Transcript Special Considerations

Special Considerations
The
pediatric
and
geriatric
patients
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Nationwide over 30% of all
patients transported are over
age 65
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Leading Causes of Death or
Disability:
• Heart disease
• Misuse of drugs
• Cancer
• Fall (leading cause
of trauma related
injuries)
• Stroke
• Fractures
• Pneumonia
• Mva's (2nd leading
cause)
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Who Is Elderly ?
• Society normally thinks of those
who are over 65
• Patient considered elderly:
– Patient physically appears elderly
– Patient is middle aged with significant
medical problems associated with elderly
– Patient is 65 years or older
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Things To Consider
• After age 35 the effects of aging start
affecting the body's ability to function
• Here are some of the things to consider
when treating the elderly
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Things To Consider
• The GEMS Diamond
• Remember the following when caring
for older people:
– Geriatric patients
– Environmental assessment
– Medical assessment
– Social assessment
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Aging Statistics
• 13% of people in the US
are over age 65.
• “Baby Boomers” will
increase this number.
• Expect to see an increase
in emergency calls
involving older patients.
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Case Study
• Dispatched to a residence for an
84-year-old woman who has
fallen
• Patient, Mrs. Reed, cannot get
up.
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Mrs. Reed
Case Study (continued)
• Mrs. Reed is on the kitchen
floor.
• She is alert but weak.
• States she fell last night
• Has pain in left hip
• Vital signs are normal.
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Mrs. Reed
Living Arrangements
• Most live at home.
• Women are more likely
to live alone.
• Less than 5% are
institutionalized.
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Case Study (continued)
• You conduct a GEMS exam:
– Small amounts of food, home is
warm and clean
– No significant medical history, no
medications
– Son reports that mother lives
alone, no regular contact with
friends
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Mrs. Reed
Access to Essential Services
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Transportation
Meal preparation
Health care
Social activities
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Case Study Conclusion
• Mrs. Reed is transported to
ED.
• Report to Social Services for
potential follow up.
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Mrs. Reed
Aging
• Number of people over age 65 is rising
• Older people have many social and
environmental concerns.
• We must understand and accept aging.
• Family remains the most common residence
for the older population.
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Leading Causes of Death in
Older People
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Disease of the heart
Cancer
CVA/Stroke
COPD
Pneumonia
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Case Study
• Dispatched for 79-year-old man
with difficulty breathing
• Says he always gets winded
easily and cannot catch his
breath today
• Environment is clean and warm.
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Mr. Brophy
Case Study (continued)
• History of AMI, CHF, COPD,
hypertension, diabetes
• Pulse = 112 beats/min
• Respirations = 28 breaths/min
• Blood pressure = 160/96 mm
Hg
• ECG = A-fib
• Pulse Ox = 92% on oxygen
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Mr. Brophy
Case Study (continued)
What factors influence how
well Mr. Brophy can
compensate for his illness?
How will aging affect these
factors?
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Mr. Brophy
The Aging Body:
Integumentary System
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Wrinkles
Thinner skin
Decreased fat
Gray hair
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The Aging Body:
Respiratory System
• Changes in airway
• Decreasing muscles of
ventilation
• Increased residual volume
• Decreased sensitivity of
chemoreceptors
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Respiratory
• Dental prosthesis
• Pulmonary function can be reduced as
much as 50 % by age 75
• Reduction in gas exchange through the
pulmonary capillaries
• Increased respiratory rate
• Overall decrease in effectiveness
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The Aging Body:
Cardiovascular System
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Development of atherosclerosis
Decreasing cardiac output
Development of arrhythmias
Changes in blood pressure
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Cardiovascular
• Increase in PVR
• Between 30 and 80,
resting cardiac output
decreases about 30%
• Significant drop in organ perfusion
• Reduction of cardiac output by as much
as 50 %
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Cardiovascular
• Diminished ability to
raise the heart rate
• Decrease in compliance
of the ventricle
• Decrease response to hormone
stimulation
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Even without specific heart
disease advanced aging
produces varying
degrees of congestive
heart failure
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The Aging Body:
Nervous System
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Brain shrinkage
Slowing of peripheral nerves
Slowed reflexes
Decreasing pain
sensation
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Neurological and Sensory
• Brain requires a continuous supply of
oxygen to function
• As much as a 45% loss of brain cells
• Also affected are the senses
• Response to stimuli is diminished
• Slowed reaction time
• Decreased response to pain
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Renal System Changes
• Renal blood flow falls an average of
50% between the ages of 30 and 80
• Decline of renal function places the
older patient at greater risk of renal
failure
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The Aging Body:
Renal, Hepatic, and GI
Systems
• Kidneys become smaller.
