Liozard Daniel
Zarwindo Sumardi
8 Juni 2013
 

 Indonesia  daerah endemik berbagai spesies ular

 Kasus kesehatan kerja bagi tenaga pertanian /
perkebunan
 Banyak informasi kurang tepat mengenai tatalaksana
darurat untuk gigitan ular, terutama yang tradisional
 Penelitian mengenai bisa ular masih minim
 

 Golongan Elapidae (ular sendok, belang, cabai, dll.),

 Viperidae (ular tanah, ular bandotan)
 Bisa ular melalui taring  IM / SC
 

 Tidak ada aturan sederhana untuk identifikasi ular

berbisa (WHO)
 Pengecualian bagi beberapa jenis ular berbisa;
 Kobra/ular sendok
 Pola cincin belang multipel, pola belang hitam kuning
 Desis khas dari jenis ular tertentu
 

 Mengandung berbagai enzim, toksin polipeptida, dan

protein nontoksin lain.
 Enzim2 pro-koagulan  DIC
 Faktor2 anti hemostatik
 Lesitinase  merusak mitokondria, eri-leuko-trombo,
ujung saraf tepi, otot, endotel, berbagai membran sel
 Hyaluronidase  mempermudah penyebaran bisa ular
 Enzim2 proteolitik & sitotoksin  meningkatkan
permeabilitas vaskular, edema, nekrosis jaringan
 Neurotoksin
 Gigitan ular berukuran kecil ~ ular berukuran besar
 

-Ansietas
-Hiperventilasi
-Agitasi

Gejala akibat
tatalaksana yang tidak
tepat:
-Nyeri turniket
-Pneumonia aspirasi
 

 DO NO HARM
  IDENTIFIKASI JENIS ULAR

  EMERGENCY LIFE SUPPORT (ABC)

  IMOBILISASI

  TRANSFER

 NO interference with the bite wound!!!

 Tight (arterial) Tourniquet
NOT RECOMMENDED!!!
 

 Amankan lokasi korban, minimalkan manipulasi pada

luka gigitan.
 Tenangkan korban

 Cari pertolongan

 Lokasi gigitan->posisi fungsional  imobilisasi

 Benda yang membuat konstriksi-> pindahkan

 Balut tekan

 Korban harus sadar, hindari pergerakan

 

 Do NOT allow the person to become over-exerted. If necessary, carry

the person to safety.
 Do NOT apply a tourniquet.
 Do NOT apply cold compresses to a snake bite.
 Do NOT cut into a snake bite with a knife or razor.
 Do NOT try to suck out the venom by mouth.
 Do NOT give the person stimulants or pain medications
unless a doctor tells you to do so.
 Do NOT give the person anything by mouth.
 Do NOT raise the site of the bite above the level of the person's heart.
 

 REVIEW (ABC);
 Syok, gagal napas, toksisitas sistemik, hiperkalemia,
 AKI, sepsis, DIC
 TENTUKAN DERAJAT EFEK RACUN
  ANTIVENOM  Treatment / SABU (serum anti bisa ular)
  Antibiotik, Antitetanus
 

 Serum polivalen dari plasma kuda yang dikebalkan thd

bisa ular yg bersifat neurotoksis dan hematoksis.
 Efek samping : Rx.anafilaksis, serum sickness,
demam/menggigil pasca pemberian i.v., nyeri tempat
suntikan pasca pemberian jumlah besar biasa pasca 24
 jam
 Tidak ada neutralisasi silang
 

 Diutamakan pada pasien dengan benefit > risk

 Sebaiknya diberikan beberapa jam setelah gigitan
 Resiko reaksi alergi!!!
 Siapkan Epineprin!!!
 Intravenous push (< 2ml/mnt) atau 
infusion dalam NaCl 0,9% / D5% selama 1 jam.
 Intramuskular hanya bila perjalanan ke RS jauh, area
terpencil, akses intravena tak dapat diperoleh.
 Dosis anak = dewasa
 

 Systemic envenoming
 Haemostatic abnormalities: Spontaneous systemic bleeding
(clinical),
 coagulopathy  (20WBCT or other laboratory tests such as
 prothrombintime) or thrombocytopenia (<100 000/cu mm)
(laboratory).
  Neurotoxic signs: ptosis, external ophthalmoplegia, paralysis etc
(clinical).
 Cardiovascular abnormalities: hypotension, shock, cardiac
arrhythmia(clinical), abnormal ECG.
  Acute kidney injury (renal failure): oliguria/anuria (clinical), rising
blood creatinine/ urea (laboratory).
 ( Haemoglobin-/myoglobin-uria: ) dark brown urine (clinical), urine
dipsticks, other evidence of intravascular hemolysis or generalised
rhabdomyolysis (muscle aches and pains, hyperkalemia) (clinical,
laboratory).
 Supporting laboratory evidence of systemic envenoming
 

 Local envenoming
 Local swelling involving more than half of the bitten limb
(in the absence of a tourniquet) within 48 hours of the
bite. Swelling after bites on the digits (toes and especially
 fingers).
 Rapid extension of swelling (for example, beyond the
wrist or ankle within a few hours of bite on the hands or
 feet).
 Development of an enlarged tender lymph node draining
the bitten limb
 

CORAL SNAKE
 

CORAL SNAKE
 

CORAL SNKE
 

BLUE TEMPLE
 VIPER
 

PIT VIPER
 

BANDEDKRAIT
SNAKE
 

RETICULATED
PHYTON
 

KING COBRA
 

SPITTING COBRA
 

PHYTON
 

 White Snake
 

  Warell, DA. Guidelines for the management of snake-bites.

 World Health Organization, 2010.
 

 Atheris squamigera

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