This multi-facility study describes the clinical features, pre-hospital first aid practices, in-hospital management, and outcomes of 227 snakebite cases in two high-burden districts of Northern Uganda. Overall, the findings demonstrate important gaps in the documentation and management of snakebite despite generally favourable patient outcomes. Snakebite predominantly affected children, adolescents, and young adults, with students and agricultural workers representing the most commonly documented occupations, reflecting the vulnerability of economically productive and school-going populations. Documentation of key clinical information, including occupation, snake species, and pre-hospital first aid, was frequently incomplete, limiting comprehensive clinical assessment and surveillance. Furthermore, recommended diagnostic investigations for snakebite envenomation, particularly coagulation and renal function tests, were infrequently performed, and snake antivenom was administered to only one-third of patients with documented envenomation. Although most patients recovered and were discharged, the occurrence of deaths highlights persistent deficiencies in the timely recognition and management of severe envenomation. Collectively, these findings highlight important opportunities to strengthen clinical documentation, improve adherence to evidence-based snakebite management guidelines, ensure timely access to essential diagnostics and antivenom, and enhance the quality of emergency care in high-burden settings, thereby contributing to reductions in snakebite-related morbidity and mortality.

Demographically, most cases were female (58.6%), young, and either students or agricultural workers, mirroring patterns reported in other studies from Uganda and the wider SSA region, where rural occupations, school-age outdoor activity, and household tasks at dawn and dusk drive exposure [27, 28]. The lower limb was the predominant bite site (85.9%), and most bites occurred during the second and third quarters of the year, consistent with peak rainy-season activity of medically important African snakes and increased agricultural labour during planting and weeding seasons [15]. These findings highlight the need for targeted community-based snakebite prevention strategies focusing on high-risk populations, including school-going children and farming communities. They also support the implementation of seasonal risk communication campaigns, promotion of protective footwear and safe farming practices, and strategic prepositioning of antivenom, essential medicines, and trained healthcare personnel in anticipation of periods of increased snakebite incidence.

The predominance of pain (60.8%), local swelling/blisters (58.7%), and fang marks (26.9%), alongside a smaller proportion of systemic features, suggests that most cases presented with mild-to-moderate severity or with dry bites in which little or no venom was injected. A relatively short median delay from bite to facility (2 hours; IQR 1–6) likely limited progression to severe systemic disease and contributed to the high recovery rate. Nevertheless, 18.5% of patients exhibited features consistent with systemic envenomation, including paralysis (4.0%), moderate-to-severe bleeding (7.1%), and respiratory difficulty (10.6%), all of which are clinically important presentations that warrant timely antivenom administration and intensive supportive care [3, 8, 29]. These findings emphasise the need to enhance community awareness in promoting early health-seeking behaviour. It is also crucial to ensure that frontline health facilities are equipped with trained personnel, antivenom, and essential emergency care resources. This will enable them to quickly identify and manage severe envenomation before life-threatening complications arise.

A striking finding was that snake species, or symptoms was undocumented in 76.2% of records. This likely reflects a combination of patients not seeing or being able to describe the snake, limited community familiarity with locally important species, and incomplete clinical history-taking and documentation by healthcare workers [15]. Without syndromic classification suggesting either neurotoxic, cytotoxic, or haematotoxic, distinguishing dry bites and bites from non-venomous snakes from genuine envenoming is difficult, and antivenom decisions may be delayed or inappropriate. Because the offending snake is rarely identified and clinical features alone are seldom diagnostic, WHO recommends a syndromic approach — classifying cases by the pattern of local swelling, the presence of incoagulable blood on the 20-minute whole-blood clotting test, and signs of neurotoxicity — to guide rational, algorithm-based use of polyspecific antivenom. Routine syndromic documentation would therefore both improve individual case management and strengthen surveillance. [8]. Poor documentation also compromises surveillance and antivenom procurement planning, and could affect post-marketing monitoring of antivenom safety and effectiveness [30].

Pre-hospital practices identified in this study echo broader concerns about community knowledge and health-system reach. The frequent use of inappropriate first aid options such as tourniquets (29.3%) and herbal remedies (8.9%), together with the absence of any documented first aid in most cases (59.1%), suggests limited public awareness of evidence-based snakebite first aid (immobilisation of the affected limb, rapid transport to a health facility, and avoidance of tourniquets, incision, suction, and traditional remedies) [31]. Tourniquet application in particular has been repeatedly associated with worsening local tissue necrosis, ischaemic injury, and post-release rebound envenomation WHO guidance is unequivocal that a tight (arterial) tourniquet should never be applied; recommended first aid instead consists of reassurance, immobilisation of the whole patient and especially the bitten limb (for example with a splint or sling), and rapid, passive transport to a facility able to give antivenom. Importantly, when a patient reaches hospital with a tourniquet or other constricting band still in place, antivenom, if indicated, should be started before the band is loosened, because releasing venom sequestered in the occluded limb into the general circulation can precipitate abrupt, life-threatening systemic envenomation. [2, 32]. Reliance on traditional remedies has been linked to delays in formal care and worse outcomes, and frequently reflects geographic and economic barriers to health-facility access as much as cultural preference [9, 33]. These findings support sustained investment in community sensitisation, school health education, and engagement with traditional healers as community gatekeepers.

