Pre-Hospital Care

Focused

dr. Luh Sumiari

e-mail: omi.davmayra@gmail.com

dr. I Made Widiarta Kusuma

e-mail: imwkkusuma@gmail.com
 EPIDEMIOLOGI

Guidelines for the Clinical Management of Snakes bites in the South-East Asia Region, World Health Organization, 2005
Penatalaksanaan gigitan ular berbisa. BAIPD E IV J I . FKUI. Jakarta, 2006. p207-44
EPIDEMIOLOGI
Data di Indonesia?
Epidemiology of snakebite
in South-East Asia Region
countries
Situs:
http://apps.who.int/bloodproducts/snakeantivenom
s/database
/
 Epidemiology of snakebite
in South-East Asia Region INDONESIA
Exc.: Maluku dan
countries Papua

Bungarus candidusBungarus fasciatus Bungarus flaviceps

Malayan pitviper White-lipped island pitvipe

White-lipped pitviper

Southern
Siamese Russell's viper Indonesian King cobra
spitting cobra

Etc.
Snake Bite as Occupational
Disease
Pekerjaan yang beresiko:
1. Petani
2. Perkebunan
3. Pengembala
4. Restauran Ular
5. Usaha kulit ular
6. Pemburu
7. Nelayan
8. Budi daya ikan
Untuk kepentingan medis, dibuat
kategori
(Kategori 1) (Kategori 2)
Highest Medical Secondary Medical
Important Important
 BISA ULAR VENOMOUS

Cardiotoxin Hemotoxin Neurotoxin

Necrotoxin Nephrotoxin

KOMPOSISI
BISA
- 90% bisa adalah protein ( > 100 jenis protein)
- dibagi menjadi:
a. Enzim viper (80 90%), Elapidae (25 70%)
b. Non Enzim Toxin dan Non-toxin (ex.: nerve growth
factor)
 Gejala dan Tanda Gigitan Lokal
Ular Berbisa

a. Tanda gigitan ( 2,5 cm gigitan viper Russell)

b. Perdarahan lokal (40 menit pasca gigitan)
c. Lepuhan, bengkak, dan memar (Malayan Pit Viper)
d. Lepuhan dengan nekrosis awal (Kobra)
e. Lepuhan + nekrosis awal (indo-chinese spitting cobra)
 Gejala dan Tanda Gigitan Lokal
Ular Berbisa

a. Pembengkakan lokal (Kalenjar getah bening)

b. Abses (Russell Viper)
c. Nekrosis ( Cobra dan Malayan Pit Viper)
Gejala dan Tanda Gigitan SISTEMIK
Ular Berbisa

(Bilateral Kemosis gigitan Russell Viper)

Gejala dan Tanda Gigitan SISTEMIK
Ular Berbisa
Gejala dan Tanda Gigitan SISTEMIK
Ular Berbisa
 Gejala dan Tanda Gigitan SISTEMIK
Ular Berbisa

Pasien digigit Russel Viper dengan gejala

neurotoksik
Gejala dan Tanda Gigitan SISTEMIK
Ular Berbisa
NTIVENOM
 SNAKE ANTIVENOM

MONOVALENT POLYVALENT
 SERUM
SABU ANTI
covers BISA ULAR
3 venomous snakes
1.(SABU)
Agkistrodon rhodostoma
2. Naja sputatrix
3. Bungarus fasciatus
Trimeresurus albolabris

Thailand
product
Each vial price
USD170
INDONESIA????
Other ANTIVENOM
PENANGANAN TRADISIONAL?????
HOW TO MANAGE SNAKE BITE CASE
OUT OF HOSPITAL?
HOME
DO NOT PANIC
DO NOT GIVE CONSTRICTING BAND
(TORNIQUET), SUCKING, or OTHER
TRADITIONAL TREATMENT
IMMOBILIZE BITTEN AREA (will be
discussed)
SEND TO PRIMARY HEALTH CARE OR
EMERGENCY DEPARTMENT
BRING DEAD OR ALIVE SPECIMENT
OR SNAKE PHOTO INTO EMERGENCY
TO BE IDENTIFIED TO GIVE A
SUITABLE ANTIVENOM
 HOW TO MANAGE SNAKE BITE CASE
OUT OF HOSPITAL?
PRIMARY HEALTH CARE
DO GENERAL EXAMINATION, MAKE IT
STABLE!
EVALUATE THE IMMOBILIZATION
GIVE IMMOBILIZATION IF NO IMMOBILIZATION
BEFORE
GIVE ANALGESIA WHEN NEEDED
MARK THE EDEMA BY USING RPP TEST (will
be discussed)
DO NOT DO CROSS INCISION !!!!
BRING THE PATIENT TO THE EMERGENCY
DEPARTMENT
 HOW TO MANAGE SNAKE BITE CASE
OUT OF HOSPITAL?
Other Examination
TES SEDERHANA
20 minutes Whole Blood Clotting
Test (20WBCT)
Rate Proximal Progression (RPP)
Test
 HOW TO MANAGE SNAKE BITE CASE
OUT OF HOSPITAL?
20 MINUTES WBCT
TES SEDERHANA
20 minutes Whole Blood Clotting Test
(20WBCT)
Tujuan: Untuk memastikan hemotoksin atau
tidak dari pembekuan darah
Prosedur:
Ambil botol kaca, JANGAN GUNAKAN BOTOL PLASTIK
Tampung darah 2 cc di dalam botol kaca
Tunggu selama 20 menit
Ulangi test minimal dua kali
Hasil:
20 menit:
membeku (+) : tidak ada gangguan pembekuan (Non-
Hemotoxin)
Membeku (-) : Gangguan pembekuan (HEMOTOXIN)
RateHOW
Proximal Progression
TO MANAGE SNAKE BITE CASE
Test OUT OF HOSPITAL?
TES SEDERHANA
Rate Proximal Progression (RPP) Test

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.
How to do RPP Test?

5 cm / 2 hours,
so
5 cm RPP = 2.5
cm/hour
 Lowest side of
tape 1to lowest
side of tape 2 is 4
cm. So we have
RPP test is 2
cm/hour
 10 cm in 3 hours
RPP = 3.3 cm/hour
BAGAIMANA MENILAI DERAJAT
KEPARAHAN GIGITAN ULAR???

DERAJAT KETERANGAN
I keracunan minimal, bekas taring dan gigitan,
terasa sangat nyeri dan edema serta eritema
seluas 1-5 inci dalam 12 jam, tidak ada
gejala sistemik
II keracunan tingkat sedang terdapat bekas taring
dan gigitan, terasa sangat nyeri dan edema serta
eritema yang terjadi meluas antara 6-12 inci
dalam 12 jam. Kadang- kadang dijumpai gejala
sistemik seperti mual, gejala neurotoksi, syok,
pembesaran kelenjar getah bening regional
III Gejala keracunan yang hebat, bekas taring dan
gigitan, terasa sangat nyeri, edema dan eritema
yang terjadi luasnya lebih dari 12 inci dalam 12
jam. Juga terdapat gejala sistemik seperti
hipotensi, petekhiae, dan ekimosis serta
syok
Pre-Hospital Care
Focused

VIDEO
WORKSHOP

dr. Luh Sumiari

e-mail: omi.davmayra@gmail.com

dr. I Made Widiarta Kusuma

e-mail: imwkkusuma@gmail.com