FARMAKOLOGI OBAT

KEGAWATDARURATAN

Dr. Rahma Triliana, S.Ked., M.Kes, PhD

18 OKTOBER 2018
 Emergency
serious and often dangerous or live
threatening situation which requires
immediate action to prevent death,
worsening condition and or debilitating
illnesses
 Emergency
Dangerous / Gawat  e.g. coma
Immediate action / Darurat  e.g.
drowning
Gawat & Darurat e.g. Syock, Status
Asthmaticus, Status Epilepticus
 Emergency in today
Discussion are:
• SYOK
• STATUS EPILEPTIKUS
• STATUS ASTHMATICUS
• POISONING
 SHOCK
• Inadequate perfusion to the vital organs
•  Pulse (> 100 x/min)
•  Blood pressure (< 80 (sys) and < 40 (dia)).
• Type/causes of shock
• Hypovolemic  blood loss or low blood volume
• Cardiogenic  cardiac pumping problems
• Anaphylactic  acute, severe, and vast vasodilatation
due to allergic responses
• Septic  severe vasodilatation due to infectious agents
• Neurogenic  shock induced by severe/extreme pain
 Simplified
Pathogenesis of
Hypovolemic
shock & drugs
used
Green Box: Hypovolemic shock can lead
to cardiogenic shock due to myocardial
damage/problem/dysfunction
Blue box: Hypovolemic shock with tissue
damage give similar pathophysiology of
septic shock and anaphylactic shock

H P Rang, J M Ritter, R J Flower, G Henderson,

in RANG AND DALE’S Pharmacology, 8th,
2016, Elsevier Ltd.
 Guideline Indonesia Faskes Primer
Syok Hipovelomik
1. Infus cepat kristaloid untuk ekspansi volume intravaskuler
melalui kanula vena besar (dapat lebih satu tempat) atau
melalui vena sentral.
2. Pada perdarahan maka dapat diberikan 3-4 kali dari jumlah
perdarahan. Setelah pemberian 3 liter disusul dengan
transfusi darah. Secara bersamaan sumber perdarahan
harus dikontrol.
3. Resusitasi tidak komplit sampai serum laktat kembali
normal. Pasien syok hipovolemik berat dengan resusitasi
cairan akan terjadi penumpukan cairan di rongga ketiga.
4. Vasokonstriksi jarang diperlukan pada syok hipovolemik
murni.
 Hypovolemic Shock
• Severe or continuous loss of intravascular fluid
• Due to bleeding and or water/electrolyte loss (i.e.
dehydration)
• Most Important Treatment:
• Oxygen
• Intravenous fluid replacements
• Blood transfusion
 Oxygen Therapy
• Depend on
• Oxygen requirements (dose)
• Determined by types of diseases and severity of
hypoxemia
• Oxygen delivery method
• Depend on
• age of the patient
• therapeutic goals
• patient tolerance
• humidification needs
Note: Oxygen therapy should not be delayed in the
treatment of life threatening hypoxia
 Before Starting
• Do ABGs & put on Pulse Oximetry in:
• All critically ill patients
• Unexpected/inappropriate hypoxaemia (oxygen saturation, 94% or
requiring supple-mental oxygen to maintain this)
• Deteriorating saturation, increasing oxygen need or increasing
dyspnoea in a previously stable patient
• Patients at risk of type 2 respiratory failure with acute dyspnoea,
decreasing saturation, drowsiness or other symptoms suggestive of
hypercapnia.
• Dyspnoeic patients who are at risk of metabolic acidosis
(e.g.diabetes and renal failure)
• Dyspnoeic or critically ill patients with an inadequate/unreliable
oximetry signal due to poor peripheral circulation.
DOI:•10.1183/20734735.025212
Unexpected change in early warning score or fall of.3% in saturation
Emergency oxygen therapy: From guideline to implementation. Breathe, June 2013, Vol. 9, No 4, Page 247 – 254
 Normal Values
• Normal ABGs  Previous lecture
• Normal oxygen saturations at rest;
• Pre-term (36 weeks or less) neonates; 88-92%
• Term (>36 weeks) neonates and children; greater than 94%
• Adults < 70 years of age; 96% - 98%.
• Adults > 70 and above; greater than 94%.
• Note that fingers, then earlobes, are more accurate than toes as measurement
points
• Clinical indicator for initiating, monitoring and adjusting oxygen
therapy is peripheral oxygen saturation (SpO2).
• See also colour, RR, & work of breathing
Recommendation for Emergency Oxygen Use

