J.H. Bowdle2, S.A. King3, L.M. Smith1, C.L. McKnight1 1University of Tennessee Graduate School of Medicine, Trauma Critical Care/Surgery, Knoxville, TENNESSEE, USA 2University of Tennessee Health Science Center, University Of Tennessee Health Science Center, Memphis, TN, USA 3James H. Quillen College of Medicine, East Tennessee University, Johnson City, TN, USA
Introduction: Crotalid envenomation is a significant cause of hospital admissions in North America, but standardized assessment and treatment protocols are lacking. This study aimed to evaluate the consistency and accuracy of snakebite severity scores (SSS) calculated by surgical residents and their impact on patient care.
Methods: A retrospective chart review was conducted on all venomous snakebite (VSB) cases at a level I trauma center from March 2017 to September 2023. Patients were treated according to institutional protocols. Data included initial SSS documented by residents, recalculated SSS based on clinical documentation using the Crotalid Snakebite Severity Score, patient hospital course, and antivenin doses. Both initial and recalculated SSS were classified as mild, moderate, or severe. Discrepancies between the two scores were analyzed for potential changes in treatment. Statistical analysis was performed using SPSS version 29.
Results: Among 134 patients (average age 46.5 years; 64.9% male), 91 (67.9%) were transferred from referral centers. Most bites were from copperheads (76.9%). The mean resident-calculated SSS was 3.19, while the recalculated SSS was 3.62, with a correlation coefficient of 0.889 (p<0.001). SSS classifications matched in 81 cases (60.4%) as mild, 31 (23.1%) as moderate, and 4 (3.0%) as severe. Discrepancies occurred in 47 cases (35.1%), with 40 recalculated scores being higher and 7 lower than the resident scores. Eighteen discrepancies (13.4%) could have led to changes in treatment. In 11 of 17 cases (64.7%) with discrepancies, the resident SSS aligned with the correct clinical course. One case was misclassified by both scores, delaying appropriate care. Ten patients with mild resident scores but moderate recalculated scores required no antivenin. Three patients with mild resident scores improved with antivenin, despite the resident score suggesting no treatment. Two patients with moderate resident scores and severe recalculated scores had clinical courses supporting the resident's assessment. One patient received unnecessary antivenin, and another had delayed ICU admission due to misclassification.
Conclusion: Inconsistent use of the institutional protocol for VSB highlights the need for additional education. Inaccurate SSS calculations led to potential mismanagement of antivenin. A score of 4 may not always indicate the need for antivenin. Implementing a computer-based EMR checklist could reduce human error and improve adherence to protocols.