Indonesia

Total snake species : 349

Venomous snake species:

 Elapidae : 55
 Viperidae : 21
 Colubridae : 1
Problems
• Data
• First Aids
• Indonesia Guideline
• Doctors and Nurses Skills (A,B,C)
• Antivenom Availability
• Transportation
Snakebites Cases In Indonesia
From 2012-2018
200
180
160
140
120
100
80
60
40
20
0
HIV snakebites cancer
 In Hospital
Mortality
20
18
16
14
12
10
8 2016
6 2017
4 2018
2
0
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VENOMOUS
Snake Families And General Venom Effects
Venomous Snake
Families

Elapidae Hydrophiidae Viperidae Colubridae

Myotoxic Cytotoxic Coagulopathic

Renal toxicity Myotoxic
Coagulopathic

Neurotoxic
+Cytotoxic In Cobra & King Cobra
+ Coagulopathy In Australasian Elapids
HUMAN LYMPHATIC DRAINAGE
PBI
FIRST AID
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
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
 Physical Examination
1. Vital sign (BP, Pulse, RR, Temp)
2. Pain Score
3. General Examination
 Head And Neck Include Ptosis
 Chest (Lungs And Heart)
 Stomach
 Upper And Lower Limb
4. Localized Examination
 Fang Mark (Do Not Mark The Bite Site!)
 Bleeding
 Necrotic Tissues
 Bulae
 Etc.
MONITORING
 Vital sign (BP, RR,
Pulse, Temp)
 Complain
 Pain Score
 RPP Test
 Bitten Area Evaluation
 TREATMENT
(1)
Keep the Airway Breathing and Circulation stable
1. 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 (+)
2. Breathing
• Evaluate the respiratory rate
3. 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
 TREATMENT
(2)
1. Immobilize bitten area by using Pressure Bandaging
Immobilization
2. Antivenom : DRUG OF CHOICE
• If the snake that bite the patient include in 3 snakes which are covered
by the SABU, we can give SABU quickly
• 2 vials SABU + 500mml Normal saline 0.9% dripped 0-80 drop
perminute
• Repeated every 6 hours. BE AWARE TO RE-ENVENOMATION
SIGN!!!
3. Symptomatic
• Analgesia : morphine (PS≥7) and paracetamol infusion or oral (PS<7)
4. Antibiotic
• When indicated, example : leucocytosis
 TREATMENT
(3)
1. Anticholinesterase drugs
• Especially for neurotoxin envenoming
• Should give atropine before giving the drugs to prevent physostigmine
intoxication.
• Physostigmine dose
• Adult (>12 yo) : 1.0-2.0 mg
• Children ≤ 12 yo : 0.02 mg/kg/dose (max single dose 0.5 mg)
• Should be given slowly 3-5 minutes by IV push,repeat every 4 hour
 20 MINUTE20 wbct
TESWBCT
1. Aim : to make sure hemotoxin or not by knowing
from the coagulation.
2. 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)
RPPateProximal Progression Test
1. Aim : to evaluate the edema progression to make a best
next medical treatment.
2. 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
Neurotoksin(julian
whie,2016)
Haemotoxin system
Snake Antivenom In Indonesia
 SERUM ANTI BISA ULAR (SABU)
• SABU Covers 3 Venomous Snakes
1. Agkistrodon Rhodostoma
2. Naja Sputatrix
3. Bungarus Fasciatus
 SNAKE ANTIVENOM

MONOVALENT POLYVALENT
 Antivenom
• Equine Hyperimmune serum (IgG).
• Crude protein (Whole IgG).
• F(ab’)2.
• F ab.
• Low molecular weight.
• Decrease chance of hypersensitivity.
• Monovalent and Polyvalent antivenom
COBRA
BITE
Trimeresurus Bite
(Local Phase)
 Trimeresurus Bite
(Hemotoxin, Systemic Phase)
Calloselasma Bites
NeurotoXin SNAKEbite
King Cobra Bites
Venom Oftalmia