Emergency oxygen therapy: From guideline to implementation. Breathe, June 2013, Vol. 9, No 4, Page 247 – 254
DOI: 10.1183/20734735.025212
 Critical illness Requiring High Levels of
Supplemental Oxygen
• Initial O2 therapy is a reservoir mask at 15 L/min pending readings.
• Assessed possible reduction of O2 dose  maintain target saturation of
94–98%.
• If oximetry is unavailable, continue initial tx until definitive treatment (+)
• Patients w/ COPD & risk of hypercapnia who develop critical illness 
similar target saturations pending the results of ABG
• Target range 88–92% or supported ventilation if there is severe
hypoxaemia and/or hypercapnia with respiratory acidosis.
 Serious illnesses requiring moderate levels of
supplemental oxygen if the patient is hypoxaemic
• The initial oxygen therapy is :
• Nasal cannulae at 2–6 L/min (preferably)
• Simple face mask at 5–10 L/min unless stated otherwise.
• Patients w.o. risk of hypercapnic respiratory failure & have saturation < 85%
 started with a reservoir mask at 15 L/min
• Recommended initial O2 saturation target range is 94–98%.
• If oximetry is not available, give O2 as above until results are available.
• Change to reservoir mask if the desired saturation range cannot be
maintained with initial therapy
• Ensure to consult senior medical staff
• If patients have coexisting COPD or other risk factors for hypercapnic
respiratory failure  saturation 88–92% pending results & adjust to 94–
98% if the PCO2 is N (unless there is a history of previous hypercapnic
respiratory failure requiring NIV or IMV)
• Recheck blood gases after 30–60 min,
Serious Illnesses Requiring Moderate
Levels Of Supplemental Oxygen If
The Patient Is Hypoxaemic
 For patients which were monitored closely
but oxygen therapy is not required unless
patient is hypoxaemic
• If hypoxaemic, the initial oxygen therapy is:
• Nasal cannulae at 2–6 L/min or
• Simple face mask at 5–10 L/min unless saturation is below
85% (use reservoir mask) or if at risk from hypercapnia.
• Recommended initial target saturation range is 94–98%.
• If oximetry is not available, give O2 as above.
• If patients have COPD or other risk factors for hypercapnic
respiratory failure, aim at a saturation of 88–92% pending
blood gas results but adjust to 94–98% if the PCO2 is
normal (unless there is a history of respiratory failure
requiring NIV or IMV) & recheck ABG after 30–60 min
 COPD & Other Conditions Requiring
Controlled Or Low-dose Oxygen Therapy
• Prior to availability of blood gases, use:
• 24% Venturi mask at 2–3 L/min or
• 28% Venturi mask at 4 L/min or
• Nasal cannulae at 1–2 L/min
• Aim for an oxygen saturation of 88–92% for patients with risk factors for hypercapnia
but no prior history of respiratory acidosis.
• Adjust target range to 94–98% if the PCO2is normal (unless there is a history of
previous NIV or IMV) and recheck blood gases after 30–60 min
Treatment Algorithm
For Oxygen Therapy
† If oximetry (-) or O2 saturations undetermined
& hypoxaemia is suspected  Give O2 :
• 1-2 L/min via nasal cannulae or 2-4 L/min
via 24% or 28% Venturi mask in patients
with acute exacerbations of COPD or
conditions known to be associated with
chronic respiratory failure (e.g
hypoventilation syndrome, chest wall
deformities, cystic fibrosis, bronchiectasis or
neuromuscular disease)
• 4 L/min oxygen via nasal cannulae in
patients who are not critically ill and life-
threatening hypoxaemia is not suspected.
• 5-10 L/min via simple face mask or 15
L/min through a reservoir mask in patients
who are critically ill or in whom life-
threatening hypoxaemia is suspected (e.g.
post-cardiac arrest or resuscitation, shock,
sepsis, near drowning, anaphylaxis, major
head injury, or in suspected carbon
monoxide poisoning). Consider NIV or
invasive ventilation & treatment in HDU or
ICU.

