Luka Gigitan Binatang

• Krisandi Primadian • Fauzan Akmal

• Synthia Zaesalia Soetanto • Nurul Rizqina
• Ikhbar Falah
• Tri Taufiqurachman
• Selvy Harianti
• Rifqi Yanda Muhammad
• Mitra Riswanda H
 Snake
Rabies
Bite

Scorpion Leech
SNAKE BITE
 EPIDEMIOLOGI
• Angka kejadian tidak dapat dipastikan karena sejumlah besar pasien tergigit ular akan berobat ke
pengobatan tradisional (bukan Rumah Sakit)
• Kejadian tertinggi saat musim panen dan musim hujan
• Gigitan terbanyak ditemukan di kaki dan pergelangan kaki pekerja ladang yang tidak menggunakan
alas kaki
• Total gigitan ular per tahun di dunia > 5 juta, dengan angka mortalitas 125.000

● Di Indonesia :

• Diperkirakan terdapat 135.000 kasus gigitan ular pada tahun 2017 di Indonesia

• Spesies penting antara lain adalah B. candidus, N. sputatrix, N. sumatrana, C. rhodostoma, T.

albolabris, D. siamensis dan di Papua dan Maluku – Acanthophis laevis
Venomous vs Non Venomous
Types of venom
•RBCs or other tissue
Hemotoxic venom •Hemolysis, disrupts blood clotting, etc
•Tissue damage are permanent

•Muscle tissues or kidney

Myotoxic venom •Paralysis, loss muscle contraction
•Benefits for the snakes to eat and leave the prey flaccid

•Nervous system, respiration

Neurotoxic venom •Vomiting, droppy eyelids, etc

•Destroy and attacks the living cells of all sorts

Cytotoxic venom •Bleeding, swelling, etc

WHO. Guidelines for The Management of Snakebites. 2016 .

 Venom composition
Venom enzymes: digestive hydrollases, hyaluronidase, and
activators/inactivators of physiological processes, such as kininogenases.

Zinc metalloproteinases

Procoagulant enzymes

Phospholipases A2 (lecithinase)

Proteolytic enzymes (metalloproteinases, endopeptidases or hydrolases) and

polypeptide cytotoxins

Venom polypeptide toxins (neurotoxin)

WHO. Guidelines for The Management of Snakebites. 2016 .

 Klasifikasi
• Elapidae : bertubuh panjang, tipis, biasanya berwarna seragam dengan pola sisik yang besar, halus dan
simetris di bagian atas kepalanya. Spesies yang memiliki kepentingan di ranah medis yakni kobra
(Naja), krait (Bungarus), death adders, taipan, ular hitam, brown snakes (Acanthopis, oxyuranus,
pseudechis, pseudonaja) dan ular laut.12
• Viperidae : menjadi viperinae (beludak sejati) dan crotalinae (beludak kepala ceruk) atau pit vipers
yang memiliki heat sensitive loreal/pit organ yang terletak di antara lubang hidung dan mata. Vipers
atau beludak relatif bertubuh pendek, berbadan tebal, berekor pendek dengan banyak sisik kecil kasar
di bagian atas kepala serta pola warna khas pada punggungnya
• Colubridae: red necked keelback (Rhabdophis subminiatus) dan Yamakagashi (R. tigrinus) diketahui
paling berbahaya
Pathophysiology of Human Envenoming

Bleeding and
Hypotension and
Local Envenoming Blood Clotting
Shock
Disturbances

Complement
Neurotoxicity Myotoxicity
Activation

Generalized
Acute Kidney Increase in
Injury Capillary
Permeability
WHO. Guidelines for The Management of Snakebites. 2016 .
Clinical effects of snakebite
When venom has not
been injected
Another source of
symptoms and signs not
caused by snake venom
is first aid and traditional
treatments.
WHO. Guidelines for The Management of Snakebites. 2016 .
Anxious people may over
breathe  pins and needles
(paresthesiae) of the
extremities, stiffness or tetany
of their hands and feet and
dizziness.
Vasovagal shock, highly
agitated and irrational.
Blood pressure and pulse rate
may increase, sweating and
trembling.
Vomit and diarrhea.
Clinical effects of snakebite (2)

Local symptoms and

When venom has signs in the bitten
been injected part.
Generalized
(systemic) symptoms
and signs.

