SINDROMA KOMPARTEMEN PADA GIGITAN ULAR

RSUD Kabupaten Landak

dr. Albertus Geovani
Sandi

PENDAHULUAN
Gigitan ular keadaan darurat medis di Asia Tenggara

Komplikasi hingga kematian atau cacat kronis

Orang muda yang aktifpekerja di sektor pertanian dan

perkebunan.
Gejala lokal dan gejala sistemik dapat muncul setelah
gigitan ular
Sindrom kompartemen dapat berkembang pada anggota
badan yang terkena karena edema dan nekrosis jaringan

WHO Regional office for South East Asia. Guidelines for the Management of Snake Bites. India: WHO Publisher; 2010.

Identitas Pasien
Nama

Ny. Suntin

Jenis Kelamin

Wanita

Umur

46 tahun

Pekerjaan

Petani, Ibu Rumah Tangga

Pendidikan

Tidak Diketahui

Status Pernikahan

Menikah

Agama

Katolik

Alamat

Dusun Pawis Hilir

Tanggal Masuk RS

24 Mei 2016 jam 00.56

Tanggal Masuk Bangsal

24 Mei 2016 jam 03.20

No. CM

00.15.17

Anamnesa
Autoanamnesa, Alloanamnesa (suami)

Keluhan Utama
Nyeri pada lengan dan tangan kanan

Riwayat Sakit Sekarang

Nyeri pada lengan dan tangan kanan setelah digigit ular

14 jam SMRS . Nyeri dirasakan seperti terbakar, terus

menerus. Nyeri semakin berat saat digerakkan. Nyeri
tidak berkurang dengan obat antinyeri. Bengkak (+) pada
lengan dan tangan. Kesemutan (+) pada ujung jari tangan
kanan.
Nyeri kepala (+), sesak (+), badan terasa lemah,

keringat dingin (+). Keluhan muntah, demam, pingsan

ataupun kejang disangkal oleh pasien. BAK (+) 1x
warna kuning pucat.

Riwayat Sakit Sekarang

Pasien digigit ular di lengan kanan atas 1x, bekas gigitan

terdapat 2 bekas gigi ular, perdarahan aktif (-). Di sekitar luka

bekas gigitan, terdapat bekas melepuh. Jenis ular tidak
diketahui, berwarna hitam. Ular tidak dibunuh/dibawa.
Setelah kejadian, keluarga langsung membawa pasien ke
perawat, kemudian diberikan infus, injeksi ketorolac, injeksi
Cefotaxime, injeksi dexamethasone dan asam mefenamat tab.
Tidak dilakukan penghisapan.
Karena semakin nyeri dan bengkak pasien selanjutnya dibawa
ke Rumah Sakit.

Riw. Penyakit Dahulu

Riwayat tergigit ular

sebelumnya disangkal

Riw. Penyakit Keluarga

Keluarga tidak ada yang

mengalami keluhan yang

sama

Riwayat HT, DM, asma,

alergi disangkal oleh

pasien

Riwayat HT, DM, Alergi,

Asma disangkal

Pemeriksaan Fisik
STATUS PRESENT

Keadaan Umum
: Tampak sakit sedang
Kesadaran
: Compos mentis
Tanda Vital
:
Tensi
: 90/70 mmHg (lengan kanan, terlentang)
Nadi
: 100x/menit (lemah)
RR
: 20x/menit
Suhu
: 36,3 o C

Status Generalis
Kulit: Turgor cepat.
Kepala: Normocephali.

Rambut hitam, lurus, tidak

mudah dicabut.
Mata: CA (-)/(-), SI(-)/(-),

Pupil isokor /3 mm, reflek

cahaya (+)N/(+)N, perdarahan
konjungtiva (-/-), ptosis (-/-),
oftalmoplegi (-/-),

Hidung: Nafas cuping (-),

discharge (-), deviasi septum

(-), nafas cuping hidung (-).
Telinga: Discharge (-)/(-)
Mulut: Bibir pucat (-), bibir

sianosis(-).
Leher: Simetris, pembesaran

kel. Limfe (-), trakea di tengah

Status Generalis
Paru - Paru
Inspeksi : Simetris, statis,

dinamis
Palpasi: Fremitus taktil

simetris kanan dan kiri.

