Rosen’s Emergency Medicine Concepts and Clinical Practice 9e

Obat Non Psikoaktif Tintinalli’s Emergency Medicine Manual 8th Ed

• Acetaminophen

Aspirin NSAID
 Clinical Emergency Medicine-McGraw-Hill; Lange (2014)

Z
A
T

P
S
I
K
O
A
K
T
I
F
 SSRI ALCOHOL
CYCLIC ANTIDEPRESSANT

Rosen's Emergency Medicin Concepts and Clinical Practice Edition 9th

Tintinalli’s Emergency Medicine Manual 8th Ed
 Alcohol
ETHANOL ISOPROPANOLOL METHANOL

S&S - disinhibited behavior similar to that of ethanol but - metabolic acidosis

- slurred speech produces a greater degree of - CNS depression
- impaired coordination intoxication than ethanol - visual changes (classically, a
followed later by: complaint of looking at a
- respiratory depression • Severe: snowstorm)
- central nervous system (CNS) - coma
depression - respiratory depression
- hypotension
Commonly alcoholic drink - rubbing alcohol - windshield washing fluid
found in - solvents - solid fuel for stoves
- skin and hair products - solvents
- paint thinners
- antifreeze

Acetone is the principal toxic

metabolite.

Tintinalli’s Emergency Medicine Manual 8th Ed

HALLUCINOGENS

Tintinalli’s emergency medicine manual. 8th Edition. USA: McGraw-Hill Education, 2018.
HEAVY METAL

Rosen's Emergency Medicin Concepts and Clinical Practice Edition 9th

Tintinalli’s Emergency Medicine Manual 8th Ed
 Tintinalli’s Emergency Medicine Manual 8th Ed
Chemical, Inhalant & Gas Clinical Emergency Medicine-McGraw-Hill; Lange (2014)

Organophospate

Hydrocarbon

Amonia Carbon Monoxide

Tintinalli’s Emergency Medicine Manual 8th Ed

Clinical emergency medicine (LANGE)
Acetaminophen
• Acetaminophen is metabolized to non - toxic glucuronide and sulfate
conjugates, and to a highly reactive metabolite N-acetyl-p-
benzoquinoneimine (NAPQI) via CYP isoforms.
• At therapeutic dosing, NAPQI binds to nucleophilic glutathione;
• but, in overdose, glutathione depletion may lead to the pathological
finding of hepatic necrosis

Benzodiazepine
• Benzodiazepine  efek sedatif, hipnotik, anxiolytic, antikonvulsi
dengan cara meningkatkan aksi inhibisi GABA.
• Pengikatan benzodiazepin ke reseptor spesifik benzodiazepin 
meningkatkan efek GABA pada chloride channel di reseptor GABAA
 meningkatkan intracellular flux dari ion klorida & hiperpolarisasi
sel  kemampuan sel saraf u/ menginisiasi potensial sel berkurang
 menghambat transmisi neural
Barbiturat
• Barbiturat menekan aktivitas semua sel
yang dapat dieksitasi, terutama yang ada di
SSP dengan meningkatkan aktivitas GABA,
• Pada OD akut: barbiturat menurunkan
transmisi saraf pada ganglia otonom,
miokardium, dan GIT dan juga
menghambat respons terhadap asetilkolin
di neuromuscular junction.
• Reseptor GABAA merupakan kompleks
protein yg ditemukan pada membrane
pascasinaps di SSP. Secara structural terdiri
dari beberapa situs reseptor berbeda yg
mengelilingi saluran Cl- .
• GABA membuka saluran klorida  Cl-
masuk ke dalam sel  meningkatkan
negative resting potential, hiperpolarisasi,
dan menstabilkan membrane
• Barbiturat menghasilkan efek depresi terkait
dosis mulai dari sedasi ringan hingga koma
dan henti pernapasan fatal.
• Barbiturat diklasifikasikan berdasarkan
onset dan durasinya:
- Ultra short acting (segera setelah dosis IV,
durasi: menit)
- Short acting (onset 10-15 menit setelah dosis
oral, durasi: 6-8 jam)
- Intermediate acting (onset 45-60 menit, durasi:
10-12 jam)
- Long acting (onset 1 jam, durasi: 10-12 jam)
• Barbiturat dapat melewati plasenta dan ASI.
Pengguanaan selama kehamilan dapat
menyebabkan cacat lahir (kategori D)
Rosen's Emergency Medicine Concepts and Clinical Practice Edition 9th
 Ethanol

