Presented by:

Dr. dr. Tri Maharani, M.Si., Sp. EM

• 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.
Maharani ,2016
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)
• 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
 WHO review 2016

Kolaborasi dokter dan herpetologi

sudah dimulai RECSINDONESIA
sejak tahun 2013 sampai sekarang
dalam hal identifikasi ular
 Faktor penting:
1.First aids
2.Transportasi
3.Manajemen di pkm dan rs
4.Kesadaran masyarakat
5.Pemulihan fisik dan mental
6.Dukungan pemerintah
Papua New Guinea has some of the highest snakebite rates in the world, with the
country’s rural central province recording an annual incidence of 561.9 cases per
100 000 population
• Snakebites are concentrated in mainly rural areas and vary considerably by
season, with the peak incidence seen in the rainy and harvesting seasons
 Indonesia
Jumlah total ular 348 jenis
Yang berbisa:
• Elapidae: 55 jenis
• Viperidae: 21 jenis
• Colubridae: 1 jenis
Micropechis ikaheka

Foto oleh M.D. Kusrini

Death adder
Papuan taipan (Oxuyuranus
scutellatus)
Papuan black snake (Pseudechis
papuanus)
Eastern brown snake
(Pseudechis textilis)
 Ular laut
Blue spotted sea snake
(Hydrophis cyanocinctus)
Thailand
 venom

Snake Venom Complex mixture of proteins

including Large enzymes-local tissue
destruction.
Low molecular weight polypeptides-lethal
systemic effects -Acidic. -Sp Gravity: 1.030-
1.070 -On drying Fine needle like crystals. -
Water Soluble. -Lethal Dose: Cobra-0.12gm,
Krait0.06gm- Russell’s V-0.15gm
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 enters surrounding
tissue direct venom action blood vessels
lymphatics
Target organs-systemic effect Capillary
absorption
 Patofisiologi venom (WHO
review 2016)
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
PBI
 Di rumah sakit
 Ada antibisa ular yang siap diberikan
 Kapan PBI dipakai
 Jarak jauh
 Ular tidak diketahui jenisnya
 Neurotoksin kuat (bungarus dan sea snake)
 CLINICAL
MANIFESTATION
 LOCAL SYSTEMIC
• Swelling > half bitten • Haemostatic abnormality
limb/48 hours • Neurotoxic signs
• Toes especially fingers • Cardiovascular
• Rapid extension within a abnormalities
few hours • Acute kidney injury
• Enlarged tender • Myoglobinuria/generalised
lymphnode draining the rhabdomyolysis/haemolysi
affected area s
• Supporting lab evidence
of systemic envenoming
• 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)
• 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
• 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)
• 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.
 5 cm / 2 hours, so
5 cm RPP = 2.5 cm/hour
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
 Neuromuscular
junction snake
toxin

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
Haemotoxin system
Nekrotoxin,julian white,2016
 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)
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