Comprehensive Study Notes: Protocols 2, 9, and 26 - Bites, Stings, Allergies, and Death Calls 8/5/26 Hour 1

Classification of Venomous Snakes

• Venomous snakes are categorized into two primary groups for emergency dispatch purposes: Elapids and Non-elapids.

• Elapids

  • Elapids are characterized by their slender bodies.

  • Their venom is extremely potent, designed to cause rapid death or suffocation so the snake can escape predators quickly.

  • Because their venom is so effective, they do not require significant body mass or weight (heft).

  • Common elapids include:

    • King cobra

    • Green mamba

    • Black mamba: One of the fastest snakes on Earth; it is gray in color but has a black interior mouth.

    • Coral snake: Specifically the Eastern coral snake is highly venomous and contains neurotoxins. It is native to North America.

    • Yellow-bellied sea snake: Native to North America.

• Non-elapids

  • Non-elapids generally possess more weight and heft and are less slender than elapids.

  • This category includes vipers and pit vipers such as rattlesnakes, water snakes (water moccasins/cottonmouths), and copperheads.

  • Non-elapid venom can be classified into different types of toxins:

    • Neurotoxins: Affect the nervous system, potentially stopping breathing.

    • Hemotoxins: Cause internal bleeding by rupturing capillaries or causing total blood clotting.

    • Cytotoxins: Written as $CYTO$, these cause any tissue the venom touches to rot away.

Identification and Mimicry

• Mimicry Examples

  • The Eastern coral snake (venomous elapid) and the Scarlet king snake (non-venomous) share the same colors, but their patterns differ.

  • The Scarlet king snake is considered a beneficial snake because it eats venemous snakes.

  • Mnemonics for identification include variants of: "Red on yellow, kill a fellow; red on black, friend of Jack."

• Procedural Identification

  • Rattlesnakes are often identifiable because they announce their presence audibly.

  • If a caller provides one of the five specific names (King cobra, Green mamba, Black mamba, Coral snake, Yellow-bellied sea snake) or uses the word "Elapid," elapid-specific instructions are given.

  • If any other snake name is used, if the snake is described as non-elapid, or if the type of snake is unknown, non-elapid instructions are provided.

  • Non-elapid instructions are innocuous enough that they will not cause harm even if the snake is non-venomous.

Protocol 2: Bites and Stings

• Safety and Priorities

  • The first key question is "Where is the snake now?"

  • This question is displayed in red font to signify it is a safety issue. Safety is the first objective.

  • The term "(snake bite)" at the start of the question is blue, indicating it is a Pre-Question Qualifier ($PQQ$). It is only asked if the incident involves a snake.

• Medical Suffixes

  • Suffix I: Used if an injection was administered or advised.

  • Suffix M: Used if medication (like Benadryl tablets or creams) was administered or advised.

  • Snake bites are treated as envenomations rather than allergies, so they do not naturally code with these suffixes unless an allergy-specific treatment is advised.

• Treatment Instructions (PDIs and AI Cards)

  • Elapids: Instructions involve a compression bandage. The limb should be bandaged from the bite site to the hand or foot, then back up to the body snugly. The bandage must be loose enough to allow one finger to slip between the skin and the bandage to avoid creating a tourniquet.

  • Non-elapids: Compression bandages are harmful and should never be applied. The bitten area should be kept below heart level if possible. Do not apply ice, do not use a tourniquet, and do not provide alcohol to the victim.

  • General Stance (PDI-C): For Delta or Charlie codes (excluding difficulty speaking), the patient should lie down. For difficulty speaking, the patient should sit down.

• First Aid and Antivenom

  • Commercial snake bite kits found in retail first aid kits are harmful and should be discarded.

  • Treatment for venomous bites requires antivenom, which is extremely expensive ($phenomenally expensive$).

  • Antivenom is not stocked by all hospitals and cannot be administered by medics, RNs, or patients; it can only be administered by a physician.

Sea Creature Protocols

• Lionfish

  • Covered in spikes and have no natural predators in the Atlantic Ocean, where they have become an invasive species upsetting the health of coral reefs.

  • Sting treatment: Apply a cloth soaked in tolerably hot water to the wound. Reheat and reapply until paramedics arrive.

• Jellyfish

  • Treatment: Flush the area several times with seawater (not freshwater) to remove tentacle bits.

