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Dr Mohammad Zikri Ahmad Emergency Medicine Specialist Hospital Universiti Sains Malaysia

Jika ular menyusur akar sekalipun tak akan hilang bisanya

Orang mulia atau berpangkat tinggi tidak akan jatuh darjatnya sekalipun dia bergaul dengan orang kebanyakan

Anda diingatkan bahawa tindakan tatatertib akan dikenakan kepada sesiapa yang mengular di dalam kelas ini

Your camping trip fella c/o sudden foot pain

He suspects something has bitten him and quickly it slithers away into the wood..

First aid
Suck Cupping Incise Ice Tourniquet DONT!

Kill? Bring it to hospital? Hold snake? Transfer

Key points
Retard absorption BLS Complications

Reassurance Pressure immobilisation Leave wound alone No tourniquet Transfer ASAP

Your patient is now at the ED

Pt comes with tournique

Triage ABC + Resuscitation Release tournique? Surge of venom Anti venom Anaphylaxis

Ular dipalu biarlah mati, pemalu janganlah patah, tanah janganlah lembang
Apabila membuat sesuatu pekerjaan biarlah dengan cermat, bijak, dan berhati-hati

With ptosis
Brain at stake? Elapidae? Viperidae? Other findings? Whats the worst that can happen?

Pain/swelling Ptosis Ophthalmoplegia Dysphagia Aphasia Respiratory paralysis


Minimal skin lesion CNS manifestation

With severe body/muscle ache

Sea snake? Rhabdomyolysis

With multiple bruises

Bleeding at stake?

Extensive local effects Immediate pain Swelling Blisters Necrosis Systemic bleeding tendencies

Aha, we have antivenom in the fridge..

Lets roll But WAIT!

Ask for
Part of body Timing Type of snake Atopy

Look for
Vital signs Fang marks Local skin signs Distal pulses Bleeding/ecchymosis Neurotoxicity Muscle tenderness Urine

Urine 20 min whole blood clotting test PT/aPTT/INR Others

Ular berlingkar di gulungan tikar..

Orang jahat yang menyamarkan diri dalam kumpulan orang baik-baik

Whats inside the venom?

Procoagulant enzymes Phospholipase A2 myo/neuro/cardiotoxic Proteases necrosis Polypeptide toxins NMJ trans Lots more!

What does antivenom do?

Heterologues antibodies Binds/neutralize venom molecules

Antivenom : Indications
Progressive signs and symptoms i.e. Worsening local injuries Abnormal results Systemic manifestations

Antivenom : Systemic
Hemostatic abnormalities Neurotoxity CVS dysfunction Rhabdomyolysis ARF

Antivenom : Local injuries

limb swelling Extensive bruising Rapid swelling

Which antivenom?
Monovalent Polyvalent

Aint got no antivenom!

Kraits, coral, green vipers

Species Antivenom Manufacturer

Initial dose 100 mls

Malayan pit viper Thai Red Cross Cobra

Twyford Pharmaceuticals (monovalent)

50 mls (local) 100 mls (systemic) Serum Institute of India; 50 mls (local) Biological E. Limited, India 100 150 mls (Polyvalent) (systemic)
Thai Red Cross (Monovalent)

King cobra Common sea snake

50 100 mls

CSL, Australia (polyvalent) 1 000 units (1 vial)

Antivenom Preparations
May repeat until sign resolved Dilute 5-10ml/kg Big child dilute in 500ml 1 hour

Sensitivity test X Local injection X Pretreatment adrenaline SC controversial Adrenaline/HCT/H-antagonist/resus

HCT/antihistamine premed?

Reaction to antivenom
Early Anaphylaxis Pyrogenic reactions Late reactions serum sickness

Malaysian krait/coral snakes Edrophonium Neostigmine Atropine

What else?
Analgesia Antibiotics Antitetanus Respiratory support AKI

Wound management Compartment syndrome > fasciotomy Ortho/surgeon referral DIVC Wound I&D

What do I do?
First Aid Resuscitation Antivenom Symptomatic Supportive Neuro complication Hemorrhagic complications Rhabdomyolysis/AKI

Manusia mati meninggal belang, ular mati meninggalkan..?

Reflex bite

A 20 year old comes to you with alleged snake bite

and a bag containing a snake!

Is it venomous?
Viperidae Elapidae (Cobra/Coral/Krait/Sea snake)

How would Viperidae look like?

Triangular head Pits: eye-nostril Retractable fangs

How would Elapidae look like?

Short fixed fangs Brightly coloured Triangular body shape Tail flat laterally Defensive posture

prophylactic antivenom

Delayed antivenom at district hospitals

Polyvalent antivenom for ALL

Smaller antivenom doses for children

Hydrocortisone/antihistamine pretreatment

Identification of: Viperidae Elapidae Pitfalls

First Aid Emergency management Antivenom Symptomatic Supportive

Ular apa paling rendah IQnya ?

Ular kapak bodoh

Ular apa paling paling rajin sembahyang?

Ular kapak tokong

Ular Kobra (Naja naja spuitatrix)

Ular katang belang/Banded krait

Blue coral snake

Yellow bellied sea snake

Ular tikus

Thanks for listening!

Tintinnali Emedicine A PPT by Consultant Paediatrician