Presented by:

Dr. dr. Tri Maharani, M.Si., Sp. EM

Creeated by
dr Fanky Ardyansyah
 According to WHO 2009, Snake bite is a Neglected Tropical
Disease. Common cause of morbidity and mortality in tropical
countries, especially South East Asian Countries.
The number of cases about 2.5 million per year, resulting in
125.000 deaths.
In 1998, the cases about 5 million in the world with 125.000
mortality cases. In the same year, about 2 million cases were
held in Asia, with 100.000 mortality cases.

(Inggrianita, 2013) ; (Yanuartono, 2008) ; (Rahadian, 2012)

 In 1954, Swaroop and Grab of the Statistical Studies Section,
WHO, estimated that among half a million snake-bites and
between 30.000 and 40.000 snake-bite deaths each year in
the world as a whole, there were between 25.000 and 35.000
deaths in Asia.
Indonesia doesnt have updated data about snake bite cases.
 In Bondowoso, East Java, noted that there are 55 cases during
March 2015 until October 2015, with 45 cases caused by
Trimeresurus insularis, and the others caused by Bungarus sp.
and Naja sp.
Venomous species that cause human fatalities and frequent
snake bite cases in Indonesia are the Malayan pit viper
(Calloselasma rhodostoma), Southern Indonesian spitting cobra
(Naja sputatrix), Banded krait (Bungarus fasciatus) and the
Malayan Krait (Bungarus candidus).
Snake bite treatment in Indonesia mostly use some traditional
treatments, like herbal treatment, keris and batu ular.
Sucking and cross incision are common treatment which are
found in primary health care.
 SNAKE

NON-VENOMOUS VENOMOUS

Cardiotoxin Hemotoxin Neurotoxin

Necrotoxin Nephrotoxin
 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)
MONOVALENT POLYVALENT
 SABU covers 3 venomous snakes
1. Agkistrodon rhodostoma
2. Naja sputatrix
3. Bungarus fasciatus
 Thailand product
Each vial price
USD170
INDONESIA????
 HOME
DO NOT PANIC
DO NOT GIVE CONSTRICTING BAND (TORNIQUET), SUCKING, or OTHER
TRADITIONAL TREATMENT
IMMOBILIZE BITTEN AREA (will be discussed)
SEND TO PRIMARY HEALTH CARE OR EMERGENCY DEPARTMENT
BRING DEAD OR ALIVE SPECIMENT OR SNAKE PHOTO INTO
EMERGENCY TO BE IDENTIFIED TO GIVE A SUITABLE ANTIVENOM
PRIMARY HEALTH CARE
DO GENERAL EXAMINATION, MAKE IT STABLE !
EVALUATE THE IMMOBILIZATION
GIVE IMMOBILIZATION IF NO IMMOBILIZATION BEFORE
GIVE ANALGESIA WHEN NEEDED
MARK THE EDEMA BY USING RPP TEST (will be discussed)
DO NOT DO CROSS INCISION !!!!
BRING THE PATIENT TO THE EMERGENCY DEPARTMENT
 Complain
Main complain
Others
Snake Identification
Head shape
Colors
The tails
Timeline
How it can be happened?
Location
Where the snake bite the patient?
 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.
 RESULT
A. MILD : 1-2 mm
B. MODERATE : 3 mm
C. SEVERE : 4 mm
 20 minutes Whole Blood Clotting Test (20WBCT)
Rate Proximal Progression (RPP) Test
Electrocardiography
Laboratory check
Haemoglobin
White blood cells
Platelet count
Liver function test
Renal function test
PT
APTT
INR
 Aim : to make sure hemotoxin or not by knowing from the
coagulation.
How to do?
Take a glass bottle, DO NOT USE PLASTIC BOTTLE
Take 2 ml of blood
Then take that blood into the glass bottle
Wait for about 20 minutes
Repeat that test 2 times minimal
Result :
After waiting about 20 minutes:
Clotting (+) : no coagulation disorder (NonHemotoxin)
Clotting (-) : coagulation disorder (HEMOTOXIN)
 Aim : to evaluate the edema progression to make a
best next medical treatment.
How to do?
Take a tape as a mark to measure the edema
Make sure the proximal margin of the edema, then take the
distal margin of the tape into the proximal margin of the
edema.
Note the time when the tape was given (date and time)
Repeat the evaluation of the edema every 2 hours
Result : cm/hour
Example : 10/10/15 ; 09.00 11.00 = 4 cm. So we have
evaluated that the edema increase about 2 cm per hour.
 5 cm / 2 hours, so
5 cm RPP = 2.5 cm/hour
 Lowest side of tape 1to
lowest side of tape 2 is 4
cm. So we have RPP test
is 2 cm/hour
 10 cm in 3 hours
RPP = 3.3 cm/hour
 If the patient or family bring the snake to us, we can identify
what the species of the snake is. Then we can make a best
assessment to give a correct/spesific treatment (antivenom) to
the patient.
Example: Neurotoxin snake bite ec Bungarus candidus bite.

But if the patient didnt bring the snake, we can identify by

knowing the clues (like head shape, colors, tail, etc). But we have
to remember that we cant make a best assessment because we
do not see the snake directly. So we must say unidentified.
Example: Hemotoxin snake bite ec Unidentified snake (susp.
Trimeresurus insularis bite)
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% (dont forget to take some
blood for laboratory checking)
Blood pressure
Pulse
Oxygen saturation by using pulse oxymetri
Blood or Fresh Frozen Plasma as indicated
 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 + 100 ml Normal Saline 0.9% dripped 60-80 drop per
minute
Repeated every 6-8 hours. BE AWARE TO RE-ENVENOMATION SIGN!!!
Symptomatic
Analgesia : morphine (PS7) and paracetamol infusion or oral (PS<7)
Antibiotic
When indicated, example : leucocytosis
 Bites by cobras, king cobras, kraits, Australasian elapids or sea
snakes may lead, on rare occasions, to the rapid development
of life-threatening respiratory paralysis. This paralysis might be
delayed by slowing down the absorption of venom from the site
of the bite.
The bandage is bound firmly (at a pressure of 50-70 mmHg),
but not so tightly that the peripheral pulse (radial, posterior
tibial, dorsalis pedis) is occluded or that the patient develops
severe (ischaemic) pain in the limb.
 Compared with control animals without treatment, the pressure
immobilization group had longer survival, less swelling. On the
contrary, many historically recommended first aid techniques
(eg, incision and suction,cryotherapy, electroshock) have been
shown to worsen envenomation sequelae or even result in injury
independent of the bite.
Pressure immobilization is recommended for first aid field
treatment of venomous snakebites in Australia. The technique
involves wrapping the entire extremity, starting at the bite site,
with an elastic or compressive bandage and immobilizing it with
a splint. When properly applied, this technique has been shown
to slow systemic spread of venom.
(Sean P. Bush,MD et all, 2004)
 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
 Vital sign (BP, RR, Pulse, temp)
Complain
Pain score
RPP test
Bitten area evaluation
THANK
YOU!!!
Created by
Dr. frank
Any questions after this meeting? Feel free to reach Dr. dr. Tri Maharani, M.Si, Sp. EM
by phone or whatsapp 085334030409 (Telkomsel) or 08973665684 (Tri)