Dr.

PINNAMANENI
SIDDHARTHA INSTITUTE OF MEDICAL
SCIENCES & RESEARCH FOUNDATION
Chinoutpalli—521 286

DEPARTMENT OF GENERAL MEDICINE

P.G DISSERTATION PROTOCOL SUBMISSION
PROFORMA
01. Name of the student and department:
Post – graduate student : Dr. Ajith Balineni

Department : General Medicine

02. Title of the Dissertation : THE STUDY OF COMPLICATIONS
AND SEVERITY OF SNAKE BITE AND ITS CORRELATION WITH
SERUM CHOLESTEROL
03. Guiding faculty: Dr. T.V.D. SASI SEKHAR, MD.
04. HOD : Dr. ANJANEYA PRASAD. MD
05. Duration of Research / Dissertation work:24 months (june
2024 to may 2026)
 NEED FOR STUDY
 Snake bite is an occupational hazard causing significant morbidity and mortality all
over the world commonly in rural, agricultural, and tropical regions.
 An estimated 5 million people worldwide are bitten by snake each year with 1.8
million to 2.7 million envenoming’s. Around 80,000 to 1,37,000 people die among
them.
 There are around 45,000-80,000 deaths per year in India making India one of the
worst effected country.
 Winkler et al was the first to observe to observe the decrease in serum cholesterol
in hematotoxic snake bites.
 But not many studies have demonstrated the decrease in serum cholesterol in
snake bites
• Hence there is a need of studying the correlation of serum cholesterol with the
complication and severity of snake bite.
AIM OF THE STUDY
 To study the changes in levels of total serum total
cholesterol in patients with snake bite
 OBJECTIVES OF THE STUDY
• To correlate the severity of envenomation at
the time of admission with serum total
cholesterol levels
Inclusion criteria :
 All patients above18 yrs with history of snake
bite.
Exclusion Criteria :
 Patients below 18 years who will not give informed
consent.
 Patient with history of hyper cholestrolemia or hypo
cholesterolemia.
 On lipid lowering drugs.
 On anti-coagulant drugs.
 Patients with history of haematological disorders.
06. Detailed Research Plan:
SOURCE OF THE DATA
50 patients with snake bite admitted in
Dr. PINNAMANENI SIDDHARTHA INSTITUTE OF MEDICAL
SCIENCES AND RESEARCH FOUNDATION
METHODS AND MATERIALS:
• Sample size: 50
Methodology :
• In this study, 50 patients who are admitted with
history of snake bite and confirmed by fang marks to
the ER of Dr.PSIMS and RF will be included in the
study.
• The study will be conducted for a period of 2 years.
• All the basic investigations will be done immediately at
the time of admission along with the total serum
cholesterol and 20-min WBCT.
• The lab values of serum total cholesterol will be
analysed with the clinical profile and the outcome.
• All statistical analysis will be performed using SPSS
(software package used for statistical analysis) package
• SNAKEBITE SEVERITY SCORE(1,2,3)
 PROFORMA

• NAME:
• AGE:
• SEX:
• IP No:
• Identification of species of snake:
• Presence of snake fang marks:
• Snake bite duration:
• History of:
– Pain and swelling in the effected areas
– Neurological symptoms
– Bleeding symptoms
– Other symptoms.
–
• Past history:
– Dyslipidaemia:
– Taking lipid lowering agents:
– Haematological disorders:

• General physical examination:

• BP: PR: RR: sPO2: height: weight: BMI:
• Local examination:
– Fang marks:
– Swelling:
– Cellulitis:

• Systemic examination:
• CVS:
• RS:
• ABDMONEN:
• CNS:
• 20 MIN WBCT:
INVESTIGATIONS REQUIRED

CBP, LFT, RFT, LIPID PROFILE, SERUM ELECTROLTES, PT-INR, ECG,

20 MINUTES WBCT,
• Study design:
A Cross sectional study
• STATISTICAL ANALYSIS:
• The collected data will be tabulated and statistically
analysed .
• For qualitative data, frequency and percentage
distribution will be calculated and for comparison
between groups, the chi square test will be used.
• For quantitative data, mean and standard deviation
will be calculated and for comparison between the
groups, student t test will be used.
• Analysis of variance (ANOVA) will be used to find out
the significance of study parameters between three or
more groups of patient.
• REVIEW OF LITERATURE:

