VENOM

(SNAKE BITE, INSECT BITE,

DOG BITE)

Dr dr AKHMAD MAKHMUDI SpB,SpBA

Pediatric Surgery Div. Surgery Dept. Dr.Sardjito-Hospital /
Medicine. Public health and Nurse School
of Gadjah Mada University
 VENOM
 Venom (venenom, racun), khususnya racun yang
disekresi oleh hewan seperti ular atau artropoda,
anjing, kucing, kera.
 Viper, jenis ular yang berbisa dari Afrika, Asia dan
Eropah
 Russell’s viper v., racun ular berbisa Russel, vipera
russelli, yang bekerja in vitro sebagai tromboplastin
intrinsik dan berguna dalam menentukan defisiensi
koagulasi faktor X.
 VENOM
 Snake venom, bisa ular beracun yang
mengandung hemotoksin, hemaglutinin,
neurotoksin, leukotoksin, atau endoteliotoksin.
Racun-racun dari berbagai spesies telah
digunakan sebagai hemostatik

 Spider venom, racun laba-laba seperti

Atrax,Ctenus, Latrodectus, atau Lycosa
 Classification Protein
According functions
 Type of prot Exp use
 ---------------------------------------------------------------------
 Structural collagen in struct of connect tissue
 keratin in struct of hair and nails
 Contractile myosin, in muscle contraction
 actin
 Storage ferritin in storage of iron needed
 to make Hb
 Transport Hb, in carrying O2
 ser. Alb in carrying fatty acid
 Hormones Insulin in metabolism of CH
 Enzym pepsin in digestion of protein
 Protective gamma glob in antibody formation
 fibrinogen in blood clotting
 Toxin venome prisons
 Type Venom Product

 Snake bite:
(1) Coral snake: contribute 3% and 1.5% death
 Anthropod bites :
(1) Bees & Wasps
(2) Spiders :
a. Black Widow Spider
(Latrodectus mactans)
b. Brown Recluse Spider
(Violin spider,Laxosceles reclusa)
 Is snake, dog, and insect bite
having problem?
 The venom of poisonous snake consists of enzymatic,complex
proteins that affect all of tissues

 Venom have been shown to have neurotoxis, hemorrhagic, anti

thrombogenic, hemolytic, cytotoxic, antifibrinolytic, and
anticoagulant effects, hyalluronidase
 The rapid spread of venom by way of the superficial lymphatic

 Neurotoxic features: muscle cramping, fasciculation, weakness,

and respiratory paralysis
 Hemolytic characteristic may predominate
Hymenoptera venom

Hymenoptera (which includes

bees, yellow jackets, wasps,
and hornets)
 Spider venom

Black widow spider Tarantula

DOG BITE
(RABIES)
 Snake Venom

 {{main|Snake venom}}
 The reptiles most known to use venom
are [[snake]]s, some species of which
inject venom into their prey via
[[tooth|fang]]s.
 Snake venom is produced by glands
below the eye (the [[Submandibular
gland|mandibular gland]]) and
delivered to the victim through tubular
or channeled fangs
 Snake Venom

 Snake venoms contain a variety of [[peptide]] toxins,

including [[Proteases]], which [[hydrolysis|hydrolyze]]
protein peptide bonds, [[nucleases]], which hydrolyze
the [[phosphodiester]] bonds of [[DNA]],

 and neurotoxins, which disable signalling in the

nervous system. Snakes use their venom principally for
hunting, though they do not hesitate to employ it
defensively
The three major families
of venomous snakes

 Elapidae (cobra, king cobra,

krait, and coral snake)
 Viperidae (vipers)
 Hydrophidae (sea snake)
In India, more than 200 species but
only 52 are poisonous
- saw-scaled vipers: almost
two-thirds of bites
-Russell's viper: about one- fourth
-cobras and kraits: only a small
proportion
The three major families
of venomous snakes

 Elapidae (cobra, king cobra,

krait, and coral snake)
 Viperidae (vipers)
 Hydrophidae (sea snake)

