimulatied NK Cell
ADCC DTH (-)
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Gejala Putus Obat
Tanda-tanda objektif Takikardi Meningginya tekanan darah Meningkatnya respirasi (pernapasan) secara mencolok Suhu badan meninggi Mual, muntah Diare Insomnia Gemetar/tremor Kejang-kejang kecil Lemas
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Gejala Putus Obat =
Mata berair
Seperti pilek
Bersin
Keringat banyak
Tangan gemetar
Kulit angsa
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CRAVING= Suges(ti)
INTERNAL CRAVING≈ endorphin
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EXTERNAL CRAVING
Lebih lama 2 th ( ? )
KEPRIBADIAN ADIKSI
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POLA ENDORPHIN DI SSP
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MCI / SAKIT HEBAT TRAUMA
Morfin
Endorphin
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SAKIT KANKER
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HIV
• 12 (75%) dari 16 orang ( IGD RSCM ) tahun 1999• 19 orang dari POKDISUS tahun 2000• 11 (45,8%) dari 24 orang (RS. Sulianti Saroso Jakarta)• 2150 Kasus HIV AIDS di Indonesia (23
Propinsi) 258 telah meninggal (YPI)
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HIV / AIDS (1)
Cara penularan yang penting saat ini di Indonesia,
yaitu di kalangan pecandu narkotika karena
kebiasaan memakai jarum suntik bersama
dan jarum yang tidak steril
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Terjadinya :a. Aspirasib. Multiple, Cavitary lung lesion
associated with pulmonary emboli
c. Community acquired bronchopneumonia
d. Pulmonary abcessese. TBC
Pneumonia Drug Abuse (Infeksi Paru oleh karena Opiat)
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Pneumonia DrugAbuse
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Cardiovascular infection
Berhubungan dengan IDU Bakteri berasal dari kulit & pelarut Staphylococcus aureus (50 %) Streptococcus Enterococcus Pseudomonas Klebsiella Serratia Candida
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HCV
• 57,7% dari 898 orang (data Dr. Nanang.
S )
RS. Swasta (Sep 1997-Mei 1999)
Sekarang 80 %
• 15 (78,9%) dari 19 orang (IGD RSCM)
tahun 1999•
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Upaya - Upaya Pada Penderita Hepatitis C
Cukup istirahat
Hindari konsumsi alkohol, narkoba
Hindari pemakaian obat-obat yang tidak diperlukan (obat pusing, dll)
Makan makanan yang bergizi
Konsultasi rutin dengan dokter
Dr.Nanang Sukmana, SpPD. KAI
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Cellulitis abscesses Skin ulcers
Septic thrombophlebitis Necrotizing fascitis & myositis
Skin
Infection
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Hematologi :
Trombositopenia
( Yang berfluktuasi )
Thrombosis
ACA
1. CVD
2. DVT
Protozoa
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Adverse effect of Mood-Altering on pregnancy and the newbornAdverse effect of Mood-Altering on pregnancy and the newborn
Drug
AmphetaminesBarbiturates Sedative Tranquilizers
Spontaneous Abortion
Premature Delivery
+
+
Perinatal Mortability
+
+
NeonatalWithdrawal
+
+
Fetal Distress
+
+
Congenital Abnormality
++ + + + + +Heroin
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Prinsip Penatalaksanaan Kasus Keracunan
Penatalaksanaan kegawatan
Penilaian Klinis
Dekontaminasi racun
Pemberian antidotum
Terapi suportif
Observasi dan konsultasi
Rehabilitasi
Dr.Nanang Sukmana, SpPD. KAI
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Keadaan Klinis Yang Perlu Mendapat Perhatian
Koma Kejang
Henti jantung Henti napas
Syok
Dr.Nanang Sukmana, SpPD. KAI
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O P I A T , S E D A T I V E, O RO P I A T , S E D A T I V E, O R E T H A N O L I N T O X I C A T I O N E T H A N O L I N T O X I C A T I O N
KomaDepresi pernapasanMIOSISHipotensiBradikardiHipotermiEdema pulmonerBising usus menurunHiporefleksiKejang (kasus berat)
NarkotikNarkotik BarbituiratBarbituirat BenzodiazepinBenzodiazepin MeprobamatMeprobamat EtanolEtanol KlonidinKlonidin
Opiat : morpin, pethidin, heroin, dan kodein
Dr.Nanang Sukmana, SpPD. KAI
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Jenis obat opium, dosis fatal, dan dosis pengobatan
Jenis Obat
KodeinDextrometorphanHeroinLoperamid (imodium)Meperidin (petidin)MorpinNaloxone (Narcan, Nokoba)*)Opium (Papaver somniferum)Pentazocaine (Talwin)
Dosis fatal Dosis pengobatan (grm) (mg)
0,8 600,5 60-120/day0,2 40,5 1 1000,2 10
0,30,3
*) Antagonis narkotika. Dosis s/d 5 mg tidak menyebabkan kematian.Dr.Nanang Sukmana, SpPD. KAI
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Perkiraan waktu deteksi dalam urin beberapa jenis obat
Jenis obat Lamanya waktu bisa dideteksi
Amfetamin 2 hariBarbiturat 1 hari (short acting)
3 minggu (long acting)Benzidiazepin 3 hariKokain 2 - 4 hariKodein 2 hariHeroin 1 - 2 hari Methadone 3 hariMorpin 2 - 5 hari
Dr.Nanang Sukmana, SpPD. KAI
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Penatalaksanaan Overdosis Opioid
Gejala klinis Penurunan kesadaran disertai salah satu dari:
70% pengguna narkoba melalui suntikan (Injection Drug User / IDU),
1. Frekuensi pernapasan < 12 kali/menit
2. Pupil miosis (seringkali pin-point).
3. Adanya riwayat pemakaian morfin/heroin/ terdapat needle track sign
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Tindakan
1. Tanpa hipoventilasi : Dosis awal diberikan 0,4 mg iv.2. Dengan hipoventilasi : Dosis awal diberikan 1-2 mg iv. 3. Bila tidak ada respon dalam 5 menit ,diberikan nalokson 1-2 mg iv hingga timbul respon perbaikan kesadaran dan hilangnya depresi pernapasan, dilatasi pupil atau telah mencapai dosis maksimal 10 mg. Bila tetap tidak ada respons lapor konsulen Tim Narkoba.
Penanganan kegawatan
Bebaskan jalan nafas Berikan oksigen 100% sesuai kebutuhan Pasang infus D5% emergensi atau NaCl 0,9%; cairan koloid bila diperlukan
Pemberian antidotum naloxone (1)
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4. Efek nalokson berkurang 20–40 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.5. Simpan sampel urin untuk pemeriksaan opioid urin dan lakukan foto toraks.6. Pertimbangkan pemasangan ETT ( endotracheal tube ) bila :
7. Pasien dipuasakan untuk menghindari aspirasi akibat spasme pilorik
Pemberian antidotum naloxone (2)
Pernapasan tidak adekuat Oksigenasi kurang meski ventilasi cukup Hipoventilasi menetap setelah pemberian nalokson ke – 2.
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