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Dr. Harun Hudari, SpPD

Toxicology

DIVISION OF TROPICAL INFECTIOUS DISEASESDEPARTMENT OF INTERNAL MEDICINE

SCHOOL OF MEDICINE, SRIWIJAYA UNIVERSITY

MOH. HOESIN HOSPITAL

PALEMBANG



Definition of Toxicology - the basic science of poisons (old)

- the study of the adverse effects of

cheical agents on biological systes

(ne!)



The study of the adverse effects of a toxicant on

living organiss

" #dverse effects

$ any change fro an organis%s noral state

$ dependent upon the concentration of active copoundthe target site for a sufficient tie.

" Toxicant (Poison)

$ any agent capable of producing a deleterious response i

a biological syste" &iving organis

$ a sac of !ater !ith target sites, storage depots and

en'yes



hat is a Poison

#ll substances are poisons*

there is none that is not a poison.

The right dose

differentiates a poison and a reedy.

Paracelsus (+-+/+)



H#T T01230&042STS D0 -involved in the recognition, identification,

and 5uantitation of ha'ard

-develops standards and regulations to

protect health and the environent - involved in safety assessent and use of

data as basis for regulatory control of ha'ards

- deterines ris6 associated !ith use of cheicals



72S8 #SS9SS:9;T- Ha'ard identification

- Dose 7esponse #ssessent

- 9xposure #ssessent- 7is6 3haracteri'ation



2;T9779&#T9D 30:P0;9;TS 0< TH9 72S8 #SS9SS:9;T

- cheical or physical agent

- biological syste- effect or response

- exposure situation



#79#S 0< T01230&04=

(<29&DS 0<SP932#&T=)

-descriptive

-echanistic-regulatory

-forensic

-clinical

-environental



:#>07 <#3T07S TH#T 2;<&?9;39

T01232T=

-route of adinistration

-duration and fre5uency of exposure

-dose or concentration



SP93T7?: 0< ?;D9S279D 9<<93TS-allergic reactions

-cheical allergies

-idiosyncratic reactions-iediate vs. delayed toxicity

-reversible vs. irreversible toxicity

-local vs. systeic toxicity



2;T97#3T20; 0< 3H9:23#&S

- #dditive

- Synergistic

- Potentiation

- #ntagonis ( functional, cheical,

dispositional, receptor)



Dose

The aount of cheical entering the body

This is usually given as

g of cheical@6g of body !eight A g@6g

The dose is dependent uponB The environental concentration

B The properties of the toxicant

B The fre5uency of exposure

B The length of exposure

B The exposure path!ay



hat is a 7esponse

The degree and spectra of responses depend upon the dose and

the organis--describe exposure conditions !ith description ofdose

" 3hange fro noral state

$ could be on the olecular, cellular, organ, or organislevel--the syptos

" &ocal vs. Systeic

" 7eversible vs. 2rreversible

" 2ediate vs. Delayed" 4raded vs. Cuantal

$ degrees of the sae daage vs. all or none



D0S9 79SP0;S9

-#SS?:PT20;S

-response is due to cheical adinistered

-the response is related to the dose

-there is a receptor site !ith !hich the

cheical interacts



D0S9 79SP0;S9

-#SS?:PT20;S (contd) -the degree of response is related to

the concentration at the site

-the concentration at the site is related to the dose adinistered

-has a 5uantifiable ethod of easuring and a

precise eans of expressing the toxicity



Dose-7esponse 7elationship

#s the dose of a toxicant increases,so does the

response.

2

3

4

0 1 DOSE

RESPONSE

E-+ ;0#9&

F- &inear 7ange

:axiu 7esponse

D0S9 D9T97:2;9S TH9 G20&0423#& 79SP0;S9



&D/E

" Cuantal responses can be treated as gradient !hen datafro a population is used.

