KePPo – Penanganan Gigitan Ular

Kelas extra Pembinaan Pramuka Jogja

Kwarda DIY, 18 Mei 2019

YAYASAN SIOUX ULAR INDONESIA

Evaluasi : Aji, Mei 2019

 Sejarah SIOUX
• Didirikan pada tanggal 23 November 2003 di Gedung Kwartir
Nasional Jl Merdeka Barat, Jakarta oleh 4 orang pendiri
– Aji Rachmat (purna DKN)
– Edwin Firdiansyah (purna DKN)
– Irwan Febriansyah (purna DKN)
– Lydia
• Menjadi Yayasan SIOUX Ular pada tahun 2010
– Dewan Pembina : Edwin Firdiansyah
– Dewan Pengawas : Irwan Febriansyah
– Dewan Pengurus
• Ketua : Aji Rachmat
• Sekretaris : Iil Holillah
• Bendahara : Dian
 Porto Folio Yayasan SIOUX
PT VICO Indonesia - Muara Badak WWF Riau
PT Pertamina Hulu Energi ONWJ KEHATI
ELNUSA – Cibodas Yayasan Survival Indonesia
Banyan Tree Hotel and Resort – P. Bintan Komunitas Ciliwung Condet
Rajawali Flying School WANADRI
Nusa Flying School Pramuka
PT Cargill Kalimantan (Sawit) Taman Nasional Gunung Gede
PT Medco Agro Pangrango
Royal Lestari Utama – Karet, Jambi

Pasukan Intai Amfibi TNI AU Aardwolf Pest Care

Brigadir Mobil (Brimob) – Surabaya IMAGO Pest Control
Polsek Depok Timur Spectra Pest Control
Jambore SAR Nasional 2018 dst

Universitas Sriwijaya Palembang Trans corp.

Universitas Muhammadiyah Metro JakTV
Universitas Juanda Bogor MNC TV
Universitas Islam Negeri Jakarta Indosiar
Universitas Katolik Atmajaya Jakarta Kompas TV
Institut Pertanian Bogor Lite FM
 BUKAN
PAWANG ULAR
Semua Muscle Sioux TIDAK KEBAL terhadap efek bisa
Sioux TIDAK MELATIH kekebalan terhadap bisa

SIOUX berbagi pengetahuan karakter ular

indonesia
dan mengembangkan teknik untuk menghindari bahaya
ular
sehingga dapat hidup berdampingan secara benar di
habitatnya

Kami lebih senang disebut ...

SNAKE HANDLER
 Relawan SIOUX = Muscle SIOUX
• Area Jawa Barat = 70 muscles
• Area Jakarta = 40 muscles
• Area Banten = 13 muscles
• Area Jawa Tengah = 27 muscles
• Area DIY = 78 muscles
• Area Jawa Timur = 38 muscles
• Area Bali NTB NTT = 20 muscles
• Area Kaltim = 9 muscles
• Area campur = 18 muscles
 Profil Trainer Utama
1. Komisaris PT Satu Benih Organik
2. Direktur Utama CV LareAngon Indonesia
3. SIOUX
1. Salah satu Pendiri SIOUX
2. Ketua Yayasan SIOUX Ular Indonesia
3. Sertifikasi Trainer Utama, Yayasan SIOUX Ular
Indonesia, Pemateri ular sejak tahun 1998 dengan
lebih dari 1000 jam Sebagai Trainer
4. Sertifikasi BNSP AJI RACHMAT P, ST
1. “Fasilitator Experiential Learning level Utama (Programmer)”
2. Sertifikasi BNSP “Pemandu Wisata Gunung level Madya” 08176800446
3. Sertifikasi BNSP “Tour Guide” @aji_rachmat
4. Sertifikasi BNSP “Asesor Kompetensi”
5. Instruktur Kegiatan Alam Terbuka &Pembina Pramuka
6. Pendamping Host Petualangan Liar TV7, Jejak Petualang
Trans7, Host Sang Pawang Lativi
Mengapa Ular ada di
sekitar Pemukiman ?
 Mengapa ular ?

Satwa Liar yang habitatnya paling dekat dengan manusia

Mencari makanan

Mencari tempat sembunyi

Mendapatkan area yang tidak terganggu

Membutuhkan area bereproduksi (bertelur) tetapi tidak membuat sarang

Rantai Makanan
Makanan Ular
ULAR BERBISA TINGGI
Highly-venomous Snake
 Laticauda colubrina
Highly-venomous Snakes
 Ophiophagus hannah
Highly-venomous Snakes
 Bungarus fasciatus
Highly-venomous Snakes
 Bungarus candidus
Highly-venomous Snakes
 Naja sputatrix
Highly-venomous Snakes
 Naja sumatrana
Highly-venomous Snakes
 Calloselasma rhodostoma
Highly-venomous Snakes
 Daboia rusell
Highly-venomous Snakes
 Trimeresurus albolabris
Highly-venomous Snakes
 Trimeresurus insularis
Highly-venomous Snakes
Trimeresurus purpureomaculatus

