Update manajemen

snakebite
Dr.dr.Tri Maharani Msi SpEm
 BIODIVERSITY OF INDONESIAN SNAKE

Wallacea

Papua New
Guinea
Sundaland
 Snakebites data
 Data : 135.000/year incidence
 mortality over 10% people per year
 Cases report in ITS : 500-1000 cases,kematian 50-
100 dari data ITS
 Indonesia memiliki biodiversitas yang tinggi untuk ular berbisa
Namun kasus gigitan ular yang dilaporkan* masih jauh dari angka yang seharusnya

6 spesies (Australian elapidae)

4
*periode 2015 - 2021
 Snake families and general venom effects

Venomous Snake
families

Elapidae
Hydrophiidae Viperidae
Colubridae

Neurotoxin
Neurotoxic Myotoxic Cytotoxic
(bungarus sp),calliophis Renal Myotoxic Coagulopathi
+cytotoxic in cobra & king toxicity Coagulopathic c
cobra
+ coagulopathy in
Australasian elapids
 Indonesia
Total snake species : 350
Venomous snake species:
• Elapidae: 55
• Viperidae: 21
• Colubridae: 1
Cylindrophis ruffus vs Calliophis intestinalis

Courtesy E. N. Smith
Courtesy E. N. Smith

Lycodon sidiki vs Bungarus candidus

Venomous vs non venomous

Courtesy B. Dupont
 Guideline for the Management of snake bite WHO
2016
• CATEGORY 1: Highest Medical Importance - highly venomous
snakes that are common or widespread and cause numerous
snake-bites, resulting in high levels of morbidity, disability or
mortality.
• CATEGORY 2: Secondary Medical Importance - highly venomous
snakes capable of causing morbidity, disability or death, but for
which (a) exact epidemiological or clinical data are lacking or (b) are
less frequently implicated because of their behaviour, habitat
preferences or occurrence in areas remote from large human
populations.
 Indonesia Barat
• Cat 1:
Elapidae:
Bungarus candidus (Sumatra, Jawa, Bali)
Naja sputatrix (Java, Bali, NTB, Sumbawa, Flores)
Naja sumatrana (Sumatra, Kalimantan)

Viperidae:
Calloselasma rhodostoma (Jawa, Madura)
Trimeresurus (T.) albolabris (Jawa, Sumatra, Kalimantan)
Daboia siamensis (Yogyakarta, Jawa Timur, Bali, NTB, Komodo, Flores)
1 Bungarus candidus (Ular weling)
 1
Naja
sputatrix

Courtesy Akrom
Caloselesma rhodostoma

Madura 2014

Trenggalek
2016
Caloselesma rhodostoma/untup di kalbar

Cargill 2016
BGA 2016
 Daboia siamensis

Courtesy Ahmad Arifiandi

2 Bungarus fasciatus (Ular welang)

Courtesy E. N. Smith
Courtesy E. N. Smith

2 Calliophis bivirgata Ular cabe besar

Micropechis ikaheka Acanthophis laevis Pseudoechis papuanus

Pseudonaja textilis Oxyuranus scutellatus

Sea krait Beaked sea snakes Spine-bellied sea snake

Tidak Berbisa
Non venomous
Hasil bekas gigitan pada
ular tidak berbisa
berbentuk V.appertum
dan V .abrasio
venomous
Bekas
gigitan ular
berbisa
yaitu
tusukan
atau
V.ictum
First aid
Step terapi (1)
Terapi kegawatdaruratan
• Airway
• 02 Non Re-Breathing Mask 12 lpm
• Laryngeal Mask Airway and Endotracheal Tube (if needed)
• Suction if gargling (+), Head tilt and chin lift if snoring (+)
• Breathing
• Evaluate the respiratory rate
• Circulation
• Make iv access, give Normal Saline 0.9% (don’t forget to
take some blood for laboratory checking)
• Blood pressure
• Pulse
• Oxygen saturation by using pulse oxymetri
• Blood or Fresh Frozen Plasma as indicated
Step terapi (2)
Fase Lokal dan sistemik
Jika fase local :
-First aid:
• Imobilisasi :
• A.imobilisasi
• B.PBI
• C.Pads Pressure imobilisasi
• Simptomatis (analegesik dan antivomit dsb)
-Sistemik:
• Antivenom :
• BiosaveG OF CHOICE
• 2 vials SABU + 500mml Normal saline 0.9% dripped 40-80 drop permminute hemotoxin bites
• Repeated every 6 hours. BE AWARE TO RE-ENVENOMATION SIGN!!!
Antivenom Thailand dan australia
• Symptomatic
• Analgesia : morphine (PS≥7) and paracetamol infusion or oral (PS<7)
• Antibiotic
• When indicated, example : leucocytosis
Snake antivenom in Indonesia
Snake Antivenom
Monovalent Polyvalent
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Step terapi(3)

• Anticholinesterase drugs
• Especially for neurotoxin envenoming
• Should give atropine before giving the drugs to prevent physostigmine
intoxication.
• Physostigmine dose
• Adult (>12 yo) : 0,5-2,5 mgevery 1-3 hours up to 10 mg/24hours
• Children ≤ 12 yo : 0.01 mg-0,04/kg
• Should be given slowly 3-5 minutes by IV /IV/SC repeat 2-4 hours
• Atropin inj bradikardia
Neurotoksin(julian
whie,2016)
Haemotoxin system
Venom oftalmia
44
Mitos ,mistis
20 wbct dan
RPP alat
penunjaang
diagnose
gigitan ular
• 20 minutes Whole Blood Clotting Test (20’WBCT)
• Rate Proximal Progression (RPP) Test
• Electrocardiography
• Laboratory check
• Haemoglobin
• White blood cells
• Platelet count
• Liver function test
• Renal function test
• PT
• APTT
• INR
• Aim : to make sure hemotoxin or not by knowing from the
coagulation.
• How to do?
• Take a glass bottle, DO NOT USE PLASTIC BOTTLE
• Take 2 ml of blood
• Then take that blood into the glass bottle
• Wait for about 20 minutes
• Repeat that test 2 times minimal
• Result :
• After waiting about 20 minutes:
• Clotting (+) : no coagulation disorder (NonHemotoxin)
• Clotting (-) : coagulation disorder (HEMOTOXIN)
wound care snakebite
dan rehabilitasi
gigitan ular
• Aim : to evaluate the edema progression to make a
best next medical treatment.
• How to do?
• Take a tape as a mark to measure the edema
• Make sure the proximal margin of the edema, then take the
distal margin of the tape into the proximal margin of the
edema.
• Note the time when the tape was given (date and time)
• Repeat the evaluation of the edema every 2 hours
• Result : cm/hour
• Example : 10/10/15 ; 09.00 – 11.00 = 4 cm. So we have
evaluated that the edema increase about 2 cm per hour.
 5 cm / 2 hours, so
5 cm RPP = 2.5 cm/hour
53
54
Calloselesma
bittes
Caloselesma bite (kasus Kediri 8 agustus
2019)
Chaloselesma bite and cobra bite (naja spurtatix
and sumatrana)
Ophiophagus Hannah by trimaharani
Head ophiophagus Hannah by trimaharani
collection museum LIPI
King cobra bites by trimaharani
Retic bites
Snakebite in child
Snakebite in
woman Caloselesma rhodostoma bite in pregnancy
Bungarus bite
Mitos ,mistis
 Analisa gigitan ular
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