" The cuulative proportion of the population responding

to a certain dose is plotted per dose--+E-E fold variatio

!@in a population" 2f :ortality is the response, the dose that is lethal to /E

of the population &D/E can be generated fro the curve

" Different toxicants can be copared--lo!est dose is o

potent



2ndividual Susceptibility

--there can be +E-E fold difference in response

to a toxicant in a population

" 4enetics-species, strain variation, interindividual

variations (yet still can extrapolate bet!een aals--

siilar biological echaniss)

" 4ender (gasoline nephrotox in ale ice only)

" #ge--young (old too)

$ underdeveloped excretory echaniss

$ underdeveloped biotransforation en'yes

$ underdeveloped blood-brain barrier



2ndividual Susceptibility

" #ge--old

$ changes in excretion and etabolis rates,

body fat" ;utritional status

" Health conditions

" Previous or 3oncurrent 9xposures $ additive --antagonistic

$ synergistic



T0&97#;39

- state of decreased responsiveness to a toxic

effect of a cheical, resulting fro previous

exposure

-dispositional tolerance* a decreased aount

of drug reaching the site

-cellular* reduced responsiveness of a tissue



9xposure Path!ays

" 7outes and Sites of 9xposure

$ 2ngestion (4astrointestinal Tract)

$ 2nhalation (&ungs)

$ Deral@Topical (S6in) $ 2nIection

" intravenous, intrauscular, intraperitoneal

" Typical 9ffectiveness of 7oute of 9xposure

iv J inhale J ip J i J ingest J topical



7#P2D2T= 0< 79SP0;S9 2TH

79SP93T T0 70?T9 0< 91P0S?79-intravenous

-inhalation

-intraperitoneally

-intrauscular

-intraderal

-subcutaneous

-topical



9xposure Duration

#cute K Fhr usually + exposure

Subacute + onth repeated doses

Subchronic +-o repeated doses

3hronic J o repeated doses

0ver tie, the aount of cheical in the body can build uit can redistribute, or it can over!hel repair and reoval

echaniss



#D:9

#bsorption, Distribution,

:etabolis, and 9xcretion" 0nce a living organis has been exposed to a toxicant, the

copound ust get into the body and to its target site in an

active for in order to cause an adverse effect.

" The body has defenses

$ :ebrane barriers

" passive and facilitated diffusion, active transport

$ Giotransforation en'yes, antioxidants

$ 9liination echaniss



#bsorptionability of a cheical to enter the blood

(blood is in e5uilibriu !ith tissues)

" 2nhalation--readily absorb gases into the blood strea via

the alveoli. (&arge alveolar surface, high blood flo!, and

proxiity of blood to alveolar air)" 2ngestion--absorption through 42 tract stoach (acids),

sall intestine (long contact tie, large surface area--villi*

bases and transporters for others)

$ +st Pass 9ffect (liver can odify)" Deral--absorption through epideris (stratu corneu),

then deris* site and condition of s6in



Distributionthe process in !hich a cheical agent

translocates throughout the body

" Glood carries the agent to and fro its site of action,

storage depots, organs of transforation, and organs of

eliination" 7ate of distribution (rapid) dependent upon

$ blood flo!

$ characteristics of toxicant (affinity for the tissue, and

the partition coefficient)

" Distribution ay change over tie



DistributionStorage and Ginding

" Storage in #dipose tissue--Lery lipophylic copounds

(DDT) !ill store in fat. 7apid obili'ation of the fat

(starvation) can rapidly increase blood concentration

" Storage in Gone--3heicals analogous to 3alciu--<luoride, &ead, Strontiu

" Ginding to Plasa proteins--can displace endogenous

copounds. 0nly free is available for adverse effects or

excretion



Target 0rgans adverse effect is dependent

upon the concentration of active copound at the

target site for enough tie

" ;ot all organs are affected e5ually

$ greater susceptibility of the target organ

$ higher concentration of active copound" &iver--high blood flo!, oxidative reactions

" 8idney--high blood flo!, concentrates cheicals

" &ung--high blood flo!, site of exposure

" ;eurons--oxygen dependent, irreversible daage

" :yocardiu--oxygen dependent

" Gone arro!, intestinal ucosa--rapid divide



Target Sites

:echaniss of #ction

" #dverse effects can occur at the level of the olecule, cell,

organ, or organis

" :olecularly, cheical can interact !ith

Proteins &ipids D;#

" 3ellularly, cheical can

$ interfere !ith receptor-ligand binding

$ interfere !ith ebrane function

$ interfere !ith cellular energy production

$ bind to bioolecules

$ perturb hoeostasis (3a)

: t b li



:etabolisadverse effect depends on the concentration of active

copound at the target site over tie

" The process by !hich the adinistered cheical (parent

copounds) are odified by the organis by en'yatic

reactions.

