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Dr .dr.

Tri Maharani MSi SpEM


Cara Tradisional

-Sucking Poison Snake dengan mulut


-Compress Bite Wounds with bonggol pisang,asam
jawa,akar kayu gambir
-black stone and electric treatment
-Torniqueit
-inj corticosteroid
-cross incision dengan pisau

Black stone from papua

Menurut WHO 2010


PENANGANAN GIGITAN ULAR (SNAKEBITE)
Curiga snakebite seharusnya diterapi sebagai kegawatan
medik.
Step 1 : Metode pressure immobilisasi untuk Snakebite
Step 2 : Identifikasi dan deteksi venom/racun ular
Step 3 :Penanganan Envenomisasi

Apa itu bisa ular?

Venom composition
More than 90% of snake venom (dry weight) is
protein.
Each venom contains more than a hundred
different proteins:
enzymes (constituting 80-90% of viperid and 2570% of elapid venoms),
non-enzymatic polypeptide toxins,
and non-toxic proteins such as nerve growth
factor.

Venom enzym

These include digestive hydrolases,


hyaluronidase, and activators or inactivators
of physiological processes, such as
kininogenase.
Most venoms contain -amino acid oxidase,
phosphomono- and diesterases, 5nucleotidase, DNAase, NAD-nucleosidase,
phospholipase A and peptidases.
l

Zinc metalloproteinase haemorrhagins:


Damage vascular endothelium, causing bleeding.
Procoagulant enzymes:
Venoms of Viperidae and some Elapidae and Colubridae contain
serine proteases and other procoagulant enzymes that are thrombinlike or activate factor X, prothrombin and other clotting factors.

These enzymes stimulate blood clotting with formation of fibrin in the


blood stream.
Paradoxically, this process results in incoagulable blood because most
of the fibrin clot is broken down immediately by the bodys own
plasmin fibrinolytic system and, sometimes within 30 minutes of the
bite, the levels of clotting factors are so depleted (consumption
coagulopathy) that the blood will not clot.
Some venoms contain multiple anti-haemostatic factors.
For example, Russells viper venom contains toxins that activate
factors V, X, IX and XIII, fibrinolysis, protein C, platelet aggregation,
anticoagulation and haemorrhage

Phospholipase A (lecithinase):
The most widespread and extensively studied of all
venom enzymes. It damages mitochondria, red blood
cells,leucocytes, platelets, peripheral nerve endings,
skeletal muscle, vascular endothelium, and other
membranes, produces presynaptic neurotoxic activity,
opiate-like sedative effects, leads to the
autopharmacological release of histamine and anticoagulation.
Acetylcholinesterase: Although found in most elapid
venoms, it does not contribute to their neurotoxicity.
Hyaluronidase: Promotes the spread of venom through
tissues.Proteolytic enzymes (metalloproteinases,
endopeptidases or hydrolases) and polypetide
cytotoxins (cardiotoxins): Increase vascular
permeability causing oedema, blistering, bruising and
necrosis at the site of the bite.
2

Venom polypeptide toxins (neurotoxins)


Postsynaptic () neurotoxins such as bungarotoxin and cobrotoxin, consist of 60-62
or 66-74 amino acids. They bind to acetylcholine
receptors at the motor endplate.
Presynaptic () neurotoxins such as bungarotoxin, crotoxin, and taipoxin, contain
120-140 amino acids and a phospholipase A
subunit.
These release acetylcholine at the nerve endings
at neuromuscular junctions and then damage
the endings, preventing further release of
transmitter.

Envenomasi sistemik dan lokal

First aid

Venom detection kit

kasus

Kasus
O Laki-laki 16 tahun datang ke IGD RSU Dr. H. Koesnadi

Bondowoso dengan keluhan utama sesak nafas.


Keluhan penyerta kesulitan membuka mata, nyeri
hebat di seluruh tubuh, dirasakan sejak 2 jam sebelum
dibawa ke IGD. Diketahui 4 jam sebelumnya pasien
digigit oleh ular belang berwarna hitam putih pada jari
ke 4 tangan kanan.
O Hasil laboratorium : Normal
O Elektrocardiografi : sinus takikardi
O Tes 20 menit pembekuan darah : koagulatsi (+)

Pendahuluan

O Pada tahun 1954, menurut Swaroop dan Grab pada

penghitungan statistik, WHO, diperkirakan sekitar


500.000 kasus gigitan ular dan sekitar 30.000
40.000 kasus kematian di dunia dalam 1 tahun, sekitar
25.000 35.000 kematian di Asia.
O Pada tahun 1998, Chippaux mempublikasikan sebuah
penelitian dengan total kasus gigitan ular per tahun
sekitar 5 juta kasus dengan 125.000 kasus kematian di
dunia. (1)
O Kasus gigitan ular yang tercatat di Indonesia sangat
terbatas, distribusi data juga sangat kurang. (2)
O Terdapat 3 kasus gigitan ular Bungarus sp. yang terjadi
di Bondowoso dengan tidak ada satupun kasus
kematian.