Perkusi: Sonor di seluruh

lapangan paru
Auskultasi

: Suara dasar
vesikuler, Suara tambahan (-)

Jantung
Inspeksi: Ictus cordis tak

tampak
Palpasi: ICS V, linea

midklavikularis sinistra
Perkusi: Batas jantung kanan

ICS IV LSD, batas jantung kiri ICS

V linea midklavikularis sinistra.
Auskultasi: Suara jantung

murni, Bising (-), Gallop (-)

Status Generalis
Abdomen
Inspeksi: Datar, supel, ruam

Ekstremitas
Akral dingin

kulit (-), benjolan (-), Venektasi (-)

Edema
Auskultasi: Bising usus (+)

normal

Reflek fisiologis :

Perkusi: Timpani seluruh lapang

abdomen, nyeri ketok (-)

Reflek patologis :

Palpasi: Nyeri tekan (-), Lien tak

teraba, hepar tak teraba.

Kekuatan otot :

(general weakness)

Status Lokalis
Ekstremitas Superior Dextra
Look:
Regio Brachii: Tampak jejas (+), bekas gigitan ular
berbentuk dua buah titik, warna kehitaman, edema (+),
perdarahan aktif (-). Pada Sekitar bekas gigitan tampak
bekas melepuh.
R. Cubiti anterior: hematom + uk 0,5 x 2,5 cm
R. Antebrachii: edema (+)
R.dorsum manus: tampak mengkilap warna pucat
kebiruan , edema (+)

Feel:

R. Brachii , antebrachii, dorsum manus: Nyeri tekan (+),

edema (+) >25cm, teraba keras (+) dan dingin. Pulsasi
arteri radialis sulit dilakukan.

Move:

Nyeri gerak pasif/peregangan (+), gerak aktif (+), nyeri

gerak aktif (+). ROM terbatas

PEMERIKSAAN PENUNJANG

Hematology

Value

Unit

Normal Value

Hemoglobin

17.9

g/dL

11.0 17.0

Hematocrit

42.7

35.0 55.0

MCV

72.7

fl

80.0 100.0

MCH

30.4

pg

31.0 35.5

MCHC

41.9

g/dL

31.0 35.5

21.700

/ L

4,000 12,000

Thrombocyte

222.000

/ L

150,000 400,000

Bleeding Time

min

13

Clotting Time

730

min

3 15

Leukocyte

(Hb)
(MCV)

(Leukositosis)

PEMERIKSAAN PENUNJANG

Clinical Chemistry

Value

Unit

Normal Value

Random Glucose

213

g/dL

75 140

SGOT/AST

78

U/L

M:0-37, F:0-31

SGPT/ALT

15

U/L

M:0-42, F:0-32

Ureum

29

mg/dL

10 50

Creatinine

1.3

mg/dL

0.5 1.5

(SGOT)

RINGKASAN

Wanita + 55 tahun. Nyeri lengan dan tangan kanan setelah

digigit ular di regio brachii dextra disertai bengkak dan
kesemutan. Pemeriksaan fisik hemodinamik: tanda-tanda syok,
edema pada lengan dan tangan.

DAFTAR MASALAH
1. Vulnus Morsum Serpentis Derajat III pada regio

Brachii Dextra
2. Sindroma Kompartemen pada regio brachii,
antebrachii dan dorsum manus ec vulnus morsum
serpentis

1. GIGITAN ULAR
BERDASARKAN

Anamnesis: Pasien digigit ular di lengan kanan atas, terdapat

bekas gigitan ular. Nyeri (+), edema dan terdapat bekas

melepuh. Nyeri kepala (+), sesak (+), badan terasa lemah,
keringat dingin (+).

PF: TD: 90/70 mmHg; Nadi 100x/menit lemah, akral dingin.

Vulnus morsum regio brachii dekstra, edema luas, hematom.
PP: -leukositosis, Hb, MCV, SGOT

DIPIKIRKAN
Vulnus Morsum Serpentis Derajat III pada regio Brachii Dextra

1. GIGITAN ULAR
RENCANA DIAGNOSIS
Darah Lengkap, Bleeding Time, Clotting Time
GDS, Ur/Cr, SGOT/SGPT, Urinalisis, EKG
RENCANA TATALAKSANA
Diet TKTP
O2 Nasal Kanul
2-4 L/min
IVFD Ringer Laktat
Guyur 500 mL, kemudian 500 mL per 8
jam
Ketorolac Inj. IV 30 mg
Metilprednisolon Inj. IV 125 mg
Serum Anti Bisa Ular (SABU)
2 vial iv perlahan
Skin test

2. SINDROMA KOMPARTEMEN
BERDASARKAN
Anamnesis: Nyeri pada lengan dan tangan kanan setelah digigit
ular, semakin berat. Bengkak (+) pada lengan dan tangan. Kesemutan
(+) pada ujung jari tangan kanan.
PF: R. Brachii , antebrachii, dorsum manus: nyeri tekan (+), edema
dingin, teraba keras (+), nyeri gerak pasif/peregangan (+). Dorsum
manus tampak pucat kebiruan.
PP: (-)
DIPIKIRKAN
Sindroma Kompartemen Et Causa Vulnus Morsum Serpentis

