Snake Bite Phenomenon_dr. Trimaharani

Dr .dr.Tri Maharani MSi SpEM

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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 

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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

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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

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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, 5’ nucleotidase, DNAase, NAD-nucleosidase, phospholipase A and peptidases. l

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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.

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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 body’s 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, Russell’s viper venom contains toxins that activate factors V, X, IX and XIII, fibrinolysis, protein C, platelet aggregation, anticoagulation and haemorrhage

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Phospholipase A (lecithinase):

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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.

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 Venom

polypeptide toxins (“neurotoxins”)

 Postsynaptic

(α) neurotoxins such as αbungarotoxin and cobrotoxin, consist of 60-62 or 66-74 amino acids. They bind to acetylcholine receptors at the motor endplate.   Presynaptic (β) neurotoxins such as βbungarotoxin, 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.

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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.

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Hasil laboratorium : Normal

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Elektrocardiografi : sinus takikardi

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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.

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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)

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Kasus gigitan ular yang tercatat di Indonesia sangat terbatas, distribusi data juga sangat kurang. (2)

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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, pain all of the body, he spoke more fluently

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

He moved tocouldn’t speak observation room fluently, pain  with a betterall of the body condition

 Airway Breathing BloodPress. 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

21

29

20

24

24

88

144

120

79

80

36.9

36.6

36.8

36.8

36.4

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

-

-

-

Platelet(/mm)

337.000

-

Repeat :- 100 cc NaCl 0.9% + 2  vial SABU

-

-

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

29 TH MARCH 2015 AT 11.30 PM

30th March 2015

 Time

2/10

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)

-

-

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 -

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

118/78 19 90

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30 TH 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

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-

-

-

-

-

o

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

 V E N O M O P H T H A L M I A : DISCUSSION

Symptoms

and complications include :

-pain -hyperemia -blepharitis -blepharospasm -corneal erosions -anterior uveitis or lack of treatment may may result in corneal Delay or opacity, 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)

 V E N O M O P H T H A L M I A :

 WH  W H A T C A U S E S O C U L A R  TO  T O X I C I T Y ?

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

 V E N O M OPHTHALMIA:WHAT CAUSES OCULAR  TO  T O X I C I T Y ? 2. Corneal collagenase 

calcium dependent zinc metalloenzyme

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mediates the development development of corneal liquefaction liquefaction and opacification

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Enhanced by topical steriods causing corneal melting

1.FIRST AID IRRIGATION 

Initial management- pre hospital and in the emergency department

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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 kerato-

*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

3. TOPICAL CYCLOPEGICS 

Recommended for anterior segment inflammation

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atropine, scopolamine

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Reduces risk of posterior synechiae formation and ciliary spasm

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Reduces patient discomfort

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Complication: acute glaucoma in anterior chamber

4. TOPICAL ANTIBIOTICS 

Recommended if corneal erosion cannot be excluded by flourescein stain and slit lamp examination

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Prevents secondary bacterial infection

  Tetracycline,

cmc, penicillin-streptomycin ointment and

polymixin B sulfate

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Do and don’t  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.

ompas 2015

u

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