ABG: Arterial blood gas, COPD: Chronic obstructive pulmonary

disease, HDU: High Dependency Unit, HFNC: High flow nasal
cannulae, ICU: Intensive Care Unit, MDI: Metered dose inhaler, NIV:
Non-invasive ventilation, O2: Oxygen, PaCO2: Arterial partial
pressure of carbon dioxide, PaO2: Arterial partial pressure of oxygen,
Sats: oxygen saturations, SpO2: Oxygen saturation determined by
pulse oximetry.
 Oxygen Delivery Methods
• Oxygen therapy can be delivered using a low flow or high
flow system with humidification
• Low flow delivery method
• Simple face mask
• Non re-breather face mask (mask with oxygen reservoir bag and
one-way valves to prevent/reduce room air entrainment)
• Nasal prongs (low flow)
• Tracheostomy mask
• Tracheostomy HME connector
• Isolette - neonates (usually for use in the Neonatal Intensive
Care Unit only)
• Note: low flow systems is usually titrated on the O2 flow meter
& recorded in L/min (LPM). .
 Oxygen Delivery Methods
• Oxygen therapy can be delivered using a low flow or high
flow system with humidification
• High flow delivery method
• Ventilators
• CPAP/BiPaP drivers
• Face mask or tracheostomy mask used in conjunction with
humidifier
• High flow nasal prong therapy (HFNP)
• Humidification
• Reduce Cold, dry air, and drying effect on mucous membranes
resulting in airway damage
• Secretions thickened & difficult to clear  cause airway
obstruction & bronchoconstriction.
 High-concentration reservoir Tracheostomy mask
Simple face mask mask (non-rebreathing mask)

Nasal Canule
Large volume nebulisation-
based humidifier
 Nasal Cannulae

• Deliver 24-30% oxygen

• Flow rate 1-4L/min (4L will dry
the nose, 2L is more
comfortable)
• Used in non-acute situations or if Hudson mask
only mildly hypoxic (e.g.
• Rarely used
saturations stable at 92% in a
• Delivers 30-40% oxygen
patient without lung disease)
• Flow rate 5-10L/min

Oxford Medical Education (OME)

(I) Venturi mask Venturi Mask + valve &
suggested O2 flow in relation
(II)Range of concentrations to respiratory rate
available

Delivers 24-60% O2 Different colours deliver different rates

Flow rate: Varies with colour .
BLUE= 2-4L/min = 24% O2
WHITE = 4-6L/min = 28%O2
YELLOW= 8-10L/min = 35% O2,
RED = 10-12L/min = 40% O2
GREEN = 12-15L/min = 60% O2
 High-concentration reservoir
mask (non-rebreathing mask)
• Delivers 85-90% oxygen
• 15L flow rate
• Bag with valves stops
rebreathing of expired
air
• For acutely unwell
patients
Note:
• Saturations maintained at 94-98%, not 100%.
• Do not keep patients on 15L longer than necessary  over-O2
for prolonged periods can be harmful.
Oxford Medical Education (OME)
 Positive Airways Continuous (CPAP)
• High pressure air/oxygen
Pressure (PAP)
with a tight-fitting mask
• Positive pressure all the time
to help keep airways open
(split them)
• Used in acute pulmonary
oedema and sleep apnoea

Bilevel (BiPAP)
• High positive pressure on inspiration and lower positive
pressure on expiration
• Used in exacerbations of COPD and ARDS
Oxford Medical Education (OME)
 Remember
• Oxygen is a treatment for hypoxaemia not
breathlessness.
• Oxygen is a drug and should be prescribed with a
target saturation range.
• The recommended O2 saturation target in patients
without risk of type II respiratory failure is 94–98%.
• The recommended O2 saturation target in patients at
risk of type II respiratory failure is 88–92%.
Emergency oxygen therapy: From guideline to implementation. Breathe, June 2013, Vol. 9, No 4, Page 247 – 254
DOI: 10.1183/20734735.025212
National Clinical Guideline Centre (NICE). Intravenous fluid therapy in adults in hospital, Clinical Guideline <CG174>
Methods, evidence and recommendations, December 2013
Myburgh, JA, Mythen MG, Resuscitation FluidsEngl J Med 369, 2013
 Adult Maintenance IV Fluid
Requirement

If Oral Hydration is LIMITED, use 50ml/kg/day water or

= urine production rate/hour (measure via catheter use)
Algorithms of IV fluid Therapy in Children and Young People in Hospital
Routine Maintenance
Neonate Fluid Calculation