In India, more than 200 species of snakes

have been identified but only 52 are
poisonous; the common krait (Bungarus
caeruleus), Indian cobra (Naja naja),
Russell's viper (Daboia russelii), and saw-
scaled viper (Echis carinatus) are the most
poisonous (“the big four”).[10,11] In the
Indian setting, almost two-thirds of bites
are attributed to saw-scaled vipers, about
one-fourth to Russell's viper, and only a
small proportion to cobras and
kraits.[12,13]
Rattlesnakes

Symptoms
 Symptoms specific to
rattlesnake bites are
immediate and include:
 severe pain
 drooping eyelids
 low blood pressure
 thirst
 tiredness or muscle weakness
Water moccasins or cottonmouths

Symptoms
 Water moccasin bites share
symptoms with copperhead
bites. Specific symptoms
include:
 immediate pain and symptoms
 change in skin color
 shock
 low blood pressure
 weakness
Coral snakes

Symptoms
 Symptoms specific to coral
snake bites include:
 pain that is not immediate
 symptoms that set in hours
after the bite
 convulsions
 drooping eyelids
 stomach pain
 change in skin color
 difficulty swallowing
 headache
 shock
 paralysis
 Procoagulant aktivation
snake venom

Procoagulan snake venom in cascade (from Warrel adaptation)

 Clinical Manifestation

 Venomous snake bites may cause a variety of

symptoms, including pain, swelling, tissue
necrosis, low blood pressure, convulsions,
hemorrhage (varying by species of snake),
respiratory paralysis, kidney failure, coma and
death.
SNAKE BITE
Clinical Manifestation
Clinical Manifestations grading of Crotalid Envenomation:
Grade
0: no envenomation
I: Minimal envenomation
II: Moderate envenomation
III: Severe envenomation
IV: Very Severe envenomation
Signs and Symptoms
One or more fang marks, minimal pain, less than 1 inchi of
surrounding edema and erythema at 12 h, systemic
involvement
Fang marks; moderate and severe pain, 1 to 5 inches of
surrounding edema and erythema in the first 12 h after
bite, systemic involvement usually notpresent
Fang marks;severe pain, 6 to 12 inches of surrounding
edema and erythema in the first 12 h after bite, possible
systemic involvement including nausea, vomiting,
giddiness, shock or neurotoxic symptoms
Fang marks;severe pain, more than12 inches of
surrounding edema and erythema usually present and
may include generalized petechiae and ecchymosis
Systemic involment is always present, and symptoms may
include renal failure, blood-tinged secretions, coma and
death; local edema may extend beyond the involved
extremity ti the ipsilateral trunk
 First aid for snake bites

Should you be bitten by a snake, it’s

essential to get emergency treatment as
quickly as possible. However, there are some
tips that you should also keep in mind:

•Call 911 immediately.

•Note the time of the bite.
•Keep calm and still as movement can cause
the venom to travel more quickly through the
body.
 First aid for snake bites

Should you be bitten by a snake, it’s essential to

get emergency treatment as quickly as possible.
However, there are some tips that you should also
keep in mind:

•Remove constricting clothing or jewelry because

the area surrounding the bite will likely swell.
•Don’t allow the victim to walk. Carry or transport
them by vehicle.
•Do not kill or handle the snake. Take a picture if
you can but don’t waste time hunting it down.
 First aid myths

There are also several outdated first aid

techniques that are now believed to be
unhelpful or even harmful:
•Do not use a tourniquet.
•Do not cut into the snake bite.
•Do not use a cold compress on the bite.
•Do not give the person any medications
unless directed by a doctor.
 First aid myths

There are also several outdated first aid

techniques that are now believed to be unhelpful or even
harmful:

•Do not raise the area of the bite above the victim’s heart.
•Do not attempt to suck the venom out by mouth.
•Do not use a pump suction device. These devices were
formerly recommended for pumping out snake venom, but
it's now believed that they are more likely to do harm than
good.
 Management snake bite