2. SINDROMA KOMPARTEMEN
RENCANA DIAGNOSIS
Pengukuran tekanan intrakompartemen
Darah Lengkap, Bleeding Time, Clotting Time
GDS, Ur/Cr, SGOT/SGPT, Urinalisis, EKG

RENCANA TATALAKSANA
Fasiotomi

PROGNOSIS

Ad

Subjektif

Assesment

Program

Penurunan kesadaran (+)

Sesak napas (+)

Syok anafilaktik ec

Diet TKTP

snake bite

O2 3 Lpm nasal kanul

Epinefrin 0,1 mcg/kgBB/menit via

syringe pump
Informed consent keluarga risiko tinggi
operasi

Objektif
GCS: E3M5V4
TD: Tidak terukur
HR: 130x/menit, lemah (carotis)
RR: 28x

Pembuluh darah pecah pada pemasangan infus

Akral dingin

24 MEI 2016 jam 9.00

Visite dr. Anthony Sp.An

Subjektif

Assesment

Program

Pasien post op cito

fasiotomi 1,5 jam lalu.
Nyeri luka post op (+)
Ujung jari tangan kanan
sulit digerakkan (+),
terasa sebal (+)
Pusing (+) seperti
mengambang
Nyeri ulu hati (+)

Post op fasiotomi

Diet TKTP

regio brachii,
antebrachii & dorsum
manus dextra pada
sindroma
kompartemen ec
vulnus morsum
serpentis
Vulnus Morsum
Serpentis Derajat III
pada regio Brachii
Dextra

O2 3-4 Lpm nasal kanul

Objektif
KU: tampak lemah, Kes: CM,
TD: 100/70 mmHg, HR: 117 x/mnt, RR: 31 x/m

SpO2: 100%
Mata: CA (+/+)
Cor: BJ 1 dan 2 tunggal, reguler,
Pulmo: SND vesikuler, Rh (-/-), Wh (-/-)
Abd: datar, BU (+), timpani (+), Nyeri tekan (+)
epigastrium
Eks: akral dingin, CRT > 2 dtk, nadi arteri radialis
sulit teraba
Status lokalis: Ekstremitas superior dextra
L: luka post op tertutup verban, rembesan darah
(+), distal jari kebiruan, edema (+), eritema (-)
F: Nyeri tekan luka post op (+), sensorik pada

IVFD Jalur IRL III: D 5% I /24 jam

IVFD Jalur II NaCl 0,9% (drip ABU 2

vial) 40 tpm
Inj. Dexketoprofen 50mg/ 8 jam drip
dalam infus
Pethidin 100mg/8 jam drip (2x
pemberian)
Cefoperazone 1 gr/ 12 jam
Cefobactam 1 gr/24 jam
Ceftazidime 1 gr/12 jam
Asam tranexamat 1 gr/8 jam, Vit K 1
amp/12 jam
Norepinefrin 0,05 mcg/kgBB/menit
Inj. Ranitidine 50 mg/ 12 jam
Metilprednisolon 125 mg/12 jam
Cek Hb post op

PEMERIKSAAN PENUNJANG

Hematology

24 5 - 2016

Pre op
Jam 7.23

Post op
jam 21:20

Unit

Normal Value

Hemoglobin

17.9

12.8

g/dL

11.0 17.0

Hematocrit

42.7

30.7

35.0 55.0

MCV

72.7

70

fl

80.0 100.0

MCH

30.4

29.2

pg

31.0 35.5

MCHC

41.9

41.7

g/dL

31.0 35.5

21.700

26.000

/ L

4,000 12,000

Thrombocyte

222.000

190.000

/ L

150,000 400,000

Bleeding Time

min

13

Clotting Time

730

min

3 15

Leukocyte

Jam 5.20

Jam 5.26

Jam 5.35

TD tiba-tiba turun
60/palpasi
O2 facemask
5L/menit
Norepinefrin 2
cc/jam

HR asytole

Epinefrin 1 ampul

Jam 5.25

Jam 5.30

Jam 5.45

Tiba-tiba HR turun

Lapor dokter

Pasien dinyatakan
meninggal dihadapan
keluarga dan perawat

48x/menit
SA 1 ampul bolus,
RL guyur

25 MEI 2016

RJP 30:2
Epinefrin 1 ampul

bedah dan dokter

anestesi

Pembahasan

Sindroma Kompartemen
pada Gigitan Ular

Anatomi

a
dari

Anatomi

Kompartemen:
daerah tertutup yang
dibatasi oleh tulang,
membran intraosseus dan
fascia, yang melibatkan
jaringan otot, saraf dan
pembuluh darah

