A 48 Years Old Female

with Snake Bite on

Dexter Manus Region
BY: FARIS KHAIRUDDIN S & AFRIZAL TRI HERYADI
SUPERVISED BY: DR. AMRU SUNGKAR, SPB., SP.BP-RE
Patient Status
Identity

Name : Mrs. P
Age : 48 years old
Sex : Female
Religion : Islam
Occupation : Farmer
Address : Kowang, Ngargotirto, Sumberlawang, Sragen
Medical Record : 01-32-51-59
Admission : 31 Desember 2015
Chief Complain

Pain on right hand

Recent Illness History

Patient was referred from RSUI Kustati with pain in his right hand after being
bitten by snake. Approximately 1 week prior to the admissions of patient was
bitten by a snake on his right hand. The snake was black-white and triangles-
headed. After being bitten she complained her right hand felt ached and 2
hours after being bitten her hand began swelling.
Patients also complained of vomiting and urinating blood, like reddish color
urin once. She was taken to hospital Yaksi Gemolong by the family. While in RS
Yaksi Gemolong patients were given medications and performed urinary tube
installation. Due to the limited facilities the patient was referred to RSUI Kustati.
Currently in RSUI Kustati in patients after cleaning the wound (debridement) 3
times dated December 28, 2015, December 30, 2015 and December 1, 2015.
Due to the limited facilities the patient was referred to Hospital Dr Moewardi
Surakarta with snake bite on dexter manus region with anemia and
thrombocytopenia.
Medical History

Past Illness Family History

Asthma : denied Heart Disease : denied
Allergy : denied Hypertension : denied
Diabetes Mellitus : denied Diabetes Mellitus: denied
Hypertension : denied Asthma : denied
Heart Disease : denied Allergy : denied
Hospitalization : denied
Snake bite : denied
Anamnesis Sistemik
Head: dizziness (-)
Eyes: blurred (- / -), pale (- / -), double vision (- / -)
Nose: cold (-), nosebleeds (-), nasal congestion (-)
Ear: hearing loss (- / -), discharge (- / -), otalgia(- /
-)
Mouth: dry mouth (-), bluish lips (-), thrush (-), gums
bleeding (-), cracked lips (-)
Throat: pain on swallowing (-), vomiting blood (+)
Respiration: shortness (-), cough (-), bloody cough
(-), wheezing (-)
Cardiovascular: chest pain (-), leg swelling (-),
sweating (-), fatigue (-)
Gastrointestinal: nausea (-) vomiting (-), stomach
burnt (-) bloating (-), obstruction (-), vomiting
blood (-), black stools (-), mucoid bloody stools (-),
difficult on defecation (-)
Genitourinary: reddish urin (+), pain when
urinating (-)
Musculoskeletal: muscle pain (+) on the left leg,
joint pain (-), swollen joint (-)
Extremities: Top: Pale (-/-), bluish (-/-), swelling (+/-
), injuries (-/-), cool (-/-), feels invulnerable (-/-),
restricted movement (-/-)
Below: pale (-/-), bluish (-/-), swelling (-/-), injuries (-
/-) feels cold (-/-), limited movement (-/-)
Physical Examination
Primary Survey

Airway Free

Inspection: right = left chest movement, spontaneous,

thoracoabdominal, breathing 20 x / min
Breathing Palpation: crepitation (-)
Percussion: Sonor (+/+)
Auscultation: vesicular sound (+ / +), additional sound (-)

Circulation Blood pressure: 110/70 mmHg, Pulse Rate: 86 x / min

Disability GCS E4V5M6, light reflex (+ / +), pupil isokor (3mm / 3mm)
Exposure Temperature 36.5 C, lesion (+) see status localist
Physical Examination
Secondary Survey

Head Eyes Nose Ears Mouth Neck Thorax

Mesochepal Conjunctival Septal secretions (- malocclusion Lymphnode normochest

pallor (- / -) deviation (-) / -), blood (- / (-), cyanosis enlargement shape, breast
Sclera Crepitus (-) -), tenderness (-), bleeding (-), increase development
jaundice (- / - Discharge (-) mastoid (-), gums (-) in JVP (-) right = left,
) tenderness retraction (-),
Pupil isokor tragus (-) tenderness (-)
(3mm / 3mm)
Eyelid
edema (- / -)
Light reflex (+
/ +),
Physical Examination
Secondary Survey

Heart : Pulmo: abdomen: extremities:

