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SNAKE BITE

CASE PRESENTATION
Dr. Dion Faisal
SMF Bedah RSUD Dr. Soedono Madiun

Case
Nama: Tn. ES
Umur : 45 Tahun
Alamat : Dsn. Segulung RT 29 RW 1, Kec.
Dagangan, Madiun
MRS : 28 Januari 2016
No. DMK : 6659143
JK
: 16.00 WIB
JD
: 22.05 WIB

Anamnesis
KU: Bengkak di kaki kiri
RPS: Dialami setelah digigit ular 6 jam sebelum MRS. Kaki
kiri bengkak dan nyeri. Memar kebiruan di tangan kanan
dan kiri. Kepala pusing (+), mual & muntah (-), demam (-).
Riwayat digigit ular di perjalanan pulang dari kebun.
Heteroanamnesis keluarga pasien ular jenis bandotan
macan telah dibunuh di tempat kejadian.
Riwayat berobat di IRD RSUD Dolopo dilakukan cross incisi,
pasien menolak MRS karena alasan biaya. Terapi yang telah
diberikan: SABU 1 vial, dexamethasone 1 ampul.
Keluhan dirasakan memberat selanjutnya pasien kembali
dibawa ke RSUD Dolopo diberikan SABU 2 vial dan dirujuk
ke RSUD Soedono.

Pemeriksaan Fisik
STATUS GENERAL
KU Lemah, GCS 456, BP 110/70 mmHg, HR 90
bpm, RR 18 x/mnt, Tax 37,2OC
KL: anemis (+), ikterus (-)
Thoraks: simetris (+) retraksi (-)
Cor: S1S2 tunggal reguler
Pulmo: vesikuler +/+, rhonki -/-, wheezing -/ Abdomen:
I: Flat

P: soepel, defans (-)

A: bising usus (+) P: pekak hepar (-)


Ekstrimitas: edema (+) cruris s, echymosis (+)
antebrachii d/s

STATUS LOKAL (Regio Cruris


Sinistra)
I: V. Morsum 2 buah telah dilakukan cross incisi, edema
(+), hiperemis (+), petechiae (-), echymosis (-), bulae
(-)
P: teraba dingin, nyeri tekan (+)

Lab
Hb 11,8
Hct 34,8%
Leukosit 4.100
Trombosit 22.000
GDA 309
Ur/Cr 41,5/1,12
Na/K/Cl 137/3,6/107

Assestment
Diagnosis Primer: Snake Bite Grade 3
Diagnosis Sekunder: Diagnosis Komplikasi: trombocitopenia,
leucopenia, hiperglikemia

Planning
MRS intensive care
Nacl 0,9% 1500cc/24 jam
Drip SABU 2 vial dalam Nacl 0,9% 500cc
Ceftriaxone 2x1 gr iv
Metronidazole 3x500 mg inf
Ketorolac 3x30 mg iv
Transfusi FFP 2 kolf/hari
Transfusi TC 10 bag/hari
Immobilisasi dgn splint
Observasi ketat VS, spontan bleeding

Klinis 18 jam paska gigitan

Ecchymosis
Petechiae

SNAKE ENVENOMATION

HEMATOTOXIC
NEUROTOXIC
SITOTOXIC

Tintinalli JE, Kelen GD, Stapcynski JS, eds. Snake bites.


Emergency Medicine: A Comprehensive Study Guide. 6th ed.

Derajat

Vener
asi

Klasifikasi Parrish
Luka gigit

Nyeri

Odema/
eritema

Tanda sistemik

+/-

<3cm/12 jam

+/-

<3cm/12 jam

II

+++

>12cm25cm/12jam

+. Neurotoksik,
mual, pusing, syok

III

++

+++

>25cm/12ja
m

++, syok, petekie,


ekimosis

IV

++

+++

Pada satu
ekstremitas
secara
menyeluruh

++, gangguan faal


ginjal, koma,
perdarahan

Schwartz dan Way (Depkes, 2001):

Derajat 0 dan I tidak diperlukan SABU, dilakukan evaluasi dalam 12 jam, jika derajat meningkat maka diberikan SABU

Derajat II: 3-4 vial SABU

Derajat III: 5-15 vial SABU

Derajat IV: berikan penambahan 6-8 vial SABU

Venomous snakes: Medically important


species in South-East Asia Region
countries (WHO 2010)
Elapidae: cobras, king cobra, kraits, coral snakes,
Australasian snakes
Hidrophydae: sea snakes.
Viperidae: typical vipers (Viperinae) & pit vipers
(Crotalinae).
Colubridae: the red-necked keelback Rhabdophis
subminiatus, Large pythons (Boidae), notably the reticulated
python Python reticularis

Warren DA, 2015

Elapidae
Relatively long, thin, uniformly-coloured snakes with large smooth
symmetrical scales (plates) on the top (dorsum) of the head. There is no
loreal scale between the preocular and nasal scales

Hidrophydae
Flattened paddle-like tails and their ventral scales are greatly
reduced in size or lost.

Viperidae
Relatively long fangs (solenoglyph)
which are normally folded flat against
the upper jaw but, when the snake
strikes, they are erected. Special sense
organ, the loreal pit organ, to detect
their warm-blooded prey. This is
situated between the
nostril and the eye.