Me
Me
Lon

Definisi
Sindrom kompartemen merupakan suatu
kondisi dimana terjadi peningkatan
tekanan dalam suatu kompartemen
sehingga mengakibatkan penekanan
terhadap:
saraf
pembuluh darah
otot

di dalam kompartemen
osteofasial yang tertutup

Klasifikasi
1. Sindroma kompartemen akut
Sindroma kompartemen akut merupakan
suatu tanda kegawatan medis. Ditandai
dengan pembengkakan dan nyeri yang
terjadi dengan cepat

2. Sindroma kompartemen kronik

Sindroma kompartemen kronik bukan
merupakan suatu kegawatan medis dan
seringkali dikaitkan dengan nyeri ketika
aktivitas olahraga

Sin
M
S

Etiologi
Sindroma kompartemen

Volume
kompartemen:
penutupan defek
fasia
traksi internal
yang berlebihan
pada fraktur
ekstremitas

Tekanan eksternal:
Balutan yang
terlalu ketat
Berbaring diatas
lengan
Gips

Tekanan internal
pada struktur
kompartemen:
Perdarahan atau
trauma vaskuler
Peningkatan
permeabilitas
kapiler
Penggunaan otot
yang berlebihan
Luka bakar
Operasi
Gigitan ular
Obstruksi vena

EPIDEMIOLOGY
Usia

Sumber:
1. Alirol E, Sharma SK, Bawaskar HS, Kuch U, Chappuis F. Snake bite in south asia: a review. PloS Negl Trop Dis. 2010, 4(1):603e
2. Evers L, Bartscer T, Lange T, Mailander P. 2010. Adder Bite: An Uncommon Cause of Compartment Syndrome in Northern
Hemisphere. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine. 18: 50

Kasturiratne A, Wickremasinghe AR, Silva N, Gunawardena NK, et al. The Global Burden of Snakebite: A Literature Analysis and
Modelling Based on Regional Estimates of Envenoming and Deaths. PLoS Medicine. 2008; 5(11): e218.

Kasturiratne A, Wickremasinghe AR, Silva N, Gunawardena NK, et al. The Global Burden of Snakebite: A Literature Analysis and
Modelling Based on Regional Estimates of Envenoming and Deaths. PLoS Medicine. 2008; 5(11): e218.

Species Identification
(West Indonesia)
Famili

Contoh

Spesies di Indonesia

Keterangan

Elapidae

Cobra, King Cobra,

Kraits, Ular batu
karang, ular australia,
serta ular laut

Bungarus candidus

Kepala kecil dan bulat,

pupil bulat dan taring lebih
kecil (1-3 mm). Kobra
dapat menyemburkan bisa
dari 1 meter.

(Jawa & Sumatera)

Naja sputarix
(Jawa)

Naja sumatrana
(Sumatera & Kalimantan)

Acanthrophis laevis
(Papua & Maluku)

Viperidae

2 sub famili:
1. Viperinae
2. Pit Vipers
(crotalinae)

Calloseleasma rhodostoma
(Jawa)
Cryptelytrops albolabis
Daboia siamensis

Kepala berbentuk
triangular, pupil mata
elips, terdapat lubang
antara hidung dan mata.
Pit Viper memiliki taring
panjang (3-4 cm)

Species Identification
(West Indonesia & Available Anti-Venom)

Bungarus fasciatus
(ular belang)
Agkistrodon rhodostoma (ular tanah)
Naja sputatrix
(ular kobra)

Species Identification

Venomous or harmless snake?

Most venomous snakes
Size, shape, color, pattern of markings
Behavior and sound when they are threatened

WHO Regional office for South East Asia. Guidelines for the Management of Snake-Bites. India: WHO Publisher; 2010.

PATHOPHYSIOLOGY
VENOM

90% Protein & Enzyme. Injected SC or IM, rarely IV.

Activated by body temperature & tissue pH

Phospholipase A22

Hyaluronidase
Enzyme

Tissue hydrolysis
Tissue permeability
Venom spread

Myotoxin

Zinc
metalloproteinase
haemorrhagins

Damage vascular
endothelium &
basal membrane
Venom spread

Necrotoxin

L-arginine
Esterase

Presypnatic &
Postsypnatic
Neurotoxins

Bradykinin release
Pain, hypotension,
nausea, vomiting

Neuromuscular
junction. Paralysis,
Paresthesia, spasm,
diplopia, trismus,
etc.