Inspection: ictus Inspection: right = Inspection: Superior Dx: akral

cordis does not left chest distension (-) cold (-), edema (+),
appear Development Auscultation: bowel injury (+) see status
Palpation: ictus Palpation: Fremitus (+) normal localist
cordis palpable not touch right = left, Percussion: timpani Superior Sn: akral
strong lift tenderness (- / -), Palpation: sociable, cold (-), edema (-)
Percussion: cardiac crepitus (- / -) tenderness (-), Inferior Dx: akral
border impression is Percussion: sonor / defans muscular (-) cold (-), edema (-)
not widened resonant Inferior Sn: akral
Auscultation: I-II Auscultation: SDV cold (-), edema (-),
heart sounds of (+ / +)
normal intensity,
regular, noisy (-)
Physical Examination
Secondary SurveyStatus localist

Regio manus dextra Regio Anthebrachii Dextra

Inspection: fang mark (+), Inspection: Oedema (+)

edema (+), bull (+) broke Palpation: Tenderness (-),
Palpation: tenderness (+), CRT <2 seconds, passive
CRT <2 seconds, passive stretch test (-)
stretch test (-), saturation
digiti I (94%), digiti II (96%),
digit III (96%), digiti IV (96%),
digiti V (96%)
 ASSESSMENT I
Snake bite manus region dextra
PLANNING I
Complete blood laboratory examination
D5% infusion of 250 cc + SABU 1 Amp 20 MDGs (drip)
Inf Asering
Metamizole injection of 1 g / 24 hours
Treat the wound by moist gauze
Laboratory Findings

Examination Result Unit Normal Range

Haemoglobin 7.5 g/dL 12.0-15.6
Hematocryte 41 % 33 45
Leucocyte 17.2 ribu/l 4.5 11.0
Trombocyte 227 ribu/l 150 450
Erytrocyte 2.61 juta/l 4.5-5.90
PT 70.0 detik 10.0 15.0
APTT >120.0 detik 20.0 40.0
INR 0.000
Creatinine 0.5 mg/dl 0.9-1.3
Ureum 37 mg/dl < 50
Blood Sugar 143 mg/dl 60-140
Blood Natrium 130 mmol/L 136-145
Blood Kalium 4.1 mmol/L 3.3-5.1
Blood Chloride 103 mmol/L 98-106
 ASSESSMENT II
Post snake bite pedis region of the left
PLANNING II
D5% infusion of 250 cc + SABU 1 Amp 20 MDGs (drip)
Inf Asering
Metamizole injection of 1 g / 8 hours
Treat the wound by moist gauze
PRC transfusion until Hb> 10 mg / dL
Literature
Review
Definition

Bite wounds are injuries caused by the mouth and teeth of animals or
humans 4
These injuries can cause 4
Tissue damage
Serious bleeding when the large blood vessels are injured
Infection by bacteria or other pathogens, such as rabies
Toxinemia such as the snake bite
Beginning of inflammation
Snake species can be distinguished on vipers and snakes are not
venomous 2.5
Classification of Snakes

Family Colubridae (weak)

Snake cow (Zaocys carinatus), snake strap (Dendrelaphis Pictus), a rat snake or serpent
jali (Ptyas korros), and snakes litter (Sibynophis geminatus).

Family Elapidae, Hydropiidae, or Viperidae (strong)

Elapidae have short fangs and erect permanent. Some examples of members of this family are snake
chili (Maticora intestinalis), snake weling (Bungarus Candidus), cobra (Naja sumatrana), and the king
cobra snake(Ophiophagus hannah)

Viperidae has long fangs that normally can be folded into the upper jaw, but can be enforced when it is
attacking its prey
Viperinae
Crotalinae
Crotalinae organs to detect warm-blooded prey (pit organs), which lies between the nostrils and eyes.
Some examples are the snake Viperidae bandotan (Vipera russelli), snake soil (Calloselasma rhodostoma), and the
carcasses of sea snakes (Trimeresurus albolabris) 5
Differences Venomous and Not
Venomous Snake
Snake venin

Venom contains more than 20 constituent elements, mostly proteins, including enzymes and toxins polypeptide. Here are some elements of the
venom that has a clinical effect 2:

Procoagulant enzyme (Viperidae) can stimulate blood clots but can cause can not be coagulated blood. Can of snakes Russel contains several
different procoagulant and activate the different steps of the blood clotting cascade. The result is the formation of fibrin in the blood stream. Most
can be decomposed directly by the fibrinolytic system of the body. Immediately, and sometimes between 30 minutes after the bite, the rate of blood
clotting factors become unbelievably low (consumptive coagulopathy) so that the blood can not clot.

