Dyah Trifianingsih, S. Kep. Ners. M.

Kep
 Menjelaskan pengertian keracunan
 Mengenali tanda-tanda keracunan
 Memberikan pertolongan pertama pada
penderita keracunan
the overconsumption of normally harmless
substances
 Masuknya zat ke dalam tubuh yang dapat
menganggu kesehatan bahkan dapat
menimbulkan kematian

 Dicurigai mengalami keracunan bila:

1. Mendadak sakit
2. Gejala sesuai dengan patologis
3. Hasil anamnesis mendukung
4. Perubahan keadaan cepat memburuk
 Mulut
 Terhisap/ inhalasi
 Terserap oleh kulit
 Suntikan
 Sengatan/ Luka
 Korosif (Asam klorida, asam sulfat, bensin)
 Non korosif (makanan, obat-obatan)

 Bentuk racun: padat, gas dan cair

 Tentamen suicide

 Homicide

 Accidental
 Sengaja bunuh diri
 Diracuni
 Tidak sengaja
 Berlebihan/ overdosis
 Keracunan pabrik/ limbah
 Unconsiousness

 Seizures

 Shock

 Cyanosis
 Exposure or consumption time and route

 Evidence stuff

 Individual, family or social problems

 First aid
1) Age of the person:
 Children and old people generally are more susceptible to the
toxic agents due to decrease detoxification power.
2) Genetic factors:
 Persons suffering from glucose-6-phosphate dehydrogenase
deficiency are susceptible at therapeutic doses to heamolytic
effect of some drugs like vitamin K and sulphonamides.
3) Personal hypersensitivity:
 Very small harmless doses can produce severe symptoms in
sensitive patients e.g. therapeutic dose of penicillin or iodine
may produce anaphylaxis in some hypersensitive patients.
4) Tolerance:
 Repeated intake of substances of abuse leading to the
development of tolerance where the addicts can stand big dose
without ill-effect. So, they have to increase the dose to get the
same effect.
5) Idiosyncrasy:
 Abnormal response to some drugs e.g morphine may produce
convulsion instead of depression of CNS.
6) State of health :
 Patients suffering from liver or kidney diseases may
show signs of increased toxicity of the poisons.
7) Condition of the stomach:
- Type of food:
 Fatty foods delay the absorption of arsenic while they
increase the absorption of some poisons as DDT and
phosphorus.
- Gastric secretion:
 Poisoning with potassium cyanide may not be fatal in
case of achlorhydria as HCL in stomach is important to
form the severely toxic hydrocyanic acid.
- Empty or full stomach :
 A poison taken on full stomach has slower action than
the same dose of poison on empty stomach.
8) Synergism:
 The action of one drug may be increased if given with
another drug e.g. alcohol and barbiturate.
9)State of the poison.
 Poisons in gaseous form are more rapidly absorbed
followed by liquid poisons, fine powder
10) Routes of administration:
 The quick.. inhalation followed by IV, IM, SC,
ingestion, absorption through mucous membranes,
lastly absorption through the intact skin
11) Dose of the poison:
 The bigger the dose, the more toxic the effect.
12) Cumulation:
 After repeated small doses of certain drugs, that
are not readily metabolized, the effect of a single
large dose is reached leading to poisoning e.g.
digitalis.
 Umum (A, B, C)
Symtomatis/ menghilangkan gejala
Antidot/ penawar yang tidak spesifik
Muntah paksa

 Khusus
Cuci lambung
Antidot/ penawar spesifik
Diuresis
Dialisis/ Cuci darah
  Vital sign

 Level of consiousness

 Spesific signs and symptoms

 Routine laboratory (blood, urine, faeces)