Children Fluid Calculation

National Clinical Guideline Centre (NICE).
Intravenous fluid therapy in adults in
hospital, Clinical Guideline <CG174>
Methods, evidence and recommendations,
December 2013
 KOMPONEN DARAH & TRANFUSI
KOMPONEN DARAH
Darah Lengkap (whole
blood/WB) bentuk segar
(fresh WB) atau bentuk
tersimpan (Stored WB)
Eritrosit (Packed Red
Cells/PRC)
Eritrosit degliserolisasi beku ~200mL eritrosit, sedikit leukosit, tanpa
(Washed Erythrocytes)
Plasma segar beku (Fresh
frozen plasma)
Cryoprecipitate
Konsentrat Trombosit
(Thrombocyte Concentrate)
Konsentrat granulosit
KOMPOSISI
430mL darah dalam 63mL antikoagulan
250-350mL dengan HCT 70-80%
plasma
200-300mL plasma, semua faktor
pembekuan, trombosit (-)-
80-100 unit F.VIII dalam 10-15mL
plasma, ~250 mg fibrinogen
5,5 x 1010 trombosit dlm 50mL plasma
(donor acak).
3 x 1011 trombosit dlm 300mL plasma
(trombo-sitaferesis donor tunggal)
10 granulosit dalam 300-500mL plasma ~ Sepsis bakterial pada
25mL eritrosit
INDIKASI CATATAN
-  volume darah + - Harus kompatibel ABO dan
hipoksia Uji silang.
- HCT rendah -  beban sirkulasi
-  Risiko gagal jantung,
- Waspada Reaksi demam &
alergi
Anemia Harus kompatibel ABO dan Uji
silang
Transfusi pada pasien dengan - Harus kompatibel ABO dan
antibodi terhadap eritrosit atau Uji silang
reaksi terhadap leukosit/plasma Biaya pembuatan komponen mahal
Gangguan pembekuan - Harus kompatibel ABO dan
Uji silang.
- Risiko Reaksi demam & alergi
Defisiensi F-VIII Perlu beberapa unit untuk terapi
Penyakit Von-Willebrand defisiensi F-VIII
Defisiensi Fibrinogen
Defisiensi trombosit - Harus kompatibel ABO
- Dapat timbul anti HLA
- Harus kompatibel ABO
granulositopenia berat - Sering sebabkan reaksi demam
 Guideline Indonesia Faskes Primer:
Syok Kardiogenik
1. Optimalkan pra-beban dengan infus cairan.
2. Optimalkan kontraktilitas jantung dengan inotropik sesuai keperluan,
seimbangkan kebutuhan oksigen jantung. Selain itu, dapat dipakai
dobutamin atau obat vasoaktif lain.
3. Sesuaikan pasca-beban untuk memaksimalkan CO. Dapat dipakai
vasokonstriktor bila pasien hipotensi dengan SVR rendah. Pasien syok
kardiogenik mungkin membutuhkan vasodilatasi untuk menurunkan SVR,
tahanan pada aliran darah dari jantung yang lemah. Obat yang dapat
dipakai adalah nitroprusside dan nitroglycerin.
4. Diberikan diuretik bila jantung dekompensasi.
5. PAC dianjurkan dipasang untuk penunjuk terapi.
6. Penyakit jantung yang mendasari harus diidentifikasi dan diobati.
 Cardiogenic Shock
• Cardiac inability to pump blood with or without volume
depravations
• Due to low cardiac inotropic/contraction, arythmic heart
beat, heart block/arrest
• Most Important Treatment:
• Cardiac inotropic drugs
• Antidysrythmic drugs
 Inotropic Drugs
• Dobutamine
• β1agonist (non-selective) for cardiogenic shock
• AE: Dysrhythmias
• R: i.v. (titration), 2 - 5 ug/kgbw/min
• ADME: Plasma t1/2 ∼2 min
• Dopamine = dobutamine  5 –10 ug/kgbw/min,
• Adrenaline/Epinephrine
• α/β agonist  Asthma, anaphylactic, cardiac arrest, hypotension (shock)
• AE: Hypertension, vasoconstriction, tachycardia (or reflex bradycardia),
ventricular dysrhythmias
• R : Given i.m. or s.c. or i.v. infusion, 0.05 – 1 mcg/kgbw/min
• ADME: Poorly absorbed P.O. Rapid removal by tissues, Metabolized by
MAO and COMT, Plasma t1/2 ∼2 min
• Noradrenalin/norepinephrine = Adrenaline (0.1mcg/kgbb/min)
H P Rang, J M Ritter, R J Flower, G Henderson, in RANG AND DALE’S Pharmacology, 8 th, 2016, Elsevier Ltd.
 Antidysrhythmic drugs
• Serious dysrhythmias is emergency condition
• Treatment : pacing, electrical cardio-version (direct
current/DC shock to the chest) or an implanted device/pace
maker better than drugs.

