SNAKE BITES,

CAT and DOG BITES

& HUMAN BITES
AFRIYANTI SANDHI
Plastic Reconstructive and Aesthetic Surgeon
 Snake Bite :
Rare But Serious
Grass Snake

You’re much more likely to get struck by lightning

than die from snake bite.

Still, it’s best to avoid them and to treat any bite

as a medical emergency.
Dr. Tri Maharani, SpEM
 Snake Bite according to WHO is a Neglected Tropical Disease.
Incidence : 1.841.000 per year  Death Case : 94.000 (WHO 2016)
Countries : South Asia, South-East Asia, Africa

Indonesia : No Data

Coral Snake
Rattle Snake

Of 2000 species of snakes in the world : 250 are venomous

Indonesia :
Of 247 species of snakes ; only 5 - 10 are venomous
 ELAPIDAE HYDROPIIDAE VAPERIDAE

VENOMOUS SNAKE IN SOUTH-EAST ASIA :

1. ELAPIDAE :
Short Fang (Ular Weling, Welang, Cabai, Cobra, King Cobra)
2. HYDROPIIDAE :
Sea Snake
3. VAPERIDAE :
Long Fang (Ular Tanah, Ular Bandotan Puspo)
TOTAL SPECIES OF SNAKE IN INDONESIA : 348

✓Elapidae : 55 species
✓Viperidae : 21 species
✓Colubridae : 1 species
Elapidae - Naja sputatrix
Elapidae – Ophiophagus hannah
Elapidae Family
Ular Viper Pohon
Ular Tanah – Calloselasma rhodostoma Ular Viper Pohon – Trimeresurus insularis
Bungarus candidus - Ular Weling
Bungarus fasciatus - Ular Welang
 PERKIRAAN JUMLAH KASUS GIGITAN ULAR PER BULAN DI BEBERAPA LOKASI
BERDASARKAN LAPORAN DOKTER TAHUN 2016
PROPINSI LOKASI JUMLAH KASUS PER BULAN
BANTEN Serang 10-15
YOGYAKARTA Yogyakarta 5-6

JAWA TENGAH Semarang 1-3

JAWA TIMUR Surabaya dan Sidoarjo 2-5
JAWA TIMUR Madiun 1-3
BENGKULU Bengkulu 2-4
KALIMANTAN TIMUR Samarinda 1-4
NUSA TENGGARA BARAT Lombok 5-8
MALUKU Wetar 5-8
PAPUA Timika 1-3
SULAWESI TENGAH Palu 1-2
Maharani, 2016
Snake Bite Data in Kab Bondowoso, Jawa Timur from March 2015 – August 2016
(Maharani, 2016)

Venomous Snake Number of Case

Ular Viper Pohon (Trimeresurus insularis) 85
Ular Weling (Bungarus candidus) 5
Ular Kobra (Naja sputatrix) 15
Ular Tanah (Colleselasma rhodostoma) 2

Non Venomous Snake Number of Case

Ular Kopi (Coelognathus flavolineatus) 18
Ular Air (Xenochropis trianguligera) 18
CLINICAL
MANAGEMENT FOR
SNAKE BITE
Non Venomous Venomous
SNAKE FANG ANATOMY AND VENOM EFFECTS

Neurotoxic

Cardiotoxic

Hemotoxic

Anticoagulant - Antifibrin
 SNAKE VENOM
Cholinesterase Neurotoxin
Proteinase Necrotizing effect in tissue, Anticoagulant
Adenosine Triphosphates Central Neurotoxin
Phosphodiesterase Cardiotoxic
Amino Acid Oxidase Enhancing other Toxin
Hyaluronidase Accelerating other Toxin Penetration
GENERAL CLINICAL SIGNS & SYMPTOMPS AFTER SNAKE BITE

