Snakebites

Dr.dr.Tri maharani MSi SpEM

 Berbisa

Tidak Berbisa
GIGI ULAR TAK BERBISA
GIGI ULAR BERBISA
Snake families and general venom
effects
Venomous
Snake families

Elapidae Hydrophiidae Viperidae Colubridae

Myotoxic Cytotoxic Coagulopathic

Renal toxicity Myotoxic
Coagulopathic
Neurotoxic
+cytotoxic in cobra & king cobra
+ coagulopathy in Australasian elapids
Medically important snakes in
Indonesia

Australasia
n snake
species

South East
Asian
snake
species

There are a lot more medically

important species in Indonesia!!!
Indonesia
Total snake species : 348.
Venomous snake species:

Elapidae:55
Viperidae: 21
Colubridae: 1
Problems identified

 Data
 First Aids
 Transportation
 Doctors and nurses skills (A,B,C)
 Antivenom availability
Snakebites cases in Indonesia
from 2012-2018
200
180
160
140
120 dise…
100
80
60
40
20
0
HIV snakebites cancer
In hospital mortality
20
18
16
14
12
10
8 2016
6 2017
4 2018
2
0
HUMAN LYMPHATIC DRAINAGE
PBI
First aid
FIRST AID

100%
90%
80%
70%
60%
CASES 2012
50%
CASES 2016
40%
30%
20%
10%
0%
WHO TRADDISIONAL
 CLINICAL MANIFESTATION
LOCAL
 Swelling > half bitten limb/48 hours
 Toes especially fingers
 Rapid extension within a few hours
 Enlarged tender lymphnode
draining the affected area
SYSTEMIC
• Haemostatic abnormality
• Neurotoxic signs
• Cardiovascular abnormalities
• Acute kidney injury
• Myoglobinuria/generalised
rhabdomyolysis/haemolysis
• Supporting lab evidence of
systemic envenoming
(A. Khaldun, 2015)
Physical Examination
 Vital sign (BP, pulse, RR, temp)
 Pain score
 General examination
 Head and neck include ptosis
 Chest (lungs and heart)
 Stomach

 Upper and lower limb

 Localized examination
 Fang mark (do not mark the bite site!)
 Bleeding

 Necrotic tissues
 Bulae

 Etc.
PTOSIS MEASUREMENT

RESULT
A. MILD : 1-2 mm
B. MODERATE : 3
mm
C. SEVERE : 4 mm
MONITORING

 Vital sign (BP, RR, Pulse, temp)

 Complain
 Pain score
 RPP test
 Bitten area evaluation
TREATMENT (1)
Keep the Airway Breathing and Circulation stable
• Airway
• 02 Non Re-Breathing Mask 12 lpm
• Laryngeal Mask Airway and Endotracheal Tube (if needed)
• Suction if gargling (+), Head tilt and chin lift if snoring (+)
• Breathing
• Evaluate the respiratory rate
• Circulation
• Make iv access, give Normal Saline 0.9% (don’t forget to take some blood for
laboratory checking)
• Blood pressure
• Pulse
• Oxygen saturation by using pulse oxymetri
• Blood or Fresh Frozen Plasma as indicated
TREATMENT (2)
• Immobilize bitten area by using Pressure Bandaging
Immobilization
• Antivenom : DRUG OF CHOICE
• If the snake that bite the patient include in 3 snakes which are
covered by the SABU, we can give SABU quickly
• 2 vials SABU + 500mml Normal saline 0.9% dripped 0-80 drop
permminute hemotoxin bites
• Repeated every 6 hours. BE AWARE TO RE-ENVENOMATION SIGN!!!
• Symptomatic
• Analgesia : morphine (PS≥7) and paracetamol infusion or oral
(PS<7)
• Antibiotic
• When indicated, example : leucocytosis
TREATMENT (3)

 Anticholinesterase drugs
 Especially for neurotoxin envenoming
 Should give atropine before giving the drugs to prevent physostigmine
intoxication.
 Physostigmine dose
 Adult (>12 yo) : 1.0-2.0 mg
 Children ≤ 12 yo : 0.02 mg/kg/dose (max single dose 0.5 mg)
 Should be given slowly 3-5 minutes by IV push,repeat every 4 hour
Neurotoksin(julian
whie,2016)
Haemotoxin system
In hospital length of stay

30

25

20

no AV
15
AV
10

0
neuro hemato necro nefro
Cost for in hospital patients given
AV versus not given AV
300

250

200
non AV
150 AV
Column1
100

50

0
neuro hemato necro nefro
Sequele of snakebite cases

100%

80%

60%

40% sequele

20%

0%
hemato
neuro
nefro
necro
What next???

 Net working
 Standard guideline
 Education & Training
 Drug & management ABC

Antivenom
WHO Guideline 2016 and Guideline
of Poisoning Management 2017
President Toxinology Society of
Indonesia

DR dr Tri Maharani Msi SpEM

RECS Indonesia consultations

800
700
600 2014
500 2015
2016
400
2017
300
2018
200
100
0
snakebite
Journal Publication

 Cross reactivity and lethality neutralization of venoms of Indonesian

Trimeresurus complex species by Thai Green Pit Viper Antivenom

Choo Hock Tan, Jia Lee Liew, Nget Hong Tan,

Ahmad Khaldun Ismail, Tri Maharani, Sumana
Khomvilai, Visith Sitprija

Toxicon, 2017, 140, 332-37.

Donation of BioCSL Australia neuropolyvalent antivenom to Sorong Hospital
and training of snakebites management 100 doctor in Sorong, West Papua.
Snake antivenom in Indonesia
SNAKE ANTIVENOM

MONOVALENT POLYVALENT
Cobra bite
Trimeresurus bite (local phase)
Trimeresurus bite
(hemotoxin, systemic phase)
Calloselasma
bites
NeurotoXin SNAKEbite
King cobra bite
10 July 2017 ECG and
echocardiography
15 july 2017 9am
17 July 2017 10 am

10.30 am shortness
of breath
11 am in mini
hospital kuningan
11.35 am apneu
11.45 am +
Klinik Heroku
Venom
oftalmia