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EMSC Connects
December 2023; Vol.12, Issue 12
Pedi points
Tia Dickson, RN, BSN
Primary Children's Hospital
There have been several adult fatalities In Utah this year related to dog attacks. You learned in our last issue that animal injuries were tied for the third leading cause of death in children during Utah's last trauma cycle statistics (pictured here). While you will rarely transport a child with a dangerous animal bite, the things we see rarely are those we need to learn more about. Check this out.
The doc spot
Animal bites
Stuti Das, MD MSc
Pediatric Emergency Medicine Fellow, PGY-5
University of Utah, Department of Pediatrics, Primary Children's Hospital
Excerpts from November 13, 2023 PETOS
Domesticated cats and dogs inflict practically all of the bites encountered in emergency rooms in the U.S. Those are the animals we interact with the most. Dogs bites account for 60 to 90% of bites as opposed to cats at 5 to 20% but cat bites are associated with more infection. Children are more likely to be bit on their head, face, and neck due to their proportionally larger head and shorter stature, while adult bites are more common on the hands and arms.
We will also touch on other animal bites that are seen frequently here in Utah.
Dog bites
- Happen more often in men and children.
- The patient usually knows the dog and the bites are less commonly provoked.
- Injury occurs most commonly from teeth puncturing and/or tearing soft tissue or blunt force breaking bones.
- Dog bites are more commonly macerated.
- Between 30 and 50 people die from dog bites each year.
Cat bites
- Cats bites are more common in women and adults, and the bites more often result from provocation.
- Cat bites are narrow and deep as the animal rarely pulls or shakes its head, simply biting and holding on.
- This type of injury is more likely to seal itself relatively quickly, providing an anaerobic environment for the inoculated bacteria as well as initially appearing less consequential and prolonging time to seeking medical care.
Treatment for dog and cat bites
Treatment for these bites is the same. Irrigation with saline and a course of antibiotics (usually Augmentin), along with any skin repair needed.
Benefits of wound irrigation
Bottle irrigation method
Syringe irrigation method
Black widows
- Part of the Latrodectus species.
- From 2011–2015, an average of 8,500 spider exposures and 34,000 insect exposures were reported to the U.S. poison control center. (Over this time, only 5 fatalities were reported, 3 of which were from the Hymenoptera, bee and wasp category)
- Black widows can be found anywhere in the U.S. The spider pictured here was found in the ambulance bay at PCH a few years ago.
Spider bites
Typically they start out with local signs:
- Painful, redness, and swelling which develops central blanching
- Isolated sweating in the area
- Severe muscle pain and cramping within an hour
- Progressing to tachycardia, tachypnea, and hypertension associated with increased pain.
Latrodectus species will often have systemic manifestations (15 to 60 minutes after the bite)
- Diffuse muscle rigidity and cramping
- Tenderness and burning in the extremity
- Truncal or abdominal tenderness
- Nausea and vomiting
- Progression of pain
- These bites can cause premature labor in pregnant women due to abdominal muscle spasms.
Spider bite treatment
An important consideration for any bite, but especially these, is pain management.
The next consideration is, does this patient need antivenom? PCH considers using antivenom when the patient presents with severe hypertension, muscle pain, or cramping unrelieved by muscle relaxants, analgesics, or sedation, particularly those in patients younger than 1 year of age. Antivenom does have some risk. Patients can experience an immediate hypersensitivity or a delayed onset of 7–14 days after the administration. Dosing of antivenom is based on symptoms, rather than patient weight.
Rattlesnakes
- 3–4 bites per 100,000 population
- Clinically significant injury occurs in fewer than 60% of cases, and only a few deaths are reported yearly.
- Rattlesnakes are the most common snake envenomation in the U.S.
- Typical victim is a young, intoxicated male who was attempting to handle the snake.
- Bites happen more often in warm weather.
These snakes listed are not neurogenic and injuries from them most often effect soft tissue. Local effects can present within minutes of the bite. Burning, pain, and swelling are common. Within hours the swelling may be significant. The most serious complications from these rattlesnake bites are necrosis, coagulopathy, thrombocytopenia, hypovolemic shock, and compartment syndrome.