" +o obIective--a6e cheical agents ore !ater solubleand easier to excrete

$ decrease lipid solubility --J decrease aount at

target

$ increase ioni'ation --J increase excretion rate --Jdecrease toxicity

" Gioactivation--Giotransforation can result in the

foration of reactive etabolites



Giotransforation

" 8ey organs in biotransforation

$ &2L97 (high)

$ &ung, 8idney, 2ntestine (ediu)

$ 0thers (lo!)

" Giotransforation Path!ays

B Phase 2--a6e the toxicant ore !ater solubl

B Phase 22--&in6s !ith a soluble endogenous

agent (conIugation)



9xcretion Toxicants are eliinated fro the body by several

routes" ?rinary excretion

$ !ater soluble products are filtered out of the blood by t

6idney and excreted into the urine

" 9xhalation

$ Lolatile copounds are exhaled by breathing

" Giliary 9xcretion via <ecal 9xcretion

$ 3opounds can be extracted by the liver and excretedinto the bile. The bile drains into the sall intestine an

is eliinated in the feces.

" :il6, S!eat, Saliva



:anageent of Toxicology



0bIectives

" 4eneral approach to the poisoned

patient

" Toxidroes" Specific antidotes

" Decontaination and enhanced

eliination



4eneral #pproach

" #G3%s

" History

" Physical exaination

" &abs, iaging

" Diagnosis, antidotes

" Disposition



#ir!ay

" Airway obstruction can cause death after poisoning $ <laccid tongue

$ #spiration

$ 7espiratory arrest

" 9valuate ental status and gag@cough reflex " #ir!ay interventions

$ Sniffing position

$ >a! thrust

$ Head-do!n, left-sided position

$ 9xaine the oropharynx

$ 3lear secretions $ #ir!ay devices nasal trupet, oral air!ay

" 2ntubation $ 3onsider naloxone first



Greathing

" Deterine if respirations are ade5uate

" 4ive suppleental oxygen

" #ssist !ith bag-valve-as6

" 3hec6 oxygen saturation, #G4" #uscultate lung fields

$ Gronchospas #lbuterol nebuli'er

$ Gronchorrhea@rales #tropine

$ Stridor Deterine need for iediate intubation



3irculation

" 2L access

" 0btain blood !or6

" :easure blood pressure, pulse

" Hypotension treatent $ ;oral saline fluid challenge, FE &@6g

$ Lasopressors if still hypotensive

$ P7G3%s if bleeding or aneic

" Hypertension treatent

$ ;itroprusside, beta bloc6er, or nitroglycerin" 3ontinuous 934 onitoring

$ #ssess for arrhythias, treat accordingly



Supportive 3are

" <oley catheter

" 7ectal teperature

" #ccuchec6, treat hypoglyeia

" 3oa coc6tail

$ Thiaine +EE g 2L, before dextrose

$ Dextrose /E gras 2L push

$ ;aloxone E.E+ g@6g 2L



Supportive 3are

" Treat Sei'ures $ &ora'epa F g 2L, ay repeat as needed

$ Dilantin +E g@6g 2L" 3ontrol agitation

$ Haldol /-+E g 2:

$ #tivan F- g 2: or 2L $ 4eodon FE g 2:

" Thin6 about traua



79#SS9SS. . . fre5uently



History@#naneses

" hat, !hen, ho! uch, !hy

" 7x, 0T3, herbals, suppleents, vitains

" Tal6 to faily, friends, 9:S" Pill bottles, needles, beer cans, suicide not

" 3all pharacy

" #llergies, edical probles



Physical exaination

" Lital signs GP, H7, 77, T, 0F sat

" :outh odors, ucous ebranes

" Pupils" Greath sounds

" Go!el sounds

" S6in" ?rination@defecation

" ;eurologic exa



9ssential &aboratory Tests

" 9lectrolytes

" 4lucose

" G?; and creatinine

" &<T%s, 38 " ?rinalysis, urine drug screen

" 9toh, alcohol screen

" Seru osolality

" #cetainophen, salicylates" Specific drug levels

" Pregnancy test



#nion 4ap

" ;a $ (H30 M 3l)

" ;oral N-+F 95@&

" 3auses

$ Methanol $ Ureia

$ D8#

$ Paraldehyde, phenforin

$ Iron, isonia'id, ibuprofen

$ Lithiu, lactic acidosis

$ Ethylene glycol

$ Strychnine, starvation, salicylates



0solar 4ap

" 3alculated osolality $ easured osolality

" F(;a) M glucose@+N M G?;@F.N

" ;oral A FN/-FE 0s@&

" 4ap J +E 0s@& suggests the presence of extrasolutes $ 9thanol, ethanol

$ 9thylene glycol, isopropyl alcohol

$ :annitol, glycerol

" Clinical Pearl: Anion gap acidosis with an osmolar gap should suggest methanol or ethylene glycol poisoning