 Spesific test

 Toxicology test

 Otopsi
  First aid

 Emergency measurements

 rehabilitation
  Inhalation  fresh air and oxygen

 Skin absorpsion  shower and shampooing

 Eye contamination  irrigation

 Ingestion encourage to vomit ( mechanical,

IPECAC, NORIT). CI : unconsioussness,
corosive, hidrocarbon.
 Bila racun tertelan
◦ Encerkan racun yang ada dalam lambung, sekaligus
menghalangi penyerapannya. Cairan yang dipakai: air susu
◦ Rangsang muntah
Efektif bila dilakukan dalam 4 jam setelah racan ditelan
Cara mekanik: merangsang dinding faring dengan jari
Garam ± 1-2 sdm/ 1 gelas air hangat
Kontraindikasi rangsang muntah:
Keracunan zat korosif: asam/ basa kuat
Keracunan minyak tanah, bensin
Penurunan kesadaran
 Bila racun melalui kulit/ mata
Cuci/ bilas bagian yang terkena dengan air
Pakaian yang terkontaminasi dilepas
Perhatikan jangan sampai penolong ikut
terkena
 Bila racun memalui inhalasi
◦ Pindahkan penderita ke tempat yang aman
◦ Pernafsan buatan penting untuk mengeluarkan
udara yang terhisap
◦ Jangan lakukan pernafasan dari mulut ke mulut
  BLS / resusitation (ABC)

 Elimination (emesis,katarsis,gastric
lavage,dialisis)

 Antidotum

 Symtomatic
 Airway
Periksa kelancaran jalan nafas
Depresi pernafasan
Kelancaran jalan nafas (chin lift/jaw thrust/NPA/
OPA
Cegah aspirasi isi lambung
 Breathing
Kaji ventilasi adekuat : Analisa gas darah,
spirometri
Depresi pernafasan, syok, tidak sadar: Berikan
oksigen, ventilasi mekanik
 Circulation
◦ Gangguan sirkulasi: Syok
◦ Pasang IV line
◦ Kaji TTV
◦ Pantau EKG
 Disability
Pantau status neurologis: Tingkat kesadaran/
GCS, ukuran dan reflek pupil, TTV
Penurunan kesadaran akibat: penurunan
oksigenasi, depresi pernafasan
  Psikiater

 Support system
Manifestation :
 lungs : aspiration, cough, ALO, irritation
 GI track : nausea, vomitting, bleeding
 Systemic : convulsi, CNS depression, coma,
fatique, headace
 Skin and eyes : irritation

 Thorax photo
 BGA
 Tx : elimination is effective
 Poisonous food ( chemical 1-6 hours, biological
6-12 hours,microbiological 12-48 hours)
 Insidens in a group after having a party

Manifestations :
 Nausea vomitting, dehidration
 Serum electrolyte,BUN Creatinin

 Oralit
 Norit
 IV line
 Gejala klinis:
Masa inkubasi 8 jam – 8 hari
Muntah
Gangguan penglihatan
 Tindakan:
◦ Usahakan muntah
◦ Bilas lambung
◦ Periksa laboratorium
◦ Antidot
 Gejala klinis:
Masa inkubasi ¼ - 4 jam
Pruritis
Mual, muntah
Badan lemas
Sulit bernafas
 Tindakan:
A,B,C,D
Anti histamin
Usahakan muntah
Bilas lambung
Berikan nafas buatan
 Gejala klinis:
Mulut, nafas dan urin bau jengkol
Sakit penggang dan perut
Rasa sakit saat miksi, kadang bercampur
darah

 Tindakan:
◦ Berikan minuman yang banyak
◦ Berikan analgesik
 Ethanol  CNS depressant ; aditif ;
hypoglichemic

 Toxic dose : 0,7 g /kg pure ethanol  blood

concentration 100 mg/dl 
drunk,hipoglicemi

 300 mg/dl  coma

Metabolism :
 25 % ethanol absorbed in gaster, 75% in small
intestine
 Water increase the absorbsion, while fats
decrease it.