Colubridae
Large pythons (Boidae), notably
the reticulated python Python
reticularis in Indonesia, have
been reported to attack and even
ingest humans, usually
inebriated farmers

Management
1. Assestment: airway, breathing,
circulatory status, and
consciousness.
2. Urgent resuscitation shock
(cardiovascular toxicity),
respiratory failure (neurotoxin),
and cardiac arrest (due to hypoxia,
cardiac toxicity, or hyperkalemia
from rhabdomyolysis).
3. Severity of the bite &
identification of the species
4. Last tetanus immunization,
use of any medication,
presence of any systemic
disease, and history of
allergy
5. SPECIFIC THERAPY: Anti
snake venom (ASV)
immunoglobulins
6. Supportif
7. Transfusion: FFP, TC, fresh WB

Management of Poisonous
Snakebites

Severe Snake Envenomation


Snake identified is a very venomous one
Rapid early extension of local swelling from the
site of the bite
Early tender enlargement of local lymph nodes,
indicating spread of venom in the lymphatic
system
Early systemic symptoms
Early spontaneous systemic bleeding (especially
bleeding from the gums)
Passage of dark brown urine
Warrell DA. WHO/SEARO Guidelines for the clinical management of
snakebite in the Southeast Asian Region. SE Asian J Trop Med Pub

SABU (serum anti bisa ular)


Polivalen, plasma kuda yang dikebalkan terhadap bisa ular:
neurotoksik (Naja sputatrix & Bungarus fasciatus) &
hemotoksik (Ankystrodon rhodostoma)
Komposisi: tiap ml menetralisasi10 - 15 LD50 bisa ular
tanah (Ankystrodon rhodostoma), 25 - 50 LD50 bisa ular
belang (Bungarus fasciatus), 25 - 50 LD50 bisa ular kobra
(Naja sputatrix), & fenol 0,25% v/v
Dosis yang tepat sulit jumlah bisa yang masuk sistemik,
keadaan korban saat menerima anti serum.
Loading dose 2 vial @ 5 ml larutan 2% dalam garam faali,
infus 40-80 tpm, diulang setelah 6 jam.
Apabila diperlukan: terusdiberikan tiap 24 jam maksimum
80-100 ml.
Dosis untuk anak-anak sama atau lebih besar daripada dosis
dewasa.

Indications for anti-snake venom


System

Clinical features
Spontaneous systemic bleeding
Whole blood clotting time >20 min
Thrombocytopenia (platelets
<100,000/mm3)
Shock
Arrhythmia
Abnormal electrocardiogram

Neurological

Ptosis and paralysis

Renal

Acute renal failure


Generalized rhabdomyolysis and
muscular pains
Hyperkalemia
Local swelling involving more than half
of the bitten limb
Rapid extension of swelling

Pressure immobilization
Ideally: elasticated bandage, approximately 10 15
cm wide and at least 4.5 metres long (Canale et
al., 2009)
Prevent lymphatic drainage
Prevent the pumping action of theskeletal
muscles.

www.health.qld.go
v.au. 2015

Prevention (GENERAL)
Avoid snakes as far as possible, including those displayed
by snake charmers who are frequently bitten.
Never handle, threaten or attack a snake and never
intentionally trap or corner a snake in an enclosed space.
Keep young children away from areas known to be snakeinfested.
In occupations that carry a risk of snake-bite, such as rice
farming and fish farming, employers might be held
responsible for providing protective clothing (boots).
Snakes search of food (rats) pest control
In Myanmar, farmers can take out special low-cost
insurance to cover them specifically against snake-bite.
(Chappuis et al., 2007)

Prevention (FARM YARD,


COMPOUND, GARDEN)
Try not to provide hiding places for snakes. Clear
termite mounds, heaps of rubbish, building
materials etc. from near the house.
Keep grass short or clear the ground around
your house and clear low bushes in the vicinity
so that snakes cannot hide close to the house.
Keep your granary away from the house, it may
attract rodents that snakes will hunt.
Water sources, reservoirs and ponds may also
attract prey animals such as frogs and toads.
Use a light when you walk outside the house or
visit the latrine at night.
(Chappuis et al., 2007)

Calloselasma rhodostoma
(bandotan berdekik, Bandotan bedor,oray
lemah,oray gibug,ular edor,Malayan pit viper)

REFERENSI
Daley.B.J., 2006. Snakebite. Department of Surgery, Division of Trauma
and Critical Care, University of Tennessee School of Medicine.
ww.eMedicine.com.
De Jong W., 1998. Buku Ajar Ilmu Bedah. EGC: Jakarta
Depkes. 2001. Penatalaksanaan gigitan ular berbisa. Dalam SIKer,
Dirjen
POM Depkes RI. Pedoman pelaksanaan keracunan untuk rumah sakit.
Sudoyo, A.W., 2006. Buku Ajar Ilmu Penyakit Dalam. Pusat Penerbitan
Departemen Ilmu Penyakit Dalam. Fakultas Kedokteran Universitas
Indonesia.
Warrell, D.A., 1999. Guidelines for the Clinical Management of Snake
Bite in the South-East Asia Region. World Health Organization. Regional
Centre for Tropical Medicine, Faculty of Tropical Medicine, Mahidol
University, Thailand.
Warrell,D.A., 2005. Treatment of bites by adders and exotic venomous
snakes. BMJ 2005; 331:1244-1247