If treatment un-available drugs to

use are :
• Class I: block voltage-sensitive sodium
channels. (Ia, Ib and Ic).
• Class II: β-adrenoceptor antagonists.
• Class III: drugs prolong cardiac action
potential.
• Class IV: calcium antagonists
H P Rang, J M Ritter, R J Flower, G Henderson, in RANG
AND DALE’S Pharmacology, 8th, 2016, Elsevier Ltd.
H P Rang, J M Ritter, R J Flower, G Henderson, in RANG AND DALE’S Pharmacology, 8 th, 2016, Elsevier Ltd.
 Alergic Emergency
• Anaphylaxis & angio-oedema  risk of airways obstruction
• Oxygen & Fluid Therapy
• Treatment  Adrenaline (epinephrine)  IM or IV or IM
spring-loaded syringe (epipen)  severe hypersensitivity
reactions & anaphylaxis.
• Antihistamine 1  Promethazine, Chlorphenamine, IM or IV
• Corticosteroid  Hydrocortisone, prednisone, MP
• Icatibant  bradykinin, B2 receptor antagonist  for
acute attacks hereditary angio-oedema
 Guideline Indonesia Faskes Primer:
Syok Distributif
1. Pada SIRS dan sepsis, bila terjadi syok ini karena toksin atau
mediator penyebab vasodilatasi. Pengobatan berupa resusitasi
cairan segera dan setelah kondisi cairan terkoreksi, dapat
diberikan vasopresor untuk mencapai MAP optimal. Sering terjadi
vasopresor dimulai sebelum pra-beban adekuat tercapai. Perfusi
jaringan dan oksigenasi sel tidak akan optimal kecuali bila ada
perbaikan pra-beban.
2. Obat yang dapat dipakai adalah dopamin, norepinefrin dan
vasopresin.
3. Dianjurkan pemasangan PAC.
4. Pengobatan kausal dari sepsis.
Pharmacologic Tx of Anaphylactic Reactions

M.A. Chisholm-
Burns, T.L.
Schwinghammer
, B. G. Wells,
P.M. Malone,
J.M. Kolesar, J.T.
DiPiro,
Pharmaco-
therapy
Principles &
Practice 4th ed,
2016 McGraw
Hill ltd
Pharmacologic Management of Anaphylactic Reactions

M.A. Chisholm-
Burns, T.L.
Schwinghammer
, B. G. Wells,
P.M. Malone,
J.M. Kolesar, J.T.
DiPiro,
Pharmaco-
therapy
Principles &
Practice 4th ed,
2016 McGraw
Hill ltd
Management of Septic Shock
 Brain & Eye Edema
• Osmotic diuretics  inert substances filtered by
glomerulus but not reabsorbed by nephron (e.g.
mannitol)
• Increase in plasma osmolarity by solutes that do not
enter the brain or eye  water efflux from
compartments  decrease pressure.
• AE: Headache, nausea, vomiting, hyponatraemia and
transient expansion of extracellular fluid volume  risk
of left ventricular failure
 Guideline Indonesia Faskes Primer:
Syok Obstruktif
1. Penyebab syok obstruktif harus diidentifikasi dan segera
dihilangkan.
2. Pericardiocentesis atau pericardiotomi untuk tamponade jantung.
3. Dekompressi jarum atau pipa thoracostomy atau keduanya pada
tension pneumothorax.
4. Dukungan ventilasi dan jantung, mungkin trombolisis, dan
mungkin prosedur radiologi intervensional untuk emboli paru.
5. Abdominal compartment syndrome diatasi dengan laparotomy
dekompresif
 Low Dose Aspirin,
ADP antagonists,
Clopidogrel,
Prasugrel, Ticagrelor,
Abciximab, Tirofiban,
Dipyridamole,
Epoprostenol
 Parenteral
Anti-
hypertensive
agents for
Hypertensive
emergency

M.A. Chisholm-Burns, T.L.