Haemorrhagins (zinc metalloproteinase) can damage the endothelial covering the blood vessels and cause systemic bleeding
spontaneously (spontaneous systemic haemorrhage).

Cytolytic toxins or necrotic - digest hydrolase (proteolytic enzyme and phospholipase A) polipentida toxins and other factors that increase cell
membrane permeability and cause local swelling. These toxins also can destroy cell membranes and tissues.

Phospholipase A2 haemolytic and myolitik - ennzim can destroy the cell membrane, endothelial, striated muscle, nerve and red blood cells.

Phospolipase A 2 neurotoxin pre-synaptik (Elapidae and some Viperidae) - is phospholipases A2 that damage nerve endings, initially releasing
transmitters and increase the release of acetylcholine.

Post-synaptic neurotoxins (Elapidae) -polipeptida to compete with acetylcholine receptors at the neuromuscular junction gets and causes paralysis-
like paralysis kuraonium 2

Venom is composed of several polypeptides that phospholipase A, hyaluronidase, ATP-ase, 5 nukleotidase, choline esterase, protease,
fosfomonoesterase, RNA-ase, ase DNA. This enzyme causes local tissue destruction, is toxic to the nerves, causing hemolysis or histamine release
causing anaphylactic reactions. Hyaluronidase damage cell base material so as to facilitate the spread of toxins 6.
 b. properties Snake venin
Based on the body of its prey, the venom can be divided into hemotoksik, which could
be affecting the heart and vascular system; can be neurotoxic, which could be affecting the
nervous system and the brain; and can be cytotoxic, which can only work at the site of the bite.
Venom that is toxic to blood (hematotoksik)
Venom that is toxic to blood, the venom that attack and destroy (destroy) cells, red blood cells
by way of destroying the stroma lecethine (the walls of red blood cells), so as the red blood cells
become crushed and dissolved (hemolysis) and out into vessels -pembuluh blood, resulting in
the onset of bleeding in mucous membranes (mucus) in the mouth, nose, throat, and others.
Venom that is toxic to the nervous (neurotoxic)
Namely venom destructive and paralyzing nerve cell tissues around the bite wound that causes
tissue death of the nerve cells with signs of skin around the wound looked bluish and black
(necrotic).His next deployment and poisoning affects the central nervous system by way of
paralyzing the central nervous system, such as respiratory and cardiac nerve. The spread of
venom through the body via lymph vessels 4.
Pathophysiology Venomous Snake Bite

Snake venom produced and stored in a pair of glands under the eyes. Can be removed from
the hollow fangs located in the upper jaw. Fangs the snakes can grow up to 20 mm on a large
rattlesnake.Dose of venom per bite depends on the time elapsed since the first bite, the degree
of threat received by a snake, as well as the size of the prey. Nostrils respond to heat emission of
prey, which can allow the snake to change the number could be issued.
Can usually be liquid. Protein enzymatic ingredients can deliver destructive. Proteases,
collagenase, and arginine ester hydrolase has been identified in can pit viper. Local effects of
the venom is a potential marker for the systemic breakdown of the organ system functions. One
effect is local bleeding, coagulopathy usually does not happen when venomasi. Other effects,
such as localized edema, increase capillary leakage and interstitial fluid in the lungs.
Pulmonary mechanism may change significantly. The end effect in the form of cell
death that can increase the concentration of lactic acid secondary to changes in volume
status and requires an increase in minute ventilation. The effects of neuromuscular blockade
can cause a worsening of the movement of the diaphragm. Heart failure can be caused by
acidosis and hypotension. Myonekrosis caused by myoglobinuria and kidney disorders 7.
 D. Signs and Symptoms of snakebite By Type Snake

Bite Elapidae

(eg: cobra, snake Weling, cobra, snake anang, chili snake, coral snake, Mambas, kraits)

Bursts cobra in the eye can cause throbbing pain, stiffness of the eyelids, swelling around the mouth.

Picture of severe pain, blisters, and skin damaged

Once bitten by a snake

15 mins: systemic symptoms

10 hours: paralysis of the muscles of the face, lips, tongue, throat, making it difficult to speak, difficulty swallowing, muscle weakness, ptosis, headache, cold skin, vomiting, blurred vision, paresthesia around the mouth. Death can occur within 24 hours

Bite Viporidae / Crotalidae

(eg land snakes, green snakes, snake bandotan Puspo)

Local symptoms arise within 15 minutes, after a few hours in the form of swelling near the bite that spreads to the whole body.