PANIC
SYSTEMIC SIGNS & SYMPTOMPS :
▪ Sweating, Hypersalivation
▪ Hypotension, Shock
▪ Arrhythmia
▪ Lung Edema
▪ Conjunctival Edema and Chemotic
▪ Spontaneous Bleeding (Petechiae, Epistaxis,
Hemoptysis)

LOCAL SIGNS & SYMPTOMPS :

▪ Pain
▪ Numbness
▪ Edema
▪ Ecchymosis, Necrotic
SPECIFIC CLINICAL SIGNS & SYMPTOMPS AFTER SNAKE BITE

COAGULOPATHY :
Bleedings from snake bite site or vein puncture.
Spontaneous Bleeding : Petechiae, Epistaxis, Hemoptysis, Hematuria,
Hematemesis, Melena.
NEUROTOXICITY :
Paralysis in Cranial Nerves : Ptosis, Progressive Ophthalmoplegia
Flaccid Paralysis in Extremity Muscles
Paralysis in Respiratory Muscles
MYOTOXICITY :
Especially after SEA SNAKE bite.
Muscle pain, Tenderness, Myoglobinuria
Acute Renal Failure, Hyperkalemia, Cardiotoxicity
 HOW TO MANAGE SNAKE BITE CASE OUT OF HOSPITAL ?

Do Not PANIC
Do Not put Tourniquet, Sucking the Venom or Other Traditional Treatment

IMMOBILIZE BITTEN AREA >> Will be discussed in the next slide

Refer patient to Emergency Department as soon as possible
Bring Dead or Alive the Snake or Photography of the Snake into ER to be identified and
choose the suitable Anti Venom

IN THE PRIMARY HEALTH CARE :

Do General Examination (ABCDE) >> Make sure the Patient is in Stable Condition
Give ANALGESIA
Mark the EDEMA using RPP TEST >> Will be discussed in the next slide
DO NOT make CROSS INCISION
SNAKE BITE FIRST AID METHOD : PRESSURE IMMOBILIZATION METHOD

1-3:
Apply a broad elastic bandage from
below upwards and over the bite site as
soon as possible.

4 – remove
Do not 6 : trousers, as the
movement doing so will assist venom to
spreadainsplint
Apply the blood
to the stream.
leg, immobilizing
joints either side of the bite.
Extend the bandage as high as
possible,
Bind ideallyfirmly,
the splint up towalking
the groin.
should be
restricted.

Bites on the hand and forearm : bind to

the axilla, use a splint to the elbow and
use an arm sling.

PRESSURE BANDAGE WILL BE REMOVED IN THE HOSPITAL

 SPECIFIC TEST FOR SNAKE BITE INJURY
20 Minutes WHOLE BLOOD CLOTTING TEST (20’WBCT)
RATE PROXIMAL PROGRESSION TEST
ELECTROCARDIOGRAPHY (ECG)

LABORATORY EXAMINATION :
Hemoglobin
White Blood Cells
Platelet Count
Liver Function Test
Renal Function Test
Prothrombin Time (PT) : external coagulation pathway
aPTT (Activated Partial Thromboplastin Time) : internal coagulation pathway
INR (International Normalized Ratio) based on PT, in patient with anticoagulant therapy (Warfarin)
 20 Minutes WHOLE BLOOD CLOTTING TEST (20’WBCT)
AIM : to identify the presence of Hemotoxin
▪ Take a GLASS BOTTLE, do not use Plastic Bottle
▪ Draw 2 ml of vein blood
▪ Put the blood into the Glass Bottle
▪ Wait 20 Minutes
▪ Repeat the test TWICE if needed

RESULT :
CLOTTING (+) : NO COAGULATION DISORDER – NO HEMOTOXIN

CLOTTING (-) : COAGULATION DISORDER – HEMOTOXIN IS PRESENT

 RATE OF PROXIMAL PROGRESSION (RPP) TEST
AIM : to evaluate the EDEMA PROGRESSION to make a decision for the best medical treatment.