9lectrocardiogra

" Prolonged C7S $ T3#s

$ Phenothia'ines

$ 3alciu channel bloc6ers

" Sinus bradycardia@#L bloc6 $ Geta-bloc6ers, calciu channel

bloc6ers

$ T3#s

$ Digoxin

$ organophosphates

" Lentricular tachycardia $ 3ocaine, aphetaines

$ 3hloral hydrate

$ Theophylline $ Digoxin

$ T3#s



Diagnosis

" :ay not identify ingested substance(s)

" Provide #G3s and supportive care" 4ive antidote !hen appropriate



Disposition

" 3ase-based

" 23? adission

" Period of observation" Psychiatric evaluation



Toxidroes

" 0pioids $ 7espiratory depression

$ :iosis

$ Hypoactive bo!el sounds

" Sypathoietics $ Hypertension

$ Tachycardia

$ Hyperpyrexia

$ :ydriasis

$ #nxiety, deliriu

Clinical Pearl: Sweating differentiates sympathomimetic

and anticholinergic toxidromes



3holinergics

" 0rganophosphates $ 2rreversibly bind cholinesterases

" 3arbaate $ 7eversibly bind cholinesterases, poor 3;S penetration

" :uscarinic and nicotinic effects" Pesticides, nerve agents $ :ilitary personnel

$ <ield !or6ers, crop dusters

$ Truc6ers

$ Pest control, custodial !or6ers

" #ntidote $ #tropine for uscarinic effects

$ Pralidoxie reverses phosphorylation of cholinesterase



3holinergic Toxidroe

Diarrhea Salivation

Urination Lacriation

Miosis Urination

Bradycardia Defecation

Bronchospas G2 upset

Eesis Eesis

LacriationLip

Salivation, s!eating



#nticholinergics

" #tropine

" Scopolaine

" 4lycopyrrolate

" Gen'tropine

" #ntispasotics

$ Dicycloine

$ Hyoscyaine

$ 0xybutynin

$ clidiniu

" T3#s

" :ydriatics

" #ntihistaines $ 3hlorpheniraine

$ 3yproheptadine

$ Hydroxy'ine $ Diphenhydraine

$ :ecli'ine

$ proetha'ine

" #ntipsychotics

$ 3lo'apine $ 0lan'apine

$ Thiorida'ine



#nticholinergic Toxidroe

" Dry ucus ebranes (Dry as a bone)

" :ental status changes (:ad as a hatter)

" <lushed s6in (7ed as a beet)

" :ydriasis (Glind as a bat)" <ever (Hot as a hare)

