LITERATURE REVIEW

BACKGROUND

Snakebite is one case of emergency-related environmental, employment and season

and quite a lot going on in various parts of the world, especially in rural areas. Workers in
agriculture and children are frequently bitten group.
In 2009, the World Health Organization WHO was first introduced as a neglected
tropical disease.Insidens snake bite is especially the cause of death is still quite high in the
world. In 1998 the death rate is estimated at about 125,000 out of 5 million cases per year,
including 100,000 deaths of 2 million cases in Asia the number of permanent disability are
not terhitung1 because it is still difficult availability and access Serum Can Snake (SABU).
Similarly, in the region of Southeast Asia. However, for the exact number is unknown
because of morbidity acute and chronic still unclear and inadequate record-keeping and
reporting systems in various regions. In Indonesia alone reported about 20 deaths of
thousands of cases of snake bites per year.
Knowing the type of snake bite because it is important for optimal handling. Prehospital first treatment against snake bite victims are still frequently encountered in the
community according to the research has more disadvantages than advantages. Therefore, this
case report compiled in order to better understand and learn how the diagnosis and
management of patients with snakebite.
1. CLASSIFICATION
Diagnosis of species of snake bite victims are important to note. Can be done by
identifying the snake who is dead, or the characteristics of the clinical manifestations muncul.
From 2500-3000 snake species spread across the world there are approximately 500
beracun.3 Family Viperidae snakes (vipers, adders, pit vipers, and mocassins), Elapidae
(cobras, Mambas, kraits, coral snakes, Australasian Venomous snakes, and sea snakes),
Atractaspididae (burrowing AS)

Viperidae

Elapidae

Atractaspididae

PS) - has the ability to inject could use a modified teeth (canines).

Figure 1: Types of poisonous snakes

Figure 2: venomous snake species in Indonesia

Category 1: Vipers are widespread and result in morbidity, disability and mortality are
high
Category 2: The rattlesnake that resulted in morbidity, disability and mortality are
high but based on epidemiological data are rare due to habitat and behavior of snakes are far
from human populations
venom is produced and stored in a pair of glands under the eyes and fangs connected
to the connecting channel toxins poison glands to basic canine (fang).

Figure 3: Anatomy bag snake venom and venom duct

Until now there is no fixed rule to distinguish poisonous snakes or not. Some nonvenomous snakes have evolved to resemble poisonous snake and vice versa so it looks almost
the same. Although in some respects rattlesnake has certain characteristics such as size and
shape, skin patterns, behavior and sound if the state is threatened. 1 As an example of the type
of cobra snake is well known to be straightened up, spitting venom and aggressive pecking
opponent if under threat.
Snake venom production (snake venom) dangerous, could the issuance of the
remaining 90% is protein is protein nontoksis nonenzim like carbohydrates and metals. Could
it contains more than 20 different kinds of enzymes including phospholipases A2, B, C, D
hydrolases, phosphatases (acid to alkaline), proteases, esterases, acetylcholinesterase,
transaminases, hyaluronidase, phosphodiesterase, nucleotidase and ATPase and nucleosidases
(DNA and RNA).
2. VENOM
Some of the enzymes contained in the venom, among others:

Zinc metalloproteinase haemorrhagins: Damaging the vascular endothelium, resulting

in bleeding.
procoagulant enzymes: serine proteases and enzymes Contains procoagulant which is
a substance activating factor X, prothrombin and factor that stimulates blood clotting
coagulant to form a fibrin threads in the bloodstream. Ironically, this process makes
the blood becomes difficult because almost all of the fibrin clot is broken and blood
clotting factors tersebuat be reduced in about 30 minutes after the snakebite.
Phospholipase A2 (lecithinase): Damaging mitochondria, red blood cells, leukocytes,
platelets, peripheral nerve, skeletal muscle, vascular endothelium, and other
membranes, resulting in presynaptic neurotoxic activity, and triggers the release of
histamine and anticoagulants.
Acetylcholinesterase
Hyaluronidase: could increase the spread to the entire network.
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proteolytic enzymes: increase vascular permeability so menybabkan edema, the

appearance of the bull, bruising, and necrosis at the site of the bite.

In addition there constituent substances that are neurotoxic venom post synapse is bungarotoxin and cobrotoxin, which consists of 60-62 or 66-74 aminio acids and
phospholipase A subunit that release acetylcholine at the neuromuscular junction in the
peripheral nerves and prevents the release of neurotransmitters.
Increased vascular permeability if it continues will lead to shock or shock which if untreated
can lead to death. Often is neurotoxic venom that causes paralysis (paralysis) and cessation of
breathing, as well as cardiotoxic effect causes the heartbeat stops also affect the occurrence of
miotoksik.

