This Clinical Practice Guideline (CPG) was developed to provide pragmatic clinical guidance for military medical providers managing snakebite envenomations in far-forward, expeditionary settings.

Recognizing the ethical and logistical challenges of conducting rigorous clinical trials for time-critical envenomations on the battlefield, the recommendations herein are based on the best available evidence. Where high-quality published data is limited, the guidance reflects a synthesis of available literature, author experience, and expert recommendations. The methodology incorporates SME opinion, operational experience, observational studies, and unpublished data to address gaps in military or civilian literature.

In line with Joint Trauma System (JTS) policy, this CPG prioritizes operational relevance, speed, and real-time performance improvement. Therefore, it does not adhere to all standards of the National Academy of Sciences, Engineering, and Medicine, such as formal strength-of-evidence grading. Final adjudication was achieved through a structured, iterative expert review and consensus of selected senior authors, rather than a formal Delphi methodology. While potentially useful for civilian providers in austere environments, this CPG is specifically tailored to the unique capabilities and needs of military medical personnel.

Roles & Responsibilities

The development and revision of this CPG were managed through a structured process involving a working group leader, section authors, and a senior author group.

• Working Group Leader: The first author (JM) led the JTS Snakebite Envenomation Working Group, defined the scope, provided revisions, and ensured compliance with JTS development standards.
• Senior Author Group: A senior group composed of JMB, BG, CD, EB, AF, and JM conducted a secondary review and iterative revisions of all draft sections. This group represented key stakeholders across the continuum of care, including conventional and special operations paramedics, emergency medicine physicians, toxicologists, and non-toxicologist experts in austere envenomations.
• Additional Subject Matter Experts: JMB and BG also consulted with DR, MC, JL, CP, NB, BW, KM, and SG as additional domain SMEs on specialized topics throughout the process.

The original CPG was divided into the following sections for initial review and revision:

Approval & Finalization

Draft sections were extensively reviewed by the senior author group to ensure clinical validity and operational feasibility. Once consensus was achieved, the recommendations were passed to the first author (JM) for final review. The consolidated document was then reviewed by designated DoD toxicology reviewers and advanced through the formal JTS review and approval pathway.