" Tachycardia

" Hypertension

" Decreased bo!el sounds" ?rinary retention

" Sei'ures

" #taxia



#ntidotes

" #cetainophen ;-acetylcysteine

" 0rganophosphates #tropine, pralidoxie

" #nticholinergic physostigine

" #rsenic, ercury, gold diercaprol" Gen'odia'epines flua'enil

" Geta bloc6ers glucagon

" 3alciu channel bloc6 calciu

" 3arboxyheoglobin +EE 0F" 3yanide nitrite, ;a thiosulfate

" Digoxin digoxin antibodies



#ntidotes

" 9thylene glycol foepi'ole, HD

" Heparin protaine

" 2ron deferoxaine

" 2sonia'id pyridoxie" :ethanol foepi'ole, HD

" :etheoglobin ethylene blue

" 0pioids naloxone

" Salicylate al6alini'ation, HD" T3#%s sodiu bicarbonate

" arfarin <<P, vitain 8



Decontaination



Principles of Decontaination

" 9xternal $ Protect yourself and others

$ 7eove exposure

$ 2rrigate copiously !ith !ater or noralsaline

$ Don%t forget your #G3%s

" 2nternal $ Patient ust be fully a!a6e or

intubated $ :ost coon coplication is

aspiration

$ Lery little evidence for their use



Decontaination

" S6in $ Protect yourself and other H3

!or6ers

$ 7eove clothing

$ <lush !ith !ater or noral saline

$ ?se soap and !ater if oilysubstance

$ 3heical neutrali'ation can potentiate inIury

$ 3orrosive agents inIure s6in andcan have systeic effects



Decontaination

" 9yes

$ reove contact lens

$ <lush copiously !ith !ater or noral saline $ ?se local anesthetic drops

$ 3ontinue irrigation until pH is noral

$ Slit lap and fluorescein exa



Decontaination

" 2nhalation

$ 4ive suppleental huidified oxygen

$ Observe for airway obstruction $ 2ntubate as necessary



42 Decontaination

" Syrup of ipecac $ ithin inutes of ingestion

$ #spiration, gastritis, :allory-eiss tear, dro!siness

$ 7arely, if ever, given in 9D

" 4astric lavage $ Does not reliably reove pills and pill fragents

$ ?sed E-OE inutes after ingestion

$ ?seful after caustic li5uid ingestion prior to endoscopy

$ ;ot used for sustained release@enteric coated ingestions

$ Perforation, nosebleed, voiting, aspiration

" Recent studies suggest that activated charcoal alone is just aseffective as gut emptying followed by charcoal



42 Decontaination

" #ctivated charcoal

$ &iits drug absorption in the 42 tract

$ ithin OE inutes of ingestion $ Patient ust be a!a6e or intubated

$ Loiting, aspiration, be'oar foration

$ 3ontraindication bo!el obstruction or ileus!ith distention

$ + gra@6g P0 or 4T



#ctivated 3harcoal

" ;ot good for

$ &ithiu

$ 2ron

$ #lcohols

$ &ead

$ Hydrocarbons

$ 3austics



42 Decontaination

" 3athartics $ Hasten passage of ingestions or #3

$ 3ontraindications obstruction or ileus

$ Severe fluid loss, hypernatreia, hyperosolarity $ +E agnesiu citrate l@6g or E sorbitol +-FQ.@6g

" hole bo!el irrigation $ &arge ingestions, S7 or 93 tablets, pac6ers (ex.

cocaine) $ 3ontraindications obstruction or ileus $ #spiration, nausea, ay decrease effectiveness of

charcoal



Intoksikasi Ins!ktisis"a #os$at O%ganik

o ;aa lain (2<0)

-2nse6tisida organo fosfat atau

-2nse6tisida cholinesterase inhibitor.

" 2<0 erupa6an inse6tisida poten yang paling banya6 diguna6andala pertanian dengan to6sisitas tinggi

Etiologi

" 2<0 dibagi dua aca 2<0 urni R gol. 3arbaate.

" Geberapa contoh 2<0 :alathion, Dia'inon, Gasudin, Paraoxon,

Phosdrin, 7aid, Systox, dll." Salah satu contoh gol.carbaate Gaygon



Ga&'a%an (linik

" =ang paling enonIol adalah 6elainan visus,hipera6tivitas 6elenIar ludah @6eringat, saluran a6an dan6esu6aran bernafas.

" 7ingan anore6si, nyeri 6epala, leah, rasa ta6ut, treorlidah R 6elopa6 ata, iosis pupil

" Sedang nausea, untah, 6eIang@6ra perut,hipersalivasi, hiperhidrosis, fasi6ulasi otot, bradi6ardi.

" Gerat diare, pupil pin-point, rea6si cahaya (-), sesa6,sianosis, edea paru, in6ontinensia urin R alvi, 6onvulsi,6oa, blo6 Iantung, a6hirnya eninggal.



Diagnosis

" Ditega66an atas dasar gabaran 6linis yang 6has.

" &aboratoriu rutin tida6 banya6 enolong.

" Pengu6uran sel darah erah dan plasa, penting untu6easti6an diagnosis 6eracunan 2<0 a6ut aupun6ronis.



P!ngo'atan)

a. 7esusitasi

b. 9liinasi@Gilas labung elalui ;4T

c. #ntidotu- #trofin Sulfat (S#), enghabat efe6a6uulasi #8h pada tepat penupu6an.

- Dosis* ula-ula bolus iv +-F,/ g,dilanIut6an E,/-+ g setiap /-+E-+/ enit,sapai tibul geIala atropinisasi. 8eudianinterval diperpanIang setiap +/-E-OE enit,selanIutnya setiap F- -O dan +F Ia.



- S# dihenti6an inial setelah F x F Ia

- rea6tivator 8h9-be6erIa eotong i6atan

2<0-8h9, hingga tibul rea6si en'i 8h9.

