From Clinical guidelines — Diagnosis and treatment manual › Chapter 10: Medical and minor surgical procedures · Médecins Sans Frontières, Current online edition, 2026
MSF clinical guidance on diagnosis and management of snake bites, scorpion stings, spider bites and hymenoptera stings for healthcare workers in resource-limited settings.
- Issuer
- Médecins Sans Frontières
- Edition
- Current online edition, 2026
- Audience
- Clinicians in resource-limited settings
- Evidence
- Expert consensus
- Reviewed
- 22 Oct 2026 · GMJ
What this guideline says
GMJ summary
This MSF clinical guideline provides systematic protocols for managing venomous bites and stings from snakes, scorpions, spiders and hymenoptera (bees, wasps, hornets). More than 50% of snake bites are ‘dry bites’ with no envenomation. When envenomation occurs, two major syndromes require recognition: neurological disorders evolving to respiratory paralysis (elapid snakes: cobra, mamba) and extensive local lesions with coagulation abnormalities (viperid and crotalid snakes). Early diagnosis relies on whole blood clotting tests performed in a dry tube at arrival and every 4 to 6 hours for the first day.
Antivenom serum is the aetiological treatment but should only be administered when clear clinical manifestations of envenomation or coagulation abnormalities are present. All asymptomatic patients require monitoring for at least 12 hours (24 hours preferred). The guideline emphasises that tourniquets, incision-suction and cauterisation are ineffective and dangerous, and that most infections are associated with traditional treatment or premature surgery rather than the bite itself.
For scorpion stings, most cause only local effects requiring supportive care; antivenom use is controversial except in regions with severe envenomations (North Africa, Middle East, Central America, Amazonia) and only within 2–3 hours of the sting. Spider bite management is primarily supportive, with calcium gluconate for muscle spasms. Hymenoptera stings require local care and preparedness for anaphylactic reactions with precise epinephrine dosing protocols.
Key points
For clinicians — doses and thresholds as stated in the guideline
- Perform whole blood clotting test using 2–5 ml whole blood in a dry tube: wait 30 minutes; incomplete or no clotting indicates coagulation abnormality requiring monitoring every 4–6 hours initially, then daily until normal
- Administer snake antivenom serum only if clear clinical manifestations of envenomation or coagulation abnormalities are observed; repeat after 4 or 6 hours if symptoms persist
- Monitor all asymptomatic snake bite patients for at least 12 hours (24 hours preferred) before discharge
- For scorpion antivenom, administer only within 2–3 hours of sting in severe envenomations; after this time, risk of anaphylaxis outweighs benefit
- Administer 10% calcium gluconate slow IV (5 ml in children, 10 ml in adults over 10–20 minutes) for muscle pain from scorpion stings or spider bites
- For anaphylactic reactions to hymenoptera stings: give epinephrine 1:1000 IM (children <6 years: 0.15 ml; 6–12 years: 0.3 ml; >12 years and adults: 0.5 ml); repeat after 5 minutes if no improvement
- Do not use acetylsalicylic acid (aspirin) for analgesia in snake bite patients; tourniquets, incision-suction and cauterisation are ineffective and dangerous
- Delay surgical intervention for tissue necrosis until lesions stabilise (minimum 15 days); infections are relatively rare and most often associated with traditional or premature treatment
Snake bite clinical signs and treatment by time since bite
Table extracted from the guideline
| Time since bite | Clinical manifestations | Possible aggressor | Treatment |
|---|---|---|---|
| 0 (Bite) | Fang marks, pain at site | ? | Strict rest, immobilisation with splint, wound cleansing, tetanus prophylaxis, observe for envenomation |
| 10–30 minutes | Hypotension, myosis, excessive salivation/sweating, dysphagia, dyspnoea, local paraesthesia, paresis | Elapids | Insert IV line, IV antivenom serum as soon as possible |
| 10–30 minutes | Inflammatory syndrome: intense pain, extensive regional oedema | Viperids/Crotalids | Insert IV line, IV antivenom serum, analgesics (not aspirin), IV or PO anti-inflammatories |
| 30 minutes–5 hours | Cobra syndrome: bilateral eyelid drooping, trismus, respiratory muscle paralysis, shock | Elapids | Intubation and assisted ventilation, treat shock |
| 30 minutes–48 hours | Haemorrhagic syndrome: epistaxis, purpura, haemolysis or DIC, shock | Viperids/Crotalids | Monitor coagulation, transfuse fresh blood if severe anaemia, treat shock |
| 6 hours or more | No signs or changes in coagulation | ? | Reassure patient, send home after 12 hours |
| Variable | Tissue necrosis | — | Remove blisters, clean, daily non-occlusive dressings; surgery after minimum 15 days if needed |
Source: Médecins Sans Frontières, Venomous bites and stings — Clinical guidelines — MSF Clinical guidelines. Reproduced in summary form.
From the guideline
Verbatim
“Antivenom serum should be administered as early as possible: by IV infusion (in 0.9% sodium chloride) if using a poorly purified serum; by slow IV in the event of severe envenomation if the serum is known to be well purified.”