WHO. Guidelines for The Management of Snakebites. 2016 .

Local symptoms and signs in the bitten part
Local
bleeding

Fang
marks
Bruising,
blistering

Blistering

WHO. Guidelines for The Management of Snakebites. 2016 .

Blistering
Local symptoms and signs in the bitten part (2)

Local pain Lymphangitis

Inflammation
Lymph node
(swelling,
enlargement
redness, heat)

WHO. Guidelines for The Management of Snakebites. 2016 .

Local symptoms and signs in the bitten part (3)

Spreading
local
swelling Local
infection,
abcess
formation

Necrosis

WHO. Guidelines for The Management of Snakebites.

2016.
 Generalized (systemic) symptoms and signs(1)

WHO. Guidelines for The Management of Snakebites. 2016 .

Peningkatan Kardiovaskular (Viperidae) :
• Gangguan visual, dizziness, syncope, syok, hipotensi, aritmia, kerusakan pada
miokard

• permeabilitas kapiler: chemosis, bilateral parotid enlargement, efusi pleura dan

perikadium, edema pulmonal, albuminuria massif, hemokonsentrasi

• Gangguan perdarahan dan pembekuan darah: perdarahan lokal dari luka yang
sudah dalam proses penyembuhan dan lokasi pemasangan infus, perdarahan
sistemik spontan (epistaksis, hematemesis, tanda lateralisasi/koma dari perdarahan
cerebral), hematemesis, haemoptysis, haematuria, etc.
Neurologis (Elapidae, Viperidae eg Russell’s viper D. russelii, Gloydius
species)
● Ptosis bilateral, ophthalmoplegia eksternal, descending paralysis  progress to
generalized flaccid paralysis,
● Generalized rhabdomyolysis: kaku otot, nyeri, nyeri saat diregangkan secara
pasif, trismus, urin coklat gelap
● Acute Kidney Injury: nyeri punggung bawah, haematuria, haemoglobinuria,
myoglobinuria, oligouria/anuria, uraemia
 Acute Pituitary Insufficiency (Russell’s viper)
● Akut

○ Syok

○ Hipoglikemi
● Kronis

○ Weakness

○ Hilangnya pertumbuhan rambut seksual sekunder

○ Penurunan libido

○ Amenorrhoea

○ Atrofi testicular

○ Hipotiroidisme
Generalized (systemic) symptoms and signs(2)

WHO. Guidelines for The Management of Snakebites. 2016 .

Clinical Syndromes of Snakebite in
South-East Asia

Syndrome • Local envenoming (swelling etc) with

bleeding/clotting disturbances
1
• Local envenoming (swelling etc) with bleeding/clotting
Syndrome disturbances, shock or acute kidney injury = Russell’s viper with
conjunctival oedema (chemosis) and acute pituitary
insufficiency = Russell’s viper, Myanmar and South India with
2 ptosis, external ophtalmoplegia, facial paralysis, etc, and dark
brown urine = Russell’s viper, Sri Langka and South India

WHO. Guidelines for The Management of Snakebites. 2016 .

Clinical syndromes of snakebite in south-east asia (2)

Syndrome •Local envenoming (swelling etc) with paralysis = cobra or king cobra

Syndrome •Paralysis with minimal or no local envenoming: Bitten on land while

sleeping on the ground with/without abdominal pain = krait
•Bitten in the sea, estuary and some freshwater laes = sea snake

4 •Bitten in Indonesia Maluku or West Papua with/without

bleeding/clothing disturbance = Australian elapid

WHO. Guidelines for The Management of Snakebites. 2016 .

