Mohamad Romdhoni.,dr.Sp.

B FInaCS
Waled general hospital
Snake bite
Introduction

Major public health problems in the tropics.

Emerging as an occupational disease of agricultural
workers
 In view of their strong beliefs and many associated
myths, people resort to magico –religious treatment
for snake bite thus, causing delay in seeking proper
treatment.
SNAKE BITE INCIDENCES
Snake bite deaths worldwide
June 2013-May 2016
COMMONEST INDONESIA venomous snakes –
COMMONEST INDONESIA venomous snakes –
IDENTIFICATION FEATURES
IDENTIFICATION FEATURES
Common location of snake bites
Healthy, angered and hungry snakes unload more venom
than a recently satiated and surprised snake .
Due to the venom, there is cell function degeneration and the final outcome depends on the
type of venom injected.
Snake bite-venom injected

Neurotoxic
enters surrounding tissue Hematotoxic
direct venom action
Cardiotoxic
Capillary absorption

blood vessels lymphatics

Target organs-systemic effect

Neurotoxic
Hematotoxic
Cardiotoxic
Myotoxic
 Fang marks Persistent bleeding from fang
marks 40min after bite of pit
viper

Blistering at
site of bite
Snake bite- Grade (PARRISH)
Other classification
Compartment syndrome
DIC

Pethecie, eccimosis, hematom, subkonjunctival

bleeding Gastrointestinal bleeding
 FIRST AID

The first aid recommended is based around the mnemonic:

"Do it R.I.G.H.T."
It consists of:
R. = Reassure the patient. Seventy per cent of all snakebites are from non venomous species. Only
50% of bites by venomous species actually enveno-mate the patient
I = Immobilize in the same way as a fractured limb. Children can be carried. Use bandages or cloth
to hold the splints, not to block the blood supply or apply pressure. Do not apply any compression in
the form of tight ligatures, they do not work and can be dangerous!
G.H. = Get to Hospital immediately. Traditional remedies have NO PROVEN benefit in treating
snakebite.
T = Tell the doctor of any systemic symptoms such as ptosis that manifest on the way to hospital.
 PRESSURE IMMOBILISATION

Its purpose is to retard the

movement of venom from
bite site into circulation,
thus buying time for the
patient to reach
medical care.
 DO NOTS IN FIRST AID

 Do not apply a tourniquet.

 Do not make cuts or incisions on or near the bitten area.
 Do not use electrical shock.
 Do not freeze or apply extreme cold to the area of bite.
 Do not attempt to suck out venom with your mouth.
 Do not give the victim drink, alcohol or other drugs.
 Do not attempt to capture, handle or kill the snake
and patients should not be taken to quacks.
HOSPITAL MANAGEMENT

Airway breathing circulation Disabiltiy Exposure

Find the sign n symptoms

Hematotoxic, cardiotoxic, neurotoxic, myotoxic

Complete blood count, APTT, PT, INR, Fibrinogen, D-Dimer

SGOT/SGPT, Ureum/Creatinin, electrolite, Blood gas analysis, lactate
ECG
Urine test (Myoglobinuria)
 SKIN TEST is a MUST
Administer in normal saline or D5 500 cc
In 30-6o minutes
Anti-snake Venom Administration

INDICATIONS
 Evidence of systemic toxicity.
 Hemodynamic or respiratory instability
 Hypotension, respiratory distress
 Hemotoxicity
 Clinically significant bleeding or
abnormal coagulation studies
 Neurotoxicity
 Any evidence of toxicity usually beginning with CN
abnormalities and progressing to descending
paralysis including diaphragm Evaluate the progressive of soft
 Evidence of local toxicity tissue swelling by marking the
edema and pain area from non-pain
 Progressive soft tissue swelling site
 NOTE
Different in every country
Depends on the type
(production) of antivenom
Snake bite management PARACETAMOL DONT USE
TRAMADOL NSAID

PAIN
Respiratory paralysis- Cryoprecipitate
ventilator Hematotoxic Fresh frozen plasma
Neurotoxic
Atropine sulfate DIC
VIT K
Nesotigmine Dexamethasone

Wound cleansing
Dopamine Cardiotoxic
ATS/TT
Dressing
Norepinephrine Shock Local wound Elastic bandage
Epinephrine arritmia Antibiotic broad spectrum
Debridement  close defect

Hemodialisis RENAL Compartment

syndrome
Delayed if
FAILURE Fasciotomy PT/APTT>>>
CVVH
Debridement, fasciotomy, closed defect
REFERENCES

 WHO Fact Sheet On Snake Bite .Geneva.WHO. 2015.

 National snakebite management protocol, India. (2008). [online] Avaialable at www://mohfw.nic.in
(Directorate General of Healthand Family Welfare, Ministry of Health and Family Welfare, India).
 Adiwinata R, Nelwan EJ. Snakebite in Indonesia. Acta Medica Indonesiana. 2015; 47(4). hlm. 358-65.
 Biofarma. Serum anti bisa ular (kuda) [internet]. Bandung: Biofarma; 2015 [diakses tanggal 11 Agustus
2017]. Tersedia dari: http://www.biofarma.co.id/?dt_portfoli o=polyvalent-anti-snake-venom-sera.
 Djunaedi D. Penatalaksanaan gigitan ular berbisa. Dalam: Setiati S, Alwi I, Sudoyo AW, Simadibrata M,
Setiyohadi B, Syam AF, editors. Buku ajar ilmu penyakit dalam. Edisi ke-6. Jakarta: Interna Publishing;
2014. hlm. 1085-93.
HATUR NUHUN