Dear Editor,
We read the article authored by Kumar et al.,[1] recently published in your esteemed journal, with great interest. We would like to highlight some concerns and suggestions.
In this retrospective, observational, descriptive study, the authors have tried to highlight the clinico-epidemiological pattern and the outcome following the snake bite in the southern part of India. Calculating the envenomation severity without a validated score such as snake bite severity score (SSS) is inaccurate and is a major concern here.[2,3] The SSS uses other parameters like respiratory, hematological, neurological, renal, and gastro-intestinal symptoms to grade the severity of envenomation accurately.[2,3] In this study, only local signs without any information on other systems have been used, whereas a comparative description of local and systemic symptoms of envenomation and complications could have given a better picture of the clinical manifestations of envenomation [especially for a bite by elapid (cobra and krait) and Viperidae family (Russel’s viper, saw-scaled viper)].[3,4]
As most of the bites were neurotoxic, detailed information on the percentage of patients who required an intensive care unit (ICU) and mechanical ventilation and an objective measurement of the severity of neuroparalysis using head lift and/or single breath count would have better represented the outcome parameters.[1,3,4] Similarly, in the case of viper bite, the information on the percentage of patients who developed acute renal failure and required dialysis is missing.[1] In local manifestations, compartment syndrome, which is an important complication of cobra and viper bite, is not mentioned. Krait bite is most common as per the study data,[1] but krait bite occurs mainly in India from July to October so that a seasonal distribution could have added better representation.[5] In addition, kraits have small fangs and are not known to develop obvious local signs or symptoms. Therefore, it would be prudent to utilize SSS to capture neuroparalysis and autonomic neuropathy.
In 41 cases, species could not be identified.[1] However, the readers would be interested to know how many of them had abnormal 20-minute whole blood clotting test (WBCT), PT, aPTT, INR, and Hb (hemolysis), which could reflect the hemotoxic manifestations of envenomation.[4,5] In the case of patients referred from other remote areas, data on first aid measures undertaken before reaching the study hospital and the number of hospitals visited before reaching the ED, mode of transport, and reason for the delay in reaching are important epidemiological factors to explore as they reflect the need for awareness and community empowerment to reduce the burden of mortality and morbidity following snake bite.[5] Similarly, information on the number of ASVs received before presenting to the study center and the time for snake bite to the administration of ASV (needle time) could have added more authenticity to the manuscript as it can affect the final clinical outcome.[3,4,5]
To conclude, we hope that the points mentioned earlier will be informative for the readers.
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References
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