A 12YEARS OLD FEMALE WITH

SNAKE BITE ON DEXTER

DORSUMPEDIS REGION

BY:
PAKSI SURYO B G 9 914116 5
JINAN FAIRUZ AR G 9 914117 2

S U P E R V I S E D B Y: D R . A M R U S U N G K A R , S P B . , S P. B P - R E
IDENTITY
Name : Mrs. P
Age : 48 years old
Sex : Female
Religion : Islam
Occupation : Student
Address : Sragen
Medical Record : 01-32-xx-xx
Admission : 30 Januari 2016
CHIEF COMPLAIN
Pain on right foot
RECENT ILLNESS HISTORY
Patient came with complain of pain and swollen on the right leg after snake bite 2 days before admitted to hospital
when she walk to go to home at night. Patient say that the snake was a green. Pain and swwollen felt at the
bite spot in the back of the right food. Pain was felt continuously. There was no breathless, no limp, no nausea
nad no vomit, but there was a movement limitation at right food. Two hours after biten, her parent was bring
her to the traditional healer, then the healer bandage the right foot.. Next day because the complain was no
different then before, her parent go to orderly to seek an antibiotic. Next day pain was still felt, her parent bring
the patient to emergency unit at Moewardi Hospital.
PAST ILLNESS F A M I LY H I S T O R Y

Asthma : denied Heart Disease : denied

Allergy : denied Hypertension : denied
Diabetes Mellitus : denied Diabetes Mellitus : denied
Hypertension : denied Asthma : denied
Heart Disease : denied
Allergy : denied
Hospitalization : denied
Snake bite : denied
ANAMNESIS SISTEMIK
Head: dizziness (-)
Eyes: blurred (- / -), pale (- / -), double vision (- / -)
Nose: cold (-), nosebleeds (-), nasal congestion (-)
Ear: hearing loss (- / -), discharge (- / -), otalgia(- / -)
Mouth: dry mouth (-), bluish lips (-), thrush (-), gums
bleeding (-), cracked lips (-)
Throat: pain on swallowing (-), vomiting blood (-)
Respiration: shortness (-), cough (-), bloody cough
(-), wheezing (-)
Cardiovascular: chest pain (-), sweating (-), fatigue
(-)
Gastrointestinal: nausea (-) vomiting (-), stomach burnt (-)
bloating (-), obstruction (-), vomiting blood (-), black stools
(-), mucoid bloody stools (-), difficult on defecation (-)
Genitourinary: reddish urin (-), pain when urinating (-)
Musculoskeletal: muscle pain (+) on the right foot, joint
pain (+) right ankle, swollen joint (+) on the right foot
Upper Extremities : Pale (-/-), bluish (-/-), swelling (-/-),
injuries (-/-), cool (-/-), feels invulnerable (-/-), restricted
movement (-/-)
Lower Extremities : pale (-/-), bluish (-/-), swelling (+/-),
spot bite (+/-) feels cold (-/-), limited movement (+/-)
PHYSICAL EXAMINATION
PRIMARY SURVEY
Airway • Free
• Inspection: right = left chest movement, spontaneous,
thoracoabdominal, breathing 20 x / min
Breathing • Palpation: crepitation (-)
• Percussion: Sonor (+/+)
• Auscultation: vesicular sound (+ / +), additional sound (-)
Circulation • Blood pressure: 110/70 mmHg, Pulse Rate: 86 x / min
Disability • GCS E4V5M6, light reflex (+ / +), pupil isokor (3mm / 3mm)
Exposure • Temperature 36.5 ° C, lesion (+) see status localist
PHYSICAL EXAMINATION
SECONDARY SURVEY

Head Eyes Nose Ears Mouth Neck Thorax

•Mesochepal •Conjunctival •Septal •secretions (- / •malocclusion •Lymphnode •normochest

pallor (- / -) deviation (-) -), blood (- / -), (-), cyanosis (- enlargement shape, breast
•Sclera •Crepitus (-) tenderness ), bleeding (-), increase in development
jaundice (- / -) •Discharge (-) mastoid (-), gums (-) JVP (-) right = left,
•Pupil isokor tenderness retraction (-),
(3mm / 3mm) tragus (-) tenderness (-)
•Eyelid edema
(- / -)
•Light reflex (+
/ +),
PHYSICAL EXAMINATION
SECONDARY SURVEY
Heart : Pulmo: abdomen: extremities:

