Presented by:

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

• 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
 LOCAL SYSTEMIC
• Swelling > half bitten • Haemostatic abnormality
limb/48 hours • Neurotoxic signs
• Toes especially fingers • Cardiovascular
abnormalities
• Rapid extension within • Acute kidney injury
a few hours • Myoglobinuria/generalised
• Enlarged tender rhabdomyolysis/haemolysis
lymphnode draining • Supporting lab evidence of
the affected area systemic envenoming

(A. Khaldun, 2015)

• 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.
• 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.
• 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 40-80 drop per
minute neurootoxin
• Repeated every 2 hours. BE AWARE TO RE-ENVENOMATION SIGN!!!
• 2 vials SABU + 500 ml Normal Saline 0.9% dripped 40-80 drop per
minute hemotoxin
• Repeated every 6hours. 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
Laporan kasus trimeresurus
albolabris
Laporan kasus di indonesia
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)