 Snake has been an important cultural symbol which

has been used by various cults, religions, and
societies.
 In Greeks, Apollo, the son of Zeus and Leto was
attempted to be killed by Hera when she was
pregnant by sending python
 The symbol of Medicine originated from Greeks.
Asclepius (son of Apollo).
 There are over 3000 species of snakes in the world of
which 600 species are considered Venomous.
• LIPID METABOLISM• Lipids are utilised by living organisms
as:
– 1. Regulator of membrane fluidity;
– 2. Precursor to steroid hormones and bile acids;
– 3. Major source of energy in the post-absorptive state;
– 4. Absorption, synthesis and transport of fat soluble vitamins;
– 5. Maintenance of the cell membrane; and
– 6. Other biological activities such as production of
prostaglandins,leukotrienes, lipoxins, prostanoids,
prostacyclines, thromboxanes and gangliosides
All nucleated cells synthesize cholesterol, but only hepatocytes
and enterocytes caneffectively excrete cholesterol from the body,
into either the bile or the gut lumen. In theliver, cholesterol is
secreted into the bile, either directly or after
conversion to bileacids(7)
• In study done in 2008 in Korea and published in korean jourmal of Medicine by
Kim et al, 98 patients with snake bite were enrolled and further divided into
coagulopathy and DIC group, and it was found that there was significant
decrease in cholesterol levels in coagulopathy group as compared to normal
patients (mean 108+/49 <0.022) and further there was significant decrease in
cholesterol levels in DIC group compared to non-DIC coagulopathy group
(mean 96.6+/- 42 p<0,044), signifying that serum total cholesterol levels were
negatively correlated with severity of envenomation.(4)
• Winkler et al in Israel, studied Vipera palestinae bite in 44 patients and studied
the admission serum total cholesterol levels and found that cholesterol levels
were significantly lower as the severity of envenomation increased and that
concomitant decrease in serum albumin were not significant, suggesting that
the traditionally known transcapillary leakage is not the only mechanism, and
an alternative mechanism of decrease in serum cholesterol may exist, most
probably involving changes in lipoprotein transport and metabolism by
Phospholipase A2 component of snake venom. These findings were
reciprocated in animal models, where dose-dependent decrease in cholesterol
was seen after non-lethal injection of purified V. palaestinae venom.(5)
• Ophitoxemia (Venomous Snakebite) by joseph L. Mathew and
Tharun Gera, mentioned about similar role of Serum
Cholesterol in assessing the severity of envenomation.(6)
REFERENCES :
1. Snakbite severity scale (SSS). Dart et al., 1996.
2. Validation of a severity score for the assessment of crotalid snake bite. R
C Dart et al. Ann Emerg Med, 1996 march.
3. Docs the traditional snakebite severity score correctly classify
envenomated patients? Seungho Kang et al Clin Exp Emerg Med 20163(1)
34-40
4. Coagulopathy in patients who experience snakebite, Kim et al. The
KoreanJournal of Internal Medicine : 23:94-99, 2008
5. Decreased serum cholesterol levels after snake bite (Vipera
Palaestinae) as a marker of severity of envenomation. Wikler E et
al J lab Clin med, 1993 jun;121(6):774-8.
6. Ophitoxemia (Venomous snakebite) Joseph L. Mathew and tarun
Gera.
OTHER REFERENCES

7. Lipids and lipoprotein metabolism, Soneil Guptha, Pg-1232, chapter 18.3, APIText Book
of Medicine, 9* Edition.
8. Menon JC, Joseph JK, Complications of hematotoxic snakebite in India, Toxinology:
2014: 1 - 21.
9. Mohapatra B, Warrell DA, Suraweera W, Bhatia P, Dhingra N, et al, Snakebite mortality
in India: a nationally representative mortality survey. PLoS Negl Trop Dis, 2011: 5: e1018
10. Gutierrez JM, Leon G, Burnouf T (2011). Antivenoms for the treatment of snakebite
envenoming: The road ahead. Biologicals 39: 129-142
11. Kini RM, Anticoagulant proteins from snake venoms: Structure, function and
mechanism, Biochem J 2006: Aug 1: 397: 3: 377 - 387.
12. Clinical Profile and Laboratory Parameters in 1051 victims of Snakebite from a Single
Centre in Kerala, South India Menon et al Journal of the Association of Physicians of India
Vol. 64 August 2016
• Proforma for investigations of PG (MD/MS) students, 2023-2024
Batch

• Name of the Student :Dr. Ajith Balineni

• Registration No :PG-23-37

• Department :GENERAL MEDICINE

• Guide :Dr. T.V.D. SASI SEKHAR, MD.

• Dissertation Title : THE STUDY OF COMPLICATIONS AND

SEVERITY OF SNAKE BITE AND ITS CORRELATION WITH SERUM
CHOLESTEROL
• INVESTIGATIONS REQUIRED FOR THE DISSERTATION WORK :
• Total estimated cost : No financial aid needed
Routine Specialized
investigations investigations
Estimat
ed Cost
Lab CBP, LFT, RFT, LIPID Nil No
Investigations: PROFILE, SERUM
financi
ELECTROLTES, PT-INR,
ECG, 20 MINUTES al aid
WBCT needed
Radiological Nil NIL No
Investigations: financia
l aid
needed
Any other NIL NIL No
Interventions/P financia
rocedures/ l aid
Surgeries needed
VI. CONSENT FORM:
Title of the Project: THE STUDY OF COMPLICATIONS AND SEVERITY OF SNAKE BITE AND ITS
CORRELATION WITH SERUM CHLOESTEROL
NAME OF THE INVESTIGATOR: Dr Ajith Balineni
Participants name:
Contact Number:

The details of the study have been provided to me in writing & explained in my own language. I

confirm that I have understood the above study and had the opportunity to ask questions. I

understand that my participation in the study is voluntary & that I’m free to withdraw at any time,

without giving any reason, without the medical care that will normally be provided by the hospital

being affected. I agree not to restrict the use of any data or results that arise from this study

provided such a use is only for scientific purpose(s). I have been given an information sheet giving

details of the study. I fully consent to participate in the above study.

Signature of the participant: ___________________ Date:

Signature of the witness: ______________________ Date:

THANK YOU