• Inspection: ictus • Inspection: right = left • Inspection: distension • Upper Extremities :

cordis does not chest Development (-) Pale (-/-), bluish (-/-),
appear • Palpation: Fremitus • Auscultation: bowel swelling (-/-), injuries
• Palpation: ictus cordis touch right = left, (+) normal (-/-), cool (-/-), feels
palpable not strong tenderness (- / -), • Percussion: timpani invulnerable (-/-),
lift crepitus (- / -) • Palpation: sociable, restricted movement
• Percussion: cardiac • Percussion: sonor / tenderness (-), defans (-/-)
border impression is resonant muscular (-) • Lower Extremities :
not widened • Auscultation: SDV (+ / pale (-/-), bluish (-/-),
• Auscultation: I-II heart +) swelling (+/-), spot
sounds of normal bite (+/-) feels cold (-
intensity, regular, /-), limited
noisy (-) movement (+/-)
PHYSICAL EXAMINATION
SECONDARY SURVEYSTATUS LOCALIST
Regio pedis dextra
Inspection : fang mark (+), oedem (+)
Palpation : pain (+), hipoestesi (-), CRT < 2 detik
ASSESSMENT I
 Snake bite regio dorsum pedis dextra

 PLANNING I
 Complete blood laboratory examination including PT/APTT
 IVFD RL + SABU 1 vial 20 dpm (drip)
 Inj Metronidazole 500mg / 8h
 Inj Ceftriaxon 500 mg / 12h(skin test)
 Inj ATS 1500 IU (skin test)
 Vital sign monitoring
LABORATORY FINDINGS
Examination Result Meassurement Normal
HEMATOLOGI RUTIN
Hemoglobin 14.2 g/dL 13.5-17.5
Hematokrit 41 % 33 – 45
Leukosit 11.5 ribu/µl 4.5 – 11.0
Trombosit 237 ribu/µl 150 – 450
Eritrosit 5.01 juta/µl 4.5-5.90
Golongan darah O
HEMOSTASIS
PT 14.7 detik 10.0 – 15.0
APTT 32.3 detik 20.0 – 40.0
INR 1.220
HbsAg Non reactive Non reactive
ASSESSMENT II
 Post snake bite regio dorsum pedis dextra

 PLANNING II
 IVFD D5% + SABU 1 vial 20dpm (drip)
 Inj. Ceftriaxon 500mg/12h
 PT/APTT evaluation check
 Diet 1200 Kkal, protein 30gr
 Elevasi of the right foot
Literature Review
Definition
 Bite wounds are injuries caused by the mouth and teeth of
animals or humans 4
 These injuries can cause 4
 Tissue damage
 Serious bleeding when the large blood vessels are injured
 Infection by bacteria or other pathogens, such as rabies
 Toxinemia such as the snake bite
 Beginning of inflammation
 Snake species can be distinguished on vipers and snakes are
not venomous 2.5
Classification of Snakes
Family Colubridae (weak)
Snake cow (Zaocys carinatus), snake strap (Dendrelaphis Pictus), a rat snake or serpent
jali (Ptyas korros), and snakes litter (Sibynophis geminatus).

Family Elapidae, Hydropiidae, or Viperidae (strong)