The Mojave rattlesnake is one found in Utah whose venom contains a neurotoxin. It inhibits acetylcholine release at the neuromuscular junction. This can cause muscle weakness, ptosis, and respiratory arrest. Unlike other rattlesnakes, there is little swelling or evidence of tissue damage. This snake is found in the extreme southwest corner of Utah.
Snake bite management
- Start with the ABCs.
- If angioedema or facial bite is present observe for airway compromise.
- Immobilize the affected extremity in a padded splint in near-full extension and elevate above the level of the heart to avoid dependent swelling.
- Mark the leading edge of swelling with a pen and if you can get circumferential measurements of the extremity.
- Place an IV and start a 20cc/kg NS or LR bolus.
- Rapid transport to the medical facility.
- Manage pain.
- Antivenom reverses coagulopathy and thrombocytopenia.
- If someone has placed a tourniquet on the extremity before you got there, you should remove it. Most of these snakes cause tissue necrosis and blood flow with help mitigate the tissue injury.
EMS considerations for animal bites
Scene safety always the first priority. You may need to call police or animal control. Do not put a provider in danger by attempting to capture the offending creature for identification purposes. Any threat should be neutralized before patient contact. The mnemonic MARCH is a great approach to animal bites.
It's important to collect a history to guide treatment and you are best positioned to discover this information.
- Type of bite/sting
- Description or photo of animal
- Time, location, size of bite/sting
- Previous reaction to bite/sting
- Domestic vs. wild
- Tetanus and rabies risk
- Immunocompromised patient
- Remove jewelry or anything that will be affected by swelling
- Contact poison control if you are concerned about envenomation
Protocols in practice—Snake Bites
For additional guideline direction check out the UPTN website or the new app, "Utah PTN" on android and apple devices.
CME credit for this issue
Training officers may review the topic above as a team training AND perform a simulation/skills check as directed here. Once complete, send a roster of participants to Utah.PETOS@gmail.com and those listed will be issued 1-hour of CME credit from the DHHS Office of EMS and Preparedness.
Individuals who don't have a training officer can get CME credit on their own by viewing the PETOS in our archives associated with this topic and completing the instructions on the webpage.
Simulation training
For this issue, perform an anaphylaxis trauma simulation using found below,
News from national EMSC
EMSC Pulse
National EMSC has a newsletter filled with fantastic pediatric information, resources, and links. Check it out!
News from Utah EMSC
Happy Holidays
Autism awareness trainings (for agencies and hospitals)
If your agency is interested in Jeff's autism training or in receiving the free John Wilson autism kits, contact Jeff @jeffwilson122615@gmail.com.
Stories from the field: After receiving this autism training for nurses a member of the class reported that she has a child in their family that is autistic. She said that this child would not have anything to do with her. She took advice from the class and started carrying sensory popper toys especially for this child. They are now best friends. She credits the toys and what she learned from the course.
The Medical Home Portal is a unique source of reliable information about children and youth who have special health care needs (CYSHCN) and offers a “one-stop shop” for their:
· Families
· Physicians and medical home teams
· Other professionals and caregivers
PECC development
For Utah hospital and EMS agency PECCs
Pediatric readiness—improving survival through pediatric readiness at trauma centers
New research presented at the American College of Surgeons (ACS) Clinical Congress 2023 shows children treated at trauma centers that are well-prepared for pediatric care have a better chance of survival.
“What happens in that first hour after injury really impacts whether you survive, so rapid access to trauma center care for kids is important,” Aaron Jensen, MD, MEd, FACS, FAAP, principal investigator, told ACS. “But most children in the United States receive initial trauma care at non-pediatric centers because they are more readily available.”
Jensen is the trauma co-lead at the EMSC Innovation and Improvement Center (EIIC) and a surgeon at the University of California, San Francisco (UCSF). The research team included experts from EIIC and ACS. The study's lead author, Caroline Melhado, MD, MS, an EMSC trauma fellow and general surgery resident at UCSF, presented the paper at the ACS Clinical Congress.
In the study, researchers worked to find the minimum level of pediatric readiness that lowers the risk of patient death. They used data from the 2021 assessment by the National Pediatric Readiness Project (NPRP). The NPRP aims to make sure that all emergency departments (EDs) in the U.S. can provide high-quality care to children.
The study included 790 trauma centers in the U.S., most of them not pediatric-specific trauma centers. The researchers found that centers in the top 25% of readiness—scoring higher than 93 out of 100 points on the NPRP assessment—had 17–27% lower odds of death than others.