Table 1: The protein in snake venom and clinical interests

3. EPIDEMIOLOGY
In 1998 the death rate is estimated at about 125,000 out of 5 million cases per year, including
100,000 deaths of 2 million cases reported in Asia.1 In America 4000-7000 Ukar bite cases
per year with an average of 4 cases per 100,000 population. During the 5-year retrospective
study of 25 cases of bites, 4 of which require action Fasciotomy and 2 require skin grafts with
the ratio of male: female = 9: 1 and 50% common in the age of 18-28 years.5 In Indonesia
reported around 20 deaths of thousands of cases of snake bites year.
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4. PATHOGENESIS
Blood clotting disorders
Generally rattlesnake, usually containing serine proteases, metalloproteinases that interfere
with hemostasis by activating or inhibiting the coagulant factor or platelet and vascular
endothelial damage. Enzymes in snake venom binds to platelet receptors induce or inhibit
platelet aggregation. Procoagulant enzymes will activate prothrombin, factor V, X, XIII and
pasminogen endogenous. Combinations of anticoagulant activity, disruption of number and
platelet function and damage to the endothelial walls of the blood vessels resulting in severe
bleeding in patients,
Diseases of blood clotting (coagulation) marked defibrinasi associated with platelet counts. In
addition it can convert prothrombin to thrombin and reducing factor V, VII, protein C and
plasminogen.Tekanan in the cardiovascular system causing DIC or pressure in the heart
muscle.
NEUROTOXIC
Is neurotoxic venom that would hinder the excitation of peripheral neuromuscular junction in
various ways. So that the most frequent symptoms are drowsiness, indicating that there may
influence the central sedation associated with a small non-protein molecules contained in the
king cobra snake venom. Most of neurotoxins will result in pamanjangan effects of
acetylcholine, resulting paralysis symptoms such as ptosis, external ophtalmoplegia,
mydriasis, and depression airway and total flacid paralysis as in patients with Myastenia
Gravis. In addition there is a pattern that is difficult descending paralysis described in
pathophysiology.

Figure 4: Neuromuscular junction and neurotoxic venom proteins

HYPOTENSION
Hypotension that occurs after a snake bite is because a lot of things related to snake venom
itself. There are several factors that memepngaruhi permeability of blood vessels resulting in
extravasation of plasma into the interstitial tissue. In addition, substances in the venom will
have a direct or indirect effect on cardiac muscle, smooth muscle and other tissues. Through
the bradykinin-potentiating peptide, the hypotensive effect of bradykinin will increase with
no active peptidyl peptidase functioning destroy bradykinin and convert angiotensin I to
angiotensin II. The pathophysiology invention is beginning the synthesis of ACE inhibitors
captopril and others.
5. DIAGNOSIS
ANAMNESA
History and mechanism of occurrence, type of snake bite (color, size, shape, characteristic)
can be asked directly to the bite victims, but often patients do not know. In addition it needs
to be asked time events that may affect the treatment and prognosis of the patient, the
patient's symptoms are feeling right now as well as a history of allergies, medication
(anticoagulants) and earlier disease (heart, lung, kidney)
CLINICAL MANIFETASION
- Snakebite without the inclusion of snake venom
On snake bite victims are still suspected or bitten snake will usually symptoms of panic,
anxiety and restlessness due kerakutan common that can appear rigid extremity symptoms or
vasovagal shock. Blood pressure and pulse will increase with chills and sweating.
- Snakebite by the inclusion of snake venom
SIGN AND SYMPTOM
After the entry of fangs on the skin will appear later developed pain burning sensation,
throbbing and pain will be intensified and will rise to the proximal part of the bitten part.
Enlargement of regional lymph nodes are common (KGB ingunalis if bitten is inferior
extremity and KGB axila if bitten is superior extremity.
Physical Examination
1. Check vital signs (airway, breathing, circulation / ABC)
2. Check the shape of a snake bite marks two former point fangs
3. Status generalist:

fatigue, nausea, vomiting, abdominal pain

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hypotension
impaired vision, conjunctival edema (chemosis)
sweating and hypersalivation
arrhythmias, pulmonary edema, shock
Signs of spontaneous bleeding (petechiae, epistaxis, hemoptoe)
Paresthesia.

4. Status localist:

there is a pair lubangan (puncture) bites as a sign of injury,

swelling around the bite and reddish (a marker of inflammation) that appear in 5
minutes to 12 hours after the incident
the area around the bite of pain, appears bullae
numbness (numbness) or tingling sense of throbbing (tingling) around the face or
limbs.