 After 5 minutes in gaster  detect in blood 

totally detect in 30 – 180 minutes
Hepar :
ethanol --------> acetaldehyde ------->
acetyl CoA
( alcohol dehydrogenase) (aldehyde
dehydrogenase)

--------> H20 + CO2

(TCA cycle)

 10% absorbed ethanol is excreted without any

change in urine, breath, and sweat
Manifestations:
Acute : euforia, ataksia, nistagmus, reflex
impairmaent, defect in judgement ability,
agresive, hipogliecemic  coma, miosis, CNS
depressant
Chronic : GI bleeding, hepatitis, CH, EH,
hipokalemi, hipofosfatemi, hipomagnesemi,
tiamin defisiensi
 Acute alcoholic psychosis (Korsakoff
Syndrome) : mental disorder, disorientation,
loss of memory
Withdrawl Syndrome:
Tremulousness,convulsi, hiperaktivitas
simpatis

Laboratory:
Ethanol concentration, CBC, glucose, BUN
Creatinin, SGOT/PT, elecrolyte, BGA
 Management:
- resusitation
-elimination  less usefull
-supportive : IV line D5% + B1, anticonvulsant
- (-) antidotum
 Malathion,diazinon,basudin,baygon
(carbamate)…

 IFO +KhE ----- > IFOKhE ------ >

AkHKhE(inaktif)
(fosforilasi) (hidrolisis)

----------- > AkH accumulation

 Irreversible after 24- 36 hours

 Muskarinik : defecetion, urination, miosis,
bradikardi, bronchospasme, emesis,
lacrimation, salivation

 Nicotinic : muscle weakness, tachicardia,

cramping, hypertention

 SSP: cephalgy, convulsion, coma, emotion

changes
 KhE concentration in erythrocyte
mild : 40-70% N
intermediate : 20-40% N
severe : < 20% N

 Lung and cerebral edema

Management :
- Resusitation
- Elimination
- Supportive

- Antidotum : Atropin Sulphat (SA)  inhibit

the effect of AkH accumullation
IV 1-2.5mg – 0,5-1mg ( 5’-10’-
15’)atropinisasi
 15’-30’-60’-2 hr-4hr-6hr-12hr
2x24hr
- Reactivator KHE :pralidoxime
 Silent killer, Highly toxic gas, Acute reaction
 Greenhouse effect, Global warming, Incomplete
combustion
 50 ppm : Threshold limit, no apparent toxic
symptoms

 Myoglobin Carboxymyoglobin cherry pink meat

 Mitochondrial Cytochrome Oxidase  ATP <
 Haemoglobin
- 98,5 % Oxygen carried by Hb, 1,5% solvent in
serum
- CO affinity 200x > Oxygen
- Carboxyhaemoglobin  reversible
- N  0,4 – 0,7 %
 Permeabilitas
 Vasodilatasi vaskuler
 Hipoksia
 Hipoperfusi
 Demyelinisasi
 Necrosis
 B1 : takipneu, dyspneu,
wheezing,bradypneu, hipoksemia,
hipercarbia
 B2 : chest pain, hipotensi, takikardi, aritmia,
bradikardi
 B3 : headache, dizziness, confusion, letargi,
coma, memory loss, poor coordination,
bradikinesia, tremor, gangguan kognitif,
neuropsikiatri
 B4 : uncontrolled urination
 B5 : nausea, vomitting
 B6 : weakness, redness skin
 Fresh Air
 Minimalize Oxygen demand
 HbCO monitoring
 Hypoksia sign monitoring
 Hiperbaric Oxygen Therapy
HbCO  reversible bonding
The patient breathes 100% oxygen
intermittently while the pressure of the
treatment chamber is increased to greater
than one atmosphere absolute (atm abs).
Current information indicates that
pressurization should be at least 1.4 atm
abs.
Seorang wanita usia 17 tahun dibawa kerumah sakit
oleh keluarganya. Korban ditemukan keluarganya
setelah kurang lebih 30 menit mengunci diri dikamar
pada keadaan pingsan. Pada saat ditemukan mulut
berbuih dan bau obat nyamuk. Korban mengalami
penurunan kesadaran. Pada pemeriksaan fisik TD:
90/60 mmHg, Nadi: 60 bpm, rr: 7 x/menit. Dari awal
pasien ditemukan kurang lebih 60 menit

What Should you do to be a good nurse?

