tatalaksana gigitan ular

1. Presented by:
Dr. dr. Tri Maharani, M.Si., Sp. EM

2. • WHO 2010 kasus negleted ,2016 masih tetap negleted
Ular berbisa tersebar sangat luas mulai dari laut, darat (dataran
rendah sampai dataran tinggi). Luasnya daerah distribusinya membuta
ular teradaptasi dengan sempurna pada habitatnya.
Variasi habitat, pakan dan persebaran geografi memperlihatkan
perbedaan komposisi racun mereka.
Setiap ular berbisa memiliki karakter bisa yang khas, sehingga antibisa
ular yang digunakanpun juga harus khusus.

3. Maharani ,2016

4. Indonesia mempunyai kasus yang sangat banyak untuk gigitan ular berbisa.
Namun demikian data tersebut tersebar diseluarh rumah sakit dan puskesmas di seluruh
Indonesia.
Data keseluruhan belum terkumpul didalam satu sitem data base.
Data yang terkumpul (Maret 2015 – Agustus 2016) di Kabupaten Bondowoso (Jawa
Timur) saja adalah 148 kasus mulai kasus gigitan,
terdiri dari kasus gigitan Ular viper pohon Trimeresurus insularis (85 kasus),Ular weling
Bungarus candidus (5 kasus), Ular kobra Naja sputatrix (15 kasus). Ular tanah
Colleselasma rhodostoma (2 kasus), 5 kasus gigitan oleh ular tak berbisa (non venomous
snake: ular kopi Coelognathus flavolineatus dan Ular air Xenochrophis trianguligera),
dan 36 kasus gigitan yang tidak dapat diidentifikasi jenis ularnya. Selain itu, terdapat
juga 5 kejadian venom Ophthalmia (mata tersembur oleh bisa Ular kobra Naja
sputatrix) (Maharani,2016)

6. • 1.lingkungan:kebun,sawah,tambang,hutan gunung,rawa
• Carana memakai APD(sandal,sepatu boot,sepattu
berlampu,lampu sener kepala,senter,tongkat,celana panjang
• 2.rumah:rumah kotor sarang tikus,katak,kandang
ayam,membersihkan tumpukan kayu,gundukan rayap,lubang di
dinding kayu,bambu ,menaa anaman bambu,perdu
• 3.pekerjaan:petani,nelayan,penari ular,snake handler,pawwang
ular,restoan menu ular,penyamak kulit ular

8. WHO review 2016
Kolaborasi dokter dan herpetologi sudah
dimulai RECSINDONESIA sejak tahun
2013 sampai sekarang dalam hal
identifikasi ular

9. Faktor penting:
1.First aids
2.Transportasi
3.Manajemen di pkm dan rs
4.Kesadaran masyarakat
5.Pemulihan fisik dan mental
6.Dukungan pemerintah

10. Indonesia
Jumlah total ular 348 jenis
Yang berbisa:
• Elapidae: 55 jenis
• Viperidae: 21 jenis
• Colubridae: 1 jenis

11. Famili Viperidae
1. Daboia siamensis
Subfamili Crotalinae (Pit Viper)
1. Trimeresurus albolabris
2. Trimeresurus puniceus
3. Calloselasma rhodostoma
4. Tropidolaemus wagleri

12. Calloselasma rhodostoma

13. Daboia russelii siamensis

14. Trimeresurus insularis

15. Trimeresurus albolabris

16. Famili Colubridae (Colubrinae)
1. Boiga Cynodon
2. Boiga multomaculata
3. Boiga dendrophila
4. Boiga irregularis
Famili Elapidae
1. Naja sputatrix
2. Naja sumatrana
3. Opiophagus hannah
4. Calliophis bivirgata
5. Calliophis intestinalis

17. Boiga cynodon

18. Elapid….Naja sputatrix

19. Ophiophagus hannah

20. Rhabdophis chrysargos
E.N.S.

21. Calliophis intestinalis (Ular cabe kecil)

22. Bungarus candidus (Ular weling)

23. Bungarus fasciatus (Ular welang)

24. Micropechis ikaheka
Foto oleh M.D. Kusrini

25. Death adder

26. Papuan taipan (Oxuyuranus
scutellatus)

27. Papuan black snake (Pseudechis
papuanus)

28. Eastern brown snake
(Pseudechis textilis)

29. Ular laut
Blue spotted sea snake
(Hydrophis cyanocinctus)
Thailand

30. Ular laut ekor berupa paddle

31. SNAKE
NON-VENOMOUS VENOMOUS
Cardiotoxin Hemotoxin Neurotoxin
Nephrotoxin
Necrotoxin

33. Who review 2016

34. 1.Bengkak dan memar disebabkan karena venom yg menyebabkan
peningkatan permeabilitas vascular dan ischemia disebabkan karena trombosis
pada first aids yang salah berupa torniquet.
2.Hipotensi dan shock disebabkan hipovolemia leakage plasma dan darah
,vasodilatasi dan kerusakan myocardial
3.Oligopeptida dan vasodilatasii autocoid menyebabkan transient hipotensii
dini
4.Procoagulasi enzyym menyebabkan defibrinogenesis,DIC,coagulopathi
5.Phospolipase adalah anti coagulan
6.Platelet aktiasi atau inhibisi dan sequestrasi menebabkan trombositopeni
7.Perdarahan sistemik spontan disebabkan oleh enzym N metaloprotease
haemorrhagins
8.Complemen akivasi platelet koagulasi darah dan mediator humoral
Patofisiologi venom (WHO
review 2016)

37. PBI

38.  Di rumah sakit
 Ada antibisa ular yang siap diberikan
 Kapan PBI dipakai
 Jarak jauh
 Ular tidak diketahui jenisnya
 Neurotoksin kuat (bungarus dan sea snake)

40. 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)

41. • 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

45. • 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

46. • 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)

48. • 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.

49. 5 cm
5 cm / 2 hours, so
RPP = 2.5 cm/hour

50. 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

51. • 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

52. • 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

53. Presinaptik : Phosolipase A2 merusak vesikel sinaptik release
Postsinaptik:polipeptide toxin yang mengeblock acetylcholin reseptor pada
muscle end plate
Dendrotoxin:K+ channel oksin menstimulasi sehingga terjadi over release
neurotransmitter
Asciculins:anicholinesterase mengeblok normal breakdown dan recycling
neurorasmiier release
Neuromuscular
junction snake toxin

54. Haemotoxin system

55. MONOVALENT POLYVALENT

56. • SABU covers 3 venomous snakes
1. Agkistrodon rhodostoma
2. Naja sputatrix
3. Bungarus fasciatus

59. hemotoxin

64. Naja sputatrix

66. Dr.dr.Tri Maharani Msi SpEM

68. 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)
Recsindonesia.blogspot.com

69. Julian white,2016

70. Nekrotoxin,julian white,2016

72. Julian white 2016