▪ Take a tape as the marker to measure the edema, and put it on the proximal part of the edematous limb
▪ Write down the date and time at measurement
▪ Repeat the evaluation of the edema every 2 hours and measure by measurement tape
▪ Result : increase of the in cm per hour

5 cm Rate of (Edema) Proximal Progression :

in 2 Hours 2.5 cm per Hour
TREATMENT (1) :
AIRWAY :
Non Rebreathing Oxygen Mask 10-12 liter per minute
Endotracheal Tube if Needed + Ventilator Machine
Suction

BREATHING :
Evaluate the Respiratory Rate

CIRCULATION :
IV Access for Maintenance Fluid and Drugs
Blood Pressure and Heart Rate Monitoring
Oxygen Saturation
Transfusion of PRC or FFF as indicated
TREATMENT (2) :
Immobilize the Bitten Area by using
Pressure Bandage Immobilization Technique

ANTIVENOM : DRUG OF CHOICE

SABU (Serum Anti Bisa Ular) – Bio Farma
Only covers 3 kind of Species
2 Vials of SABU + 100 ml NaCl 0.9% :
60 – 80 drops per minute
REPEAT every 6-8 Hours

ANALGESIA : SABU Covers 3 Venomous Snakes :

Morphine or NSAID Agkistrodon rhodostoma (Ular Tanah)
Naja sputatrix (Ular Kobra)
Bungarus fasciatus (Ular Welang)
ANTIBIOTIC : as indicated
TREATMENT (3) :
Anti Cholinesterase Drugs - PHYSOSTIGMINE
Especially for Neurotoxin envenoming.

Should give ATROPINE before administration of

PHYSOSTIGMINE, to prevent PHYSOSTIGMINE
intoxication

PHYSOSTIGMINE dose :
▪ ADULT ( > 12 y.o ) : 1-2 mg
▪ CHILDREN ( < 12 y.o ) : 0.02 mg/kg/dose
(Max Single Dose 0.5 mg)

Give slowly by IV Push.

Dr. Tri Maharani, M.Si, SpEM : 085334030409 – 08973665684
Email : hanarani_71@yahoo.com
recsindonesia.blogspot.co.id
DOG & CAT BITES
HUMAN BITES
AND RABIES PREVENTION
 The peak incidence of dog bites occurs
among children.

Furthermore, while dog bites most often

involve the limbs in Adults; Children are
more likely to suffer bites on the face and
neck because of their small stature.
However, in a minority of cases, dog bite-associated trauma
may represent a potentially or even immediately life-
threatening situation this subset of dog bite wounds
accounts for an average of 1.4 deaths each year in Germany,
and as many as 10 to 20 deaths in the United States.

Death is usually due to penetrating neck trauma and certain

large breeds such as Pit Bulls, German Shepherds and
Rottweilers account for most of these attacks. Direct
craniocerebral injuries have also been reported among small
children.

Apparently such cases fall into the realm of advanced trauma

life support (ATLS) resuscitation Guidelines.
If you were bitten by a cat, dog, or ferret that appeared
healthy at the time you were bitten, it can be confined by its
owner for 10 days and observed.

No anti-rabies prophylaxis is needed.

No person in the United States has ever contracted rabies
from a dog, cat or ferret held in quarantine for 10 days.

Jul 5, 2017 CDC - Domestic Animals - Rabies

https://www.cdc.gov/rabies/exposure/animals/domestic.html
When infected, most animal bite
wounds reveal a polymicrobial
flora, mainly of oropharyngeal
origin from the animal.