Systemic symptoms appear after 5 minutes or after a few hours

Severe poisoning is characterized by swelling above the elbows and knees within 2 hours or marked by severe bleeding.

Bite Hydropiridae

(eg sea snakes)

Immediately arise headaches, thick tongue, sweating and vomiting.

After 30 minutes to several hours usually appear stiff and thorough pain, dilated pupils, jaw muscle spasm, muscle paralysis, myoglobinuria marked with dark brown urine (important for diagnosis), kidney damage and cardiac arrest

According to Schwartz, snake bites can be classified as follows

Degre Venerasi Bite Pain Edema / erythema Systemic signs
e wounds

0 0 + +/- <3cm / 12> 0

I +/- + + 3-12 cm / 12 hours 0

II + + +++ > 12-25 cm / 12 +

hours Neurotoxic,
Nausea, dizziness,
shock

III ++ + +++ > 25 cm / 12 hours ++

Shock, petechiae,
ecchymosis

IV +++ + +++ > ekstrimitas ++

Disorders renal
physiology,
Coma, bleeding
 Clinical Diagnosis

History:

History is right about the snake bites as well as progression of symptoms and signs of both local and systemic is very important.

The four initial questions useful:

1. on the part of the body where you are bitten by a snake?

Physicians can quickly see evidence that the patient has been bitten by a snake (for example, the former canines) as well as the origin and expansion of local envenomasi mark.

2. when and at what time you are bitten by a snake?

Estimated envenomasi severity depend on how much time passed since the patient bitten by a snake. When the patient arrived at the hospital shortly after bitten by a snake, can be obtained fraction signs and symptoms even though a large amount of venom has been
injected. If the patient is bitten by a snake while sleeping, the possibility of a snake bite is Kraits (rattlesnake), when in the rice fields, most likely by a cobra or russel viper (rattlesnake), in case when picking fruit, pit viper green (rattlesnake), when it occurs while swimming or
while crossing a river, cobra (fresh water), sea snakes (sea or brackish water).

3. treatment of snake has bitten you?

Snake has bitten patients often killed outright and kept away from the patient. If the snake has bitten been found, the snake should be brought together when the patient comes to the hospital, for easy identification if the snake is poisonous or not. If the species proved to
be harmless (or not a snake at all) the patient can be immediately soothed and discharged from hospital.

4. What do you feel right now?

This question can bring the doctor to the analysis of body systems involved. Snakebite symptoms that are common in the beginning was vomiting. Patients who experience thrombocytopenia or impaired blood clotting will bleed from a wound that has long terjdi. Patients
should be asked about the production of urine and the urine color since bitten by a snake. Patients who complain of drowsiness, which seemed to fall eyelids, blurred vision or double, the possibility of signaling has been circulating neurotoxin.

Physical examination

There is no simple way to identify venomous snakes are dangerous. Some of the venomous snakes are not dangerous has evolved to look almost identical to that venomous. However, some well-known venomous snakes can be recognized from the size, shape, color,
pattern scales, behavior and sound he made when feeling threatened. 2.

Some characteristics of poisonous snakes is coconut triangle shape, size small canine teeth and the bite wound artifacts former canines.
 Not all poisonous snake bite at a time can inject the victim. People who are bitten by a snake, although there could be injected into the body can be
a panic, breathing becomes rapid, hands and legs become stiff, and the head becomes dizzy. Symptoms and signs of snake bite will vary according
to species of snake bite and the amount can be injected into the victim. Symptoms and signs include bite marks canines (fang marks), local pain,
bleeding local, bruising, swollen lymph nodes, sore, blister, local infection, and tissue necrosis (mainly due to snake bites from the family Viperidae) 2 ,

Signs and Symptoms Local on the bite area 2:

Bite marks canines (fang marks)

Local pain

Local bleeding

Redness

Lymphangitis

Enlarged lymph nodes

Inflammation (swollen, red, hot)

Blister

Local infections, abscesses

Necrosis
 Signs and symptoms of systemic 2:

a. General (general)

nausea, vomiting, abdominal pain, weakness, drowsiness, weakness.

