Dr .dr.

Tri Maharani MSi SpEM

 
Cara Tradisional
 -Sucking Poison Snake dengan mulut
 -Compress Bite Wounds with bonggol pisang,asam
jawa,akar kayu gambir
 -black stone and electric treatment
 -Torniqueit
 -inj corticosteroid
 -cross incision dengan pisau
Black stone from papua

 Menurut WHO 2010 
 PENANGANAN GIGITAN ULAR (SNAKEBITE)
 Curiga snakebite seharusnya diterapi sebagai kegawatan
medik.
 Step 1 : Metode pressure immobilisasi untuk Snakebite
 Step 2 : Identifikasi dan deteksi venom/racun ular
 Step 3 :Penanganan Envenomisasi



 Apa itu bisa ular?

Venom composition
 More than 90% of snake venom (dry weight) is
protein.
 Each venom contains more than a hundred
different proteins:
 enzymes (constituting 80-90% of viperid and 25-
70% of elapid venoms),
 non-enzymatic polypeptide toxins,
 and non-toxic proteins such as nerve growth
factor.
 Venom enzym

 These include digestive hydrolases,
hyaluronidase, and activators or inactivators
of physiological processes, such as
kininogenase.
 Most venoms contain -amino acid oxidase,
l

phosphomono- and diesterases, 5’-

nucleotidase, DNAase, NAD-nucleosidase,
phospholipase A and peptidases.
2
Zinc metalloproteinase haemorrhagins:
Damage vascular endothelium, causing bleeding.

Procoagulant enzymes:
Venoms of Viperidae and some Elapidae and Colubridae contain

serine proteases and other procoagulant enzymes that are thrombin-
like or activate factor X, prothrombin and other clotting factors.

These enzymes stimulate blood clotting with formation of fibrin in the

blood stream.

Paradoxically, this process results in incoagulable blood because most

of the fibrin clot is broken down immediately by the body’s own
plasmin fibrinolytic system and, sometimes within 30 minutes of the
bite, the levels of clotting factors are so depleted (“consumption
coagulopathy”) that the blood will not clot.

Some venoms contain multiple anti-haemostatic factors.

For example, Russell’s viper venom contains toxins that activate

factors V, X, IX and XIII, fibrinolysis, protein C, platelet aggregation,
anticoagulation and haemorrhage
 Phospholipase A (lecithinase):
2

 The most widespread and extensively studied of all

venom enzymes. It damages mitochondria, red blood
cells,leucocytes, platelets, peripheral nerve endings,

skeletal muscle, vascular endothelium, and other
membranes, produces presynaptic neurotoxic activity,
opiate-like sedative effects, leads to the
autopharmacological release of histamine and anti-
coagulation.
 Acetylcholinesterase: Although found in most elapid
venoms, it does not contribute to their neurotoxicity.
 Hyaluronidase: Promotes the spread of venom through
tissues.Proteolytic enzymes (metalloproteinases,
endopeptidases or hydrolases) and polypetide
cytotoxins (“cardiotoxins”): Increase vascular
permeability causing oedema, blistering, bruising and
necrosis at the site of the bite.
 Venom polypeptide toxins (“neurotoxins”)
 Postsynaptic (α) neurotoxins such as α-
bungarotoxin and cobrotoxin, consist of 60-62

or 66-74 amino acids. They bind to acetylcholine
receptors at the motor endplate.
 Presynaptic (β) neurotoxins such as β-
bungarotoxin, crotoxin, and taipoxin, contain
120-140 amino acids and a phospholipase A
subunit.
 These release acetylcholine at the nerve endings
at neuromuscular junctions and then damage
the endings, preventing further release of
transmitter.


Envenomasi sistemik dan lokal


First aid

Venom detection kit

kasus

 Kasus
O Laki-laki 16 tahun datang ke IGD RSU Dr. H. Koesnadi
Bondowoso dengan keluhan utama sesak nafas.
Keluhan penyerta kesulitan membuka mata, nyeri
hebat di seluruh tubuh, dirasakan sejak 2 jam sebelum
dibawa ke IGD. Diketahui 4 jam sebelumnya pasien
digigit oleh ular belang berwarna hitam putih pada jari
ke 4 tangan kanan.
O Hasil laboratorium : Normal
O Elektrocardiografi : sinus takikardi
O Tes 20 menit pembekuan darah : koagulatsi (+)
 Pendahuluan
O Pada tahun 1954, menurut Swaroop dan Grab pada
penghitungan statistik, WHO, diperkirakan sekitar
500.000 kasus gigitan ular dan sekitar 30.000 –
40.000 kasus kematian di dunia dalam 1 tahun, sekitar
25.000 – 35.000 kematian di Asia.
O Pada tahun 1998, Chippaux mempublikasikan sebuah
penelitian dengan total kasus gigitan ular per tahun
sekitar 5 juta kasus dengan 125.000 kasus kematian di
dunia. (1)
O Kasus gigitan ular yang tercatat di Indonesia sangat
terbatas, distribusi data juga sangat kurang. (2)
O Terdapat 3 kasus gigitan ular Bungarus sp. yang terjadi
di Bondowoso dengan tidak ada satupun kasus
kematian.
DISKUSI
DISKUSI
DISKUSI
Time 29th March 2015 30th March 2015
10.30 am 1.00 pm 10.00 pm 4.00 am 7.00 am 10.00 am
Complaints Dyspneu, No dyspneu, Blurred vision, Blurred vision, Pain all of the Pain all of the
He moved tocouldn’t speak pain all of the dyspneu, pain pain all of the body body decreased
observation room
fluently, pain body, he spoke all of the body body
with a betterall of the body more fluently
condition

