Abstract
Snakebite is a neglected problem with a high mortality in India. There are no simple clinical prognostic tools which can predict mortality in viper envenomings. We aimed to develop and validate a mortality-risk prediction score for patients of viper envenoming from Southern India. We used clinical predictors from a prospective cohort of 248 patients with syndromic diagnosis of viper envenoming and had a positive 20-minute whole blood clotting test (WBCT 20) from a tertiary-care hospital in Puducherry, India. We applied multivariable logistic regression with backward elimination approach. External validation of this score was done among 140 patients from the same centre and its performance was assessed with concordance statistic and calibration plots. The final model termed VENOMS from the term "Viper ENvenOming Mortality Score included 7 admission clinical parameters (recorded in the first 48 hours after bite): presence of overt bleeding manifestations, presence of capillary leak syndrome, haemoglobin <10 g/dL, bite to antivenom administration time > 6.5 h, systolic blood pressure < 100 mm Hg, urine output <20 mL/h in 24 h and female gender. The lowest possible VENOMS score of 0 predicted an in-hospital mortality risk of 0.06% while highest score of 12 predicted a mortality of 99.1%. The model had a concordance statistic of 0·86 (95% CI 0·79-0·94) in the validation cohort. Calibration plots indicated good agreement of predicted and observed outcomes. The VENOMS score is a good predictor of the mortality in viper envenoming in southern India where Russell's viper envenoming burden is high. The score may have potential applications in triaging patients and guiding management after further validation.
Highlights
Snakebite envenoming is a serious but neglected problem in the tropics [1,2]
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The VENOMS score is a good predictor of the mortality in viper envenoming in southern India where Russell’s viper envenoming burden is high
Summary
Snakebite envenoming is a serious but neglected problem in the tropics [1,2]. South Asia, India has the largest burden of snakebite deaths and disabilities in the world [3,4]. Recent estimates suggest that annual mortality from snakebite envenomings in India is approximately 58,000; which is more than half the estimated global snakebite mortality. Thrice as many endure lifelong disabilities due to long-term consequences [4,5]. In South Asia, the snake species under the epithet of “Big 4” i.e. Daboia russelii, Echis carinatus, Bungarus caeruleus and Naja naja garner widespread attention while the other regionally important snake species are emerging as medically important [8,9]. Snakebite is a neglected problem with a high mortality in India. There are no simple clinical prognostic tools which can predict mortality in viper envenomings.
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