CV-toxin

Neurotoxin

Procoagulant
Enzymes
Consumptive
coagulopathy
Anti-hemostatic
factors

Hematotoxin

Patofisiologi

Manifestasi Klinis
Meningkatnya rasa nyeri lebih besar
dari yang diperkirakan
Teraba ketegangan pada
kompartemen
Kompartemen otot tidak simetris
Nyeri pada peregangan otot yang
terkena
Penurunan sensasi
ATLS

Manifestasi Klinis
PAIN
PARESTESI
A

PARALISIS

5P

PULSENES
S

PALLOR

depends on: Species & amount of injected venom

LOCAL
MANIFESTATION

Fang marks
Local pain
Local bleeding
Bruising
Lymphangitis (raised red lines
tracking up the bitten limb)
Lymph node enlargement
Inflammation (swelling, redness,
heat)
Blistering
Local infection, abscess formation
Necrosis

SYSTEMIC
MANIFESTATION

depends on: Species & amount of injected venom

LOCAL
MANIFESTATION

SYSTEMIC
MANIFESTATION
General - Malaise, nausea/vomiting,
drowsiness
Cardiovascular - Shock, hypotension,
arrhythmias, pulmonary edema
Bleeding & Clotting Disorders Spontaneous bleeding: Gum, epistaxis, ear
bleeding, hemoptysis, intracranial
hemorrhage, hematuria, skin (petechiae,
purpura, discoid hemorrhage)

Common Krait

Malayan pit viper

Neuro-musculoskeletal Myalgia,
drowsiness, ptosis, cranial nerves paralysis,
respiratory & general flaccid paralysis.
Renal/AKI hematuria, myglobinuria,
hemoglobinuria (dark brown urine), anuria
Other Hypoglycemia, rhabdomyolysis, etc.

Malayan pit viper

Diagnosis Banding
Diagnosis banding dari sindroma
kompartemen antara lain:
Selulitis
Deep vein trombosis dan
tromboflebitis
Gangrene
Necrotizing fasciitis
Peripheral vascular injuries

Supporting Examination
20-minute whole blood clotting (20WBCT)
Laboratory examination

Hb/Ht heamoconcentration, intravascular hemolysis

WBC neutrophil leukocytosis
Platelet decrease
PT/aPTT
SGOT/PT local muscle damage, mild hepatic dysfunction
Ur/Cr renal failure
Electrolyt
K rhabdomyolysis
Urinalysis color, RBC cast, blood/Hb/myoglobin
ABG (?) respiratory failure & acidemia, O2 saturation

ECG - arrhythmia

Pemeriksaan penunjang
Radiologi:
Rontgen: pada ekstremitas yang terkena
USG: membantu untuk mengevaluasi
aliran arteri dalam memvisualisasi Deep
Vein Thrombosis (DVT)

Pemeriksaan penunjang
Pemeriksaan lainnya
Pengukuran tekanan intrakompartemen
>30 mm Hg as absolute number
(Roraback)

Whiteside infusion
Stic technique: side port needle
Wick catheter
Slit catheter

Pulse oxymetry

Whiteside infusion

Stic Technique

Diagnosis
Anamnesis
Tergigit ular

Pemeriksaan fisik
Tampak2 bekas gigitan
ular
Pucat
Perubahanwarna kulit
Nadi hilang
Nyeri
Parestesi
paralisis
teraba dingin
edema

Pemeriksaan
penunjang
Pemeriksaan
laboratorium darah
Pemeriksaan urin
Pemeriksaan
pengukuran
kompartemen
Pulse oxymetri

EKG

Terapi Non Medikamentosa

Menempatkan kaki
setinggi jantung

Pada kasus penurunan

ukuran kompartemen,
gips harus dibuka dan
pembalut kontriksi
dilepas

Lakukan imobilisasi
pada organ yang
terkena

HBO
(Hyperbaric Oxygen
therapy)

Terapi Medikamentosa
Pada
kasus
gigitan
ular
berbisa
dapat
diberikan
anti bisa
ular

Mengore
ksi
hipoperf
usi
dengan
cairan
kristaloid
dan
produk
darah

Diuretik
dan
pemakai
an
manitol

Obatobatan
opioid
Nonopioi
d
NSAID

Antivenom Treatment
Indications

Systemic
Benefit
vs Risk (incl. supply & cost)

* WHO Regional office for South East Asia. Guidelines for the Management of Snake-Bites. India: WHO
Publisher; 2010.