• GABA
• Glutamat receptors
• Dopamine
• Neuropeptida

Pharmacological Reviews Vol. 67, Issue 4 - Mechanisms of Action and Persistent Neuroplasticity by Drugs of Abuse
IRON ARSENIC
• Iron has two distinct toxic effects • Arsenic binds avidly to sulfhydryl
1. Direct caustic injury to the groups, inhibiting enzymes in
gastrointestinal mucosa glycolysis.
• vomiting, diarrhea, and abdominal pain.
Hemorrhagic necrosis of gastric or • Disrupts oxidative
intestinal mucosa can lead to bleeding, phosphorylation by replacing
perforation, and peritonitis phosphorus in the formation of
2. Impairs cellular metabolism, high-energy phosphate bonds
primarily of the heart, liver, and (arsenolysis).
central nervous system (CNS).
• Unbound (free) iron moves into cells • Arsine causes massive hemolysis.
and localizes near the mitochondrial
cristae, resulting in uncoupling of
oxidative phosphorylation and
impairment of adenosine triphosphate
synthesis.
• Cell membranes are injured by free
radical mediated lipid peroxidation. Rosen's Emergency Medicine. Concepts and Clinical Practice 7th Ed.
 ORGANOFOSFAT in brain
• Toxicity is produced through binding and inhibition of
acetylcholinesterase-> excess accumulation of acetylcholine and
stimulation of cholinergic receptors, of both the muscarinic and
nicotinic receptor types.
• The muscarinic receptor agonism results in a cholinergic crisis known
as “SLUDGE” and “DUMBELS” effects

Rita K. Cydulka, David M. Cline, O. John Ma et al. - Tintinalli’s Emergency Medicine Manual-McGraw-Hill (2017)
 Acetaminophen NSAID Aspirin/ Salicylate

Tintinalli’s Emergency Medicine Manual 8th Ed

Clinical emergency medicine (LANGE)
Alcohol

Clinical emergency medicine (LANGE)

https://www.nejm.org/doi/full/10.1056/NEJMra1615295
Cyclic Antidepressant Opioid

Clinical emergency medicine (LANGE) https://link.springer.com/chapter/10.1007/978-3-030-16257-3_5

Hydrocarbon Carbon Monoxide

Tintinalli’s Emergency Medicine Manual 8th Ed

Clinical emergency medicine (LANGE)
Arsenic Iron

Tintinalli’s Emergency Medicine Manual 8th Ed

Clinical emergency medicine (LANGE)
http://www.floridahealth.gov/environmental-health/mercury-spills/mercury-poisoning/_documents/guidelines-for-arsenic.pdf
 ORGANOPHOSPORUS

Tintinalli’s Emergency Medicine Manual 8th Ed

https://www.semanticscholar.org/paper/Insecticides%2C-Herbicides%2C-and-Rodenticides-Do-
Ruha/52f6e1b29ef8533b09c23922da54053daa36b1cb/figure/1
Acetaminophen
Lab
• Serum APAP level Imaging
• Liver studies (aspartate aminotransferase, • Consider a head computed
alanine aminotransferase, albumin, tomography (CT) in patients
bilirubin) whose mental status does not
• Coagulation profile (prothrombin time [PT] correlate with an isolated
, international normalized ratio and partial ingestion.
thromboplastin time)
• CBC, electrolyte, anion gap, blood gas
• Cerebral edema secondary to
sampling, renal function hyperammonemia may occur in
hepatic failure.

Clinical emergency medicine (LANGE)

ASPIRIN NSAID
• ASA toxicity is a clinical diagnosis made • NSAID levels are not readily available
in conjunction with the patient’s acid– or clinically useful in assessing toxicity
base status
• Laboratory evaluation should include
• Respiratory alkalosis with an anion-gap electrolytes, glucose, renal and hepatic
metabolic acidosis, and hypokalemia
are the classic features of this function tests, and an APAP level.
poisoning. • Bedside glucose determination is
• Check bedside glucose levels in all indicated for altered mental status or
patients with altered mental status. seizures.
• Additional laboratory studies include
electrolytes, blood urea nitrogen (BUN),
creatinine, complete blood count (CBC),
prothrombin time (PT), ASA level, APAP
level (to exclude coingestion), and
blood gas
Tintinalli’s Emergency Medicine Manual 8th Ed
ETHANOL
• Glucose level should be
measured in all patients with
altered mental status
• In those patients without a
clear explanation for their
altered mental status, serum
ethanol levels may help
confirm intoxication
• For patients with comorbid
disease or injury, additional
labs that may be helpful
include the following:
electrolytes may demonstrate
an anion gap acidosis; liver
enzymes may reveal hepatic
damage.
• Obtain imaging as indicated by
external signs of trauma in the
inebriated patient.
ISOPROPANOL
• A glucose level should be
measured in all patients with
altered mental status
• Laboratory studies: may
reveal an elevated osmolal
gap, ketonemia, and
ketonuria, without acidosis.
• In the setting of upper GI
bleeding: coagulation studies,
a complete blood count
• When available, serum
isopropanol and acetone
levels confirm the diagnosis,
but are not required for
management.
METHANOL
• Elevated levels of
methanol can confirm
toxicity
• An elevated osmolal
gap is present early,
and may be useful
when methanol
testing is not
immediately available
• Basic laboratory
investigations include
a bedside glucose,
electrolytes, renal
function arterial
blood gas, urinalysis,
and methanol level
Tintinalli’s Emergency Medicine Manual 8th Ed
Benzodiazepin
• Pasien dengan gangguan status mental perlu segera melakukan
pemeriksaan kadar gula darah.
• Kualitatif immunoassay untuk benzodiazepine dalam urin tersedia tetapi
tidak membantu dalam menentukan tatalaksana
• Skrining urin (+)  belum lama terpapar, tetapi tidak mengonfirmasi
keracunan / mengindikasikan agen spesifik
• Kurangnya bau alkohol / Breathalyzer negatif / hasil tes etanol darah 
benzodiazepine / obat penenang lainnya sebagai penyebab yang mungkin.
• Flumazenil antagonis benzodiazepine tidak boleh diberikan secara rutin
pada pasien dengan koma yang tidak diketahui penyebabnya / diduga OD
benzodiazepine, untuk tujuan diagnostik