The study found common issues in lower-scoring centers, like not having a pediatric emergency care coordinator, a pediatric quality improvement plan, or a pediatric disaster plan.
Jensen emphasizes that high pediatric readiness is achievable for all trauma centers and EDs.
“The goal of pediatric readiness is not to transform every ED into a pediatric trauma center,” said Jensen. “Rather, the goal is to help EDs optimize the initial care for pediatric trauma patients.”
Read the full study in the Annals of Surgery.
Preparing for the prehospital pediatric assessment; A Q&A with Manish Shad, MD
The Prehospital Pediatric Readiness Project (PPRP) Assessment will launch in spring 2024. Below, EMS physician Manish I. Shah, MD, MS, co-lead for the PPRP Assessment Workgroup, shares some details about the inaugural assessment.
What is the PPRP Assessment?
The PPRP Assessment is a series of questions that will help EMS and fire-rescue agencies better understand their pediatric capabilities—and work to improve any gaps identified. The voluntary, online assessment is slated to launch in May 2024 and is anticipated to take place every 5 years.
Who should participate?
Prehospital organizations staffed with personnel who render medical care in response to a 911 or similar emergency call. EMS and fire-rescue agencies will receive an invitation by email in May 2024. One person per agency will be asked to complete the assessment.
How long does it take?
The estimated average time to complete the assessment is 30–45 minutes. That estimate includes the time it takes for respondents to read, interpret, retrieve the information, and answer the questions.
What are the benefits?
At an organization level, the information you learn can help your EMS or fire-rescue agency become more competent, comfortable, and confident in taking care of children. Research suggests it may also improve outcomes. At the national level, your participation helps us better understand and address challenges in prehospital pediatric care and makes the nation’s EMS system more prepared for children.
What does the assessment cover?
The assessment covers 8 categories:
- Education and competencies for providers
- Equipment and supplies
- Patient and medication safety
- Patient- and family-centered care in EMS
- Policies, procedures, and protocols
- Quality improvement and performance improvement
- Interaction with systems of care
- Pediatric emergency care coordinators
There are 3 pieces of data you may need to collect before the assessment: annual call volume, annual pediatric call volume, and the number of personnel in your agency at each level of certification.
Will my responses be shared?
Your answers are confidential. Your data may be combined with data from other agencies to help researchers better understand prehospital pediatric readiness.
How was it developed?
The PPRP Assessment was developed by the PPRP Steering Committee, which includes representatives from more than 25 national EMS- and pediatric-focused organizations and subject matter experts, and is based on a joint policy statement and technical report on pediatric EMS systems.
How can I prepare for it?
Download the PPRP Checklist to start understanding the kinds of questions you will see on the assessment as well as your agency’s potential gaps. Then, access the PPRP Toolkit with resources to help you address the gaps. You can also reach out to your state’s EMSC Program Manager with any questions or reach out to EMSpedsReadySupport@hsc.utah.edu with any questions about your agency’s designated responder to the assessment.
Most importantly, keep an eye out for the assessment invitation in May 2024!
Learn more about the overall project or view the assessment webpage.
Understanding the PECC role
For Hospital PECCs
- EMSC has launched its first pediatric emergency care coordinator (PECC) learning module for ED-based PECCs. You are invited to view the module and provide feedback.
For EMS PECCs
- EMS PECC resources can be found on the EIIC website here.
Upcoming PECC events
PECC quarterly meeting
You will receive an invitation with the link through email. If you are a PECC and don't receive this invitation contact our program manager, Jared Wright jaredwright@utah.gov.
Tuesday, Feb 20, 2024, 10:00 AM
Southern PECC workshop
PECCs are encouraged to attend an in-person PECC workshop yearly to receive up-to-date pediatric training, direction for your PECC role, and to participate in networking with other PECCs statewide. These workshops are free to designated hospital and agency PECCs. We will offer 1 in the northern part of Utah and 1 in the southern part each year. Our next planned workshop is March 15, 2024 in St. George, Utah.