Antivenom Treatment

Serum Anti Bisa Ular (SABU)

Biofarma
Trisera murni plasma kuda
Tidak berkhasiat terhadap gigitan ular di
Indonesia Timur (e.g. Acanthopis antarticus,
Xyuranus scuttelatus, Pseudechis papuanus,
dll) serta ular laut (Enhydrina cystsa)

Serum Anti Bisa Ular Polivalen yang

tidak diencerkan dapat diberikan
langsung sebagai suntikan intravena
dengan sangat perlahan-lahan.
Maksimal 80-100mL
Dosis Serum Anti Bisa Ular Polivalen
untuk anak-anak sama dengan dosis
untuk orang dewasa

LD50 = Lethal Dosage 50 (mg/kgBW)

Setiap mL mengandung anti bisa ular :

Agkistrodon rhodostoma (ular tanah) 10 LD50

Bungarus fasciatus (ular belang) 25 LD50
Naja sputatrix (ular kobra) 25 LD50
Fenol 2,5 mg (Pengawet)

Dosis: Dosis pertama SABU 10 mL intravena dalam 500 mL

NaCl 0.9% atau D5% 40-80 tpm, dapat diulang 6 jam
kemudian. Maksimal: 100 mL (20 vial).
Infiltrasi lokal SABU tidak dianjurkan

Sumber: PT. Biofarma (Persero)

Klasifikasi Gigitan Ular

Schwartz (Depkes, 2001)
Derajat

Venerasi

Luka

Nyeri

Edema/Er
itema

Sistemik

SABU

0
I

+/-

< 3 cm

+/-

3-12 cm

II

+++

12-25 cm

Neurotoksik,
mual, pusing,
syok

III

+++

> 25 cm

IV

+++

+++

> ekstremitas

++
Petekhiae, syok,
ekimosis

+++
AKI, koma,
perdarahan

3-4 vial
5-15 vial
6-8 vial

Djunaedi D. Penatalaksanaan Gigitan Ular Berbisa. In: Sudoyo AW, Setiyohadi B, Alwi I, Simadibrata M, Setiati S. Buku
Ajar Ilmu Penyakit Dalam. 5th ed. Jakarta: Interna Publishing; 2009.

Dosis: SABU 10 mL intravena dalam 500 mL NaCl 0.9% atau D5% 40-80 tpm, dapat

diulang 6 jam kemudian. Maksimal: 100 mL (20 vial). Infiltrasi lokal SABU tidak
dianjurkan

PEDOMAN TERAPI SABU

Menurut Luck
Derajat

Beratnya
Evenomasi

Taring atau
Gigi

Zona
edema/eritem
ato kulit (cm)

Gejala
Sistemik

Jumlah Vial
Anti-venom

Tidak ada

<2

Minimal

2-15

II

Sedang

15-30

10

III

Berat

>30

++

15

IV

Berat

>30

+++

15

Menurut Schwart & Way (Depkes, 2001)

Derajat 0 & I tidak diperlukan SABU, II (3-4 vial), III (5-15 vial), IV (6-8 vial)
Djunaedi D. Penatalaksanaan Gigitan Ular Berbisa. In: Sudoyo AW, Setiyohadi B, Alwi I, Simadibrata M, Setiati S. Buku Ajar Ilmu
Penyakit Dalam. 5th ed. Jakarta: Interna Publishing; 2009.
Depkes, 2001. Penatalaksanaan Gigitan Ular Berbisa. In: Pedoman Penatalaksanaan Keracunan untuk Rumah Sakit: 253-259.

* WHO Regional office for South East Asia.

Guidelines for the Management of Snake-Bites. India:
WHO Publisher; 2010.

Supportive Therapy
Manifestation

Supportive Therapy

Severe coagulopathy

FFP

Bleeding

Blood/component transfusion

Shock/Hypotension

Fluid resuscitation, vasopressor

Compartment Syndrome

Fasciotomy

Neurotoxic

Neostigmin (Acetylcholinesterase) with

Sulfas Atropin
Tetanus Prophylaxis (if needed)

Pain-killer

Paracetamol, Codein, avoid Aspirin,

NSAID

Prophylaxis

Broad-spectrum Antibiotics

Nephrotoxic/AKI

Rehydration, diuretics, strict fluid

balance

* WHO Regional office for South East Asia. Guidelines for the Management of Snake-Bites.
India: WHO Publisher; 2010.

Penatalaksanaan
Operatif
Fasciotomy

Apabila pasien didiagnosis dengan

sindrom kompartmen maka harus
segera dilakukan fasiotomi secepatnya
untuk mencegah kerusakan otot dan
saraf pada ekstremitas yang sakit (Hsu
CP, Chuang JF, et al, 2015).
Fasiotomi dapat dipertimbangkan
apabila tekanan kompartement > 30
mmHg sehingga dapat mencegah
morbiditas jangka panjang dan
amputasi (Dhar D, 2015).

