India reports \~58,000 snakebite deaths/year, over 50% of global mortality. Clinical outcomes of antivenom may vary due to regional venom differences, delayed access to care, ineffective use of existing polyvalent antivenom. There is a need for an India-specific severity assessment tool because it improves risk stratification \& clinical decisions ,guides antivenom use, supports rural healthcare infrastructure, reduces morbidity, mortality, and financial burden.
Existing scoring systems lack validation for Indian envenomation patterns. Variability in venom (both inter- and intra-species) leads to inconsistent clinical outcomes.Misapplication of non-Indian tools may cause: Inaccurate severity grading, inappropriate antivenom use, poor patient outcomes.
PRIMARY OBJECTIVE:
● To determine the predictive accuracy of Snakebite Severity Score (SSS) done at the time of presentation in identifying syndrome specific core outcomes for snakebites.
SECONDARY OBJECTIVES:
* To evaluate the predictive accuracy of SSS in identifying patients at risk of mortality at 6 weeks * To determine the predictive accuracy of modified Snakebite Severity Score (mSSS) done at the time of presentation in identifying syndrome specific core outcomes for snakebites
METHODOLOGY Study Duration: 18 months (Proposed)
* Setting: Emergency Dept, Jubilee Mission Medical College * Sampling method :consecutive sampling * Sample Size Calculation:
n = Z₍₁-α/₂)2 x SN (100-SN ) / l2 x P = 220
* Confidence Level: 95% (Z₍₁-α/₂₎ = 1.96) * Expected Sensitivity: 97% * Relative Allowable Error: 5% (l = 0.05) * Proportion: Based on core outcome occurrence = 0.22 * Drop-out Rate Assumed: 20% * minimum sample size = 264 Reference: Based on data from Dart et al."Validation of a Severity Score for the Assessment of Crotalid Snakebite,1999"
INCLUSION AND EXCLUSION CRITERIA
Inclusion Criteria:
* All patients 'clinically suspected snakebite' * Presenting within 24 hours of the event * Age ≥18 years * Providing written informed consent
Exclusion Criteria
* Stings or bites other than snake * All patients who received antivenom or blood products at another institute * All patients with known hematological malignancies, coagulation disorders, chronic liver or renal failure * All patients known to be on warfarin, heparin or any newer oral or injectable anticoagulants * Individuals withdrawing a consent later on.
STUDY FLOW AND DATA MANAGEMENT
Study Flow:
Enrollment \& Initial ED Assessment:
History, examination, bite documentation, SSS scoring Baseline labs as per institutional protocol
Monitoring \& Follow-Up Timepoints:
T0: At presentation T+3h, +6h, +12h: Direct proforma, records review T+48h: Medical records Day 30 and Day 42 : Medical records \& telephonic follow-up Outcomes Monitored: Neurotoxicity, haemotoxicity , coagulopathy, local damage, AKI, hypotension No interference with clinical care or treatment decisions.
DATA ANALYSIS PLAN:
Software: SPSS v29 Continuous variables are measured by using Mean+/-SD or median IQR Categorical variables are reported as frequencies and percentages. ROC curve analysis for SSS and mSSS. Logistic regression for mortality. Subgroup and domain-wise analysis.
ETHICAL CONSIDERATIONS:
Ethics approval to be obtained. Informed consent will be ensured. Data anonymized and securely stored. No interference with patient treatment.
All patients 'clinically suspected snakebite'
Presenting within 24 hours of the event
Age ≥18 years
Providing written informed consent
Stings or bites other than snake
All patients who received antivenom or blood products at another institute
All patients with known hematological malignancies, coagulation disorders, chronic liver or renal failure
All patients known to be on warfarin, heparin or any newer oral or injectable anticoagulants
All adult patients presenting to the Emergency Medicine Department of Jubilee Mission Medical College with clinically suspected snakebite envenomation will be screened for eligibility. Patients who meet the inclusion criteria and provide written informed consent will be enrolled in the study.
Cohort
Prospective
History, examination, bite documentation, SSS scoring,Baseline labs as per institutional protocol
Other interventionFollowing enrollment, an initial clinical assessment will be conducted in the Emergency Department (ED). This includes history taking, physical examination, documentation of bite characteristics, and calculation of the Snakebite Severity Score (SSS) at presentation. Baseline laboratory investigations will be performed as per institutional protocol. All participants will undergo serial clinical and laboratory monitoring as per institutional protocol. The development of syndrome-specific core outcomes, including neurotoxicity, haemotoxicity, coagulopathy, local tissue damage, acute kidney injury, and hypotension (Annexure) would be followed-up and evaluations will be conducted at the following time points: At presentation, Within 3 hours of ED admission, Within 6 hours of ED admission, Within 12 hours of ED admission
Performance of the Snakebite Severity Score (SSS) at Emergency Department Presentation in Predicting Syndrome-Specific Core Outcomes
The performance of the Snakebite Severity Score (SSS), recorded at the time of emergency department presentation, will be assessed for predicting the occurrence of predefined syndrome-specific core outcomes during the follow-up period. The syndrome-specific core outcomes include neurotoxicity, haemotoxicity/coagulopathy, local tissue damage, acute kidney injury, and hypotension, as defined in the study protocol. Performance will be evaluated using the area under the receiver operating characteristic curve (AUC), sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV).
Performance of the Snakebite Severity Score (SSS) at Emergency Department Presentation in Predicting All-Cause Mortality Within 6 Weeks
The performance of the Snakebite Severity Score (SSS), recorded at the time of emergency department presentation, will be assessed for predicting all-cause mortality during the 6-week follow-up period. Performance will be evaluated using the area under the receiver operating characteristic curve (AUC), sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV).
Performance of the Modified Snakebite Severity Score (mSSS) at Emergency Department Presentation in Predicting Syndrome-Specific Core Outcomes Within 30 Days
The performance of the Modified Snakebite Severity Score (mSSS), calculated at the time of emergency department presentation, will be assessed for predicting the occurrence of predefined syndrome-specific core outcomes during the 30-day follow-up period. The syndrome-specific core outcomes include neurotoxicity, haemotoxicity/coagulopathy, local tissue damage, acute kidney injury, and hypotension, as defined in the study protocol. Performance will be evaluated using the area under the receiver operating characteristic curve (AUC), sensitivity, and specificity.
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