Hanya beranfaat pada 6eracunan 2<0.Dosis* + gra iv pelan (+E-FE enit dala

infus), dapat diulang setelah E nt

sebanya6 F x F Ia.



INTO(SI(*SI *M#ET*MIN

" Sering terIadi pada usia uda, di a6hir pe6an, berdansa,tripping, enggera6an 6epala terus.

" Gersifat patologi6, paling sedi6it + bulan

Ectasy +,T-. Pertaa 6ali di >eran (++) Tergolong afetain 8elopo6 halusinogeni6 apu ebuat ilusi visual,

distorsi sensori, synesthesia (apu elihat suara dan

ebau !arna) despersonalisasi dan derealisasi ;aa 6iia :D:#

(ethylene dioxy ethaphetaine)



E$!k $a%&akologik

" Gentu6 tablet, bubu6, inIe6si

" Syste dopainergi6 bera6ibat a6tif dan penuh energi. 9fe6

serotonergi6 enibul6an disorientasi, distorsi persepsi danhalusinogeni6

" 9fe6 tibul FE-E enit, bera6hir setelah -N Ia

" Dosis letal beberapa 6ali dosis halusinogeni6

" Sering didapat dala 6obinasi dengan nar6oti6, 6afein,

lido6ain, aspirin dll.



Diagnosis

#nanesis

#da ri!ayat 6onsusi obat halusinogeni6

4eIala (ringan-berat)

;yeri 6epala, palpitasi, sesa6, nyeri dada

Parestesi, banya6 oong, euphoria, epati

Terlalu percaya diri, insonia

8adang perubahan persepsi visual ringan

8eracunan 7ingan

:udah tersinggung, ulut 6ering, palpitasi

Hipertensi ringan, gelisah, susah beristirahat

Treor, idriasis dan flushing



8eracunan sedang

7asa ta6ut, agitasi, ual, untah, nyeri perut

8eIang otot, hiperrefle6si, diaforesis, ta6i6ardi

Hipertensi, hiperteri, pani6 dan halusinasi

8eracunan berat

Deliriu, 6eIang-6eIang, geIala fo6al SSP (perdarahan

intra6ranial), 6oa, aritia 0tot 6a6u, hipertensi, gangguan heostasis, gagal nafas,

gagal ginIal a6ut, eninggal



G!/ala !ng!ntian o'at ti'ati'a

" 8elelahan otot enyeluruh, hiperteria, ipi buru6, depresiagitatif dan usaha bunuh diri

" <lash bac6, 2nsonia, hipersonia

" Perasaan dingin seluruh tubuh

" Perasaan ta6ut yang berlebihan J F inggu

*nalisis la'o%ato%i&

" Gahan darah, urine, cairan labung" #fetain dala urin bertahan F hari

" 8asus 6eracunan berat peri6sa fungsi ginIal, gas darah, ele6trolit,sa6ar darah, urinalisis, 984



Prinsip pengobatan enghindari 6onta6@eliinasi obat

dengan cara

:encegah 6onsusi obat tersebut

Geri norit @ obat 6atarsis

7angsang untah bila 6esadaran bai6

Gilas labung

Diuresis pa6sa (6arena obat ini di e6s6resi6an 6e ginIal)



P!ngo'atan si&to&atis

" #nsietas dia'epa E,E/-E,+ g@6gGG 2L atau oral. Dapatdiulang /-+E enit

" #gitasi@psi6osis haldol /-+ g iv. Dapat diulang +E-OE enit

" Hipertensi berat beta bloc6er@vasodilator

" Ta6i6ardi supraventri6ular dengan is6eia Iantung beta bloc6er

" 2s6eia io6ard orfin, nitrat" Hiperteria ruangan dingin

" 8oagulopati heparin

Pera!atan intensif

" 8asus berat dan 6esadaran turun



INTO(SI(*SI OPI*T

" ?u diguna6an untu6 engatasi nyeri elalui efe6

depresi pada ota6

4olongan opiat orfin, petidin, heroin, 6odein

terasu6 nar6oti6a, barbiturat, eprebaat,

ben'odia'epin, etanol dan putau

" Penyalahgunaan obat

;e! =or6 (+E) +FEE eninggal 6arena

overdosis

?S# +E.EEE eninggal 6arena overdosis



#a%&akologi Oiat

" Setelah peberian dosis tunggal tunggal heroin (puta!),dala O-+E enit a6an dihidrolisis oleh hati enIadi O-onosetil orfin setelah itu diubah enIadi orfin