b. Cardiovascular (Viperidae)

vision problems, dizziness, fainting, shock, hypotension, cardiac arrhythmias, pulmonary edema, edema konjunctiva (chemosis)

c. Bleeding and blood clotting disorders (Viperidae)

bleeding from a wound that had just occurred (including bleeding continuously from bites (fang marks) and a wound that has healed partially (oldrus-mene partly-healed wounds), bleeding systemic spontaneous - from gums,
epistaxis, bleeding Intracranial (meningism, derived from bleeding subdura, with signs of lateralization and or coma by bleeding cerebral), hemoptysis, hemorrhage perrektal (melena), hematuria, vaginal bleeding, antepartum
hemorrhage in pregnant women, mucosal bleeding (eg konjunctiva), skin (petechiae, purpura, bleeding discoid, ecchymosis), and retinal hemorrhage.

d. Neurological (Elapidae, Russel viper)

drowsiness, paresthesias, abnormalities tasting and smelling, ptosis, external ophthalmoplegia, paralysis of facial muscles and other muscles are innervated cranial nerves, nasal voice or afonia, regurgitation of liquids through
the nose, difficulty swallowing secretions, flaccid paralysis of respiratory muscles and generalized.

e. Skeletal muscle destruction (sea snake, several species of kraits, Bungarus niger and B. Candidus, Russell's viper western Daboia russelii)

whole body pain, stiffness and pain in the muscles, trismus, myoglobinuria, hyperkalemia, cardiac arrest, acute renal failure.

f. Urogenital system

lower back pain, hematuria, hemoglobinuria, myoglobinuria, oliguria / anuria, signs and symptoms of uremia (respiratory acidosis, hiccups, nausea, pleural pain, and others)

g. endocrine symptoms

pituitary insufficiency / adrenal glands caused infarction of the anterior pituitary. In the acute phase: shock, hypoglycemia. Chronic phase (several months to years after the bite): weakness, loss of secondary sexual hair, loss of
libido, amenorrhea, testicular atrophy, hypothyroidism
Management

First aid; to inhibit the toxin absorption, maintain the victim's life and avoid
complications before getting medical treatment
Calming victims anxious
Immobilization
Consider pressure-immobilisation on Elapidae bite
Avoid disruption to bite because it can increase the absorption and can
cause local bleeding
Victims should be immediately taken to the hospital as soon as possible, in
a way that is safe and comfortable as possible by the fireman's method
and positioned oblique (recovery posotion)
Treatment of Snake Bites

Stabilization of ABC
Clean the injured with physiological fluids or sterile water
For local effects is recommended immobilization using elastic cotton bandage
with a width + 10 cm, length 45 m, which was wrapped around a strong bitten
body part
A tetanus shot, if the victim never get toxoid then given a single dose of
tetanus toxoid.
Injections crystalline penicillin 2 million units intramuscularly.
Analgesics for pain relief.
Antivenin serum
Anti-venin Guidelines of Parrish

Degree Venerasi Bite wounds Pain Edema / Systemic signs

erythema
0 0 + +/- <3cm / 12 hours 0
I +/- + + <3cm / 12 hours 0
II + + +++ > 12cm-25cm / +. Neurotoxic, nausea,
12h
dizziness, shock
III ++ + +++ > 25cm / 12h ++, shock, petechiae,
ecchymosis
IV +++ + +++ At one ++, Impaired kidney
extremity function, coma,
thoroughly bleeding
Supporting Investigation

Laboratory examination :
Counting the number of blood cells

Pro trombine time and activated partial thromboplastin time

Fibrinogen and blood separation products

Types and kinds of blood group

Blood chemistry, including electrolytes, BUN and creatinine

Urinalysis to myoglobinuria

Blood gas analysis to patients with systemic symptoms

Radiological examination:
Thorax photo for patients with pulmonary edema

Radiography to find fangs left

Other tests:
Compartment pressure can be measured. In komersialtersedia sterile tool, simple to install or read, and trustworthy (as Styker pressure
monitor). Indications compartment pressure measurement is when there is significant swelling, pain is very great that hinder the examination,
and if it appears on a limb paresthesias bitten
Sign Envenomation

LOCAL (the bite) Systemic

a.Bite marks canines (fang marks) General (general): nausea, vomiting, abdominal
b.Local pain pain, weakness, drowsiness, weakness.
c.Local bleeding Hemostatic abnormalities: spontaneous bleeding
d.Redness (clinical), coagulopathy, or thrombocytopenia.
e.Lymphangitis Neurotoxic symptoms: ptosis, external
f.Enlarged lymph nodes ophthalmoplegia, paralysis, and others.
g.Inflammation (swollen, red, hot) Cardiovascular disorders: hypotension, shock,
h.Blister arrhythmias (clinical), ECG abnormalities.
i.Local infections, abscesses Acute kidney injury (renal failure): oliguria / anuria
j.Necrosis (clinical), increased creatinine / urea urine (lab
results). Haemoglobinuria / myoglobinuria: dark
brown urine (clinical), urine dipstick or other
evidence of the existence of generalized
intravascular hemolysis atatu rhabdomyolysis
(muscle pain, hyperkalemia) (clinical, laboratory
results). As well as other laboratory evidence
against venerasi mark.
Antivenin Injection