Elapidae have short fangs and erect permanent. Some examples of members of this family are snake
chili (Maticora intestinalis), snake weling (Bungarus Candidus), cobra (Naja sumatrana), and the king cobra
snake(Ophiophagus hannah)
Viperidae has long fangs that normally can be folded into the upper jaw, but can be enforced when it is
attacking its prey
Viperinae
Crotalinae
Crotalinae organs to detect warm-blooded prey (pit organs), which lies between the nostrils and eyes.
Some examples are the snake Viperidae bandotan (Vipera russelli), snake soil (Calloselasma rhodostoma), and
the carcasses of sea snakes (Trimeresurus albolabris) 5
Differences Venomous and Not
Venomous Snake
 Venom contains more than 20 constituent elements, mostly proteins,
including enzymes and toxins polypeptide. Here are some elements of
Snake venin
the venom that has a clinical effect 2:
 Procoagulant enzyme (Viperidae) can stimulate blood clots but also
causes blood not be coagulated.
 Haemorrhagins (zinc metalloproteinase) can damage the endothelial
covering the blood vessels and cause systemic bleeding
spontaneously (spontaneous systemic haemorrhage).
 Cytolytic toxins or necrotic - digest hydrolase (proteolytic enzyme and
phospholipase A) polipentida toxins and other factors that increase
cell membrane permeability and cause local swelling. These toxins
also can destroy cell membranes and tissues.
 Phospholipase A2 haemolytic and myolitik - enzim can destroy the cell
membrane, endothelial, striated muscle, nerve and red blood cells.
 Phospolipase A 2 neurotoxin pre-synaptik (Elapidae and some Viperidae) -
is phospholipases A2 that damage nerve endings, initially releasing
transmitters and increase the release of acetylcholine.
 Post-synaptic neurotoxins (Elapidae) -polipeptida to compete with
acetylcholine receptors at the neuromuscular junction gets and causes
paralysis-like paralysis kuraonium 2

 Venom is composed of several polypeptides that phospholipase A,
hyaluronidase, ATP-ase, 5 nukleotidase, choline esterase, protease,
fosfomonoesterase, RNA-ase, ase DNA. This enzyme causes local tissue
destruction, is toxic to the nerves, causing hemolysis or histamine release
causing anaphylactic reactions. Hyaluronidase damage cell base material
so as to facilitate the spread of toxins 6.
 b. properties Snake venom
 - Venom that is toxic to blood (hematotoksik)
 Venom that is toxic to blood, the venom that attack and destroy (destroy)
cells, red blood cells by way of destroying the stroma lecethine (the walls of
red blood cells), so as the red blood cells become crushed and dissolved
(hemolysis) and out into vessels -pembuluh blood, resulting in the onset of
bleeding in mucous membranes (mucus) in the mouth, nose, throat, and
others.
 - Venom that is toxic to the nervous (neurotoxic)
 Namely venom destructive and paralyzing nerve cell tissues around the bite
wound that causes tissue death of the nerve cells with signs of skin around
the wound looked bluish and black (necrotic).His next deployment and
poisoning affects the central nervous system by way of paralyzing the central
nervous system, such as respiratory and cardiac nerve. The spread of venom
through the body via lymph vessels 4.
 Pathophysiology
 Snake venom produced and stored in a pair of glands under the eyes. Can be removed from
the hollow fangs located in the upper jaw. Fangs the snakes can grow up to 20 mm on a large
rattlesnake.Dose of venom per bite depends on the time elapsed since the first bite, the
degree of threat received by a snake, as well as the size of the prey. Nostrils respond to heat
emission of prey, which can allow the snake to change the number could be issued.
 Can usually be liquid. Protein enzymatic ingredients can deliver
destructive. Proteases, collagenase, and arginine ester hydrolase has been identified in can
pit viper. Local effects of the venom is a potential marker for the systemic breakdown of the
organ system functions. One effect is local bleeding, coagulopathy usually does not happen
when venomasi. Other effects, such as localized edema, increase capillary leakage and
interstitial fluid in the lungs.
 Pulmonary mechanism may change significantly. The end effect in the form of cell
death that can increase the concentration of lactic acid secondary to changes in volume
status and requires an increase in minute ventilation. The effects of neuromuscular blockade
can cause a worsening of the movement of the diaphragm. Heart failure can be caused by
acidosis and hypotension. Myonekrosis caused by myoglobinuria and kidney disorders 7.
 D. Signs and Symptoms of snakebite By Type Snake