Figure 5: The clinical manifestations of patients with snakebites

Several factors influence the mortality due to bites, among others
1. Serum Anti Can Snake: Inadequate dosing or anti-venom that is specific only to a certain
type of snake spesia
2. The time when he received adequate treatment in health care centers usually elongated due
to the victim first came on alternative medicine or problems in transport
3. The existence of the multifunctional organ system failure as an example of hemorrhagic
shock or sepsis, and airway obstruction
Examination Support
Laboratory
The necessary checks are complete blood examination include leukocytes, platelets,
hemoglobin, hematocrit and leukocyte count. Physiology Hemostasis (Prothrombin time,
activated partial thromboplastin time, International Normalized Ratio), Cross Match, serum
electrolytes, renal physiology (BUN, creatinine), Urinalysis to see myoglobinuria, and blood
gas anlisis
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Imaging
Chest x-rays to see if there is pulmonary edema
Other
Looking for signs of compartment syndrome.
Diagnosis
- Anaphylaxis
- Deep vein thrombosis (DVT)
- Scorpion bites
- Septic shock
- Bee sting
- Infected wounds
Classification
The degree of snakebite:
1. Degree 0
- Former two canine bites - No systemic symptoms after 12 hours
- Swelling and minimal pain
2. Grade I (Minimal)
- Former two canine bites
- Swelling and redness with a diameter of 1-5 inches
- There is no systemic signs up to 12 hours
- Moderate to severe pain
3. Grade II (Moderate)
- Former two canine bites
- Severe pain, swelling and redness with a diameter of 6-12 inches in 12 hours
- Petechie, echimosis, perdarah to bite
- There are signs of systemic (nausea, vomiting, fever, enlargement of the lymph nodes)
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4. Grade III (Severe)

- Former two canine bites
- Very severe pain, swelling and redness of more than 12 inches
- Signs of stage I and II appear very quickly. Found signs of systemic (coagulation disorders,
nausea, vomiting, tachycardia, hypothermia, ecchymosis, petechiae thorough).
- Shock and distress breath
5. Degree IV (Extremely severe)
- Very fast deteriorating
- Swelling and redness around the bitten extremity, appear ecchymoses, necrosis and bulla
- Increased pressure intrakompartemen which can impede blood flow venous or arterial
- Multiorgan failure (kidney, heart) can be up to coma and even death.
Management
In general, the purpose panatalaksanaan patients with snake bites is to menetralisisr toxins,
reduce morbidity, and prevent complications. Groove to do is:
first aid
Referral to hospital
Reviewing clinical and resuscitation quickly and precisely
Identify the species of snake if possible
Conducting investigations
Provision of Serum Anti Can Snake (SABU)
Observe the response to administration of SABU
Supportive care and treatment of bite wounds
Rehabilitation and treatment of complications
Usually after being bitten by a snake incident will be some traditional ways of handling the
first, but should not be done in ways that:
Sucking venom by mouth
Installing torniquet tightly around the wound because it can lead to pain, swelling and block
blood flow to the extremities peripheral
Perform ompres hot, cold or incision wound
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 Provision of herbs or ice pack 1.5

What should be done as a first aid to victims of snake bite before going to the hospital (prehospital):
Ensure ABC and monitor vital signs (pulse, respiratory rate, blood pressure, temperature)
and then do the resuscitation with crystalloid approximately 500- 1000 cc.
Restrictions on movement and immobilization on the area around the bite
Immediately refer to the appropriate health care
Do not give advance SABU 1,2,5
Hospital
Always check Airway Breathing Circulation Disability of the nervous system Exposure
(avoid hypothermia) and evaluation tand signs of shock (tachypnea, tachycardia,
hypotension, altered mental status). Giving SABU based degrees bite ular.1
Circumstances that require resuscitation immediately if any signs of shock from
- The effects of snake venom on cardiovascular like hipovilemia, hemorrhagic shock, and the
release of inflammatory mediators that rarely is the primary anaphylaxis
- Failed to breath because of paralysis of the respiratory muscles
- Cardiac arrest due to hyperkalemia due to rhabdomyolysis.

Can Snake Serum (SABU)

Anti-venom therapy was first introduced by Albert Calmette from the Pasteur Institute in
Saigon in 1890.1 There are two types of snakes are the first antitoxin made from horse serum
after horses injected with sublethal doses of snake venom. Antitoxin is then processed and
refined but still containing serum proteins that may still have antigenic properties. The second
type is recommended that the FDA in 2000 monovalent fragments of sheep immunoglobulin
purified to avoid antigenic proteins. 5
SABU should be given to the patient if necessary if a greater benefit. An indication of SABU:
- The existence of hemostatic abnormalities
Clinically the presence of spontaneous bleeding, coagulopathy (seen from the physiology of
hemostasis),
- Signs neurotoksis (ptosis, respiratory muscle paralysis)
- Abnormalities of cardiovascular (hypotension, shock, arrhythmias, abnormal ECG)
- Acute Kidney Injury (oliguria / anuria, increase in serum urea and creatinine or)
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- Hemoglobin / myoglobin-Uriah (marked with dark brown urine and signs of