• Hepatic blood flow decreases.
• Production of enzymes
declines.
• Salivation decreases.
• Gastric motility slows.
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Case Study (continued)
• Mr. Brophy appears to have a
hard time hearing your
questions.
• Does not respond to all of your
requests
What are the sensory changes
found in older patients?
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Mr. Brophy
The Aging Body:
Sensory Changes
• Vision distorts and eye
movement slows.
• Hearing loss is more common.
• Taste decreases.
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Case Study (continued)
• Mr. Brophy reports feeling
“down” lately.
• Lives alone and has few
friends still around
Is this patient at risk for
depression?
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Mr. Brophy
The Aging Body:
Psychological Changes
• Depression
• Anxiety
• Adjustment
disorders
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Case Study (continued)
• When asked about
medications, Mr. Brophy
directs your attention to a
shoebox.
How does the body react to
medications with aging?
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Mr. Brophy
The Aging Body:
Musculoskeletal System
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Decreased muscle mass
Changes in posture
Arthritic changes
Decrease in bone mass
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The Aging Body:
Immune System
• Less effective immune response
• Pneumonia and UTI are common.
• Increase in abnormal immune
system substances
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Immune System
• Pre-existing nutritional
problems
• An increased susceptibility to
infection
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Case Study Conclusion
• Mr. Brophy is treated for
exacerbation of COPD.
• Admitted to hospital, found to
be on interacting medications
• On discharge, Mr. Brophy was
given follow-up visits with a
home care service.
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Mr. Brophy
Thermoregulatory
• Diminished ability to maintain normal
body temperature
• More susceptible to heat and cold
related injuries
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Chronic Medical Problems
• As the effects of illness and injury
cumulate they result in a progressive
reduction in the bodies ability to function
• As this progresses the body’s ability to
withstand the introduction of disease,
serious or even minor trauma is
reduced
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Assessing The Elderly Patient
• Difficult to separate the effects of aging /
consequences of disease or injury
• The patient may fail to report significant
symptoms
• Pain may be diminished or absent
• Chronic illness make assessment acute
problems difficult
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Assessing The Elderly
• Aging may change the individual's
response to illness or injury
• There may be minimal or absent fever
even in the presence of severe infection
• Decreased vision or hearing may
diminish the patient's ability to hear or
comprehend
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Assessing The Elderly
• Vital signs may be altered by chronic
medical problems, resulting in abnormal
findings which are normal
• Social and emotional factors may have
greater impact then in other age groups
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Assessing The Elderly
Orientation should be evaluated using
factors that are relative to that patient.
