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 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
• 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 (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
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)