Clinical syndromes of snakebite in south-east asia (3)

• Paralysis with dark brown urine and acute kidney

injury
• Bitten on land (with bleeding/clotting disturbance =
Syndrome Russell’s viper, Sri Lanka or South India
• Bitten on land while sleeping indoors = krait (B. niger,
5 B. candidus, B. multicinctus), Bangladesh, Thailand
• Bitten on the sea, estuary, and some freshwater lakes
(no bleeding/clotting disturbances = sea-snake

WHO. Guidelines for The Management of Snakebites. 2016 .

Symptoms and signs of sea-snake envenoming

Ptosis, facial Generalised Myoglobinuria

paralysis, and myalgia
trismus
WHO. Guidelines for The
Management of Snakebites.
2016.
 Grading of
envenomation

Kincaid R, Ruppert S. Rattlesnake envenomation and compartment

syndrome: a case study. Int J Adv N Pr. 2009; 11(1): 1-7.
Penanganan Awal
● Airway : Clear airway, give oxygen, asphyxiated?
● Breathing : Paradoxical respiration?
● Circulation : Intravenous line, urgent resuscitation
● Anamnesis Utama :
○ Lokasi gigitan? Kapan waktu digigit? Saat sedang beraktivitas apa? Lokasi digigit ular? Tampilan
ularnya, apakah ada foto? Apa yang dirasakan sekarang?
Pemeriksaan Lokal Gigitan
● Tingkat keparahan nyeri/ pembengkakan
● Kondisi kelenjar getah bening lokal
● Tanda awal nekrosis
Pemeriksaan Awal Umum
● Tekanan darah, hipovolemi ● Trismus, tongue
● Tanda perdarahan di gusi, hidung,
protrusion
kulit, dan mukosa
● Otot wajah
● Chemosis
●
● Gag reflex neck flexor
Nyeri abdomen
● Nyeri dan nyeri tekan punggung “broken neck sign”
bawah (loin) ● Paradoxical Respiration
● Meningism ● Paralysis dengan
● Tanda lateralisasi, ptosis bilateral, kesadaran penuh
diplopia, ophthalmoplegia (komunikasi dengan
eksternal gerakan jari)
● Gangguan kesadaran ● Urin coklat gelap + nyeri
otot
Pemeriksaan Penunjang
● Identifikasi Jenis Ular : dari deskripsi dan kondisi saat pasien digigit, gambar/foto ular tersebut, gejala klinis pasien
● Pemeriksaan Laboratorium

○ Tes pembekuan darah - 20 minute whole blood clotting test (20WBCT) : (+) koagulopati berat, memerlukan
antivenom

○ International Normalized Ratio (INR); Prothrombin time (PT), activated partial thromboplastin time (aPPT),
fibrinogen, D-dimer

○ Hematokrit, trombositopeni, leukositosis neutrofil, fragmented red cells

○ Biochemical abnormalities : creatinine, urea/blood urea nitrogen, konsentrasi potassium, peningkatan

aminotransferase, enzim otot (creatinine kinase, aldolase, dll.), hyponatremia (Krait)
Management

20 minutes whole
blood clotting test,
PT/APTT, fibrinogen,
D-dimer, INR, Hb
concentration/hemato
crit, platelet count,
WBC count, Ur/Cr,
ABG, urinalysis, chest
X-ray, USG,
echocardiography, CT
and MRI, ECG

WHO. Guidelines for The Management of Snakebites. 2016 .