 Poisoning is caused by swallowing, injecting,
breathing in, or otherwise being exposed to a
harmful substance. Most poisonings occur by
accident.
 Immediate first aid is very important in a poisoning
emergency. The first aid you give before getting
medical help can save a person's life.
 Poisoning is a significant global public health
problem.
 According to WHO data, in 2004 an estimated
346,000 people died worldwide from unintentional
poisoning
 Of these deaths, 91% occurred in low- and middle-
income countries.
 In the same year, unintentional poisoning caused
the loss of over 7.4 million years of healthy life
 Carbon monoxide gas (from furnaces, gas
engines, fires, space heaters)
 Certain foods
 Chemicals in the workplace
 Drugs, including over-the-counter and
prescription medicines (such as an aspirin
overdose) and illicit drugs such as cocaine
 Household detergents and cleaning products
 Household and outdoor plants (eating toxic
plants)
 Insecticides
 Paints
 Abdominal pain  Heart palpitations
 Bluish lips  Irritability
 Chest pain  Loss of appetite
 Confusion  Loss of bladder control
 Cough  Muscle twitching
 Diarrhea  Nausea and vomiting
 Difficulty breathing or  Numbness and tingling
shortness of breath  Seizures
 Dizziness  Skin rash or burns
 Double vision  Stupor
 Drowsiness  Unconsciousness
 Fever  Unusual breath odor
 Headache  Weakness
Dose
 The amount of chemical entering the body
 This is usually given as mg of chemical/kg of
body weight = mg/kg
 The dose is dependent upon
* The environmental concentration
* The properties of the toxicant
* The frequency of exposure
* The length of exposure
* The exposure pathway
Exposure: Pathways
• Routes and Sites of Exposure
– Ingestion (Gastrointestinal Tract)
– Inhalation (Lungs)
– Dermal/Topical (Skin)
– Injection
• Intravenous, Intramuscular, Intraperitoneal

• Typical Effectiveness of Route of

Exposure
iv > inhale > ip > im > ingest > topical
 Keracunan Zat Padat
1. Obat Salisilat: perdarahan, edema
paru, depresi pernapasan, nekrosis
tubular akut
2. Makanan: Dehidrasi, gangguan
kesadaran
 Keracunan Gas:
1. CO: Edem paru, depresi pernapasan,
syok, coma
2. Toksit iritan: Edem paru
3. Hidrokarbon: Depresi pernapasan
 Keracunan zat cair
 Alkohol

1. Perdarahan lambung dan usus

2. Kerusakan ginjal dengan zat gula dalam

kencing
3. Kerusakan hati (Liver)