Rosen's Emergency Medicin Concepts and Clinical Practice Edition 9th

 COCAINE
AND AMPHETAMINES
• Urine drug screening for cocaine is
reliable and can detect exposure within
72 hours
• Urine screens for amphetamines are less
specific
• Additional laboratory evaluation for
intoxicated patients includes a complete
metabolic panel to assess acid/base
status, kidney function, and a creatine
kinase (CK) to assess for rhabdomyolysis.
• The evaluation of altered mental status
or seizure may include a head CT to
exclude intra- cranial hemorrhage.
• Consider ECG, chest radiograph, and
cardiac enzymes in cocaine- or
amphetamine-intoxicated patients
presenting with chest pain.
emergency medicine: concepts and clinical practice, 9th Edition. Philadelphia: Elsevier, 2018.
Tintinalli’s emergency medicine manual. 8th Edition. USA: McGraw-Hill Education, 2018.
HALLUCINOGENS
• Routine drug screens will not detect LSD,
psilocybin, or mescaline
• Urine tests for phencyclidine (PCP) are
unreliable
• Urine tests for marijuana are unreliable
indicators of acute use because patients may
be positive for days to weeks after their last
use
• Check glucose, electrolytes, renal function, CK,
and urinalysis to evaluate for hyponatremia,
rhabdomyolysis, and acute kidney injury.
• Exclude other causes of altered mental status,
including traumatic injuries, hypoglycemia,
and infection in patients with hyperthermia
Iron
PEMERIKSAAN PENUNJANG
• Serum iron concentration diperiksa 3-
5 jam setelah ingesti, ulangi 6-8 jam
setelah ingesti jika meminum preparat
sustained-release/ salut enteric
• Peak serum iron < 350 μg/dL toksisitas
minimal, 350 – 500 μg/dL toksisitas
sedang, > 500 μg/dL toksisitas berat
• X-ray abdominal: untuk konfirmasi
ingesti dalam jumlah besar, tablet yg
mengandung kadar Fe signifikan akan
tampak radiopaque. False negative
dapat terjadi jika preparat besi
chewable, liquid, & seluruh komponen
besi sudah dissolved

Rosen’s Emergency Medicine. 2017

Hallucinogen
Benzodiazepin
• Henti napas
• Kematian
• Pneumonitis aspirasi
• rhabdomyolisis

https://www.ncbi.nlm.nih.gov/books/NBK482238/
Definisi:
• serangan pertama
psikosis yang
muncul secara
tiba-tiba atau
dapat didahului o/
gejala “break from
reality” namun
tidak disadari o/
orang di
sekitarnya

Kaplan & Sadock's Synopsis Of Psychiatry. 11th ed.

Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 7th ed. 2011
Gray, S.W. Competency-based Assessments in Mental Health Practice. 2011.
Kriteria diagnosis DSM-5 Gangguan Psikotik akibat
Penggunaan Substansi atau Obat

Kaplan & Sadock's Synopsis Of Psychiatry. 11th ed.

Evaluasi psikosis

Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 7th ed. 2011

Tatalaksana
• Psikoterapi:
• Empati
• Keluarga mendampingi pasien
• Membangun kepercayaan pasien
• Farmakoterapi:
• Antipsikotik diberikan jk pasien mengalami agitasi berat, schizophrenia, acute
mania, anxiety
• Keinginan melukai diri sendiri atau org lain scr episodik dan mendadak:
haloperidol, β-adrenergic receptor antagonists, carbamazepine, lithium

Kaplan & Sadock's Synopsis Of Psychiatry. 11th ed.

DAFTAR PUSTAKA
• Kaplan & Sadock’s synopsis of psychiatry: behavioral sciences/clinical
psychiatry. 11th Ed
• Rosen’s Emergency Medicine. 9th ed
• Tintinalli’s Emergency Medicine A Comprehensive Study Guide. 8th
edition. 2016
• Gray, S.W. Competency-based Assessments in Mental Health Practice.
2011.
• Pharmacological Reviews Vol. 67, Issue 4 - Mechanisms of
Action and Persistent Neuroplasticity by Drugs of Abuse
• Clinical Emergency Medicine-McGraw-Hill; Lange (2014)