An elderly patient who does not work or
keep a schedule may not have reason
to keep up with the day of the week
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Assessing The Elderly
Be careful not to assume that the patient
who has fallen simply tripped. Take into
consideration the possible underlying
conditions that may be manifested
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Assessing The Elderly
Knowledge of the medications the patient
is taking will also aid in understanding
the condition of the patient and possible
underlying causes of the incident at
hand
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Assessing The Elderly
Elderly trauma victim’s die as a result of
the same causes as trauma victims of
any age, but often due to their preexisting physical condition, can die from
less severe injuries and more rapidly
than younger patients
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Physical Exam Considerations
• General
– Patient may fatigue easily
– Patients commonly multi-layer clothing
– Explain actions clearly
– Patient may minimize or deny symptoms
– Peripheral pulses may be difficult to
evaluate
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Respiratory Distress: Causes
• Pulmonary embolism
• In silent MI dyspnea may be only initial
symptom
• Pulmonary edema
• Asthma/copd
• Respiratory infections
• Cancer
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Cardiovascular
Conditions
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Syncope
• Carries a higher incidence of morbidity
in-patients over 60 years of age
• Is a primary symptom of a silent MI
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Myocardial Infarction
• Elderly are less likely to present with
classic S/S
• Could present with syncope, dyspnea,
abdominal or epigastric pain, and
fatigue
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Stroke (CVA)
• Strokes are more common in the elderly
• TIAs are also common in the elderly
– 1/3 of all patients who experience TIAs will
have a major stroke
• TIAs are a common cause of syncope in
the elderly
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Called to an MVC
Arrive to find a 78F sitting in passenger
side of car that struck a truck broadside
Pt is CAO X3, denies any pain/discomfort
Vs bp 140/80 p 80 r 24
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Vehicular Trauma
• Estimated that more then 15 million
licensed drivers are over age 65
• In 1990, more then 7600 deaths were
attributed to vehicular crashes
• Risk of fatality from multiple trauma is
estimated to be 3 times greater at age
70 then at age 20
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Head Trauma
• Two thirds of the head-injured patients
over age 65 who are unconscious on
arrival at the ER do not survive
• Older patients are at significantly higher
risk of cervical injury
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Chest Injuries
• Any mechanism of injury suggesting
thoracic trauma must be considered
potentially lethal
• Injuries to the heart, aorta, and major
blood vessels are a greater risk to the
older patient
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Abdominal Injuries
• Abdominal injuries are often less
apparent in the elderly and require a
greater index of suspicion
• Elderly patients less likely to tolerate
surgery / more likely to develop
postoperative complications
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Musculoskeletal Injuries
• Remember that the older patient may
have decreased perception of pain
• Pelvic fractures are highly lethal in the
elderly
• The mortality rate associated with
skeletal injuries is largely due to
complications secondary to the initial
injury
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Falls
• Estimated one third of the older
population falls each year
• 1 in 4 are hospitalized for injuries
• Of hospitalized 50% die within 12
months
• Fractures most common fall related
injury
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Medications in the Elderly
• Accidental drug overdose and
medication noncompliance account for
approximately 30% of all hospital
admissions related to drug induced
illness in older people
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Common Reasons for These Medication
Mishaps Include:
• Noncompliance
• Forgetfulness
• Confusion
• Self selection
• Excessive dosing or
improper mixing of
over the counter
medications
• Multiple
prescriptions from
multiple physicians
• Changes in habits
that affect drug
metabolism
• Vision impairment
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Geriatric Abuse/neglect
It is estimated that between 1 and 4
percent of the geriatric population
suffers from some form of abuse or
neglect
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Some Things to Watch for Are:
• Inconsistencies in history
• Unexplained trauma
• History inconsistent with complaint
• Visible signs
• Contusions, lacerations, abrasions
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• Fractures, sprains, dislocations
• Burns
• Over-sedation
• Dehydration
• Poor hygiene
• Malnutrition
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SUMMARY of the Geriatric
Patient
• Take into consideration the changes
caused by the normal aging process in
assessing the ill or injured elderly
patient
• Carefully assess the patients’ mental
status and compare with what is
considered to be normal for the patient
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• Carefully assess the patient taking into
consideration the affects of chronic
conditions the patient has and any
medications the patient is taking
• Treat the elderly patient aggressively
and support vital functions
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The Pediatric Patient
Do you remember
your
first kiss?
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Who Is the Pediatric
Patient???