Degree Venerasi Bite Pain Edema / Systemic signs

wounds erythema
0 0 + +/- <3cm / 12 0
hours
I + + + <3cm / 12 0
/- hours
II + + +++ > 12cm- +. Neurotoxic,
25cm / 12h nausea, dizziness, Parrish Degree Antivenin
shock 0-1 -
III + + +++ > 25cm / ++, shock,
+ 12h petechiae, 2 5-20 cc
ecchymosis 3-4 40-100 cc
IV + + +++ At one ++, Impaired
++ extremity kidney function,
thoroughly coma, bleeding
Repeated Dose Criteria Initiation
Antivenin

Coagulopathy persist or recurrent after 6 hours or bleeding after 1-2 hours,

there is a worsening of symptoms of neurotoxic or cardiovascular
symptoms after 1-2 hours
When the coagulation of blood remain, 6 hours antivenin after initial dose,
the same dose should be repeated.
In patients who continue to experience rapid bleeding, the dose should
be repeated antibisa between 1-2 hours.
In the case of worsening symptoms of neurotoxic or
cardiovascular symptoms, antibisa initial dose should be repeated after 1-
2 hours and supportive care should be considered
Response after Antivenin Injection

General: patients feel better, nausea, vomiting and pain as a whole can be lost quickly.
Spontaneous systemic bleeding (eg from the gums): usually stalled at 15-30 minutes.
Blood coagulation: usually stops within 3-9 hours. Bleeding from wounds heal faster in part
stalled
In the shock patients: blood pressure may rise between 30-60 minutes of the first and
arrhythmias such as sinus bradycardia can be resolved
In patients with type neurotoxicity post synapse (the bite of a cobra) will improve within 30
minutes after administration antibisa, but it usually takes bebeerapa hours. In the type of
pre-synaptic toxicity (Kraits and sea snakes) do not seem response.
Active hemolysis and rhabdomyolysis decline within a few hours and the color of the urine
will return to its normal color.
Observation

General condition and vital signs, sign envenomation investigation

For the case of a dry bite (can not be injected) from the viper, observation in
the emergency department for 8-10 hours, continued observations in the room
Patients with signs envenomation (poisoning) were severe requiring special
care in the ICU for the administration of blood products, providing invasive
monitoring, and ensure protection of the airway.
Observation for coral snake bites for at least 24 hours.
Serial evaluation for grading further and to get rid of compartment syndrome.
Measure the pressure compartment every 30-120 minutes.
Fasciotomy indicated for pressure more than 30-40 mmHg. Depending on the degree
of severity of the bite, further blood tests may be needed, such as blood clotting
time, platelet count, and fibrinogen levels
Conservative Treatment

Bed rest
Wound treatment with iodine, hibitane
Intravenous access (fluids and medications)
Administration of sedative drugs (diazepam, promethazine)
Administration of analgesic drugs (ASA, Paracetamol, Ibuprofen,
Indomethacin, pethidine)
Antibiotic prophylaxis (PPF, Amoxicillin, Ampicillin, Gentamicin)
Tetanus toxoid
Steroids (Hidrocortison, Dexamethasone)
Complications

Compartment syndrome
Local wound complications can include infections and skin loss
Cardiovascular complications, hematologic complications, and lung
collapse may occur
Children have a higher risk for the occurrence of death or serious
complications because of their body size smaller
Complications associated with antivenin including rapid-type
hypersensitivity reactions (anaphylaxis, type I) and delayed type (serum
sickness, type III)7
Prognosis

Besides the fact that there may be as many as 8,000 cases of venomous snake
bites, there are fewer than 10 deaths, and most of the fatal cases have not
sought help for a reason or another.
Possible complications of non-venomous snake bites include teeth retained on
the bite wound or wound infections (including tetanus). Snakes do not carry or
transmit rabies 6
Dry bite have the same complications with the non-venomous snake bites.
A victim who is still very young, elderly, or have other systemic diseases were
able to tolerate the injection amount can be similar to healthy adults.
The availability of emergency medical care and, most importantly, antivenin,
can affect how the state of the victim.
A victim who initially look good condition can be very painful 6

Thank You