 Bite Elapidae
 (eg: cobra, snake Weling, cobra, snake anang, chili snake, coral snake, Mambas, kraits)
 Bursts cobra in the eye can cause throbbing pain, stiffness of the eyelids, swelling around the
mouth.
 Picture of severe pain, blisters, and skin damaged
 Once bitten by a snake
 15 mins: systemic symptoms
 10 hours: paralysis of the muscles of the face, lips, tongue, throat, making it difficult to speak,
difficulty swallowing, muscle weakness, ptosis, headache, cold skin, vomiting, blurred vision,
paresthesia around the mouth. Death can occur within 24 hours
 Bite Viporidae / Crotalidae
 (eg land snakes, green snakes, snake bandotan Puspo)
 Local symptoms arise within 15 minutes, after a few hours in the form of swelling
near the bite that spreads to the whole body.
 Systemic symptoms appear after 5 minutes or after a few hours
 Severe poisoning is characterized by swelling above the elbows and knees within 2
hours or marked by severe bleeding.

 Bite Hydropiridae
 (eg sea snakes)
 Immediately arise headaches, thick tongue, sweating and vomiting.
 After 30 minutes to several hours usually appear stiff and thorough pain, dilated
pupils, jaw muscle spasm, muscle paralysis, myoglobinuria marked with dark brown
urine (important for diagnosis), kidney damage and cardiac arrest
 According to Schwartz, snake bites can be classified as follows
Degree Venerasi Bite wounds Pain Edema / erythema Systemic signs

0 0 + +/- <3cm / 12> 0

I +/- + + 3-12 cm / 12 hours 0
II + + +++ > 12-25 cm / 12 hours +
Neurotoxic,
Nausea, dizziness, shock
III ++ + +++ > 25 cm / 12 hours ++
Shock, petechiae,
ecchymosis
IV +++ + +++ > ekstrimitas ++
Disorders renal
physiology,
Coma, bleeding
 Clinical Diagnosis
 History:
 History is right about the snake bites as well as progression of symptoms and signs of both
local and systemic is very important.
 The four initial questions useful:
 1. on the part of the body where you are bitten by a snake?
 Physicians can quickly see evidence that the patient has been bitten by a snake (for example,
the former canines) as well as the origin and expansion of local envenomasi mark.
 2. when and at what time you are bitten by a snake?
 Estimated envenomasi severity depend on how much time passed since the patient bitten by
a snake. When the patient arrived at the hospital shortly after bitten by a snake, can be
obtained fraction signs and symptoms even though a large amount of venom has been
injected. If the patient is bitten by a snake while sleeping, the possibility of a snake bite is
Kraits (rattlesnake), when in the rice fields, most likely by a cobra or russel viper (rattlesnake),
in case when picking fruit, pit viper green (rattlesnake), when it occurs while swimming or
while crossing a river, cobra (fresh water), sea snakes (sea or brackish water).
 3. treatment of snake has bitten you?
 Snake has bitten patients often killed outright and kept away from the patient. If the snake has
bitten been found, the snake should be brought together when the patient comes to the
hospital, for easy identification if the snake is poisonous or not. If the species proved to be
harmless (or not a snake at all) the patient can be immediately soothed and discharged from
hospital.
 4. What do you feel right now?
 This question can bring the doctor to the analysis of body systems involved. Snakebite
symptoms that are common in the beginning was vomiting. Patients who experience
thrombocytopenia or impaired blood clotting will bleed from a wound that has long
terjdi. Patients should be asked about the production of urine and the urine color since bitten
by a snake. Patients who complain of drowsiness, which seemed to fall eyelids, blurred vision
or double, the possibility of signaling has been circulating neurotoxin.