Management (2)

WHO. Guidelines for The Management of Snakebites. 2016C

Management (3)

WHO. Guidelines for The Management of Snakebites. 2016C

Management (4)

WHO. Guidelines for The Management of Snakebites. 2016

Management (5): Antivenom
● Indication:
● When a patient with proven or suspected snakebite develops one or more of the
following signs:

Neurotoxic signs: Cardiovascular

Hemostatic ptosis, external abnormalities:
abnormalities ophtalmoplegia, hypotension, shock
paralysis
Supporting laboratory
Acute kidney Haemoglobin/ evidence of systemic
injury myo-globinuria envenoming

Local swelling involving Development of an

more than half of the Rapid extension enlarged tender
bitten limb within 48 hr of of swelling lymph node draining
the bite the bitten limb
WHO. Guidelines for The Management of Snakebites. 2016
Management (6): Antivenom (SABU)
●Serum Anti Bisa Ular (SABU) is the only snake antivenom produced locally in
Indonesia.
●It is produced by Bio Farma, derived from horse plasma, is polyvalent/trivalent,
in the form of a yellowish clear liquid, marketed under the trade name Biosave®.
●Used as a first line anti-venom therapy for:
●Venomous snake, which is neurotoxic:

Naja sputratix, or cobra, or spoon snake

Jawa Bungarus fasciatus, or welang snake, rarely bites humans

Venomous snake, which is hemotoxic:

Calloselasma rhodostoma, or Agkistrodon rhodostoma, or ground snake, or also

known in Malaysia as Malayan pit viper
●Administration:
●2 vials (@ 5 ml) iv in 500 cc NaCl 0.9% / Dextrose 5%
●Rate of infusion: 40-80 dps/min

WHO. Guidelines for The Management of Snakebites. 2016

Management (7)

Kincaid R, Ruppert S. Rattlesnake envenomation and compartment syndrome: a case study. Int J Adv N Pr. 2009; 11(1): 1-7.
Antivenom
● Polyvalent (polyspecific)

○ Diberikan saat jenis ular sulit diketahui

○ Lebih poten dibandingkan monovalent (Jumlah antibody yang lebih tinggi)

● Monovalent (monospecific)

○ Diberikan saat jenis ular diketahui, sesuai dengan antivenom tersebut

○ Lebih murah, dosis protein antivenom yang lebih rendah

Cara Pemberian Antivenom
Antivenom freeze-dried dicairkan dengan sterile water for injection (10 ml water utk setiap ampoule)

1. Intravenous “push” injection

○ Antivenom diberikan IV pelan (2 ml/menit)

○ Pekerja kesehatan akan tetap terus berada di sebelah pasien bila terjadi efek samping
2. Intravenous infusion

○ Antivenom dilusi di 5 ml cairan isotonic per kg BB, diberikan secara konstan dengan durasi total 30-
60 menit
3. Intramuscular

○ Molekul antivenom besar, sulit diabsorbsi via limfatik, bioavailabilitas rendah, dapat menyebabkan
nyeri saat pemberian IM

○ Hanya boleh diberikan sebelum pasien mencapai rumah sakit dengan gejala envenoming yang jelas,
di lokasi yang sangat jauh dari akses medis, saat akses intravena tidak memungkinkan
Observation of Response to Antivenom
● General : pasien merasa lebih baik secara menyeluruh (mual, sakit kepala, nyeri
menghilang dengan cepat)
● Perdarahan sistemik spontan : berhenti dalam waktu 15 – 30 menit
● Blood Coagulability (20WBCT) kembali normal dalam 3-9 jam
● Pada pasien syok : BP meningkat dalam 30-60 mnt pertama dan aritmia menghilang
● Neurotoxic envenoming : membaik dalam waktu 30 mnt – beberapa jam. (hanya
pada gigitan jenis cobra)
● Active haemolysis & rhabdomyolysis : menghilang dalam beberapa jam & warna
urin kembali normal
Kriteria untuk menambahkan dosis Antivenom

