Transcript Child Abuse - CPR-Guy

Refresher Class Session - M
Special Populations
Elder/child abuse
Patients with special needs
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Introduction
 People over the age of 65 make up the fastestgrowing segment of the population.
 Almost 40 million in 2008, or 12.8 of the
population.
 Changes in physiology due to aging have an
effect on pathophysiology as compared to
younger adults.
 Geriatric patients typically have more than one
disease and take more than one medication
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Introduction
 Cardiovascular disease is leading cause of
death, followed by cancer, strokes, and COPD.
 They use 1/3 of all prescriptions.
 The average geriatric patient takes 4.5
medications per day.
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Pathophysiology
 Human body changes with age: cellular,
organ, and system functions
 Change in normal physiology starts around
age 30
 Process can be slowed with diet and exercise,
but it cannot be stopped entirely.
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Pathophysiology
 Cardiovascular system
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Degenerative process to the myocardium
Damage to valves
Thickening of the walls
Loss of artery elasticity
Decrease in baroreceptor activity
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Pathophysiology
 Respiratory system
 Size and strength of respiratory muscles
decrease
 Alveolar surfaces degrade, impairing gas
exchange
 Chemoreceptors begin to fail
 More turbulent airflow through the bronchioles
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Pathophysiology
 Nervous system
 Nerve cells degenerate and die as early as mid20s
 Reflexes slow, proprioception falters
 Brain atrophies with resultant increase in CSF
 Regulation of basal bodily functions becomes
less sensitive
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Pathophysiology
 Gastrointestinal system
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Sense of taste and smell diminished
Cardiac sphincter becomes weaker
Hepatic function decreases
Lining of GI system degenerates, resulting in
lesser absorption of nutrients
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Pathophysiology
 Endocrine system
 Hormones that elevate blood pressure and those
that regulate fluid balance become deranged
 Stimulation of adrenergic sites diminishes due to
failure of sensitivity of receptor cells
 Musculoskeletal system
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Loss of minerals from the bones
Vertebral disks narrow
Joints lose flexibility
Synovial fluid thickens
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Pathophysiology
 Renal system
 Decrease in nephrons, kidneys shrink
 Diminished ability to filter blood
 Fluid and electrolyte disturbances
 Integumentary system
 Skin becomes thinner from a loss of
subcutaneous layer
 Replacement cells generate more slowly
 Sense of touch dulled, less perspiration
 Less effectiveness as an external barrier
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Clues to Illness Found in the
Scene Size-Up
 Bucket next to bed
 Home O2 setup
 Medications at scene
 Tripod Position
 Abnormally hot/cold room
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Special Considerations in the Primary
Assessment of the Geriatric Patient
 Pain
 May not complain of pain due to preexisting conditions
 May not feel pain due to disease process ie diabetes
 Prickling/burning pain = superficial structures; aching-type
pain = internal organs
 Fainting may indicate a serious illness
 Mental Status
 Hypoxia causes agitation and aggression
 High CO2 causes confusion and disorientation
 Sudden onset of AMS is not normal - -indicates serious
illness or injury
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Special Considerations in the Primary
Assessment of the Geriatric Patient
 Airway
 High incidence of choking and aspiration of food
 Cervical arthritis makes head-tilt/chin lift difficult
 Loose dentures may cause airway obstruction
 Breathing
 Expect higher resting rates
 Lower tidal volume = risk of early onset of hypoxia
 Retractions less likely
 Circulation
 Expect higher resting heart rate (unless on meds)
 Irregularly Irregular pulse may be normal
 Skin
 Normally dry and less elastic; Turgor not reliable
 subcutaneous fat & skin vessel >> to ”urban hypothermia”
 Fever less common
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Emergency Medical Care
 Manual cervical spine considerations
 Assess and maintain the airway
 Determine breathing adequacy
 High-flow via NRB with adequate breathing
 High-flow via PPV @ 10-12/min if inadequate
 Maintain saturation >95%
 Assess circulatory components
 Pulse check, skin characteristics
 Control major bleeds
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Emergency Medical Care
 Initiate transport with ALS intercept
 Position the patient
 Sitting up if able to maintain own airway
 Lateral recumbent with altered mentation
 Supine if immobilized
 Constantly monitor airway, breathing, and
circulation
 Mental status changes key to determining
improvement or deterioration
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Summary
 Geriatric patients, like pediatric patients, have an
altered physiology that needs to be considered
given illness and injuries.
 The normal decline in the body systems render
them susceptible to a multitude of emergencies.
 Carefully manage and closely watch elderly
patients, as they may deteriorate suddenly.
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Special Challenges
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Introduction
 Due to lifestyle changes and medicine, the life
span of humans is lengthening.
 Advances in medicine allow technology to go
home with the patient.
 Congenital disease patients live longer at home,
due to medicine.
 EMS may not know what the medical technology
is, but they must always know what to do.
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Epidemiology
 No specific registry nor definition for what
“specially challenged” is.
 Underreporting is also believed to occur,
especially with abuse.
 Over 3 million pediatric abuse cases and over
half a million elder abuse cases.
 8 million disabled people are receiving health
care from professional providers.