The most frequent isolates

from dog bites are Pasteurella
species, followed by Streptococci
and Staphylococcus.
Animal and human bites : Evaluation and management. Acta Orthop Belgia, 2004, 70, 1-10
 HUMAN BITES
Although not so common as those inflicted by
dogs or cats, human bites are considered more serious by most
clinicians because of their higher propensity for infection.
Common pathogenic aerobes include : Streptococci,
Staphylococcus aureus, Hemophilus influenzae,
And Viridans (“oral”) streptococci.
The incidence of human bites is unknown as most bites are
associated with potentially embarrassing social circumstances such
as quarrels or extreme sexual activities, which
Auricle Injury explains the high occurrence of underreporting.
due to Human Bite
Helical Rim Reconstruction using Post Auricular Flap
 Right Alar Defect Post Human Bite Injury

Human bites have also been implicated as a

mode of transmission of Hepatitis B and C, Tuberculosis, syphilis and even tetanus.
Furthermore, human bites have been reported
resulting in transmission of human immunodeficiency virus (HIV).
INITIAL EVALUATION OF BITE INJURY

Most bite victims seeking medical

care are concerned with the
cosmetic sequelae of their wound,
the development of wound
infection or the prevention of RABIES VIRUS

rabies.
DEFINITIVE TREATMENT
Based on the findings, treatment should be addressed to the
need for rabies and tetanus prophylaxis, the prevention or
therapy of wound infection and the elimination of any
possible functional and cosmetic sequelae.
✓ Wound Toilette
✓ Antiseptics
✓ Human Rabies Ig
✓ Anti Tetanus
✓ Antibiotics
1. Wound Toilette 2. Emergency Department

3. Antiseptic 4. Wound Dressing

5. Laboratory Test
7. Injections

Anti Tetanus Injection (1st Contact, 2 mo, 3 mo, 4 mo, 1 yr)

Human Rabies Immunoglobulin Injection (1st Contact, 3rd

day, 7th day, 14th day, 28th day).

If patient has already a Rabies Vaccine, Human Rabies Ig

should not be administrated.
6. Antibiotics Prescription
Early Symptoms of Rabies (1)

1. Fever or Flu Like Syndrome

2. Drooling :

Increased amounts of saliva caused by spasms that

affect the muscles in throat.

The person will have pain when swallowing and

therefore saliva will gather in his or her mouth.
If you notice strings of drool (saliva), you should
consider this a red flag and get the patient to a
hospital.
Early Symptoms of Rabies (2)

3. The tingling sensation :

Could also be described like ‘pins and needles’,

particularly in the spot where the bite occurred.
This happens because the virus begins affecting the
person’s nerves and causing damage to them.

4. Muscle contraction :

Occurs when a person’s muscle moves but you

didn’t mean for it to actually move. When muscles
contract, they become very tight and do not relax.
This can happen to just one part of the body, or it
can happen in several parts of the body at once
Late Symptoms of Rabies (1)

Hydrophobia : is the fear of water.

This condition occurs when a bitten person enters into the
late stage of rabies infection. Patient will go into a panic or
have spasms at the sight, touch, or sound of water.

Aerophobia (fear of breezes) and Photophobia (fear of

bright lights) have also been known to occur in people who
have been infected with rabies.

Convulsions : start when the virus enters the bloodstream

and gains access to the brain.

Once in the brain, it starts to disrupt the brain’s

functioning. Patient may have uncontrolled jerky
movements of the whole body or parts of the body
Late Symptoms of Rabies (2)

Numbness : when the virus begins affecting the

nerves, it will make some parts of the body begin to
lose sensation.

Dysphagia : means the person is having difficulty in

swallowing, because the virus will cause the muscles in
the throat to begin spasming.

This can also lead to an increased amount of saliva

(drooling), and the person may also begin foaming
at the mouth.
Late Symptoms of Rabies (3)

Hallucination : the virus can make the bitten person

have sensory impressions of things that are not
present. This includes smelling things that are not there
or seeing things that are not there.

This is caused by the effect virus affecting the normal

functioning of the brain.

These late stage symptoms will generally last for two

to ten days, and will almost always result in death
Correspondence :
afriyanti.sandhi@gmail.com