DISKUSI

DISKUSI

DISKUSI

29th March 2015

Time

30th March 2015

10.30 am

1.00 pm

10.00 pm

4.00 am

7.00 am

10.00 am

Complaints

Dyspneu,

No dyspneu,

Blurred vision,
dyspneu, pain
all of the body

Blurred vision,
pain all of the
body

Pain all of the


body

Pain all of the


body decreased

Pain score

9/10

6/10

8/10

6/10

6/10

4/10

110/70

120/75

116/71

115/71

117/78

21

29

20

24

24

88

144

120

79

80

36.9

36.6

36.8

36.8

36.4

He moved tocouldnt speak pain all of the


observation room
fluently, pain
body, he spoke
with a betterall of the body more fluently
condition

Airway Breathing
BloodPress.
100/60 and
Circulation must be
Resp. Ratekeep stable30
Repeat : 100 cc NaCl
0.9% + 2 vial
Heart Rate
130 SABU
Atropine 1 mg iv and
o
Temp. ( C)
36.8 2 mg iv
Physostigmin
Morphine 1 mg iv
Ptosis (mm)

2/2

2/2

2/2

2/2

2/2

2/2

SpO2 (%)

94

100

95

98

98

99

Hb (g/dL)

12.8

WBC (/mm)

6.100

Repeat :- 100 cc

Platelet(/mm)

337.000

NaCl 0.9% + 2
vial SABU

PCV (%)

35

Repeat : Atropine
1 mg iv and
Physostigmin
- 2 mg
iv
-

29TH MARCH 2015 AT 11.30 PM

30th March 2015

Time

10.00 pm

76

7.00 pm
Repeat :
100Pain
cc NaCl
Pain all of the body
all of the body
decreased, only in bite0.9%
decreased,
+ 2 vialonly in bite
site
site
SABU
Atropine
2/10
2/10 1
mg iv and
113/72
111/71
Physostigmin
2 mg iv
18
18
Ketorolac 30
mg 81
iv
110

Temp. ( C)

36.8

36.6

36.5

36.8

Ptosis (mm)

2/2

2/2

2/2

2/2

SpO2 (%)

100

99

100

100

Hb (g/dL)

WBC (/mm)

Platelet(/mm)

PCV (%)

Repeat :
100 cc NaCl
Complaints
0.9% + 2 vial
SABU
Atropine
Pain
score 1
mg iv and
Blood
Press.
Physostigmin
2 mg iv
Resp. Rate
Ketorolac 30
mgRate
iv
Heart
o

1.00 pm
Pain all of the body
decreased, only in bite
site

2/10
103/68
17

4.00 pm

Repeat : Atropine
- 1 mg iv
and Physostigmin 2 mg iv
-

Pain all of the body


decreased, only in bite
site

2/10
118/78
19
90

30TH MARCH 2015

31th March 2015

Time

1st April 2015

4.00 am

12.00 pm

18.00 pm

04.00

Complaints

Pain only in bite site

Pain only in bite site

Pain only in bite site

No complaint

Pain score

2/10

1/10

1/10

1/10

Blood Press.

100/60

114/70

111/72

113/70

Resp. Rate

18

22

19

19

Heart Rate

88

78

81

88

Temp. ( C)

36.8

36.6

36.3

36.8

Ptosis (mm)

1/2

-/-

-/-

-/-

SpO2 (%)

100

100

99

100

HbRepeat
(g/dL):
100 cc
WBC NaCl
(/mm)
0.9%
+ 2 vial
Platelet(/mm)
SABU
(%)
Ketorolac
PCV
30 mg iv

Ketorolac 30 mg iv
-

DISKUSI

DISKUSI

DISKUSI

KESIMPULAN
O Penanganan

awal
yang
benar
dikombinasikan dengan antibisa ular
spesifik
serta
terapi
suportif
dan
simptomatis yang benar, dapat menurunkan
angka kesakitan dan kematian pasien.

Hemotoxin bite

antivenom

Mengukur Kecepatan Progresi Proksimal Rate of Proximal


Progression (RPP) Edema

TES 20 MENIT PEMBEKUAN DARAH

Hemotoxin SNAKE BITE

NEKROSIS KOBRA BITE

BULLAE
HEMOTOKSIN

Dr.dr.Tri Maharani Msi SpEM

VENOM OPHTHALMIA:
DISCUSSION

Symptoms and complications include :


-pain
-hyperemia
-blepharitis
-blepharospasm
-corneal erosions
-anterior uveitis
Delay or lack of treatment may result in corneal
opacity, hypopyon or blindness.

