This warm weather has woken many creepy, crawly things that bite and sting. This includes venom packing snakes common to the U.S.: rattlesnakes, copperheads, cottonmouth and coral snakes.

Bites can be "dry" without injection of venom. These can be painful and can cause infection or an allergic reaction. The majority of snake bites calls to 9-1-1 are those when venom is deposited. The amount of pain and damage depends on venom potency, the amount injected, and whether the poison remains locally in the tissues or enters circulation.

Severity also depends on the type of venom. A single snake can carry multiple types of venom but there are two broad categories.

• Neurotoxic: These disrupt chemical signals (neurotransmitters) sent between neurons. The most serious effect is that these neurotoxins can paralyze the respiratory muscles.
• Hemotoxic: These toxic substances can produce major clinical problems such as clotting dysfunction and bleeding, kidney damage, and shock.

Fortunately, most U.S. snake bite victims survive. The death rate for U.S. snakebites averages five deaths per year. A review of poison center reports over a 13 year period showed an average of 1,337 bites per year.Texas and Florida had the highest rates for venomous snake bites. All 50 states reported some form of snakebite injury to an infant, child, or adolescent. Young teen males are at highest risk in the pediatric population.

What can I do to prevent snakebites for my child?

Some snakebites may be hard to avoid. But you can take steps to reduce your child's risk. These include:

• Teach your child to leave snakes alone. Teach him or her not to get too close.

• Make sure your child stays out of tall grass unless he or she wears thick leather boots.

• Teach your child to stay on paths when hiking or walking in the woods.

• Do not allow your child to reach into tall grasses or other places snakes may be. Tell your child not to pick up large rocks or firewood.

• Make sure your child knows to watch for snakes when climbing on rocks.

The reality of social distancing is the same for Utahns as in many other areas of the country. However, what sets us apart is that as we are drawn away from friends and family to prevent coronavirus spread, we are called into our backyards, the back country, the desert, and mountains to fill the parts of us that are left wanting during this trying time.

While it is unclear if it's the actual physical movement caused by increased hikers and bikers on trails, or if it's simply an increased statistical probability that with more adventurers outside we are more likely to hear reports of more wildlife seen, rattlesnake encounters are being reported in numbers exceeding previous years. This is forcing medical providers to refresh our understanding of how to manage this unique medical entity.

Good first aid is the hallmark of most envenomation, but definitely for rattlesnake bites. If possible, remember the following tips:

• Remove the patient from the snake’s territory, if possible. Snakes have a “bite reflex” that allows them bite for up to 1 hour after they have died, even if they have been decapitated
• Attempt to identify the snake, either visually or with a camera phone, only if it is safe for the patient and rescuer, and it will not delay transport
• Remove jewelry or footwear from affected extremity
• Gently immobilize the affected body part in a functional position
• Do not manipulate the wound except to permit gentle splinting or bandaging
• Pressure dressing should NOT be used for rattlesnake bites
• Transport to definitive medical care ASAP

Although recommendations for snake bites are constantly in flux, the following should be avoided:

• Sucking out the venom either by mouth or with a device
• Ice application
• Cutting away the affected tissue
• Tourniquets

And, as always, emergency management of respiratory depression and shock, which for rattlesnake bites often results from excessive local bleeding secondary to coagulopathy, should be managed using tried and true methods of airway and hemodynamic support. The ultimate goal is to have your patient present as quickly as possible to a medical center, where antivenin and/or other supportive measures can continue. Remember these emergencies are time sensitive. Antivenin is a medicine that helps to reverse the effects of the poison. It should be given within 4 hours when possible. It does not usually work if given more than 12 hours after the bite.

Some exciting news! The 2020 update of the Utah EMS Protocol Guidelines has just been released!

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Primary Children's Statistics:

• Increase in COVID-19 positive rate. We were at a 4% positive rate until June. We are now up to a 12-15% positive rate.
• 11,000 pre-operative patients were tested. The rate of well-appearing positive patients is 0.2%.
• The mortality rate is 1%.
  
• PCH has screened multiple children for MIS-C (see below).
• PCH began it's surge plan (outlined in our May issue) on June 21.

Multisystem Inflammatory Syndrome in Children (MIS-C)

2 studies recently reported the following information about MIS-C, a rare but serious inflammatory condition linked to COVID-19.

• At least 285 cases of MIS-C in the United States
• Six children died (among the 285)
  
• About 1,000 pediatric cases have been reported worldwide
• The average age of the patient was 8 years old
• Researchers don’t know if adults can be affected

Missing Vaccines

By: Sally Goza, MD, FAAP, president of the American Academy of Pediatrics

“The U.S. Centers for Disease Control and Prevention (CDC) published new data that documents what pediatricians around the nation have been reporting for weeks: many, many children have missed receiving important immunizations to protect them against diseases such as measles, meningitis, and whooping cough.

• Vaccines are available to protect children and teens against 16 different deadly diseases.
• Immunizing infants, children, and adolescents should not be delayed.
• Well child checkups, including physical exams, developmental screenings, and other important care should not be delayed.
  

The American Academy of Pediatrics urges all parents to contact their pediatrician to schedule a visit to catch up on vaccines or a well-child check-up. AAP has published new recommendations to guide pediatricians in managing visits safely and effectively.

Don't spread it

We are seeing spread among caregivers. Please be careful and cautious as you spend time with your friends and co-workers, both while at work, as well as activities after work. Follow these three guidelines to keep your team and co-workers safe:

1. Wear masks to protect your co-workers as well as yourself whenever you’re around other people.
2. Maintain proper physical distancing at work and during activities outside of work settings, especially indoor activities, even when wearing a mask.
3. Use good personal hygiene including handwashing, avoiding face touching, and cleaning surfaces shared by multiple people.

Remember to leave your masks or cloth face coverings on when you’re interacting with your team members. Also wear your procedure mask or cloth face covering as you come into work and keep it on when you leave until you’ve exited the building. Exercise the same care and caution as you do when interacting with patients.

• Wear your mask and eye protection (face shield preferred) when you’re at the nurse’s station between patient contacts.
• Stagger your breaks to allow for safe distance and stay six feet apart from others.
• Wait your turn at lockers.
• Ensure you keep your distance from others when your mask is off.
• Keep your distance from others when removing your mask.
• Wash your hands after touching shared computers, desk items, or medical equipment.

COVID-19 Trackers

Johns Hopkins Global tracker (desktop)

Johns Hopkins Global tracker (mobile)

Utah Department of Health

Do you have a question for our EMSC Medical Director, Hilary Hewes, MD, PCH, ER Attending Physician about this newsletter topic or anything related to pediatrics? Shoot an email to the address below.

tdickson@utah.gov

Contact PCH EMS Liasion Lynsey Cooper at Lynsey.Cooper@imail.org

OR use the dedicated EMS follow up email

PCH-EDRTU-EMS@imail.org

If you are a pediatric advocate within your agency, we need you. Please contact our program manager, Brianne Glenn (brianneglenn@utah.gov) to find out how you can help.

The Emergency Medical Services for Children (EMSC) Program aims to ensure that emergency medical care for the ill and injured child or adolescent is well integrated into an emergency medical service system. We work to ensure that 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, no matter 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