Schwinghammer, B. G. Wells, P.M.
Malone, J.M. Kolesar, J.T. DiPiro,
Pharmacotherapy Principles & Practice
4th ed, 2016 McGraw Hill ltd
 Guideline Indonesia Faskes Primer:
Syok Neurogenik
1. Setelah mengamankan jalan nafas dan resusitasi cairan, guna
meningkatkan tonus vaskuler dan mencegah bradikardi
diberikan epinefrin.
2. Epinefrin berguna meningkatkan tonus vaskuler tetapi akan
memperberat bradikardi, sehingga dapat ditambahkan
dopamin dan efedrin. Agen antimuskarinik atropin dan
glikopirolat juga dapat untuk mengatasi bradikardi.
3. Terapi definitif adalah stabilisasi Medulla spinalis yang
terkena.
 Status Epileptikus
• Status epileptikus adalah bangkitan yang terjadi lebih dari 30 menit atau adanya
dua bangkitan atau lebih dimana di antara bangkitan -bangkitan tadi tidak
terdapat pemulihan kesadaran.
• Management
• Rujuk ke fasilitas pelayanan kesehatan sekunder yang memiliki dokter spesialis saraf.
• Pengelolaan SE sebelum sampai fasilitas pelayanan kesehatan sekunder.
1. Stadium I (0-10 menit)
• a. Memperbaiki fungsi kardiorespirasi
• b. Memperbaiki jalan nafas, pemberian oksigen, resusitasi bila perlu
• c. Pemberian benzodiazepin rektal 10 mg
2. Stadium II (1-60 menit)
• a. Pemeriksaan status neurologis
• b. Pengukuran tekanan darah, nadi dan suhu
• c. Pemeriksaan EKG (bila tersedia)
• d. Memasang infus pada pembuluh darah besar dengan NaCl 0,9 %.
3. Rencana Tindak Lanjut
• Melakukan koordinasi dengan PPK II dalam hal pemantauan obat dan bangkitan
pada pasien
‘BLACK OUT’ - DRUGS
 Anti-epileptic drug (AED) options by seizure type
1 2 3 4
Seizure type First-line Adjunctive on referral Con-Indication
Generalised Carbamazepine, Clobazama , Lamotrigine, If absence/myoclonic
tonic–clonic Lamotrigine, Levetiracetam, Sodium seizures, or if juvenile
Oxcarbazepinea, valproate, Topiramate myoclonic epilepsy
Sodium valproate suspected --> see below
Tonic or Sodium valproate Lamotriginea Rufinamidea Carbamazepine,
atonic Topiramatea Gabapentin, Pregabalin,
Tiagabine, Vigabatrin,
Oxcarbazepine,
Absence Ethosuximide Ethosuximide Clobazama, Clonazepam, Carbamazepine,
Lamotriginea Lamotriginea Levetiracetama, Gabapentin, Phenytoin
Sodium valproate Sodium valproate Topiramatea, Zonisamidea Pregabalin, Tiagabine
Vigabatrin,Oxcarbazepine
Myoclonic Levetiracetama Levetiracetam Clobazama Carbamazepine
Sodium valproate Sodium valproate Clonazepam Oxcarbazepine,
Topiramatea Topiramatea Piracetam Pregabalin
Zonisamidea Gabapentin, Phenytoin,
Tiagabine, Vigabatrin
Focal Carbamazepine Carbamazepine, Eslicarbazepine acetatea,
Lamotrigine Clobazama, Gabapentina, Lacosamide
Levetiracetam Lamotrigine, Phenobarbital
Levetiracetam, Phenytoin, Pregabalina,
Oxcarbazepine
Oxcarbazepine, Sodium Tiagabine, Vigabatrin
Sodium valproate valproate, Topiramate
Zonisamidea
Guidelines Indonesia Faskes Primer
• Asma akut berat (serangan asma atau asma eksaserbasi) adalah
episode perburukan gejala yang progresif dari sesak, batuk,
mengi, atau rasa berat di dada, atau kombinasi gejala-gejala
tersebut
• Treatment:
• Oxygen (high concentration, ≥60%),
• Inhalation of nebulized salbutamol or ipratropium
• Intravenous hydrocortisone + oral prednisolone
• Intravenous salbutamol or aminophylline or terbutaline
• Monitoring: PEFR or FEV1 & BGA + oxygen saturation
M.A. Chisholm-Burns, T.L. Schwinghammer, B. G. Wells, P.M. Malone, J.M. Kolesar, J.T. DiPiro, Pharmacotherapy Principles
& Practice 4th ed, 2016 McGraw Hill ltd
 5 Steps in Management of
Poisoned Victims
1. Resuscitation and initial stabilization
2. Diagnosis of type of poison
3. Nonspecific therapy
4. Specific therapy  the use of specific antidotes
5. Supportive care
KNOWS THE SIGN/SYMPTHOMS
Clinical Features Poisons
Odour of Breath Chloroform, Ethanol, Cyanide, Arsenic, Organophosphates, Phosphorus, Kerosene
Hypertension with Amphetamines, Cocaine, LSD, MAO inhibitors, Marijuana, Phencyclidine, Alcohol
withdrawal, Nicotine, Antihistamines, Antipsychotic agents, Antidepressants
Tachycardia
Hypotension with Antidepressants (severe cases), Barbiturates, Narcotics, Benzodiazepines, Cyanide, Nicotine,
Organophosphates,
bradycardia
Hypotension with Aluminium phosphide, Antipsychotics, Caffeine, Cyanide, Disulfiram-ethanol interaction,
Tricyclic antidepressants
tachycardia
Hyperthermia Amoxapine, Amphetamines, Antidepressants, Cocaine, Lithium, LSD, MAO inhibitors,
Phencyclidine, Anticholinergic agents, Salicylates, Antihistamines
Hypothermia Antidepressants, Ethanol, Benzodiazepine, Narcotics, Barbiturates, Phenothiazines
Tachypnoea Amphetamines, Atropine, Cocaine, Salicylates, Carbon monoxide, Cyanide, Hepatic
Encephalopathy (paracetamol, amatoxin mushrooms), Metabolic acidosis
Bradypnoea Antidepressants, Antipsychotic agents, Barbiturates, Ethanol, Benzodiazepines, Chlorinated
hydrocarbons, Narcotics, Nicotine, Organophosphates, Cobra bites
Altered sensorium Antidepressants, Antihistamines, Antipsychotics, Atropine, Organophosphates, Barbiturates,
Lithium, Cyanide, Benzodiazepines, Ethanol, Narcotics, Carbon monoxide
Seizures Antidepressants (amoxapine and maprotiline), Antipsychotic, Antihistamines, Chlorinated
hydrocarbons, Organophosphates, Cyanide, Lead and other heavy metals, Lithium, Narcotics,
Sympathomimetics (amphetamines, cocaine, phencyclidine)