 Posisi pasien terlentang

 Pencegahan penyebaran bisa ular dari daerah gigitan:
- Tourniquet (?) di proksimal daerah
gigitan/pembengkakan sehingga menghambat
aliran limfe dan vena, tetapi tidak menghalangi aliran
arteri (denyut nadi distal
tetap teraba)
- Letakkan daerah gigitan lebih rendah dari tubuh
(Trendelens position)
- boleh diberikan kompres es local (?)
- Diberi obat analgetik, obat penenang
 Management snake bite

 Posisi pasien terlentang

 penenang
 Perawatan luka: setelah dilakukan cross-section
luka dengan anestesi lokal, untuk mengeluarkan
bisa dalam darah daerah gigitan. Bila perlu darah
dihisap melalui breast pump semprit atau dengan
mulut (?) (bisa ular tidak berbahaya bila tertelan)
 Diberikan anti bisa (antivenin)
Management snake bite
Management
snake bite
MANAGEMENT
SNAKE BITE
 SERUM
ANTI BISA ULAR (SABU)
Hymenoptera venom

Hymenoptera (which includes

bees, yellow jackets, wasps,
and hornets)
 Arthropod bite and sting
 Caused by bite or sting of difference order of Arachnidae, ie;
Araneae (spider), Acarina (ticks and mite), and scorpiones
(scorpion)
 Araneae induce pain at the site of bite, which may followed by
localized erythema piloerection and sweating at the wound site.
Black widow may cause more serious condition because of
alpha-latrotoxin which may induced agonizing crampy
abdominal pain and muscle spasm and some time paralysis.
 SPIDER

Black widow spider Tarantula

 Antivenomous
serum
 Antitetanic serum (A.T.S.), antitoksin tetanus
 Antitoxic serum, anti toksin
 Anti rabies serum, antiserum yang diperoleh dari
serum darah atau plasma hewan (biasanya kuda)
yang telah diimunisasi dengan vaksin rabies,
digunakan untuk profilaksis setelah pajanan melawan
rabies. Imunoglobulin rabies digunakan didalamnya
jika tersedia.
 Manifestasi klinis

 Gigitan ular berbisa , toksin bersifat hematotoksik,

neurotoksik, atau histaminik
 Terdapat bekas gigitan yang khas, yaitu dua luka tusuk
dengan jarak tertentu, dapat disertai luka bekas gigitan
gigi bawah yang lebih dangkal
 Ecchymosis, edema dan perdarahan lokal, disertai nyeri
hebat tempat gigitan dan bengkak
 Pasien dapat kolaps atau pingsan. Depresi pernapasan
dan sirkulasi, dan atau gejala neurologik, mungkin
muntah-muntah.
DOG BITE
(RABIES)
 DOG BITE
(RABIES)

 Penyakit infeksi akut pada sistem saraf pusat yang biasanya

bersifat fatal pada mamalia, termasuk manusia, disebabkan oleh
rhabdovirus
 Penyakit ini biasanya menyebar melalui kontaminasi dengan air
liur yang mengandung virus dari gigitan hewan yang terinfeksi
 Infeksi aerosol dapat timbul melalui rute respirasi,transplantasi,
atau ingesti jaringan yang terinfeksi
 Vektor, hewan yang penting mencakup anjing, kucing,
kelelawar, musang, srigala dan rubah.
DOG BITE
(RABIES)
 Masa Inkubasi

 Pada manusia, atau hewan sangat bervariasi

 Tergantung pada ukuran gigitan dan tempat
bagian tubuh yang terkena gigitan
 Masa inkubasi pendek apabila gigitan
mengenai tempat yang lebih dekat dengan
otak
 Manifestasi klinik

 Rasa kebal, nyeri, atau sensasi terbakar pada daerah

gigitan
 Periode hipereksitabilitas, halusinasi, delirium, dan
kelakuan aneh bergantian dengan periode diam dan
lemah
 Spasme otot-otot faring dan laring yang nyeri,
hipersalivasi, dan ketakutan yang dicetuskan dengan
usaha untauk minum atau bahkan hanya melihat
cairan (hidrofobia)
 Stadium

