Bites and Envenomations History Signs and Symptoms Differential Type of bite / sting Rash, skin break, wound Animal bite Description or bring creature / Pain, soft tissue swelling, redness Human bite photo with patient for identification Blood oozing from the bite wound Snake bite (poisonous) Time, location, size of bite / sting Evidence of infection Spider bite (poisonous) Previous reaction to bite / sting Shortness of breath, wheezing Insect sting / bite (bee, wasp, ant, Domestic vs. Wild Allergic reaction, hives, itching tick) Tetanus and Rabies risk Hypotension or shock Infection risk Immunocompromised patient Rabies risk Tetanus risk Universal Patient Care Protocol Animal bites: Document contact No EMS transport ? with Animal Control Officer if not transported Yes Pain Control Protocol Position patient supine Trauma Protocols Immobilize area or limb Refer to Pain Control Protocol if there is Legend significant pain MR If there is allergic reaction refer to Allergic B EMT B Reaction Protocol I EMT- I I P EMT- P P Notify Destination or M Medical Control M M M Contact Medical Control Pearls Recommended Exam: Mental Status, Skin, Extremities (Location of injury), and a complete Neck, Lung, Heart, Abdomen, Back, and Neuro exam if systemic effects are noted Human bites have higher infection rates than animal bites due to normal mouth bacteria. Carnivore bites are much more likely to become infected and all have risk of Rabies exposure. Cat bites may progress to infection rapidly due to a specific bacteria (Pasteurella multicoda). Poisonous snakes in this area are generally of the pit viper family: rattlesnake, copperhead, and water moccasin. Coral snake bites are rare: Very little pain but very toxic. "Red on yellow - kill a fellow, red on black - venom lack." Amount of envenomation is variable, generally worse with larger snakes and early in spring. If no pain or swelling, envenomation is unlikely. Black Widow spider bites tend to be minimally painful, but over a few hours, muscular pain and severe abdominal pain may develop (spider is black with red hourglass on belly). Brown Recluse spider bites are minimally painful to painless. Little reaction is noted initially but tissue necrosis at the site of the bite develops over the next few days (brown spider with fiddle shape on back). Evidence of infection: swelling, redness, drainage, fever, red streaks proximal to wound. Immunocompromised patients are at an increased risk for infection: diabetes, chemotherapy, transplant patients. Consider contacting the North Carolina Poison Control Center for guidance (1-800-84-TOXIN). Protocol 49 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS 2009 Burns: Thermal History Signs and Symptoms Differential Type of exposure (heat, gas, chemical) Burns, pain, swelling Superficial (1st Degree) red and painful Inhalation injury Dizziness Partial Thickness (2nd Degree) blistering Time of Injury Loss of consciousness Full Thickness (3rd Degree) painless/charred or leathery skin Past medical history and Medications Hypotension/shock Thermal Other trauma Airway compromise/distress Chemical Loss of Consciousness singed facial or nasal hair Electrical Tetanus/Immunization status Hoarseness / wheezing Radiation Universal Patient Care Protocol Critical Serious Minor (Red) (Yellow) (Green) 5-15% TBSA 2nd/3rd Degree Burn >15% TBSA 2nd/3rd Degree Burn Suspected Inhalation injury or < 5% TBSA 2nd/3rd Degree Burn Burns with Multiple Trauma requiring intubation for airway No inhalation injury, Not Intubated, Burns with definitive airway stabilization Normotensive compromise Hypotension or GCS < 14 GCS>14 (When reasonable accessible, (When reasonable accessible, (Transport to the Local Hospital) transport to a Burn Center) transport to either a Level I Burn Trauma Protocols Center or a Trauma Center) Remove Rings, Bracelets, and Cool Down the Wound with Normal other Constricting Items Saline Airway Protocol Cover Burn with Dry sterile sheet or dressings Cover Burn with Dry sterile sheet or dressings IV Normal Saline, IV Normal Saline, 2 large bore IVs, infuse total of 0.25 x kg infuse total of 0.25 x kg body wt. x % TBSA per body wt. x % TBSA per I I I hour for up to the first 8 I hour for Legend hours. up to the first 8 hrs. (More info below) MR (More info below) B EMT B I EMT- I I Pain Control Protocol P EMT- P P M Notify Destination or M M Medical Control M Contact Medical Control 1. The IV solution should be changed to Lactated Ringers if it is available. It is preferred over Normal Saline. Pearls 2. Formula example and a rule of thumb is; an 80 kg patient with 50% Burn patients are Trauma Patients, evaluate for multisystem trauma. TBSA will need 