 Physical examination
 There is no simple way to identify venomous snakes are dangerous. Some of the venomous
snakes are not dangerous has evolved to look almost identical to that venomous. However,
some well-known venomous snakes can be recognized from the size, shape, color, pattern
scales, behavior and sound he made ​when feeling threatened. 2.
 Not all poisonous snake bite at a time can inject the victim. People who are bitten by a snake,
although there could be injected into the body can be a panic, breathing becomes rapid,
hands and legs become stiff, and the head becomes dizzy. Symptoms and signs of snake bite
will vary according to species of snake bite and the amount can be injected into the
victim. Symptoms and signs include bite marks canines (fang marks), local pain, bleeding
local, bruising, swollen lymph nodes, sore, blister, local infection, and tissue necrosis (mainly
due to snake bites from the family Viperidae) 2 ,
 Signs and Symptoms Local on the bite area 2:
 -Bite marks canines (fang marks) -Lymphangitis
 -Local pain -Enlarged lymph nodes
 -Local bleeding -Inflammation (swollen, red, hot)
 -Redness
 -Blister
 -Local infections, abscesses
 -Necrosis
Repeated Dose Criteria Initiation
Antivenin
 Coagulopathy persist or recurrent after 6 hours or bleeding
after 1-2 hours, there is a worsening of symptoms of neurotoxic
or cardiovascular symptoms after 1-2 hours
 When the coagulation of blood remain, 6 hours antivenin after
initial dose, the same dose should be repeated.
 In patients who continue to experience rapid bleeding, the
dose should be repeated antibisa between 1-2 hours.
 In the case of worsening symptoms of neurotoxic or
cardiovascular symptoms, antibisa initial dose should be
repeated after 1-2 hours and supportive care should be
considered
Response after Antivenin Injection
 General: patients feel better, nausea, vomiting and pain as a whole can be lost
quickly.
 Spontaneous systemic bleeding (eg from the gums): usually stalled at 15-30
minutes.
 Blood coagulation: usually stops within 3-9 hours. Bleeding from wounds heal
faster in part stalled
 In the shock patients: blood pressure may rise between 30-60 minutes of the first
and arrhythmias such as sinus bradycardia can be resolved
 In patients with type neurotoxicity post synapse (the bite of a cobra) will improve
within 30 minutes after administration antibisa, but it usually takes bebeerapa
hours. In the type of pre-synaptic toxicity (Kraits and sea snakes) do not seem
response.
 Active hemolysis and rhabdomyolysis decline within a few hours and the color of
the urine will return to its normal color.
Observation
 General condition and vital signs, sign envenomation investigation
 For the case of a dry bite (can not be injected) from the viper, observation in the
emergency department for 8-10 hours, continued observations in the room
 Patients with signs envenomation (poisoning) were severe requiring special care
in the ICU for the administration of blood products, providing invasive monitoring,
and ensure protection of the airway.
 Observation for coral snake bites for at least 24 hours.
 Serial evaluation for grading further and to get rid of compartment syndrome.
 Measure the pressure compartment every 30-120 minutes.
 Fasciotomy indicated for pressure more than 30-40 mmHg. Depending on the degree of
severity of the bite, further blood tests may be needed, such as blood clotting time,
platelet count, and fibrinogen levels
Conservative Treatment
 Bed rest
 Wound treatment with iodine, hibitane
 Intravenous access (fluids and medications)
 Administration of sedative drugs (diazepam, promethazine)
 Administration of analgesic drugs (ASA, Paracetamol,
Ibuprofen, Indomethacin, pethidine)
 Antibiotic prophylaxis (PPF, Amoxicillin, Ampicillin, Gentamicin)
 Tetanus toxoid
 Steroids (Hidrocortison, Dexamethasone)
Complications
 Compartment syndrome
 Local wound complications can include infections and skin
loss
 Cardiovascular complications, hematologic complications,
and lung collapse may occur
 Children have a higher risk for the occurrence of death or
serious complications because of their body size smaller
 Complications associated with antivenin including rapid-type
hypersensitivity reactions (anaphylaxis, type I) and delayed
type (serum sickness, type III)7
Prognosis
 Besides the fact that there may be as many as 8,000 cases of venomous snake
bites, there are fewer than 10 deaths, and most of the fatal cases have not
sought help for a reason or another.
 Possible complications of non-venomous snake bites include teeth retained on
the bite wound or wound infections (including tetanus). Snakes do not carry or
transmit rabies 6
 Dry bite have the same complications with the non-venomous snake bites.
 A victim who is still very young, elderly, or have other systemic diseases were able
to tolerate the injection amount can be similar to healthy adults.
 The availability of emergency medical care and, most importantly, antivenin,
can affect how the state of the victim.
 A victim who initially look good condition can be very painful 6
Thank You