Dr .dr.Tri Maharani MSi SpEM
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
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
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
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
2
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.
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
Phospholipase A (lecithinase):
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.
2
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.
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.
O
Hasil laboratorium : Normal
O
Elektrocardiografi : sinus takikardi
O
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.
O
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)
O
Kasus gigitan ular yang tercatat di Indonesia sangat terbatas, distribusi data juga sangat kurang. (2)
O
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 BloodPress. 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
-
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
-
-
-
-
-
-
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
mediates the development development of corneal liquefaction liquefaction and opacification
Enhanced by topical steriods causing corneal melting
1.FIRST AID IRRIGATION
Initial management- pre hospital and in the emergency department
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
atropine, scopolamine
Reduces risk of posterior synechiae formation and ciliary spasm
Reduces patient discomfort
Complication: acute glaucoma in anterior chamber
4. TOPICAL ANTIBIOTICS
Recommended if corneal erosion cannot be excluded by flourescein stain and slit lamp examination
Prevents secondary bacterial infection
Tetracycline,
cmc, penicillin-streptomycin ointment and
polymixin B sulfate
59
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