Highly-venomous Snakes
 Tropidolaemus wagleri
Highly-venomous Snakes
 Rhabdophis subminiatus
Highly-venomous Snakes
 Caliophis bivirgata
Highly-venomous Snakes
 Caliophis intestinalis
Highly-venomous Snakes
Penanganan
Gigitan Ular
Update WHO 2016
NEW SITUATION OF SNAKEBITES
MANAGEMENT IN INDONESIA
DR. dr. Tri maharani Msi,
SpEM
 Medically important snakes in
Indonesia

Australasian
snake species

South East
Asian snake
species

There are a lot more medically important

species in Indonesia!!!
 LESSER SUNDA ISLANDS

Trimeresurus insularis Laticauda colubrina

Daboia russellii

Ophiophagus hannah

Naja sputatrix
• Viperidae 2
• Elapidae 3 Bungarus candidus
• Hydrophidae 4
 Indonesia
Total snake species :
348.
Venomous snake
species:
• Elapidae: 55
• Viperidae: 21
• Colubridae: 1
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
 Problems identified

• Data
• First Aids
• Transportation
• Doctors and nurses skills (A,B,C)
• Antivenom availability
 Snakebites cases in Indonesia
from 2012-2018
200
180
160
140
120 disease
100
80
60
40
20
0
HIV snakebites cancer
 In hospital mortality
20
18
16
14
12
10 2016
8
6 2017
4 2018
2
0
HUMAN LYMPHATIC DRAINAGE
PBI
First aid
 FIRST AID
100%
90%
80%
70%
60%
CASES 2012
50%
CASES 2016
40%
30%
20%
10%
0%
WHO TRADDISIONAL
 CLINICAL MANIFESTATION
LOCAL
• Swelling > half bitten
limb/48 hours
• Toes especially fingers
• Rapid extension within a
few hours
• Enlarged tender lymphnode
draining the affected area
SYSTEMIC
• Haemostatic abnormality
• Neurotoxic signs
• Cardiovascular
abnormalities
• Acute kidney injury
• Myoglobinuria/generalised
rhabdomyolysis/haemolysis
• Supporting lab evidence of
systemic envenoming
(A. Khaldun, 2015)
 Physical Examination
• Vital sign (BP, pulse, RR, temp)
• Pain score
• General examination
–Head and neck include ptosis
–Chest (lungs and heart)
–Stomach
–Upper and lower limb
• Localized examination
–Fang mark (do not mark the bite site!)
–Bleeding
PTOSIS MEASUREMENT

RESULT
A. MILD : 1-2 mm
B. MODERATE : 3 mm
C. SEVERE : 4 mm
 MONITORING
• Vital sign (BP, RR, Pulse, temp)
• Complain
• Pain score
• RPP test
• Bitten area evaluation
 TREATMENT (1)
Keep the Airway Breathing and Circulation
stable
• 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
 TREATMENT (2)
• Immobilize bitten area by using Pressure
Bandaging Immobilization
• 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 permminute hemotoxin bites
• Repeated every 6 hours. BE AWARE TO RE-
ENVENOMATION SIGN!!!
• Symptomatic
 TREATMENT (3)
• 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
Neurotoksin(julian
whie,2016)
Haemotoxin system
 In hospital length of stay
30

25

20

no AV
15
AV
10

0
neuro hemato necro nefro
 Cost for in hospital patients given AV
versus not given AV
300

250

200
non AV
150 AV
Column1
100

50

0
neuro hemato necro nefro
 Sequele of snakebite cases

100%

80%

60%

40% sequele

20%

0%
hemato
neuro
nefro
necro
 20 MINUTES WBCT
• 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:
 Rate Proximal Progression 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
 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 !
 What next???
• Net working
• Standard guideline
• Education & Training
• Drug & management ABC

•Antivenom
 MoU MST and TSI
• Education, training, research
• During AMSEM Jogjakarta 2018
WHO Guideline 2016 and Guideline of
Poisoning Management 2017
 RECS Indonesia consultations

800
700
600 2014
500 2015
2016
400
2017
300
2018
200
100
0
snakebite
Donation of BioCSL Australia neuropolyvalent antivenom to Sorong Hospital and training of
snakebites management 100 doctor in Sorong, West Papua.
Snake antivenom in Indonesia
 SNAKE ANTIVENOM

MONOVALENT POLYVALENT
Cobra bite
Trimeresurus bite (local phase)
 Trimeresurus bite
(hemotoxin, systemic phase)
Calloselasma
bites
NeurotoXin SNAKEbite
Klinik Heroku
Venom oftalmia
0817-6800-446

@ular_indonesia

Group : Ular Indonesia

siouxindonesia.org

yayasansioux@gmail.com