Dr Muhammad Isya Firrmansyah SpEM

• 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 doesn’t 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 SYSTEMIC
 Swelling > half bitten  Haemostatic abnormality

limb/48 hours  Neurotoxic signs

 Cardiovascular abnormalities
 Toes especially fingers
 Acute kidney injury
 Rapid extension within a  Myoglobinuria/generalised
few hours rhabdomyolysis/haemolysis
 Enlarged tender  Supporting lab evidence of
systemic envenoming
lymphnode draining the
affected area
(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 (20’WBCT)
• 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 didn’t bring the snake, we can identify by

knowing the clues (like head shape, colors, tail, etc). But
we have to remember that we can’t 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% (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
 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 (PS≥7) 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