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.

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.

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.