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 Indonesia

Jumlah total ular 348 jenis Yang berbisa: • Elapidae: 55 jenis • Viperidae: 21 jenis • Colubridae: 1 jenis Famili Viperidae 1. Daboia siamensis Subfamili Crotalinae (Pit Viper) 1. Trimeresurus albolabris 2. Trimeresurus puniceus 3. Calloselasma rhodostoma 4. Tropidolaemus wagleri

Calloselasma rhodostoma Daboia russelii siamensis Trimeresurus insularis

Trimeresurus albolabris

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

Boiga cynodon Elapid….Naja sputatrix Ophiophagus hannah Rhabdophis chrysargos

E.N.S. Calliophis intestinalis (Ular cabe kecil) Bungarus candidus (Ular weling) Bungarus fasciatus (Ular welang) 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 Ular laut ekor berupa paddle SNAKE

NON-VENOMOUS VENOMOUS

Cardiotoxin Hemotoxin Neurotoxin

Necrotoxin Nephrotoxin

Who review 2016 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)

LOCAL SYSTEMIC • Swelling > half bitten • Haemostatic abnormality limb/48 hours • Neurotoxic signs • Toes especially fingers • Cardiovascular abnormalities • Rapid extension within a few • Acute kidney injury hours • Myoglobinuria/generalised • Enlarged tender lymphnode rhabdomyolysis/haemolysis draining the affected area • Supporting lab evidence of systemic envenoming

(A. Khaldun, 2015) • 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

• 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

• 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

• 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

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

hemotoxin

Naja sputatrix

Dr.dr.Tri Maharani Msi SpEM

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 Julian white,2016 Nekrotoxin,julian white,2016

Julian white 2016