• Newly-born to
• 18 years old
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PAT: Respiratory Distress
Work of
Breathing
Appearance
Normal
Increased
Circulation to Skin
Normal
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PAT: Respiratory Failure
Work of
Breathing
Appearance
Abnormal
Increased or
Decreased
Circulation to Skin
Normal or abnormal
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PAT: Shock
Work of
Breathing
Appearance
Abnormal
Normal
Circulation to Skin
Abnormal
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PAT: Primary Central Nervous
System (CNS) Dysfunction or
Metabolic Abnormality
Work of
Breathing
Appearance
Abnormal
Normal
Circulation to Skin
Normal
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Common Medical
Emergencies
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Respiratory
Cardiovascular
Metabolic abnormalities
Neurological crises
Life-threatening infections
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Peculiarities of the Pediatric
Lung
• High proportion of mucus glands
• Incomplete development of airway
cartilage
• Small peripheral airways compared to
adult lung
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Peculiarities of the Pediatric
Lung
• Less compliant than adult lung, while
chest is more compliant
• Airways smaller in boys than in girls
• More capability of regenerating than
adult lung
• Tongue is relatively large, likely to
obstruct airway
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Peculiarities of the Pediatric
Lung
• Larynx is high:
– C2 in neonate
– C3-4 in child
– C5-6 in adult
• Narrowest at the cricoid ring
• Young infants are often obligate nose
breathers
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Clinical Signs of Respiratory
Distress
• Tachypnea - rapid respirations
– What’s normal?
• Dyspnea - labored respirations
– Retractions
– Accessory muscles
– Nasal flaring
– Expiratory grunting
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Clinical Signs of Respiratory
Distress
• Abnormal sounds
– Stridor
– Wheezing
– Cough
– Rales, rhonchi, “crackles”
– Absent breath sounds - silent chest is an
ominous sign
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Clinical Signs of Respiratory
Distress
• Preferred position
– Upright except in
infants or the
unconscious child
• Initial tachycardia fast heart rate
• Later bradycardia slow heart rate
• Cardiac arrest
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Clinical Signs of Respiratory
Distress
• Initial anxiety and irritability
• Later lethargy and coma
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Clinical Signs of Respiratory
Distress
• Cyanosis - blue skin tone
– Indicates presence of hemoglobin which is
not carrying oxygen
– Can be masked by severe anemia
– Peripheral cyanosis may result from shock
– May not be obvious in newly born until
oxygen level is very low
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Respiratory Failure
• End state of any of the causes of
respiratory distress
• Failure of respiratory drive
– Apnea due to drug overdose
– Head trauma
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Causes of Respiratory Crisis
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Asthma
Bronchiolitis
Croup
Epiglottitis
Foreign body
aspiration
• Laryngeal edema as
part of anaphylaxis
• Smoke inhalation
• Fractured larynx due
to trauma
• Birth defects
• Sids
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Treatment of Pediatric
Respiratory Patients
Assess the child’s breathing
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General Treatment for all
Respiratory Distress
• Conscious child:
• Observe as much
as possible without
touching
• Minimize handling
the child
How agitation affects
breathing: A child with
respiratory problems who is
agitated or frightened by EMTs will
begin breathing harder and faster.
This leads to increased resistance
in the air passages, which in turn
worsens breathing problems.
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General Treatment
• Keep close to parent in position of
comfort
• Oxygen
• DO NOT attempt IV
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General Treatment
• Obtain brief history
• Perform limited physical exam - as
tolerated
• Do not examine or instrument the oral
cavity
• Administer any specific therapy
indicated for child’s illness
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General Treatment
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Unconscious child:
Open airway
Suction
Ventilate with oxygen immediately
Coordinate with child’s effort
Watch for chest movement with bagging
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General Treatment
• Watch for improvement
– The child who remains blue and
bradycardic is inadequately ventilated until
proven otherwise
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Watch the pupils:
• Low blood oxygen can cause the
child’s pupils to become enlarged.
If the child is responding to oxygen,
the pupils may get smaller.
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Summary
• Airway problems are common and
potentially lethal in children
• Invasive techniques should be reserved
primarily for children whose severe
airway compromise has led to loss of
consciousness.