rhabdomyolysis are muscle pain and hyperkalemia)
More than a hundred years, antibisa snake serum has been widely accepted and used as a
therapy. Therapy specific antidote for snake venom is hyperimmune globulin from animals
that have been immunized with venom and produces antibodies. In patients who emngalami
snake bites or blood clotting disorder have formed clot then giving SABU will fix d \ late
eliminate clot within 2-28 hours. In a randomized controlled study, 40 of 46 patients given
SABU will improve within 6 hours despite signs of bleeding was obtained up to 88 hours
later.
SABU given intravenously sometimes will bring allergic reactions ranging from mild, such
as pruritus or urticaria to severe (anaphylactic shock). Based on the dose, route of
administration and kulaitas SABU, these risks will emerge at 3-30% and only 5-10% of them
are severe systemic symptoms. Almost all allergic reactions that arise can be resolved with
the administration of epinephrine. Prevention of allergic reactions include premedication with
antihistamines or corticosteroids before granting SABU SABU concentration and attention to
concentrations that would diberikan.1,2,4
Two-way provision of anti-venom:
- Intravenous slowly (no more than 2 ml / min). This method provides an advantage because
if it appears allergic reaction can be stopped or handled.
- Intravenous Infusion with snake Antibisa dilution with isotonic fluids 5-10 ml / kg and
discharged within 1 hour
- Intramuscular, but this method has the disadvantage because bioavailibiltasnya low and
difficult to achieve the desired levels in the blood, as well as the risk of hematoma at the
injection site in patients with abnormalities of hemostasis.
Consider giving intramuscular if the distance to a more adequate health services are very far
or difficult intravenous access.
If an allergic reaction after administration of epinephrine SABU then given intramuscularly
in the upper third of the thigh 0.5 mg for adults or 0.01 mg / kg for children and can be
repeated 5-10 minutes.
Management-related surgery usually if found compartment syndrome characterized by 5 P
(pain, pallor, paresthesia, paralysis, pulselesness. If these signs are found there dicurgai
komparten so do Fasciotomy syndrome (indicated in patients with evidence of increased
pressure intrakompartemen.

Antibiotics

Broad-spectrum antibiotic prophylaxis is recommended that a three-generation cephalosporin

with a broad spectrum of gram-negative (Ceftriaxone) will suppress the growth of bacteria
that lead to secondary infections.
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Analgesics

If necessary can be given strong analgesics such as opioids groups: pethidine with adult dose
of 50-100 mg, children 1-1.5 kg / kg or morphine at a dose of 5-10 mg adults and children
from 0.03 to 0.05 mg / kg.
6. Complications
The main causes of disability are things local necrosis and compartment syndrome. Extensive
necrosis may require action debridement or amputation due to damage to the deeper tissues.
At a later date can only arise osteomyelitis, and chronic ulcers. If after a snake bite had
occurred resulting in paralysis of the respiratory muscles and the brain hypoxia can result in
permanent neurological deficits.
7. Monitoring
In patients with respiratory failure may be given oxygen, intubation or manual bagging and
usually will repair within 1 month. Can also be given Anticholinesterase. Bed rest and
restriction of movement necessary to avoid trauma in patients with impaired hemostasis, can
be given a transfusion of FFP (Fresh Frozen Plasma) and cryoprecipitate with platelet
concentrate, but if no one can diebrikan Whole Blood. Sometimes required vasopressor
dopamine or norepinephrine similar in patients with shock or damage to the myocardium and
dialisi case of AKI. The presence of rhabdomyolysis resulting in metabolic acidosis as the
crush injury can be corrected with the appropriate dose of sodium bicarbonate.

REFFERENCE

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Warrell, David A. 2010. Guidelines for the management of snake-bites. WHO

Regional Office for South-East Asia

Warrel, David A. 2010. Snake Bite. Department of Clinical Medicine, University of

Oxford,
Prihatini, Trisnaningsih, Muchdor, U.N. Rachman. 2007. Penyebaran gumpalan
dalam pembuluh darah (disseminated intravascular coagulation) akibat racun gigitan
ular. Indonesian Journal of Clinical Pathology and Medical Laboratory, Vol. 14, No. 1,

November 2007.
Cribari, Cris. 2004. Management of Poisonous Snakebites. American College of

Surgeons Committee on Trauma.

Snake Bite. Daley, Brian James. 2011

http://emedicine.medscape.com/article/168828-overview

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