NEUROTOXICOLOGY IN

EMERGENCY SETTINGS

Prof. Dr. dr. Sri Sutarni, Sp.S(K)

OVERVIEW
Emergency Setting: ABC, Anamnesis, Physical
examination & Supporting examination,
Diagnosis, Neurological sign & another
symptom cause by Intoxication
Toxidrome Alcohol, Antikholinergic, Kholinergic,
Opioid, Sympatomemetic & Sedative-hypnotic
Toxican Specific Antidotum and Managemen
Decontaminan and toxican elimination
BACK
GROUND
Neurotoxicology:
 The science which study about all type of toxican
and the effect to Central & Peripheral Nervorum System
How did the toxican enter the body?
Inhalation  be carefull to Respiratory System
Oral  be carefull to Digestive System
Skin Absorbtion  be carefull to Skin irritation,
Systemic effect
Alcohol
Dangerous to consume it
Rat branded
Ciu branded
Caping miring
The effect:
- excitation & inhibition central nerve system
- (Ethanol)Mabuk, teler, sakauw cause by with drawl
- tolerability  more sensitive to infection, panic, coma
• Vertigo
• Anxiety
• Neuritis
• Blind
• Heart:
Palpitation
Arythmia cordis
Tachicardi
Extra pyramidal syndrome
Allertness
 WITHOUT PRESCRIPTION
• Cocaine
• Heroine
• Ectassy
• Alcohol
• Mixture  potentially toxic
Combination of Alcohol:
Cetirizine  Central nervous system
Diazepam  potentiation effect
With drawl effect 
pain
Intra cerebral
hemorrhage  operated
Tetracycline, Digoxine, Estrogen,
Morphine  toxic
Methamphetamine (Ectassy) :
- 4 methyl Dioxy methyl amphetamine (MDMA)
- XTC
- Addiction
- Maximal effect after 20-60 min,
- Fly, tonic of muscle, dry mouth, palpitation, relaxation,
nausea, difficult to breath, blank, unshamed
- Paresthesia
- Diabetic neuropathy + alcohol  lever toxicity
 Third semester of pregnant neonatus
Tramadol:
 Blockade pain sensoric
 increase respond of pain
 Side effect: - tremor
- euphoria
- disturbance of equilibrium
- unexhausted
- sleepy
• Inner Body Toxicant Causa by chronically
treatment of Medicine
• Chronic Kidney Disease  Ureum & Creatinine? –
• > Uremia
• Out of the Body/ Environment  Pollution: Plumbum
• Side effect of Medicine: NAPZA
• Industry: Hg, As etc
• Agriculture: Pesticide, Fungiside, Insecticida
IF WE FOUND THE PATIENT WITH
DISTURBANCE OF BREATHING MAY
BE INTOXICATION OF
Barbiturat
Benzodiazepine
Medicine of cough, common cold
Smoking
Caffeine
Codeine
Phenytoine
Cetirizine
Another Target Organ: except Central & Peripheral Nervous
System e.g.
1. Kidney
2. Heart
3. Lever
4. Pulmo
5. Intestinum
The condition after absorbtion:
1. More toxic
2. Less toxic
3. Stationair
The Metabolic System Toxican will be:
1. Methylation
2. DeSulfurisation
3. Hydrogenation
4. Oxygenation
5. Deconjugation
Metabolism  Catabolism
 Anabolism
Detoxycation by Lever with Enzyme
These condition Depend on:
1. Acetylation Status Slow or Fast
2. Genetic Factor
3. Environment
4. Excretion by
4.1. Kidney  .Urine  Kidney Disease
4.2 Faeces
4.3 Respiratory  smell from the mouth
4.4. Evaporation of the Skin
Remember of:
• Dose respond
• Dose dependen

Emergency Case:  Close relation with Brain

 Central Nervorum System
 High dose of Toxican
 Tentament of Suicide
 A group of people
 EMERGENCY SETTING
Emergency Setting
The most important doing by the Doctor is Life Saving  ABC
1. Airway:
The Airway must be free from all of obstruction, especially the liquid which
the patient drink
Less than 2 hours  vomiting
2. Blood : Blood pressure must within normal limite
 Brain: Decrease of consciousness not too low in GCS assesmen
3. Circulation: - To the brain is very importan in order to minimalis
sequel
- Oxygenation 3 lt/ minute
• The effect to Central Nervous System:  High Dose
of Toxicant
• Tentamen of Suicide
• Did not know the Hazardous of Toxicant
• The Clinical manifestation:  Seizures Decrease
of Consciousness: Cremaster Reflex for Man
Lateralisation?
• Smell from the mouth
• Closed place of Toxicant with the patient
• Anamnesis:  Hetero/ Allo anamnesis
• The place of Toxican closed with patient
• Physical Examination:  GCS of the patient Mild, Moderate
or Low?
• Important to predict the prognosis of
the Patient
• Seizures:  General, Partial, or
Simple?  To decrease the Intracranial Pressure by
Dexamethasone becarefull about Stress Ulcer
• Diureticum, etc
• Pupil Reflex:  + / -? Anisokor, Slow
respond
• Miosis/ Midriasis ?
• The Type of Respiratory: Kussmaull, Apneu
• Physiological Reflex: Increase, Decrease / -
• Pathological Reflex: + / -
• Cranial Nerve Palsy
• Motoric , Sensoric, Otonoom Function?
• Laboratory Examination:  Blood, Urine, Faeces 
Toxicant?
• Neuro Physiologic Examination  EEG, Brain
Mapping
• Radiological Examination CT Scan, MRI
 TOXIDROME ALCOHOL,
ANTIKHOLINERGIC, KHOLINERGIC,
OPIOID, SYMPATOMEMETIC &
SEDATIVE- HYPNOTIC

 Inner Body Toxicant Causa by chronically treatment of

Medicine
 Chronic Kidney Disease  Ureum & Creatinine?--> Uremia
 Out of the Body/ Environment  Pollution: Plumbum
 Side effect of Medicine:
NAPZA
 Industry: Hg, As, etc
 Agriculture: Pesticide,
Fungiside,
Insecticida
BACKGROUND

• Increase of morbidity & mortality rate of young

population cause by Alcohol, drugs & others
• Decrease of quality of life , cognitif
disturbance & physical, productivity
• Sequele of Neurological impact
• Increase of criminality , etc
• Addiction
PSYCHOTROPICS
• All of the medicine / anything can influence
psychological condition
• Be carefull as a Doctor when make prescription!
• Medicine as two side of knife  treat the patient
•  side effect
• Addiction
SPECIFIC ANTIDOTUM &
MANAGEMEN

Principal managemen:
1. To neutralizer Toxican from the Body by 5
principle process Dehydrogenation,
Methylation, etc
2. British Anti Leuvisite (BAL), etc
3. Symptomatic managemen
 DECONTAMINATION &
ELIMINATION OF
TOXICANT
Decontamination:
 Not Contact with – Toxicant  Peer Group
 Contact  <2 Hours  Vomitus  Gag Reflex
 >2 Hours Absorbtion by Norit, Milk etc
 Elimination As soon as possible the Toxicant must left
from the Body
 Diureticum, Dilution with Glucose, Electrolyt balance 
Ringer
Dextrose
CONCLUSION
• In Emergency Setting of Neurotoxicology Life saving is the
most Importan doing by the Doctor
• Airway, Breathing, and Circulation were the First Step must
be Done
• Ethiology & Symptomatic Management need to do
• Anything Equipment that closed to the Victim may be can
give information
• To eliminate Toxicant from the body & using Protection to
Prevent