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Cardiovascular Crisis
• Cardiac arrest is almost always a
complication of respiratory failure, not
primary cardiac disease; mortality is
high
• Shock and bradycardia are most
frequently encountered cardiovascular
abnormalities
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Summary
• Primary cardiac disease is uncommon
in children; hypoxia, acidosis and other
metabolic derangement's are much
commoner causes of cardiac symptoms
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Metabolic Crisis - Dehydration
• More frequently seen in children than in
adults
• Increased frequency of infections
• Tendency to develop vomiting and
diarrhea with viral illness
• Tendency to develop higher fever than
adults
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Signs and Symptoms
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Dry mucous membranes
Absence of tears
Reduced skin turgor
Depressed anterior fontanel
Sunken eyeballs
Rapid respirations
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Signs and Symptoms
• Hypotension (orthostatic)
• Increased pulse rate
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Therapy of Dehydration
• Definitive therapy varies with degree of
dehydration
– <10% can often be treated with oral fluids
– >10% generally requires IV rehydration
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Treatment
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Abc's
Oxygen
Consider IV
Notify hospital
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You are called to an
unresponsive newly born.
Upon arrival you find a 1
month old child with
decreased LOC, signs of
dehydration.
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Glucose Abnormalities
• Hypoglycemia
– More common in children than adults,
especially in newly born and insulin
dependent diabetics
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Signs and Symptoms
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Anxiety
Sweating
Tachycardia
Tremors
Headache
Depressed level of
consciousness
• Seizures
• Frequent urination
• Excessive thirst
• Vomiting, abdominal
pain
• Fruity odor to breath
if child is ketotic (not
all are)
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Signs and Symptoms
• Signs of dehydration
• Kussmaul respirations
• Lethargy, coma, seizure
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Signs and Symptoms
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In neonates
Tachypnea or apnea
Jitteriness
Color changes
NO visible signs at all
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Treatment
• Check chemstrip <60% treat
• Administer sugar-containing fluid by
mouth if child is conscious and able to
tolerate oral intake
• 1 - 2 cc/kg D25 if IV access is available
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Treatment
• Remember that prolonged significant
hypoglycemia can result in permanent
CNS injury or death
• If in doubt give sugar
• Repeat chemstrip q 10 - 15 minutes
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Neurological Crisis
• Seizures
– Abnormal electrical discharge from the
brain; often results in motor activity but
may be manifested as a period of
unawareness or visual or auditory
hallucinations
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Causes of Seizures
• Febrile convulsions
– Most common in children 6 months to 6
years
• CNS infections
– Meningitis
– Encephalitis
– Brain abscess
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Causes of Seizures
• Toxic ingestion
– Lead, cocaine, PCP, amphetamine, aspirin
• Withdrawal from:
– Narcotics, benzodiazepines, cocaine
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Causes of Seizure
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Metabolic
Trauma
Epilepsy
Brain tumor
Stroke
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Treatment for Seizure
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ABC’s
Oxygen
Support ventilation
Protect child from injury
Check chemstrip
Consider anticonvulsant therapy if
seizure continues
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Neurological Crisis
• Coma
– A disturbance of consciousness in which
patient becomes unaware and
unresponsive to stimuli
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Common Causes of Coma
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Hypoglycemia, diabetic ketoacidosis
Meningitis, encephalitis
Cerebral hypoxia/ischemia
Cerebral edema
Intoxication/drug overdose
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Common Causes of Coma
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Reye syndrome
Epilepsy
Severe hypothermia or hyperthermia
Intracranial hemorrhage or contusion
Brain tumor
Increased ICP
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Reye Syndrome
• Cause unknown
– Associated with influenza,
– Chicken pox,
– Use of aspirin
– Gastroenteritis
• Occurs in children 5 - 15 years
• Fall and winter
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Reye Syndrome
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Should be considered a serious disease
Respiratory failure
Cardiac arrhythmias
Acute pancreatitis
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Treatment of Coma
• Abc's
• Oxygen
• En route focused assessment
– Check for signs of trauma, rash, bruises,
patients breath,
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Treatment of Coma - History
• Has child had recent symptoms of
infection?
• Has child sustained any trauma
recently?
• Has he access to medications, alcohol,
or household toxins?