Miosis Barbiturates, Phenothiazines, Ethanol, Narcotics, Nicotine, Organophosphates

Mydriasis Amphetamines, Caffeine, Cocaine, LSD, MAO inhibitors, Nicotine, Antidepressants,
Antihistamines, Atropine
Cyanosis Methaemoglobinaemia-inducing agents, Terminal stages of all poisonings
P. Aggarwal, R. Handa, J.P.Wali, Acute Poisoning – Management Guidelines Journal of Indian Academy of Clinical Medicine, 2013, Vol. 5, No. 2, 143 - 147
 Basic Management
• Decontamination
• Gastric  Syrup of ipecac, Gastric lavage, Cathartics, Activated
Charcoal, Whole bowel irrigation
• Skin/eye  Flushing, rinsing, eliminate exposure
• Enhancing Excretion
• Hemodialysis
• Forced alkaline diuresis Urinary alkalinization
• Multiple-doses of activated charcoal
• Specific therapy  antidote
 USE/
SELECT
PROPER
ANTIDOTE
Make sure you
have one ready

& also your

emergency drugs
 HOW TO USE
(some common antidote)
• Hyperglycemias with complications
• Insulin therapy
• Hyperkalemia
• Insulin + glucose & Calcium gluconate (IV)
• Severe hallucination  large doses of a
benzodiazepine(e.g. chlordiazepoxide) +
Thiamine
• Manic Episodes  Chlorpromazine (CPZ)