● Gangguan pembekuan darah yang persisten atau rekuren setelah 6 jam / kembali berdarah dalam waktu 1-2 jam
● Tanda-tanda neurotoxic/kardiovaskular yang terus memburuk setelah 1 jam
● Bila tetap terjadi gangguan pembekuan darah (20WBCT) 6 jam setelah pemberian initial dose antivenom 
dosis yang sama diulang
● Pasien yang terus berdarah  dosis antivenom diulang dalam waktu 1-2 jam
● Tanda neurotoxicity / kardiovaskular yang memburuk  ulang dosis awal setelah 1 jam. Mengulan dosis
antivenom setelah pasien paralisis dan terapi ventilasi belum terbukti efektif.
Adverse Reaction to Antivenom
• Reaksi cepat (dalam beberapa jam), Reaksi lambat (5 hari atau lebih)
• Angka insidensi reaksi anafilaktik/pirogenik antara 3.5% - 81% (43% sangat berat)
• Untuk menghindari reaksi yang tidak diinginkan : adrenaline (0.25 ml/mg dari 0.1% solution
subkutan) diberikan sebelum pemberian antivenom dapat mengurangi reaksi berat sebanyak
43% (95% CI 25-67) saat 1 jam, dan 38% (95% CI 26-39) saat 48 jam dan setelah pemberian
antivenom [penelitian di Sri Lanka]
 R
RABIES
Overview
● Rabies is also called “penyakit anjing gila”.
● This zoonotic disease is a disease that can be transmitted from
animals to humans through the bite of an infectious rabies animal.
● The causative agent of rabies is a virus of the genus lyssa virus and
belongs to the family rhabdoviridae.

Kemenkes RI. Buku Saku Petunjuk

Penatalaksanaan Kasus Gigitan Hewan
Penular Rabies di Indonesia. 2016.
Transmission and incubation period
● Mode of transmission of rabies through bites and non-bites (scratches or
licking of the open skin / mucosa) by animals infected with the rabies virus.
● The rabies virus will enter the body through open skin or mucosa but cannot
enter through intact skin.
● In Indonesia, animals that can be a source of transmission of rabies in
humans are dogs, cats and monkeys, but the main source of transmission is
dogs, about 98% of all rabies sufferers are infected through dog bites.
● The incubation period for rabies varies greatly between 2 weeks - 2 years,
but generally 3-8 weeks. According to WHO (2007) it is mentioned that the
incubation period is on average 30-90 days.

Kemenkes RI. Buku Saku Petunjuk Penatalaksanaan Kasus Gigitan Hewan Penular
Rabies di Indonesia. 2016.
Pathogenesis

Kemenkes RI. Buku Saku

Petunjuk Penatalaksanaan Kasus
Gigitan Hewan Penular Rabies di
Indonesia. 2016.
Clinical symptoms on Human
Prodromal stage: fever, weakness, lethargy, no appetite / anorexia, insomnia, severe headaches,
sore throat, and often found pain.

Sensory stage: tingling, paresthesia at the site of the bite, anxiety and overreaction to sensory
stimuli

Excitation stage: neurological disorders, appearing confused, anxious, hallucinating, appearing

frightened, accompanied by changes in behavior to be aggressive, and the presence of
phobias (hydrofobia), muscle spasms, hyper-discrimination, hypersalivation, hyperhidrosis,
pupillary dilatation. (5-7 days).

Paralysis stage: muscle paralysis gradually starts from the bite/scratch scar, decreased
consciousness develops slowly and eventually dies due to paralysis of the respiratory and cardiac
muscles. (13 days).

Kemenkes RI. Buku Saku Petunjuk Penatalaksanaan Kasus Gigitan Hewan Penular
Rabies di Indonesia. 2016.
Management

Wound
Antiseptic
cleaning

VAR and
SAR
Kemenkes RI. Buku Saku Petunjuk Penatalaksanaan Kasus Gigitan Hewan Penular Rabies di Indonesia. 2016.
Management (2)

Jilatan pada kulit

Jilatan/luka pada mukosa,
terbuka atau
luka di atas daerah bahu
cakaran/gigitan
(leher, wajah, kepala), luka
yang menimbulkan
pada jari tangan dan jari
luka lecet
kaki, luka di area genitalia,
(ekskoriasi) di area
luka yang lebar/dalam,
badan, tangan,
atau luka multipel
dan kaki

Kemenkes RI. Buku Saku Petunjuk Penatalaksanaan Kasus Gigitan Hewan Penular Rabies di Indonesia. 2016.
VAR (Vaksin Anti Rabies)
Post Exposure Prophylaxis:
● Purified Vero Rabies Vaccine/PVRV (Verorab®)

○ Intra-muscular injection in the upper arm (deltoid) or in the anterolateral thigh

area (children <1 year of age).