 Furious rabies, bentuk atau stadium rabies

dengan gejala yang menonjol adalah aktivitas
mororik yang berlebihan
 Paralytic rabies, bentuk atau stadium rabies
dengan gejala utamanya ialah paralisis spinal
asenden. Disebut juga dump rabies.
 Prognosis

 Sangat jarang sembuh

 Kejang-kejang, meningismus, paralisis dan
koma
 Kematian karena depresi pernapasan progresif
dan gagal kardiorespirasi
 Management
dog bite (rabies)
Penderita gigitan anjing, kucing, kera, segera:
 Cuci luka gigitan dengan sabun, deterjen lain di air mengalir selama
10-15 menit dan beri anti septik (betadine, alkohol 70% obat merah
dan lain-lain)  rujuk ke Rumah Sakit

Penanganan luka gigitan:

 Ulangi cuci luka gigitan dengan sabun/deterjen selama 10-15 menit
dan beri anti septik (betadine, alkohol 70% obat merah dll)
 Anamnesis (apakah didahului tindakan provokatif, hewan
menunjukkan gejala rabies, penderita dan hewan pernah divaksinisasi
dan kapan?)
 Identifikasi luka gigitan:
Luka resiko tinggi: Jilatan/luka pada mukosa, luka di atas daerah bahu
(mukosa, leher, kepala), luka pada jari tangan/ kaki, genitalia, luka
lebar/dalam dan luka yang banyak (multiple wound).
 Berikan vaksinasi sesuai petunjuk bagan berikut :
 Bagan penatalaksaan
Kasus Gigitan Hewan Tersangka Rabies
Kasus gigitan
Anjing, kucing, kera

Hewan tidak tertangkap Hewan tertangkap

Hilang/mati/dibunuh Observasi 10-14 hari

Luka Luka
resiko tinggi Luka resiko tinggi Luka
resiko rendah resiko rendah

Segera diberi Segera diberi Segera diberi

Vaksin & serum Vaksin Vaksin& serum Tidak diberi Vaksin
tunggu Hasil Observasi

Jika tidak Hewan Hewan Hewan Hewan

Spesimen otak hewan Dapat diperiksa sehat
Dapat diperiksa di Lab mati mati Sehat
Laboratorium
Lanjutkan vaksin
Stop Beri/lanjutkan vaksin Tidak
vaksin Di vaksin
Positif Spesimen otak hewan
Negatif
Diperiksa di Lab

Lanjutkan Stop vaksin Positif Negatif

Vaksin

Lanjutkan vaksin Stop vaksin

 Snake bite

 Seorang laki-laki umur 40 tahun, dibawa ke IGD (instalasi gawat

darurat) karena mendadak nyeri kepala, pandangan kabur, muntah,
berkeringat, menggigil dan sesak nafas. Riwayat satu jam yll,
sewaktu membersihkan semak-semak digigit ular. Pada pemeriksaan
fisik didapatkan hipotensi, kelemahan otot.

 Pada ibu jari tampak bekas gigitan ( lubang dan luka yang dibuat
taring ular), kulit sekitar gigitan bengkak, ekimosis, nekrosis dan
nyeri. Terapi dilakukan insisi silang ( cross incision), debridemen,
pemberian antivenom SABU (serum anti bisa ular), antibiotik dan
infus RL.
 References
1. Brunicardi FC, Andersen DK, Billiar TR, Dunn DL, Hunter
JG, Pollock RE. Schwartz’s Principle of Surgery.8 th ed.
New York: McGRAW-HILL. 2005
2. Way LW, Doherty GM. Current Surgical Diagnosis &
Treatment. 11th ed. Boston: McGRAW-HILL. 2003
3. Auerbach PS, Norris RL. Disorders caused by reptile bites
and marine animal exposure.In Karper DL, et al.
Harrison’s Principles of Internal Medicine. 16 th ed. New
York: McGRAW-HILL. 2005.
4. Dep. Kes. Republik Indonesia DITJEN PPM-PL
diperbanyak oleh Dinas Kesehatan Kota Yogyakarta th.
2008