Hsu CP, Chuang JF, Hsu YP, Wang SY, Fu CY, Yuan KC, Chen CH, et al. 2015.Predictors of the development of post-snakebite compartment
syndrome.Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, 23:97
Dhar D. 2015.Compartment syndrome following snake bite.Oman Med J, 30 (2): 1-3

Fasciotomy
post snake bite compartment syndrome
The diagnosis of compartment syndrome begins with physical

examination. Pressures within 30 mm Hg of diastolic blood pressure

are suggestive of compartment syndrome.
The local symptoms of envenomation and compartment syndrome
often have similar presentations, which may make it difficult to
determine a definitive diagnosis.
As a result, compartment pressure measurement is used more
frequently in the incidence of snakebite than in the trauma setting.

Anz, AW, Schweppe M, Halvorson J, Bushnell B, Sternbeg M, Koman LA. Journal American Academy of
Orthopaedic Surgeons 2010. Vol 18; No 12

Fasciotomy post snake bite compartment

syndrome
Administration of antivenin has been shown to decrease compartment

pressures in animal models; thus, monitoring pressures while

administering antivenin in the early stages of compartment syndrome
is a viable treatment option.
However, some authors advocate early fasciotomy when compartment
syndrome is confirmed or suggested on physical examination.13,38
Early diagnosis is the key to successful management. Delay can be
devastating for the patient.

Anz, AW, Schweppe M, Halvorson J, Bushnell B, Sternbeg M, Koman LA. Journal American Academy of
Orthopaedic Surgeons 2010. Vol 18; No 12

Komplikasi
Nekrosis pada saraf dan otot dalam
kompartemen
Kontraktur volkman
Trauma vaskular
Gagal ginjal akut
Sepsis
Acute Respiratory Distress Syndrome
(ARDS)

Kon
pad
Kel
Aku
Leb

DEATH FROM SNAKE BITE

Antivenom
Use

inadequate dose
use of a monospecific antivenom of inappropriate specificity

Delayed
Hospital
Treatment

from prolonged visits to traditional healers

problems with transportation
death on the way to hospital
inadequate artificial ventilation or failure to attempt such
treatment
failure to treat hypovolaemia in shocked patients
airway obstruction
complicating infections
failure to observe patients closely after they
were admitted to hospital
very rapid death a few minutes by the king cobra
Ophiophagus hannah)
many hours elapid envenoming

Time Between
Snake-bite And
Death

several days of viper envenoming

* WHO Regional office for South East Asia. Guidelines for the Management of Snake-Bites. India: WHO
Publisher; 2010.

Terima
Kasih

References &

RECOMMENDED READINGS
TEXTBOOK
1.

Djunaedi D. Penatalaksanaan Gigitan Ular Berbisa. In: Sudoyo AW, Setiyohadi B, Alwi I, Simadibrata M, Setiati S.
Buku Ajar Ilmu Penyakit Dalam. 5th ed. Jakarta: Interna Publishing; 2009.

2.

Warell, DA. Animal Hazardous to Humans: Snake. In: Strickland GT (Ed). Hunters Tropical Medicine and Emerging
Infectious Disease. 9th Ed. Philadelphia: WB Saunders Company: 949-958

GUIDELINE & REVIEW ARTICLE

3.

WHO Regional office for South East Asia. Guidelines for the Management of Snake-Bites. India: WHO Publisher;
2010.

4.

Alirol E, Sharma SK, Bawaskar HS, Kuch U, Chappuis F. Snake bite in south asia: a review. PloS Negl Trop Dis. 2010,
4(1):603e.

5.

Ibister GK, Brown SGA, Page CB, McCoubrie DL, Greene SL, Buckley NA. Snakebite in Australia: a Practical
Approach to Diagnosis and Treatment. Med J Aust. 2013; 199(11): 763-768.

6.

Juckett G, Hancox JG. Venomous Snakebites in the United States: Management Review and Update. American
Family Physician. 2002; 65(7): 1367-1374.

References &

RECOMMENDED READINGS
GUIDELINE & REVIEW ARTICLE
5.
Evers L, Bartscer T, Lange T, Mailander P. 2010. Adder Bite: An Uncommon Cause of Compartment Syndrome in
Northern Hemisphere. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine. 18: 50
6.

Dhar D. 2015.Compartment syndrome following snake bite.Oman Med J, 30 (2): 1-3

7.

