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EMERGENCY MEDICINE

Department of PharmacologyFaculty of Medicine and Health Sciences

Emergency

Required immediately attention Serious Outcome Drug Use base on evidence efficacy

short time of treatment

The Emergency of The clinicalPractice

Anaphylaxis Cardiac Arrest Metabolic

Hypoglycaemia Hyperkalaemia

Status epilepticus Organophosphorus Pesticide Poisoning Methanol Poisoning Benzodiazepine Snake Venom Poisoning Drug Poisoning

ANAPHYLAXIS Type 1 Hypersensitivity Reaction Clinical syndrome of histamine and bradykinin

release, capillary leakage, cardiovascularcollapse IgE Mediated

Sudden onset Clinical Feature :

CV : Hypotension, palpitation, collapse Respiratory : laryngeal oedema, stridor, bronchospasm Cutaneous : urticaria, angioedema, erythema, GIT : nausea, vomiting, abdominal pain

DRUGS FOR ANAPHYLAXIS

ADRENALINE (as soon as) : 0,3-0,5 mlim, sc (too slow absorption), iv (provokeventricular arrhythmia

Corticosteroid hydrocortisone 200 mgim / iv slow injection

Anti H chlorpheniramine 10 mg im/iv Bronchodilator salbutamol, terbutaline Oxygen IV Fluid NaCl 0,9%, RL

CARDIAC ARREST Circulatory failure >3 minuteshypoxic

brain damage Clinical Feature

Unconscious Absent major pulses (carotid, femoral) Absent breathing Cardiac arrhythmia

RJP Oxygenate the blood Pump the blood around the body

Drug : adrenaline 10 ml of 1 : 10000 every 3’

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HYPOGLICAEMIA The blood glucose concentration < N Clinical feature

Headache, blurred vision, sweating Convulsion, coma

Cause : insulin, sulphonylureas drugs Drug use :

Glucose oral/iv : 25 g as 50 ml 40% glucosesolution (hypertonic)

ESO : thrombosis, phlebitis Pediatric : glucose 10% 2 ml/Kg infuse over 3’ Maintain infuse glucose 10% Glucagon ineffective hyperglycaemia

HYPERKALAEMIA The blood POTASSIUM concentration > N Clinical feature

Cardiac arrhythmia (ventricular), asystole Prolongation PR Interval, broadening QRS Complexes

Risk : renal impairment, potassium sparingdiuretic, addison’s disease

Drug use : Ca gluconate 1 g (10 ml of 10% solution) iv Ca chloride : 3 x 10 ml of 10% solution Glucose 40% 5 g every 1 unit insulin (50 ml

glucose and 5 units insulin) activated potassiumpump

Beta-2 agonist (salbutamol) activated membranesodium-potassium ATPase K into Cell

STATUS EPILEPTICUS The state of continuous seizures, without a

period of complete recovery Cause neuronaldamage, death

Etiology : Hypoglicaemia Therapy : ABC Drug

Diazepam 10-20 mg (first) Lorazepam 4 mg (first) Phenytoin 15 mg/Kg iv maintain : 3-4 x 100 mg Phenobarbital 10 mg/kg If No response use paralytic and anaesthetic :

thiopental, propofol

Organophosphorus PesticidePoisoning Anticholinesterase agent acute cholinergic

syndrome Clinical feature

Ocular pain, ciliary spasm, wheezing Hypersecretion : bronchus, salivation, sweating Brochospasm Nausea, vomiting, bradycardia Miosis Circulatory failure

Organophosphorus PesticidePoisoning

Drugs Antagonist to acetylcholine Atropine : 4-8 mg iv every 5-10’ at the first

hour continue by infusion Pralidoxyme (cholinesterase reactivator) 1-2

mg iv

METHANOL POISONING Methanol metabolism to formaldehyde and

formic acid injure the retinal cell and severeacidosis

Clinical feature Nausea, vomiting, abdominal pain Headache, dizziness, paraesthesia Blurred vision, diminish visual activity Coma, dilated or un-reactive pupils permanent

blindness

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ETHYLEN GLYCOL POISONING

Like methanol used as an alcohol substitute Ethylen Glycol glycolaldehyde glycolic acid,

glyoxylic acid oxalic acid : toxic to brain,heart, lungs, kidney

Clinical feature 3 phase 1 : Neurological stage : slurred speech, ataxia, stupor,

hallucination, coma, 2 : Cardiopulmonary 12-24 h: respiratory depression,

hypertension, tachycardia, muscle tenderness,congestive cardiac failure

3 : renal stage >1-3 days : flank pain, crystaluria,oliguria and renal failure

DRUG USE

Ascidosis : bicarbonate infusion Seizures : Diazepam Ethanol inhibit metabolism methanol and

ethylene glycol to toxic metabolites (competefor alcohol dehydrogenase) oral /iv

Fomepizole (4 methylpyrazole) 15 mg/kg 10mg/kg penghambat kompetitip enzim alkoholdehidrogenase

Benzodiazepines

Risk : drug interaction with the otherdepression, > 1000 mg single

Clinical feature (30-60’) Weakness, ataxia, short term memory loss,

coma, respiratory depression

Drugs : flumazenil 200 µg iv, every 60”up to 1 mg

Snake Venom Poisoning

Neurotoxin : cobra Vasculotoxin Myotoxin : sea snake Clinical feature :

pain, paralysis, clouding of consciousness Difficult of breathing, dysphagia, salivation Coma, convulsion Oedema, haematoma, petechie, epistaxis, maelena,

haematemesis

DRUGS

ASV (anti snake venom) Anti tetanus vaccine 0,5 ml im Chlorpheniramine 10 mg iv Hydrocortisone : 100 mg iv before ASV Adrenaline (naphylaxis) Continue with ASV (2 vial) in 100 ml

glucose 5%

JAMUR

TOKSIN muskarinik Terapi Simptomatik Atropin sulfat 2 mg sc

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JENGKOL

Gejala : kolik ureter, oligouri, hematuri,anuria (berbahaya)

Terapi NaCO3 4 x 2 g peroral Jika anuria standar pengobatan pasien

uremia

ASPIRIN Gejala : hiperventilasi, keringatan,

muntah, delirium, kejang, koma, depresinafas

Terapi Simptomatis Susu Bilas lambung : NaCO3 5% Vit K bila perdarahan Jangan memberikan antikonvulsan depresi

SSP

PARASETAMOL Dosis 200mg/BB atau 2 gram Gejala : muntah berulang, nyeri perut kanan atas, gejala

hipoglikemia Penatalaksanaan (prehospital) :karbon aktif 1g/kg bb-50g (efektif

setelah tertelan < 2jam) Hospital : karbon aktif N-Acetylcysteine 300mg/kg bb dalam 3 tahap infus

selama 20-21 jam Jika potensi hepatotoksik berat maka infus dilanjut

100mg/kgbb dlm 16 jam atau150mg/kgbb/24jamperbaikan

ANTIHISTAMIN/ANTIKOLINERGIK

Mesoridazin, thioridazine, tricyclic Antidepressants.diphenhydramine dll

Gangguan jantung, kejang, ramdomiolisis Terapi Oksigen dan monitoring jantung Cuci lambung (<2 jam) Karbon aktif 1 g/kg; maximum 50 g Fisostigmin jika perlu : monitoring fungsi jantung di ICU

dan disiapkan atropin

TERIMA KASIH