  • If seawater is unavailable, use tolerably hot freshwater.

  • If tentacles remain, use a dull straight-edged object (like an expired credit card or gift card) to gently scrape the area clean. Do not rub with a towel or cloth.

  • Vinegar is used in Australia/New Zealand ($ANZ$) protocols but can be dangerous for North American jellyfish species and should be avoided.

Protocol 26: Object Stuck (Case Study)

• An incident involved a python crawling into a girl's earlobe gauge and becoming stuck.

• While initial instinct might suggest Protocol 2 (Snakes), Protocol 2 is specifically for bite/envenomation. This was determined to be Protocol 26 (Sick Person), specifically code $26-Omega-20$ for an object stuck.

• The snake was a pet python, not venomous.

• Resolution: The patient was taken to a human hospital, sedated, and the gauge was enlarged to remove the snake.

Protocol 2: Allergic Reactions and Epinephrine Instructions ($PAIP$)

• Epinephrine Administration

  • The term adrenaline is synonymous with epinephrine. "Epinephrine" is used as a clarifier if the user does not understand "adrenaline."

  • Users often refer to all injectors as "EpiPens" (a brand name), but EMDs must ask for the specific brand (e.g., AdrenaClick, Auvi-Q, Allerject) to provide specific instructions.

  • The injector should be jabbing into the outer thigh and held for $3\,seconds$. This can be done through light clothing. The area should then be massaged for $10\,seconds$.

• Expired Medication

  • Epinephrine does not "go bad" like milk; it loses potency over time.

  • Injectors $2$ to $3\,years$ past expiration retain approximately $90\%$ of their adrenaline. Injectors $5$ to $7\,years$ past expiration still retain more than $70\%$ potency.

  • EMDs should advise using an expired kit if no other option is available, as it is better than no medication.

• Third-Party Prescriptions

  • If a patient has clear symptoms of a severe allergic reaction/anaphylaxis, EMDs may advise using someone else's prescribed injector.

  • Anaphylaxis symptoms include difficulty breathing, difficulty swallowing, or becoming less awake.

  • If no clear symptoms are present, the EMD should advise waiting for paramedics and not using a third-party prescription yet.

Protocol 9: Death Calls

• Types of Death

  • Obvious Death: Defined by the Medical Director. Signs include coldness/stiffness in a warm environment, decomposition, or incineration (sixth-degree burns through the bone).

  • Non-recent Death: Defined as $6\,hours$ or more since the event.

  • Expected Death: Involves patients with a Do Not Resuscitate ($DNR$) order or those in hospice.

• DNR and CPR Procedures

  • If a Medical Director signs off on criteria $X$ (terminal illness/sent home to die), the call is handled as an expected death even if paperwork is not physically present.

  • If only criteria $Y$ (DNR) is signed, callers must have the paperwork in hand. If they do not, the dispatcher may have to code the call as a $9-Echo-1$ and begin CPR instructions.

  • Dispachers should follow agency-specific policy when a family member asks to ignore a DNR and perform CPR. In the field, medics often consult a physician (Medical Control) for these decisions.

Questions & Discussion

Participant Jeffrey (EMD) and Instructor Roleplay

• Scenario: A 4-year-old female ate a nut cookie and is having a severe reaction. She is awake, breathing, but has difficulty speaking between breaths.

• Coding: The call was coded as $2-Delta-2-I$. The "I" suffix was added because the caller mentioned the presence of an injector ("thing with a needle").

• Action: Jeffrey provided instructions from the $PAIP$ for an EpiPen Junior. He instructed the caller to form a fist, remove the blue safety cap, jab the orange tip into the thigh for $3\,seconds$, and massage the area for $10\,seconds$.

• Positioning: Jeffrey correctly told the patient to remain seated. He then transitioned to the Arrival Interface ($D-18$) to ensure the door was unlocked for responders.

• Echo Variant: If the patient had been "fighting for air," the call would have been coded as a $2-Echo-1-I$ (Awake with ineffective breathing).

Further Discussion on Injector Tech

• Auvi-Q and Allerjet: These injectors feature speaker boxes that provide voice instructions to the user. Dispatchers should still offer to walk the user through the process, as callers may be too distressed to follow the device's automated voice.

• AdrenaClick: This device typically comes in pieces that require assembly before use.