Venom Ophthalmia
Snake venom composition is
protein (more than 90%)
Wide variety of post synaptic
three finger fold
neurotoxins,
cytotoxins,cardiotoxins and
enzymes (PLA2).
Each venom contains more
than a hundred different
proteins:
1.
2.
3.

enzymes (25-70% of
elapid venoms)
non-enzymatic
polypeptide toxins
(cobrotoxin)
non-toxic proteins (nerve
growth factor)

VENOM OPHTHALMIA:
WHAT CAUSES OCULAR
TOXICITY?
1.Cardiotoxin
In large,responsible for ocular toxicity
Direct lytic factor and membrane damaging
properties accounts for chemosis and corneal
abrasions
Works synergystically with Phospholipase A2
Varying toxin and protein fractions of the
venom in different cobra species determine the
different magnitudes of topical ophthalmologic
toxicity they displace ( Fung HT et al, Hong
Kong j.emerg.med. 2009;16:26-28)

VENOM
OPHTHALMIA:WHAT
CAUSES OCULAR
TOXICITY?
2. Corneal collagenase
calcium dependent zinc metalloenzyme
mediates the development of corneal liquefaction and
opacification
Enhanced by topical steriods causing corneal melting

1.FIRST AID IRRIGATION


Initial management- pre hospital and in the emergency
department
Generous volumes of water, saline, ringers lactate or any
available bland fluid including milk

VENOM OPHTHALMIA:
Drug

Purpose

0.5% adrenaline drops

Pain relieve

Topical anaesthetic
(tetracaine)

Pain relieve

topical antimicrobials
(tetracycline or
chloramphenicol)

to prevent endophthalmitis or
blinding corneal opacities

Topical cycloplegic drops


(atropine, scopolamine
,homatropine)

prevention of posterior
synechiae, ciliary spasm and
discomfort

antihistamines
2010

To treat allergic keratoconjunctivitis

*David A Warrell. WHO-SEARO Guidelines for the management of snake-bites

2. TOPICAL ANALGESIA
Vasoconstrictors with weak mydriatic
activity, 0.5% topical adrenaline
Limited use of topical anaesthetic drops
( oxybuprocaine 0.4% or tetracaine)
Overcomes acute blepharospasm,
facilitates irrigation.
Prolonged use of topical anaesthetics
not recommended as adverse effects
include stromal keratocyte, corneal
epithelium toxicity.
Risk of bacterial superinfection in
anaesthesized damaged cornea

3. TOPICAL CYCLOPEGICS
Recommended for anterior segment inflammation
atropine, scopolamine
Reduces risk of posterior synechiae formation and ciliary spasm
Reduces patient discomfort
Complication: acute glaucoma in anterior chamber

4. TOPICAL ANTIBIOTICS
Recommended if corneal erosion cannot be excluded by
flourescein stain and slit lamp examination
Prevents secondary bacterial infection
Tetracycline, cmc, penicillin-streptomycin ointment and
polymixin B sulfate

59

Do and dont

62 KASUS DARI MARET NOPEMBER 2015


3 BUNGARUS
2 COBRA
2 VENOM OFTALMIA
2 NON VEENOMOUS
53 KASUS HEMOTOXIN (TRIMERESURUS ALBO
ATAU INSULARIS )
SEMUANYA SEMBUH
PAKAI ANTI BISA ULAR THAI 4 KASUS
DEBRIDEMENT 1 KASUS

CENTER

SUB

Non medical
Pemetaan lokasi ular
Pengetahuan penanganan awal gigitan ular
Provokasi masyarakat untuk ke tenaga
kesehatan bila digigit ular
Pengetahuan akan pusat rujukan
penanganan gigitan ular dan ketersediaan
serum antibisa ular
Image gallery jenis jenis ular

Pre hospital
In Hospital
Post hospital

Pre hospital

Panduan penanganan awal


Panduan identifikasi ular
Panduan pemetaan lokasi ular
Panduan ketersediaan serum anti bisa ular
dan cara pemakaiannya

BORANG
SNAKE BITE

step by step
1.Sosialisasi cara penanganan yang benar dan
kebutuhan antibisa ular
2..Membuat image gallery tenaga medik dan awam
bisa tahu tentang identifikasi ular
3.Kampenye untk memfoto atau membawa ular yang
mengigit

4.Medsos one line bagi tenaga medis cara


penanganan gigitan ular recs indonesia
5.kit penanganan gigitan ular
6.pemetaan ular untuk memetakan kebutuhan
antibisa ular
7.Membuat borang nasional gigitan ular
8.Membuat buku pedoman untuk puskesmas
dan rumah sakit tentang gigitan ular

Provokasi langsung

Pemerintah
Masyarakat
Tenaga kesehatan
share ilmu ke beberapa negara tetangga

Tidak langsung

Media masa dengan tujuan :


Ke pemerintah
Ke tenaga kesehatan
Ke masyarakat awam

Provokasi ke masyarakat

Pembuatan film

E.N.S.

Kompas 14 juli
2015

Kasus snake
bite dari bulan
maret sampai
juli 2015
41 kasus
35 kasus ular
hijau
(trimesurus
albolabris),2
kasus gigitan
,kobra 2 kasus
1 venom
aftalmia,2
bungarus,2
kaus uar kopi

Bungarus 2
kasus
Gigitan
kobra 2
kasus

Penanganan gigitan ular terbaru menurut WHO 2010 di RS Koesnadi Bondowos

TERIMAKASIH