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Treatment of Coma - History
• Does he have diabetes or any history of
blood sugar abnormalities?
• Has he has unexplained headaches or
vomiting?
• What medications does he normally
take?
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Treatment of Coma - History
• Did his diminished responsiveness
develop gradually following a period of
increasing lethargy or was it of sudden
onset with no premonitory signs?
• Has he had any periods where he
stopped breathing or appeared
cyanotic?
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You are called to an 18 month old child
who is said to be unresponsive. The
mother tells you that the child has had
a cold for a few days, today developed
a fever and rapid breathing, she is
having difficulty waking the child.
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Your initial assessment reveals a
pale child with poor muscle tone, who
does not appear responsive to his
surroundings.
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How will you care for this
child?
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Life-threatening Infections
• Young children are particularly prone to
serious infections
– Immune systems are not fully developed
– No sense of hygiene and explore the world
with their mouth
– Day care settings greater exposure to a
variety of pathogens
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Life-threatening Infections
• Recognition - consider in any child that
presents with
– Altered mental status,
– Cardiovascular compromise
– Respiratory compromise
– Normal, high or low body temperature
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Sepsis
• Illness resulting from invasive infection,
including spread of pathogens or toxins
via the blood stream; usually due to
bacteria but may result from
overwhelming viral or fungal infection
• Some endocrine diseases, e.G.
Diabetes or disorders of metabolism
can mimic sepsis syndromes
2005 EMT-Intermediate Curriculum
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Meningitis
• Infection of the meninges and
cerebrospinal fluid
• Most serious forms result from bacterial
infection
• Highly contagious
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Signs and Symptoms of
Meningitis
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Fever
Irritability, lethargy
Headache
Vomiting
Seizures
Stiff neck
Recent ear infection
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Signs and Symptoms
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Dehydration
Decreased LOC
Mottling, color changes
Bulging fontanel
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Serious bacterial infection
(SBI)
• Any invasive bacterial infection e.g.
pneumonia, meningitis, sepsis.
• Unsuspected trauma, as in
nonaccidental trauma/child abuse can
present as SBI.
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SBI Symptoms
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Listlessness
Lethargy
Decreased oral intake
Floppiness
Moaning Cry
Decreased activity
level
• Labored or rapid
breathing
• High-pitched cry
• Decreased urine
output.
• Grunting
• Vomiting
• Poor Color
• Bilious vomiting
• Elevated temperature
• Hypothermia
2005 EMT-Intermediate Curriculum
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Treatment for life-Threatening
Infections
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ABC’s
Oxygen
Respiratory support
If febrile cool
History – Very important!
– if the child was well 3 hours ago and is now
very ill, SBI is likely
• Transport
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One “Pill” Killers
• Theophylline
• Imipramine
(tricyclics)
• Clonidine
• Camphor
• Verapamil
• Propanolol
2005 EMT-Intermediate Curriculum
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Trauma in Oregon 1997 1998
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3090 children infant to 18 years
444 children died
210 deaths related to MVCs
45 from suicide
60 occurred due to violence
boys were injured twice as often as
girls
2005 EMT-Intermediate Curriculum
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Oregon Trauma System
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8.4% of injuries were intentional
91.6% of injuries were unintentional.
1208 children were tested for blood alcohol.
270 tested positive.
163 were involved in a motor vehicle crash,
27 were injured by a cutting or piercing object
21 by firearms.
2005 EMT-Intermediate Curriculum
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Oregon Trauma System
• 575 children were
tested for drugs.
• 172 tested positive for
one or more drugs.
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Cannabis 60.5%,
amphetamine 14.8%,
Opiates 9.0%,
Benzodiazepine 7.1%,
Cocaine 4.8%,
Barbiturate 2.9%,
Other 1.0%.
References
• Cristofani, C. B., J. Fairchild, and W. B.
Long. Pediatric Prehospital Care
Courses. Oregon Emergency Medical
Services for Children, 1990.
• TRIPP Instructor course
2005 EMT-Intermediate Curriculum
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