Diagnostic test accuracy of the 20WBCT is improved when assessing for the presence of severe coagulopathy. In this review, we conclude that the 20WBCT is capable of detecting coagulopathy following snakebite with high specificity and acceptable sensitivity. However, following a publication questioning its diagnostic accuracy, there is a lack of consensus regarding its diagnostic accuracy and utility. The test is used widely and is incorporated in multiple national and WHO guidelines. The 20WBCT is a simple, cheap and quick bedside clotting test devised to detect coagulopathy after snakebite. Coagulopathy is the commonest clinical manifestation of systemic snakebite envenoming and is indicative of a need for antivenom. Snakebite is a neglected tropical disease and responsible for an estimated 130,000 deaths per year. Both analyses that used INR and fibrinogen as the reference test displayed considerable heterogeneity. The aggregate weighted sensitivity of the 20WBCT at detecting fibrinogen <100 mg/dL was 0.72 (CI 0.58 to 0.83), the specificity was 0.94 (CI 0.88 to 0.98) and the SROC AUC was 0.93 (0.91 to 0.95). The aggregate weighted sensitivity of the 20WBCT at detecting INR >1.4 was 0.84 (CI 0.61 to 0.94), the specificity was 0.91 (0.76 to 0.97) and the SROC AUC was 0.94 (CI 0.91 to 0.96). Data was reported from 6 countries and included a total of 2,270 patients. The searches identified 3,599 studies, 15 met the inclusion criteria and 12 were included in the meta-analysis. The study protocol was prospectively registered on PROSPERO database (CRD42020168953). Included studies were evaluated for bias using a tailored QUADAS-2 checklist. Authors of 29 studies that lacked sufficient details in the manuscript were contacted and included if data meeting the inclusion criteria were provided. Data was extracted from full-text articles by two reviewers using a predetermined form. Databases were searched from inception up to to identify studies that compared the 20WBCT and INR/fibrinogen on five or more subjects.
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