CASE REPORT SESSION

* Kepaniteraan Klinik Senior/G1A217043/Ag

ustus 2018
** Pembimbing : dr. Amran Sinaga, Sp.B

snake bite

SISKA MELIANA
G1A217043
dr. Amran Sinaga, Sp.B
INTRODUCTION

 It is clear that in many parts of the South East

Asian region, snake-bite is an important medic
al emergency and cause of hospital admissio
n.
 It results in the death or chronic disability of ma
ny active younger people, especially those invo
lved in farming and plantation work.
 Diagnosis of the species of snake responsible f
or the bite is important for optimal clinical mana
gement. This may be achieved by identifying th
e dead snake or by inference from the “clin
 Case
44 year old male
 Arrived at 22/08/18 PAST HISTORY
 bitten by snake on left hand (digitis secundus)
 5 hours before he has rushed to hospital Allergies -
 while farming
 in afternoon in the wood States feels pained,
confused and nause SOCIAL ECONOMIC
 The snake that bite him was green and as big a
s the big toe Work as a farmer
 No bandage applied initially
GENERAL EXAMINATION
VITAL SIGNS
Compos Mentis (GCS 15)

BP: 120/70 mmHg

Pulse: 76x/minutes

R/R: 24x/minutes

Afebrile (36,5 C)
PHYSICAL EXAM

 Appears weak
 Vital signs stable
 Oral mucosa and tongue wet
 Lungs: vesicular (normal)
 Cardiac: murmur (-), gallop (-)
 Abdominal: normal
LOCALIZATION

I: fang marks (+), oedem (+),

hyperemic
P: local pain
M: normal passive and active
movement

REGION OF DORSUM MANUS SINISTRA PROXIMAL DIGITI SECONDUS

INVESTIGATIONS

WBC : 9,74 109/L (4-10)

RBC : 4,18 1012/L (3,50- 5,50)
HGB : 12,3 g/dl (11,0-16,0)
HCT : 37,3 % (35-50)
PLT : 230 109/L (100-300)
MCV : 89,2 fL (88-99)
MCH : 29,4 pg (26-32)
MCHC : 330 g/dl (300-350)
Glucose: 111 mg/dl (<200)
DIAGNOSE
SNAKE BITE REGION OF DORSUM MANUS SINISTRA PROXIMAL
DIGITI SECONDUS

TREATMENT
 IVFD RL 20 tpm
 Antivenins 2 vial
 Inj. Ceftriaxone 2 x 1 gr IV
 Inj. Ranitidin 2 x 1 amp IV
 LITERATURE REVIEW
 Definition
Snake bites are injuries caused by poisonous and
non-venomous snakes that result in stab wounds
inflicted by the fangs of snakes.

 Epidemiology
At least 421,000 cases of envenomation (injectio
n could be against the victim through stings / bite
s by venomous animals) and 20,000 deaths occu
r annually worldwide due to snake bites. Most esti
mates of snakebite occur in South and Southeast
Classification

The degree of a venomous snake bite case

is generally divided into 4 scales;
minor = no symptoms
moderate = local symptoms
severe = symptoms progresses to regiona
l region
major = systemic symptoms.
Venom Composition
Snake venom composition consisting of 9
0% protein. Each can have over hundre
ds of different proteins: enzymes (includin
g 80-90% can viperidae and 25-70% c
an be elapidae), non-enzymati
c polypeptide toxins, and non-toxic protein
s, such as nerve growth factors. Enzyme
s in the venom include digestive hydrolase
, hyaluronidase, and activators or inactivat
or physiological processes, su
ch as kininogenase. Most may contain L-
Pathophysiology
Snake venom is stable and resistant to temperature chang
es. In the electron microscope can be seen that the venom
is a protein that can cause damage to the endothelial cells
of blood vessel walls, causing damage to the plasma me
mbrane. Components of snake venom peptides to bi
nd to the receptors that exist on the victim's body. Bramycin
, serotonin and histamine are some of the reactions that o
ccur as a result of snake venom.
Enzymes found in snake venom, for example L-arginine est
erase causes the release of bradykinin, causing pain,
hypotension, nausea and vomiting and often leads to sweat
ing a lot after the bite. Proteases will lead to a wide variety
of tissue necrosis. Phospholipase A cause hydrolysis of th
e red blood cell membrane. Hyaluronidase can lead to dam
Clinical features