4. Kegagalan jantung

5. Oedema paru-paru (paru-paru berisi air)

6. Pembentukan methemoglobine (oleh amly

alkohol)
 Metil Alkohol: Kejang, syok, koma
1. Mencari bantuan petugas kesehatan/EMS
2. For poisoning by swallowing:
 Check and monitor airway, breathing, and pulse.
If necessary, begin rescue breathing and CPR.
 Pastikan bahwa pasien tersebut keracunan. Jika
tidak bisa  kaji tanda gejala meliputi bau racun
dari mulut, luka bakar diarea mulut, difficulty
breathing, vomiting, or unusual odors. If
possible, identify the poison.
 Do NOT make a person throw up unless told to
do so by poison control or a health care
professional.
 Jika pasien muntah  clear airway. Wrap a cloth
around your fingers before cleaning out the
mouth and throat. If the person has been sick
from a plant part, save the vomit. It may help
experts identify what medicine can be used to
help reverse the poisoning.
 If the person starts having convulsions,
give convulsion first aid.
 Keep the person comfortable. The person should
be rolled onto the left side, and remain there
while getting or waiting for medical help.
 If the poison has spilled on the person's clothes,
remove the clothing and flush the skin with
water.
3. For inhalation poisoning:
 Call for emergency help. Never attempt to
rescue a person without notifying others
first.
 If it is safe to do so, rescue the person from
the danger of the gas, fumes, or smoke.
Open windows and doors to remove the
fumes.
 Take several deep breaths of fresh air, and
then hold your breath as you go in. Hold a
wet cloth over your nose and mouth.
 Do not light a match or use a lighter because
some gases can catch fire.
 After rescuing the person from danger, check and
monitor the person's airway, breathing, and
pulse. If necessary, begin rescue breathing and
CPR.
 If necessary, perform first aid for eye injuries or
convulsion first aid.
 If the person vomits, clear the person's airway.
Wrap a cloth around your fingers before cleaning
out the mouth and throat.
 Even if the person seems perfectly fine, get
medical help.
1. Resusitasi dan stabilisasi  ABC
2. Evaluasi klinis dan difinitif diagnosa
3. Dekontaminasi
4. Antidotum
5. Perawatan suportif
EVALUASI KLINIS DAN
DEFINITIF DIAGNOSA.
ANAMNESA :
- BAGAIMANA RACUN MASUK TUBUH :
- JUMLAH RACUN YANG MASUK.
- SUDAH BERAPA LAMA KONTAK.
- PERTOLONGAN PERTAMA YANG SUDAH
DIBERIKAN.
- PROFIL PSYKOLOGI PENDERITA.
- GEJALA YANG TELAH DIALAMI PENDERITA.
 Common Physical Signs in Toxicology
Physical signs Likely Causative agent

Coma; drowsiness Alcohol, antidepressants, antihistamines, antipsychotics, barbiturates and

other sedatives, narcotics, salicylates
Breath odour Alcoholic breath: Ethanol
Smell of garlic: Arsenic, organophosphates, phosphorus
Odour of bitter almonds: Cyanides
Smell of acetone: Isopropanol, nail polish remover, salicylates
Pungent odour: Ethchlorvynol
Fragrance of violets: Turpentinne
Smell of oil of Wintergreen: Methylsalicylate liniment
Pearl-like odour: Chloral hydrate
Miscellaneous typical odours: Ammonia, kerosene, petrol, petroleum
distillates, phenol
Eyes
Pupils:
Constricted (miosis) Mushrooms (muscarinic properties), narcotics, organophosphates
Dilated (mydriasis) Amphetamines, antihistamines, atropine, barbiturates, cocaine, glutethamide,
lysergic acid Diethylamide (LSD), methanol, opiate withdrawal, tricyclic
antidepressants
Nystagmus Barbiturates, PCP, phenytoin, sedatives
Visual disturbance Botulism, digoxin, methanol, organophosphates
Visual hallucinations Alcohol, cocaine, LSD, mescaline, PCP

9/24/2019
Mouth:
Dry Amphetamines, antihistamines, atropine, narcotics
Salivation Arsenic, corrosives, mercury, mushrooms, organophosphates, strychnine.

Gum discoloration Lead, other heavy metals

Respiration:
Rate increased Amphetamines, barbiturates (early effect), methanol, petroleum distillates,
(>20/min) salicylates
Rate decreased Alcohol, barbiturates (late effect), narcotics
(<10/min)
Respiratory paralysis Botulism, organophosphates
Wheezing/pulmonary Narcotics, organophosphates, petroleum distillates
oedema

Heart Rate:
Bradycardia Digitalis, narcotics, sedatives
Tachycardia Alcohol, amphetamines, atropine, cocaine, salicylates
Gastro-intestinal:
Abdominal Colic Arsenic, heavy metals, lead, mushrooms, narcotic withdrawal,
organophosphates
Constipation Lead, narcotics
Diarrhoea Arsenic, boric acid, iron, mushrooms, organophosphates
Vomiting (sometimes Boric acid, caffeine, corrosives, heavy metals, phenol, salicylates,
bloody) theophylline
Skin:
Bullae Barbiturates, carbon monoxide
Cyanosis Carbon monoxide, nitrites, strychnine
Jaundice Arsenic, carbon tetrachloride, castor bean, mushroom (delayed effect),
paracetamol (delayed effect)
Needle marks Amphetamines, narcotics, PCP
Purpura Salicylates, snake bites, spider bites
Redness and Alcohol, antihistamines, atropine, boric acid, carbon monoxide,
flushing of skin cyanide
Sweatiness Amphetaminess, barbiturates, cocaine, LSD, mushrooms,
organophosphates