In-hospital diagnostic evaluation revealed a marked imbalance between basic vital sign monitoring (blood pressure 70.4%; pulse 67.7%) and snakebite-specific coagulation assessment (20WBCT 17.3%; INR 12.0%). Although blood pressure and pulse were documented in most patients, the 20-minute whole-blood clotting test (20WBCT) and INR/prothrombin time were performed in only 17.3% and 12.0% of cases, respectively. This finding is concerning because the 20WBCT is recommended by the World Health Organization and widely adopted across sub-Saharan Africa as a simple, inexpensive bedside test for detecting venom-induced consumptive coagulopathy and guiding decisions on antivenom administration in resource-limited settings [34, 35]. Similar underutilisation of snakebite-specific diagnostic tests has been reported in other African settings, where inadequate training, inconsistent adherence to clinical guidelines, shortages of supplies and laboratory reagents, and limited diagnostic capacity constrain evidence-based management of snakebite envenoming [35–37]. Failure to perform appropriate coagulation testing may result in delayed recognition of systemic envenomation, inappropriate use or withholding of antivenom, and missed opportunities to monitor response to treatment. From a public health and health systems perspective, these findings highlight the need to strengthen implementation of national and WHO snakebite management guidelines through healthcare worker training, routine availability of simple bedside diagnostic tests such as the 20WBCT, improved laboratory support, and regular clinical audit to promote adherence to recommended standards of care.The 20WBCT is also intended to be repeated to monitor treatment: WHO advises that if the blood remains incoagulable six hours after an initial dose of antivenom, the dose should be repeated, and testing continued every six hours until coagulability is restored.

Antivenom utilisation was a particular concern as only 15.0% of all cases and 33.3% of patients with documented envenomation received antivenom. This is consistent slightly higher than the 6.9% reported in a recent multi-region Ugandan retrospective study [15] and the 12.6% reported among severely ill patients in a rural Ugandan ICU series [11]. Underuse of antivenom in SSA is driven by a combination of high cost, which often exceeds the monthly income of affected households, supply-chain disruptions, expiry of stock at the district level, perceived risk of adverse reactions, and limited prescriber confidence [3, 38]. Strengthening antivenom procurement and distribution, ensuring deployment of WHO-prequalified products with demonstrated efficacy against locally important species, and providing protocolised guidance on indications, dosing, and management of acute reactions are critical In line with WHO guidance, antivenom is indicated in all cases of systemic envenoming and of severe local envenoming, should be given as soon as such signs appear, and has no absolute contraindication in life-threatening envenoming; children require the same dose as adults. Intradermal or conjunctival hypersensitivity testing is not predictive of reactions and is no longer recommended, so it should not delay treatment. The potential impact of closing this gap is substantial: early antivenom has historically reduced case fatality from carpet-viper (Echis) envenoming from around 20% to under 3%, underscoring that improving timely, indicated antivenom use is among the highest-yield interventions available in this setting. [2].

The heavy reliance on supportive and adjunctive treatments such as intravenous fluids (68.1%), analgesics (64.2%), antibiotics (53.1%), and corticosteroids (45.6%) indicates that snakebite management in this setting is largely symptomatic rather than definitive. Empirical antibiotic use is widely reported despite evidence that prophylactic antibiotics confer little benefit in the absence of clinical infection Consistent with WHO guidance, antibiotic treatment should be withheld until there are definite signs of infection — such as a hot, reddened, fluctuant local swelling resembling an abscess — or the wound is necrotic; prophylactic antibiotics are appropriate only where the wound has been grossly interfered with or is frankly necrotic. A tetanus toxoid booster, by contrast, is appropriate for all snakebite victims. [34, 39]. Similarly, routine corticosteroid use for envenoming is not supported by current evidence and is recommended only for the prevention or treatment of acute hypersensitivity reactions to antivenom [34]. These prescribing patterns highlight an opportunity for stewardship-focused training, locally adapted clinical algorithms, and structured supervision to align practice with international and regional guidelines [9].

Despite these gaps in clinical management, the overall mortality was 3.1%, comparable to the 2–5% range reported in regional studies and lower than rates reported from facilities with limited critical care capacity [11, 15]. The favourable outcome profile likely reflects predominantly mild envenomations (or none), short delays in presentation, and the protective effect of admission and basic supportive care. Nevertheless, the occurrence of seven deaths and two referrals demonstrates that severe snakebite envenomation continues to result in preventable morbidity and mortality, particularly where timely access to antivenom, advanced supportive care, and critical care services is limited. These findings reinforce the need to strengthen referral systems, ensure the continuous availability of effective antivenom and essential emergency care resources, and build the capacity of frontline health facilities to promptly recognise and manage severe envenomation. Such interventions are critical to reducing preventable snakebite deaths and align with the World Health Organization strategy to reduce snakebite-related mortality and disability through improved health system preparedness and access to quality care.