Anz A, Halvorson J, Bushnell B, Stenberg M, Koman A. 2010. Management of Venomous Snakebite Injury in the
Extremity. J Am Acad Orthop Surg. 18:749-759

Figure 1. Sites of action of snake neurotoxins and other substances on the

neuromuscular junction.
1. Synaptic vesicular proteins: Snake toxins: betabungarotoxin (Bungarus spp.), taipoxin (O. scutellatus); Other
toxins: botulinum toxin, tetanus neurotoxin. 2. Voltage-gated
calcium channel: Snake toxins: calciseptine (Dendroaspis
spp.), beta- bungaratoxin (Bungarus spp.); Other toxins:
omega-conotoxin (marine snail, Conus spp.); Disease states:
Lambert-Eaton myaesthenic syndrome. 3. Pre-synaptic
membrane: Snake toxins: phospholipase A2 toxins. 4. Presynaptic ACh receptor: Snake toxins: candoxin (Bungarus
candidus); Other toxins: curare; Pharmacological substances:
non-depolarising blocking drugs (atracurium). 5. Voltagegated potassium channels: Snake toxins: dendrotoxins
(Dendroaspis spp.); Disease states: neuromyotonia, Isaacs'
syndrome; Pharmacological substances: magnesium sulphate,
aminoglycosides. 6. Acetylcholine: Lysis by exogenous
acetylcholinesterase in snake venom: cobra venom (Naja
spp.). 7. Acetylcholinesterase: Inhibitors of endogenous AChE
in snake venom: fasiculins (Dendroaspis spp.). 8. Postsynaptic ACh receptors: Snake toxins: alpha-bungaratoxin
(Bungarus spp.), candoxin (B. candidus), azemiopsin (A. feae),
waglerin (T. wagleri ); Other toxins: alpha-conotoxin (marine
snail, Conus spp.); Disease states: myasthenia gravis;
Pharmacological substances: depolarising blocking agents
(e.g., succinylcholine), non-depolarising blocking drugs (e.g.,
atracurium). 9. Voltage-gated sodium channels: Snake toxins:
crotamine (Crotalus spp.); Other toxins: pompilidotoxin
(wasps), delta-conotoxin (Conus spp.), tetradotoxin
(pufferfish).

Ranawaka UK, Lalloo DG, de Silva HJ (2013) Neurotoxicity in SnakebiteThe Limits of Our Knowledge. PLoS Negl Trop Dis 7(10):
e2302. doi:10.1371/journal.pntd.0002302
http://127.0.0.1:8081/plosntds/article?id=info:doi/10.1371/journal.pntd.0002302

COMPREHENSIVE MANAGEMENT

Preventive Measures
House: do not keep livestock (esp. chicken), house design, no

tree branch touching house

Outside/countryside

Proper shoes or booths, long trousers, torch lights (night)

Do not put hands into holes/nest/hidden places

Never handle/threaten/attack/intentionally trap snake,

including dead snake. Should not be kept as pet/performing

animals
Rainy seasons: Water stream & flood; be cautious in
planting, ploughing, and harvesting
High risk occupation: Farmers, plantation workers,
fishermen, snake hunter, snake restaurant workers, etc.
* WHO Regional office for South East Asia. Guidelines for the Management of Snake-Bites. India: WHO
Publisher; 2010.

World Health Organization (WHO)

Stages of Treatment
First Aid Treatment & Transport to Hospital

* WHO Regional office for South East Asia. Guidelines for the Management of Snake-Bites. India: WHO
Publisher; 2010.

First Aid & Transport to Hospital

Aim: Retard systemic venom absorption
Pressure Bandage Immobilization of bitten limb

with elastic bandage/splint/sling

Walking is containdicated. Muscular contraction venom absorption

Avoid any wound interference

Incisions, rubbing, vigorous cleaning, massage, herb/chemicals

May introduce infection, venom absorption, local bleeding

Tight (arterial) tourniquets not recommended

Gangrenous Limb

BLS for shock & respiratory paralysis

Transport to nearest health facility A.S.A.P

Source:
Sentra Informasi Keracunan Badan POM
Alirol E, Sharma SK, Bawaskar HS, Kuch U, Chappuis F. Snake bite in south asia: a review. PloS Negl Trop Dis. 2010, 4(1):603e
Ibister GK, Brown SGA, Page CB, McCoubrie DL, Greene SL, Buckley NA. Snakebite in Australia: a Practical Approach to Diagnosis and
Treatment

Primary Survey & Resuscitation

A B C D E Approach
Respiratory paralysis
Shock

Venom primary anaphylaxis

Venom effect to Cardiovascular (Cardiogenic)
Hemorrhagic shock
Hypovolemia shock
Release of inflammatory vasoactive mediators

GCS should not be used to asses level of consciousness

Bulbar and respiratory paralysis

Antivenom Reactions
Early Anaphylactic

Low incidence of early reaction from horse-derived antivenom.

Skin test is not helpful in predicting adverse reaction.
Thainsookon A, Rojnuckarin P. Low incidence of early reactions to horse-derived F(ab)2 antivenom for snakebites in Thailand. Acta
Tropica. 2008; 105:203-205