 Local symptoms ● Systemic symptoms

 Edema  Hypotension
 Tenderness in bite wounds  Muscle weakness
 Sweating
 Ecchymosis in 30 minutes to 2  Shivering
4 hours  Nausea and vomiting
 Hypersalivation
 Headache
 Blurred vision
 Special symptoms

 Hematotoxic, bleeding at the site of the bite, lung

, heart, kidney, peritoneum, brain, gum,
melena and hematemesis, skin bleeding (petech
iae, ecchymosis), hemoptoe, hematuria, dissemi
nated intravascular coagulation
 Neurotoxic, hypertonic, fasciculation, paresis, re
spiratory paralysis, ptosis, ophthalmoplegi, lary
ngeal muscle paralysis, abnormal reflex, and sei
zures.
 Cardiotoxic, hypotensive, cardiac arrest.
DIAGNOSIS
 Anamnesis
- when the bites occur
- the type of snake especially the color and
shape
- first aid has been done
- Increasing of respiratory rate
- hands and limbs can become stiff, and di
zzy
- for some people there may occur vasova
Physical examination
 vital signs
 fang marks, local pain, local bleeding, bruising,
blistering, local infection, and tissue necrosis.
 not all venomous snakes at the time of biting inj
ects can be on the victim
 Although in some cases there’s no venom inject
ed into victim’s body, it can impact the victim’s p
hysical condition  panic, takipnea, the hands a
nd feet become stiff, and dizziness.
 ADDITIONAL EXAMINATION

 Blood tests: Hb, Leukocytes, platelets, cre

atinine, urea N, electrolytes, bleedi
ng time, freezing time, protobin time, fibrin
ogen, APTT, D-dimer, liver physiological te
st, blood type and cross-
 Urine examination: haematuria, glycosuria,
proteinuria (myoglobulinuria)
 ECG
 Chest X-rays
DIFFERENTIAL DIAGNOSIS

• Internal venous thrombosis

• Extreme vascular trauma
• Septic shock
• Wound infection
 TREATMENT
The purpose of management in cases of p
oisonous snake bites are:
Blocking / slowing the snake's absorption

Neutralize the snake that has entered into

the blood circulation
Overcoming local and systemic effects.
PROGNOSIS

The poisonous snake bite has t

he potential to cause death a
nd severe conditions, so the ne
ed for appropriate antibodies
to reduce symptoms. Extremiti
es or parts of the body that are
necrotic will generally improve,
CASE ANALYSIS 44 year old male

 Arrived at 22/08/18
- bitten by snake on left hand
5 hours before he has rushed to hospital
 - while farming
 - in afternoon in the wood
 States feels pained, confused and nauseated
 The snake that bite him was green and as big as
the big toe
 No bandage applied initially
PHYSICAL EXAMINATION
 no abnormality found.
 The patient's local status is found:

Regio manus sinistra:

 Inspection: fang mark (+), edema (+), hype
remic (+)
 Palpation: tenderness in right hand, cold ro
ot, CRT <2 sec
 Movement: active and passive sinistra moti
on is unlimited
ADDITIONAL EXAMINATION
The results of routine blood tests obtained wit
hin normal limits. Management provided are:
RL and Dextrose fluid therapy 5% 20 tpm

administration of antivenin

Inj. Ceftriaxone 1x2gr

Inj. Ranitidine 2x1 amp

Inj. Dexamethasone 3 x 1 amp IV

CONCLUSION
Snake bite can happen anytime. Snake bite
s can be venomous and not poisonous. A v
enomous snake bite contains more than 90
% protein. Each venom contains more th
an one hundred different proteins, enzy
mes (which is 80-90% of viperid and 25-70
% of the toxins elapid), non-enzymatic pol
ypeptides toxic, and non-toxic proteins s
uch as nerve growth factor. The content of t
his venom was the one who later would cau
se local symptoms, systemic symptoms an
Thank you 