1000 cc of fluid per hour. Assure whatever has caused the burn, is no longer contacting the injury. (Stop the burning process!) Critical or Serious Burns Recommended Exam: Mental Status, HEENT, Neck, Heart, Lungs, > 5-15% total body surface area (TBSA); 2nd or 3rd degree burns, or rd Abdomen, Extremities, Back, and Neuro 3 degree burns > 5% TBSA for any age group, or Early intubation is required when the patient experiences significant circumferential burns of extremities, or inhalation injuries. electrical or lightning injuries, or Potential CO exposure should be treated with 100% oxygen. (For suspicion of abuse or neglect, or patients with the primary event is CO inhalation, transport to a inhalation injury, or hospital equipped with a hyperbaric chamber is indicated [when chemical burns, or reasonably accessible].) burns of face, hands, perineum, or feet, or Circumferential burns to extremities are dangerous due to potential any burn requiring hospitalization. vascular compromise secondary to soft tissue swelling. (These burns will require direct transport to a burn center, or transfer once Burn patients are prone to hypothermia - never apply ice or cool seen at a local facility where the patient can be stabilized with interventions burns, must maintain normal body temperature. such as airway management or pain relief if this is not available in the field or Evaluate the possibility of child abuse with children and burn injuries. the distance to a Burn Center is significant.) Protocol 50 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS 2009 Burns: Chemical and Electrical History Signs and Symptoms Differential Type of exposure (heat, gas, chemical) Burns, pain, swelling Superficial (1st Degree) red and painful Inhalation injury Dizziness Partial Thickness (2nd Degree) blistering Time of Injury Loss of consciousness Full Thickness (3rd Degree) painless/charred or Past medical history and Medications Hypotension/shock leathery skin Other trauma Airway compromise/distress Thermal Loss of Consciousness singed facial or nasal hair Chemical Tetanus/Immunization status Hoarseness / wheezing Electrical Radiation Legend Universal Patient Care Protocol MR B EMT B P Cardiac Monitor P I EMT- I I P EMT- P P Eye Involvement? Continuous saline M Medical Control M flush in affected eye. Flush are with water or Normal Saline for 10-15 minutes Remove Rings, Bracelets, and other Constricting Items. Remove clothing or expose area Trauma Protocols Identify entry and exit sites, apply sterile dressings Pain Control Protocol (IV only for Burn Patients) I I IV Protocol Normal Saline Bolus Chemical and Electrical Burn Patients Must be Triaged using the Guidelines below and their care must conclude in the Thermal Burn Protocol Critical Serious Minor (Red) (Yellow) (Green) 5-15% TBSA 2nd/3rd Degree Burn >15% TBSA 2nd/3rd Degree Burn < 5% TBSA 2nd/3rd Degree Burn Suspected Inhalation injury or requiring intubation Burns with Multiple Trauma No inhalation injury, Not Intubated, for airway stabilization Burns with definitive airway compromise Normotensive Hypotension or GCS < 14 (When reasonable accessible, transport to a GCS>14 (When reasonable accessible, transport to either a Burn Center) (Transport to the Local Hospital) Level I Burn Center or a Trauma Center) Pearls Chemical Pearls Electrical Refer to Decontamination Standard Procedure (Skill) WMD Do not contact the patient until you are certain the source of the electric Page shock has been disconnected. Certainly 0.9% NaCl Soln or Sterile Water is preferred, Attempt to locate contact points, (entry wound where the AC source however if it is not readily available, do not delay, use tap contacted the patient, an exit at the ground point) both sites will generally water for flushing the affected area or other immediate water be full thickness. sources. Flush the area as soon as possible with the Cardiac monitor, anticipate ventricular or atrial irregularity, to include V- cleanest readily available water or saline solution using tach, V-fib, heart blocks, etc. copious amounts of fluids. Attempt to identify the nature of the electrical source (AC vs DC), the amount of voltage and the amperage the patient may have been exposed to during the electrical shock. Protocol 51 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS 2009 Drowning History Signs and Symptoms Differential Submersion in water Unresponsive Trauma regardless of depth Mental status changes Pre-existing medical problem Possible trauma to C-spine Decreased or absent vital signs Pressure injury (diving) Possible history of trauma ie: Vomiting Barotrauma diving board Coughing Decompression sickness Duration of immersion Apnea