Pain score 9/10 6/10 8/10 6/10 6/10 4/10

Airway Breathing
BloodPress. 100/60 and 110/70 120/75 116/71 115/71 117/78
Circulation must be
Resp. Ratekeep stable30 21 29 20 24 24
 Repeat : 100 cc NaCl
Heart Rate0.9% + 2 vial
130 SABU 88 144 120 79 80
 Atropine 1 mg iv and
o
Temp. ( C) 36.8 2 mg iv
Physostigmin 36.9 36.6 36.8 36.8 36.4
 Morphine 1 mg iv
Ptosis (mm) 2/2 2/2 2/2 2/2 2/2 2/2

SpO2 (%) 94 100 95 98 98 99

Hb (g/dL) 12.8 - - - - -
Repeat : Atropine
WBC (/mm) 6.100 - Repeat :- 100 cc - - -
1 mg iv and
NaCl 0.9% + 2 Physostigmin
Platelet(/mm) 337.000 - - - - - 2 mg
vial SABU iv
PCV (%) 35 - - - - -
29TH MARCH 2015 AT 11.30 PM
Time 30th March 2015

1.00 pm 4.00 pm 7.00 pm 10.00 pm

Repeat : Repeat :
• 100 cc NaCl
Complaints Pain all of the body • 100Pain
Pain all of the body cc NaCl
all of the body Pain all of the body
0.9% + 2 vial decreased, only in bite decreased, only in bite0.9%
decreased,
+ 2 vialonly in bite decreased, only in bite
site site site site
SABU SABU
• Atropine
Pain score 1 2/10 2/10 • Atropine
2/10 1 2/10
mg iv and mg iv and
Blood Press.
Physostigmin 103/68 113/72 111/71
Physostigmin 118/78
2 mg iv 2 mg iv
Resp. Rate 17 18 18 19
• Ketorolac 30 • Ketorolac 30
mgRate
Heart iv 76 110 mg 81
iv 90
o
Temp. ( C) 36.8 36.6 36.5 36.8

Ptosis (mm) 2/2 2/2 2/2 2/2

SpO2 (%) 100 99 100 100

Hb (g/dL) - - - -

WBC (/mm) - - Repeat : Atropine

- 1 mg iv -
and Physostigmin 2 mg iv
Platelet(/mm) - - - -

PCV (%) - - - -
30TH MARCH 2015
Time 31th March 2015 1st April 2015

4.00 am 12.00 pm 18.00 pm 04.00

Complaints Pain only in bite site Pain only in bite site Pain only in bite site No complaint

Pain score 2/10 1/10 1/10 1/10

Blood Press. 100/60 114/70 111/72 113/70

Resp. Rate 18 22 19 19

Heart Rate 88 78 81 88
o
Temp. ( C) 36.8 36.6 36.3 36.8

Ptosis (mm) 1/2 -/- -/- -/-

SpO2 (%) 100 100 99 100

HbRepeat
(g/dL): - - - -
• 100 cc Ketorolac 30 mg iv
WBC NaCl
(/mm)0.9% - - - -
+ 2 vial
Platelet(/mm)
SABU - - - -
• (%)
PCV Ketorolac - - - -
30 mg iv
DISKUSI
DISKUSI
DISKUSI
 KESIMPULAN
O Penanganan awal yang benar
dikombinasikan dengan antibisa ular
spesifik serta terapi suportif dan
simptomatis yang benar, dapat menurunkan
angka kesakitan dan kematian pasien.
Hemotoxin bite
antivenom
Mengukur Kecepatan Progresi Proksimal Rate of Proximal
Progression (RPP) Edema
TES 20 MENIT PEMBEKUAN DARAH
Hemotoxin SNAKE BITE
NEKROSIS KOBRA BITE
 BULLAE
HEMOTOKSIN
Dr.dr.Tri Maharani Msi SpEM
 VENOM OPHTHALMIA:
DISCUSSION
Symptoms and complications include :
-pain
-hyperemia
-blepharitis
-blepharospasm
-corneal erosions
-anterior uveitis
Delay or lack of treatment may result in corneal
opacity, hypopyon or blindness.
Venom Ophthalmia
Snake venom composition is
protein (more than 90%)
Wide variety of post synaptic
‘three finger fold’
neurotoxins,
cytotoxins,cardiotoxins and
enzymes (PLA2).
Each venom contains more
than a hundred different
proteins:
1. enzymes (25-70% of
elapid venoms)
2. non-enzymatic
polypeptide toxins
(cobrotoxin)
3. non-toxic proteins (nerve
growth factor)
 VENOM OPHTHALMIA:
WHAT CAUSES OCULAR
TOXICITY?