Kemenkes RI. Buku Saku Petunjuk Penatalaksanaan Kasus Gigitan Hewan Penular Rabies di Indonesia. 2016.
VAR (vaksin anti rabies) (2)
 Purified Chick Embriyo Cell-culture Vaccine/PCECV (Rabipur®)

Kemenkes RI. Buku Saku Petunjuk Penatalaksanaan Kasus Gigitan Hewan Penular Rabies di Indonesia. 2016.
VAR: management of bite cases that have a complete history of VAR administration (3)

Kemenkes RI. Buku Saku Petunjuk Penatalaksanaan Kasus Gigitan Hewan Penular Rabies di Indonesia. 2016.
VAR (Vaksin Anti Rabies) (4)
Pre Exposure Prophylaxis (PrEP)
● Providing immunity to people who have a high risk of being infected with rabies,
including: health workers handling rabies cases, veterinarians, technicians dealing with
animals at risk.

Kemenkes RI. Buku Saku Petunjuk Penatalaksanaan Kasus Gigitan Hewan Penular Rabies di Indonesia. 2016.
SAR (Serum Anti Rabies)
● Especially for high risk injuries.
● Objective: to provide passive immunity in the first 7 days (immunity had not yet
been established against the rabies virus).

Kemenkes RI. Buku Saku Petunjuk Penatalaksanaan Kasus Gigitan Hewan Penular Rabies di Indonesia. 2016.
 R
SCORPION
Overview
● Major public health problem in tropical and sub-tropical countries, especially in
India, Middle-East, Latin America.

Palmaneu
M. s
tamulus gravimanu
s

Kamath S. API Textbook of Medicine. 11th ed. Agra: Association of Physicians of India; 2019.
Management

Kamath S. API Textbook of Medicine. 11th ed. Agra: Association of Physicians of India; 2019.
LEECH
Leech
Overview
● Leeches are hermaphroditic parasites of phylum Annelida and class Hirudinea.
● Limited information is reported regarding leech bites, and the majority of case reports are
from the tropics or subtropics and occur after contact with fresh water.

Conley K, Juergens AL. Leech bite. Available at https://www.ncbi.nlm.nih.gov/books/NBK518971/. Cited on Oct 22nd 2019, 12.10 PM
Management: initial treatment
Removal of the leech or
Cleaned the wound:
leeches: saltwater,
betadine, topical
lidocaine, cocaine,
antibiotic agents
topical anesthetic spray

Controlling blood loss:

hemostatic agent,
bandage, cauterization, Preventing exposure to
local application of blood-borne pathogens
tranexamic acid,
tampon
Conley K, Juergens AL. Leech bite. Available at https://www.ncbi.nlm.nih.gov/books/NBK518971/. Cited on Oct 22nd 2019, 12.10 PM
References
● WHO. Guidelines for The Management of Snakebites. 2016.
● Dart RC. Bites of venomous snakes. N Engl J Med. 2002; 347(5): 347-55.
● Kincaid R, Ruppert S. Rattlesnake envenomation and compartment syndrome: a case
study. Int J Adv N Pr. 2009; 11(1): 1-7.
● Kemenkes RI. Buku Saku Petunjuk Penatalaksanaan Kasus Gigitan Hewan Penular
Rabies di Indonesia. 2016.
● Kamath S. API Textbook of Medicine. 11th ed. Agra: Association of Physicians of India;
2019.
● Conley K, Juergens AL. Leech bite. Available at
https://www.ncbi.nlm.nih.gov/books/NBK518971/. Cited on Oct 22nd 2019, 12.10 PM
THANK YOU