" SelanIutnya diubah enIadi :o--onoglu6oronid dan :o-O onoglu6oronid yang larut dala air (dapat dires dalaurine)

" 8arena heroin larut dala lea6 dapat elalui sa!ar ota6

dala !a6tu yang cepat



Diagnosis

" 4eIala 6linis 6has (pin point, depresi nafas, ebai6

setelah peberian nalo6son)

" 8adang diteu6an be6as sunti6an (needle trac6 sign)

" &aboratoriu tida6 selalu seiring dengan geIala 6linis

" Peeri6saan 6ualitatif urine cu6up efe6tif untu6

easti6an diagnosis



Ga&'a%an (linis

" ?unya cenderung terIadi penurunan 6esadaran (sapai6oa)

" Dosis to6si6 Selalu enyebab6an penurunan 6esadaran engantu6 sapai

6oa, bicara cadel

Pin poin pupil, dilatasi pupil terIadi pada ano6sia yang berat

Pernafasan pelan (depresi pernafasan), sianosis, nadi leah,

hipotensi, spase saluran cerna dan bilier. 9dea paru dan 6eIang



(!a"aan ts oiat

#. Salah satu 6eadaan beri6ut $ Penghentian atau penurunan dosis opiat

$ Peberian antagonis opiatG. Tiga (atau lebih) beri6ut ini yg ber6ebang beberapa hari

setelah #.

+). :ood disfori6, F). :ual untah, )nyeri otot

)la6riasi@rinorea, /)dilatasi pupil, piloere6si,

6eringat, O)diare, )enguap, N)dea,)insonia

3. 4eIala G enyebab6an gangguan fungsi sosial, pe6erIaanatau fungsi lain



(!&atian

" F- Ia setelah pea6aian oral@sub6utan

" 2L geIala lebih berat

$ Hiperteia, aritia Iantung, hipertensi, bron6ospase $ #6ut Tubular ;e6rosis (#T;) 6arena rabdoiolisis dan

ioglobulinuria dan gagal ginIal

$ 8ulit !arna 6eerahan

$ &e6ositosis dan hipogli6eia



P%insi P!natalaksanaan

" Penatala6sanaan 6ega!atan

" Penilaian 6linis

" De6ontainasi racun

" Peberian antidotu" Terapi suportif

" 0bservasi dan 6onsultasi

" 7ehabilitasi



" Penatala6sanaan 6ega!atan

$ ;ilai tanda vital seperti Ialan nafas, sir6ulasi,6esadaran

$ Tinda6an resusitasi yang uu seperti air!ays(#), Greathing (G), 3irculation (3)

" Penilaian 6linis

$ Perhati6an adanya 6oa, 6eIang, henti Iantung,henti nafas dan syo6

$ #nanesis



Peeri6saan fisis 3ari tanda atau 6elainan fungsi otono seperti

te6anan darah, nadi, pupil, 6eringat, air liur dan peristaltic usus

:isal pada geIala sipatis (sipatoieti6)diteu6an deliriu, paranoid, ta6i6ardi, hipertensi,hiperpire6sia, diaforesis, idriasis, aritia dan6eIang



P!ngo'atan ;alo6son E,-F,E g. Dosis dapat diulang pada 6eracunan

yang berat dengan panduan 6linis. 9fe6 se6itar F- Ia. Gilarespon tida6 ada setelah dosis total +E g a6a diagnosisinto6si6asi opiat di6aIi ulang

9dea paru nalo6alion Hipotensi dopaine F-/ ug@6gGG@enit

>angan diuntah6an bila into6si6asi oral

8ubah labung segera setelah into6si6asi oral, a!asi Ialannafas

8eIang dia'epa iv /-+E g. Diulang bila perlu



La&a akt D!t!ksi U%in! B!'!%aa 5!nis

Oiat

Jenis obatJenis obat Waktu deteksiWaktu deteksi

Amfetamin Amfetamin 2 hari2 hari

BarbituratBarbiturat 1 hari (Short acting)1 hari (Short acting)

3 mgg (long acting)3 mgg (long acting)

BenzodiazepinBenzodiazepin 3 hari3 hari

okainokain 2!" hari2!" hari

odeinodein 2 hari2 hari

#eroin#eroin 1!2 hari1!2 hari

$ethadone$ethadone 3 hari3 hari

$ fi$orfin 2 % h i2 % hari

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