Editor’s perspective
Why this matters for Georgia and the region
Prof. Giorgi Pkhakadze, MD, MPH, PhD
Editor-in-Chief, Georgian Medical Journal · Chair, Public Health Institute of Georgia · WHO consultant, health and migration
As chair of Georgia's Public Health Institute, I recognise that venomous bites pose a genuine burden in our mountainous and agricultural regions where Vipera species are endemic and where traditional harmful practices such as tourniquets and incision remain common in rural populations. The MSF protocol is highly applicable because it emphasises simple bedside diagnostics—the whole blood clotting test requires no laboratory infrastructure—and provides clear criteria for antivenom administration, avoiding both underuse in true envenomations and overuse in dry bites. The critical implementation challenge for Georgia is establishing a reliable cold-chain network for polyvalent viper antivenom across our mountainous terrain and ensuring that rural primary care providers are trained in the 12–24 hour observation protocol rather than immediate discharge or unnecessary referral. The guideline's emphasis on delaying surgical debridement for at least 15 days will help reduce the iatrogenic morbidity we have observed from premature interventions in regional hospitals.
ORCID 0000-0001-7609-4515 · Perspective written for the GMJ Guidelines Library, 22 Oct 2026
Applicability
Georgia and the South Caucasus
Georgia and the South Caucasus region harbour several medically important venomous species including vipers (Vipera species in mountainous areas) and, less commonly, scorpions in arid southern zones. National snakebite management protocols should verify local availability of polyvalent viper antivenom and establish cold-chain storage in regional referral centres, particularly serving rural populations in Kakheti, Samtskhe-Javakheti and mountainous areas where agricultural and pastoral exposures occur. The guideline’s emphasis on whole blood clotting tests is particularly relevant for Georgian primary care settings where laboratory infrastructure may be limited but dry-tube clotting tests require no equipment. Georgian emergency protocols should incorporate the MSF algorithm for triage and observation periods, and ensure that traditional practices such as tourniquets and incision are actively discouraged through public health messaging, as these remain prevalent in rural communities.
Questions this guideline answers
Quick answers
How do I distinguish between a dry snake bite and envenomation requiring antivenom?
More than 50% of snake bites are dry bites. Administer antivenom only if clear clinical manifestations appear (neurological signs, extensive local inflammation, coagulation abnormalities on whole blood clotting test). All patients require monitoring for at least 12 hours (24 hours preferred) even if initially asymptomatic, as signs may develop late.
How do I perform and interpret the whole blood clotting test?
Take 2–5 ml of whole blood in a dry tube, wait 30 minutes and examine. Complete clotting indicates no coagulation abnormality. Incomplete clotting or no clotting indicates coagulation abnormality and susceptibility to bleeding. Repeat every 4–6 hours for the first day if abnormal, then daily until normal. Bleeding may appear up to 3 days after the bite despite early coagulation factor decrease.
When should I give scorpion antivenom?
Scorpion antivenom use is controversial as most sera are not very effective and may be poorly tolerated. In regions with severe envenomations (North Africa, Middle East, Central America, Amazonia), follow national recommendations. Administer only within 2–3 hours of the sting; after this time, the risk of anaphylaxis outweighs benefit, unlike with snake bites.
What dose of epinephrine do I give for anaphylaxis from a bee sting?
Use undiluted epinephrine 1:1000 (1 mg/ml) IM: children under 6 years: 0.15 ml; 6–12 years: 0.3 ml; over 12 years and adults: 0.5 ml. If a 1 ml syringe is not available for children, dilute 1 mg epinephrine in 9 ml of 0.9% sodium chloride (1:10,000 = 0.1 mg/ml) and give: under 6 years: 1.5 ml; 6–12 years: 3 ml. Repeat after 5 minutes if no improvement.
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Other guidelines on this topic
- Issuer
- Médecins Sans Frontières
- Guideline
- Clinical guidelines — Diagnosis and treatment manual
- Chapter
- Chapter 10: Medical and minor surgical procedures
- Type
- Clinical guideline (chapter)
- Edition
- Current online edition, 2026
- Status
- Current
- Published
- 2026-10-14
- Scope
- Snake bites, scorpion stings, spider bites, hymenoptera stings
- Audience
- Clinicians in resource-limited settings
- Evidence
- Expert consensus
- Record history
- Created 22 Oct 2026 · updated 22 Oct 2026 · next check Apr 2027
Médecins Sans Frontières. Venomous bites and stings. In: Clinical guidelines — Diagnosis and treatment manual. Paris: MSF; 2026 Oct 14. Chapter 10, Medical and minor surgical procedures.GMJ Guidelines Library records are original summaries written by the GMJ editorial team from the issuer’s published document and reviewed by a physician. They do not replace the full guideline. The document is the copyright of its issuer and is linked, not hosted. Spotted an error or a newer edition? Tell the Guidelines Desk.
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