Friday, Mar 15, 2024, 08:00 AM
St. George, UT, USA
Pediatric education from Utah EMSC
Pediatric Emergency Trauma Outreach series (PETOS)
PETOS (pediatric emergency and trauma outreach series)
This course provides 1 free CME credit from the DHHS Office of Emergency Medical Services for EMTs and paramedics. The lectures are presented by physicians and pediatric experts from Primary Children’s Hospital. The format is informal; inviting questions and discussion.
Upcoming Topics
December—Rodeo injury
January—Traumatic brain injury
02:00 PM Mountain Time (US and Canada)
Join Zoom Meeting
https://zoom.us/j/98193757707?pwd=UzdNeXppQUdtZ01KZUp2UFlzRk9vdz09
Meeting ID: 981 9375 7707
Password: EmscPCH
Archived presentations can be viewed and also qualify for CME credits. You can access them at https://intermountainhealthcare.org/primary-childrens/classes-events/petos. To obtain a completion certificate—follow the instructions on the website
Monday, Dec 11, 2023, 02:00 PM
RSVPs are enabled for this event.
PEPP classes
Looking for a PEPP class?
Pediatric education for the prehospital provider
Register online at www.peppsite.com. Look up classes in Utah and find the 1 that works for you. Once you find the class, go to jblearning.com, and look up pepp als in the search tool. Purchase the number ($21.95). Return to peppsite.org to register for the class and follow the prompts.
If you have any questions, email Erik Andersen at erikandersen@utah.gov or text/call 435-597-7098. Continue to watch the website for additional classes.
Other pediatric education for all
Icy Hot: Rise of the Phoenix Statewide Virtual Tabletop Exercise
February 6–7. 2024 Noon–2 p.m. each day
Join us for a 2-day, virtual tabletop exercise to test Utah's
ability to respond to a burn mass casualty incident. Nearly
all aspects of an ESF-8 response will be tested, including
command and control, partner coordination, triage,
patient distribution, telehealth, resource sharing, patient
care, vulnerable and pediatric considerations, patient
transfer, tracking, follow-up, and contingency care.
Players include Utah hospitals, first responders, healthcare
coalitions, public health, emergency management,and
other ESF-8 partners.
Tuesday, Feb 6, 2024, 12:00 PM
University of Utah injury prevention learning series
University of Utah trauma/injury prevention learning series
Tuesday, Dec 19, 2023, 11:30 AM
University of Utah pediatrics ECHO 2023
University of Utah Pediatric ECHO
The Pediatrics ECHO fall series is in progress and registration is open. For those new to Pediatrics ECHO, you can earn CME for participating in a case-based learning session with experts in a variety of pediatric topics.
December 13, 2023 Bright Futures: Early Adolescence
You can view previous session recordings and other programs on the Project ECHO page. CME is available for participation in these classes.
Wednesday, Dec 13, 2023, 11:30 AM
EMS-focused education
University of Utah's EMS grand rounds
University of Utah's EMS grand rounds (Offered every 2nd Wednesday of even months)
Wednesday, Dec 13, 2023, 08:00 AM
Hospital-focused pediatric education
Primary Children's pediatric grand rounds
Primary Children's pediatric grand rounds (offered every Thursday, September-May)
The pediatric grand rounds weekly lecture series covers cutting-edge research and practical clinical applications, for hospital and community-based pediatricians, registered nurses, and other physicians and practitioners who care for children of any age.
The series is held every Thursday, 8 a.m. to 9 a.m. from September through May in the 3rd Floor Auditorium at Primary Children's Hospital. The lectures are also broadcast live to locations throughout Utah and nationwide.
Connect live
Click here for the PGR PCH YouTube channel to find the live broadcast. Archives (without continuing education credit) will be posted here within 1 week of the broadcast.
Thursday, Dec 14, 2023, 08:00 AM
Need follow up from PCH?
Emergency Medical Services for Children Utah, Office of EMS and Preparedness
The Emergency Medical Services for Children (EMSC) Program aims to ensure emergency medical care for the ill and injured child or adolescent is well integrated into an emergency medical service system. We work to ensure the system is backed by optimal resources and that the entire spectrum of emergency services (prevention, acute care, and rehabilitation) is provided to children and adolescents, regardless of where they live, attend school, or travel.
Email: tdickson@utah.gov
Website: https://bemsp.utah.gov/
Phone: 801-707-3763
Facebook: facebook.com/Chirp-UtahDepartmentofHealth