1.Cardiotoxin
In large,responsible for ocular toxicity
Direct lytic factor and membrane damaging
properties accounts for chemosis and corneal
abrasions
Works synergystically with Phospholipase A2
Varying toxin and protein fractions of the
venom in different cobra species determine the
different magnitudes of topical ophthalmologic
toxicity they displace ( Fung HT et al, Hong
Kong j.emerg.med. 2009;16:26-28)
 VENOM
OPHTHALMIA:WHAT
CAUSES OCULAR
TOXICITY?

2. Corneal collagenase

 calcium dependent zinc metalloenzyme

 mediates the development of corneal liquefaction and

opacification

 Enhanced by topical steriods causing corneal melting

1.FIRST AID IRRIGATION

 Initial management- pre hospital and in the emergency

department

 Generous volumes of water, saline, ringers lactate or any

available bland fluid including milk
 VENOM OPHTHALMIA:
Drug Purpose
0.5% adrenaline drops Pain relieve
Topical anaesthetic Pain relieve
(tetracaine)
topical antimicrobials to prevent endophthalmitis or
(tetracycline or blinding corneal opacities
chloramphenicol)
Topical cycloplegic drops prevention of posterior
(atropine, scopolamine synechiae, ciliary spasm and
,homatropine) discomfort
*David A Warrell. WHO-SEARO Guidelines for the management of snake-bites
antihistamines
2010 To treat allergic kerato-
conjunctivitis
2. TOPICAL ANALGESIA

Vasoconstrictors with weak mydriatic

activity, 0.5% topical adrenaline
Limited use of topical anaesthetic drops
( oxybuprocaine 0.4% or tetracaine)
Overcomes acute blepharospasm,
facilitates irrigation.
Prolonged use of topical anaesthetics
not recommended as adverse effects
include stromal keratocyte, corneal
epithelium toxicity.
Risk of bacterial superinfection in
anaesthesized damaged cornea
3. TOPICAL CYCLOPEGICS

 Recommended for anterior segment inflammation

 atropine, scopolamine

 Reduces risk of posterior synechiae formation and ciliary spasm

 Reduces patient discomfort

 Complication: acute glaucoma in anterior chamber

4. TOPICAL ANTIBIOTICS

 Recommended if corneal erosion cannot be excluded by

flourescein stain and slit lamp examination

 Prevents secondary bacterial infection

 Tetracycline, cmc, penicillin-streptomycin ointment and

polymixin B sulfate
59
 Do and don’t

 62 KASUS DARI MARET –NOPEMBER 2015
 3 BUNGARUS
 2 COBRA
 2 VENOM OFTALMIA
 2 NON VEENOMOUS
 53 KASUS HEMOTOXIN (TRIMERESURUS ALBO
ATAU INSULARIS )
 SEMUANYA SEMBUH
 PAKAI ANTI BISA ULAR THAI 4 KASUS
 DEBRIDEMENT 1 KASUS
CENTER

SUB
 Non medical
• Pemetaan lokasi ular
• Pengetahuan penanganan awal gigitan ular
• Provokasi masyarakat untuk ke tenaga
kesehatan bila digigit ular
• Pengetahuan akan pusat rujukan
penanganan gigitan ular dan ketersediaan
serum antibisa ular
• Image gallery jenis jenis ular
• Pre hospital
• In Hospital
• Post hospital
 Pre hospital
• Panduan penanganan awal
• Panduan identifikasi ular
• Panduan pemetaan lokasi ular
• Panduan ketersediaan serum anti bisa ular
dan cara pemakaiannya
 BORANG
SNAKE BITE
 step by step

• 1.Sosialisasi cara penanganan yang benar dan

kebutuhan antibisa ular
• 2..Membuat image gallery tenaga medik dan awam
bisa tahu tentang identifikasi ular
• 3.Kampenye untk memfoto atau membawa ular yang
mengigit
• 4.Medsos one line bagi tenaga medis cara
penanganan gigitan ular –recs indonesia
• 5.kit penanganan gigitan ular
• 6.pemetaan ular untuk memetakan kebutuhan
antibisa ular
• 7.Membuat borang nasional gigitan ular
• 8.Membuat buku pedoman untuk puskesmas
dan rumah sakit tentang gigitan ular
 Provokasi langsung
• Pemerintah
• Masyarakat
• Tenaga kesehatan
• share ilmu ke beberapa negara tetangga
 Tidak langsung
• Media masa dengan tujuan :
• Ke pemerintah
• Ke tenaga kesehatan
• Ke masyarakat awam
Provokasi ke masyarakat
Pembuatan film
E.N.S.
 Kompas 14 juli
2015
Kasus snake
bite dari bulan
maret sampai
juli 2015
41 kasus
35 kasus ular
hijau
(trimesurus
albolabris),2
kasus gigitan
,kobra 2 kasus
1 venom
aftalmia,2
Bungarus 2 bungarus,2
kasus kaus uar kopi

Gigitan
kobra 2
kasus

Penanganan gigitan ular terbaru menurut WHO 2010 di RS Koesnadi Bondowos

TERIMAKASIH