Neuromuscular:
Fasciculations/ Alcohol, amphetamines, antihistamines, barbiturate withdrawal,
convulsions chlorinated hydrocarbons, cyanide, isoniazid, lead, methaquolone,
organophosphates, phenothiazines, plants (a number of), salicylates,
strychnine, tricyclic antidepressants
Paralysis Botulism, heavy metals
Ataxia Alcohol, barbiturates, bromides, hallucinogens, heavy metals, organic
solvents, phenytoin
1. Dekontaminasi kulit dan mata  bilas
dengan air mengalir selama 10-15 menit
2. Dekomtaminasi pernafasan  high flow
oksigen 100% with NRM
3. Dekontaminasi GIT  dilusi/pengenceran,
emesis, gastric lavage, eliminasi
menggunakan carcoal
 activated charcoal – is sometimes used to treat
someone who's been poisoned; the charcoal
binds to the poison and stops it being further
absorbed into the blood
 antidotes – these are substances that either
prevent the poison from working or reverse its
effects
 sedatives – may be given if the person is
agitated
 a ventilator (breathing machine) – may be used
if the person stops breathing
 anti-epileptic medicine – may be used if the
person has seizures (fits)
1. Maintain an open airway.
2. Perform a focused history and physical exam,
include
3. SAMPLE history. Use gloved hands to carefully
remove any pills, tablets, or fragments from the
patient’s mouth.
4. Assess baseline vital signs.
5. Dilute poison by water or milk according to
medical direction.
6. Transport the patient with all containers, bottles,
and labels from the substances.
7. Perform ongoing assessment en route.
 Remove the patient to a safe area. Detect and
treat immediately life-threatening problems in
the initial assessment. Evaluate the need for
prompt transport for critical patients.
 Perform a focused history and physical exam ,
including SAMPLE history and vital signs.
 Administer high concentration oxygen.
 Transport the patient with all containers,
bottles, and labels from the substance.
 Perform ongoing assessment en route.
1. Detect and treat immediately life-threatening problems in the
initial assessment. Evaluate the need for prompt transport for
critical patients.
2. Perform a focused history and physical exam , including SAMPLE
history and vital signs. This includes removing contaminated
clothing while protecting oneself from contamination.
3. Remove the poison by doing one of the following:
a. Powder: brush off patient.
b. Liquids: irrigate with clean water for at least 20 minutes as
needed.
c. Eyes: irrigate with clean water for at least 20 minutes as
needed.
4. Transport the patient with all containers, bottles, and labels from
the substance.
5. Perform ongoing assessment en route.
Antidote poisoning Treatment regime
N-Acetylcystein Paracetamol 1. Iv NAC 150 mg/kg
dlm 200 ml D5%
diatas 30min.
Diikuti
2. 1v NAC 50 mg/kg
dlm 500 ml D 5%
diatas 4 jam
diikuti
3. Iv NAC 100 mg/kg
dlm 1L
D5%diatas 16 jam
ATROPINE 1. Organophosphat 1-2 mg per 5 menit
2. Nerve agents sampai sekresi
3. Carbamat bronchial berkurang
4. Muscarinic agent NB: ukuran pupil
bukan tujuan akhir
terapi
ETHANOL 1. Methanol 1. Iv 7.5 ml/kg dari
2. Ethylene glycol 10% Ethanol,
dilanjutkan
2. 1v 1-2 ml/kg dari
10 % ethanol
untuk
mempertahankan
serum ethanol
pada 100mg/dl