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Pathophysiology
 Mental Illness
 Mild to severe disabilities
 Commonly include the following features
• Cognitive disabilities
• Speech impediments
• Behavioral disorders
• Movement disorders
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Causes of Mental Retardation
 Down Syndrome
 Fragile X Syndrome
 Autism
 Fetal Alcohol Syndrome
 Phenylketonuria (PKU) hypothyroidism
 Rett Syndrome
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Pathophysiology
 Disabilities
 A problem of the patient that was caused by a
disease
 Results in sustained medical care for the person
 Common disabilities seen in EMS include:
• Paralysis
• Obesity
• Traumatized patients
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Pathophysiology
 Disabilities – Paralysis
 Loss of function of single or multiple muscles
 Damage to nervous system (spinal cord)
 Neuromuscular diseases
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Pathophysiology
 Disabilities – Obesity
 Over 40% of U.S. population is obese
 Obesity may be due to lifestyle choices or
medical conditions
 Obesity creates a multitude of secondary
emergencies
 Obesity also creates a patient handling and
movement concern for EMS
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Effects of Excess Weight on Organ Systems
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Pathophysiology
 Disabilities – Traumatized patients
 Head and/or brain trauma
 Commonly there are residual effects
• Mild – speech or gait impairments
• Severe – unresponsive, seizures, technology
dependent
 Most patients fall between these two extremes
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Pathophysiology
Technology Assistance/Dependency
 Medical equipment designed for patient care
• Enhance quality of life
• Sustain life
 EMS must remain aware of common types of
equipment
 Some EMS systems track where patients live
who are technology dependent
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Technology dependent patients;
Infants and Children
with Special Needs
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Pathophysiology
 Vascular Access Devices
 Devices implanted into the skin
 Allow for ongoing or multiple medication
administrations into the patient's vascular system
 Dialysis
 Replaces kidney function
 Hemodialysis – done at facility
 Peritoneal dialysis – done at home
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Pathophysiology
 Home Mechanical Ventilators
 Assist or provide total ventilatory needs to a patient
who cannot maintain own ventilatory effort
 Negative and positive pressure units
 Controls include rate, volume, and occasionally
oxygen levels
 Alarms (may be reason EMS is summoned)
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High pressure alarm
Low pressure alarm
Apnea alarm
Low FiO2 alarm
– “Fraction of inspired oxygen,” which refers to the
amount of oxygen the patient in breathing in.
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Pathophysiology
 CPAP and BiPAP
 Designed to provide “back pressure” via mask
that attaches to face
 Helps to keep small bronchioles open during
breathing, and the airway open during sleep
 Commonly found with obese patients and certain
chronic lung diseases
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Children with Special Needs
 Premature babies with lung disease
 Heart disease
 Neurologic disease
 Chronic disease or altered function since birth
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Pathophysiology
Technology Assistance/Dependency
 Apnea Monitor
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Monitors patient's breathing status
Some monitor heart rate
Common to neonates and infants
Audible alert for when patient stops breathing
 Tracheostomy Tube
 Provides artificial opening into airway
 Placed through anterior neck
 Bypasses mouth and nose
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A tracheostomy tube for older
children and adults has an
outer cannula and an inner
cannula
The EMT can ventilate
a patient with a
tracheostomy by
attaching the bag-valve
device to the
tracheostomy tube's
15/22 mm adapter.
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Tracheostomy Tube
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Tracheostomy Tube
 Complications
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Obstruction
Bleeding
Air leak
Dislodged tube
Infection
 Maintain open airway.
 Suction.
 Maintain a position of comfort.
 Transport.
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Home Artificial
Ventilation
The tubing from the
home ventilator
attaches to the
patient's
tracheostomy tube.
Assure airway.
Artificially ventilate
with oxygen.
Transport.
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Central Intravenous Lines
 IVs that are very long
 Tip in vein near heart
 Complications
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Cracked line
Infection
Clotting off
Bleeding
 If bleeding is present, apply pressure.
 Transport.
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Gastrostomy Tubes
 Gastrostomy Tubes (Feeding Tubes)
 Provide nutrition to patients who cannot chew
 “Enteral feeding” or “tube feeding”
 Types
• NG tube – nose to stomach
• OG tube – mouth to stomach
• G-tube – through skin to stomach
• J-tube – through skin to jejunum
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Gastrostomy Tube
 Tube placed directly into
stomach for child who
usually cannot be fed by
mouth
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Managing Gastrostomy
Tubes
 Assess for mental status changes.
 Assure patent airway.
 Suction as needed.
 Provide high-concentration oxygen.
 Transport patient sitting or lying on right side
with head elevated.
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Intraventricular Shunt
 Medical illnesses or anatomic defects that allow
excessive CSF to accumulate
 Increased CSF can cause damaging ICP issues
 Tube running from brain
to abdomen to drain
excess cerebrospinal
fluid.
 Assure airway.
 Ventilate as needed.
 Transport.
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Family Response
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Family Response
 When you care for an injured or ill child, you
must also care for the child’s family.
 Parent may react with anger/hysteria toward
EMT–B.
 Calming the parent calms the child.
 Parent is concerned about child's injury/illness
as well as child’s fear/pain.
 Response worsened by feeling of helplessness.
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Family Response
 Encourage the parent to be involved in child’s
care (e.g., holding oxygen mask, cup, or tubing).
 Have the parent help calm child.
 Parents of “high-tech kids” are medical experts
on their child’s condition.
 In general, other parents may not have medical
training, but they are experts on their children
and what will calm them.
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Assessment Findings
 During your assessment, ask about the medical
equipment
 Where do I get the best information regarding this
equipment?
 What does this device do for the patient?
 Can I replicate its function should it fail?
 Will this equipment change assessment findings?
 Has this ever occurred before? What fixed it?
 Has anyone attempted to remedy the problem?
 Do I have movement or handling issues with this
equipment?
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Emergency Medical Care
 Manual cervical spine considerations
 Assess and maintain the airway
 Determine breathing adequacy
 High-flow via NRB with adequate breathing
 High-flow via PPV @ 10-12/min if inadequate
 Maintain saturation >95%
 Assess circulatory components
 Pulse check, skin characteristics
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Emergency Medical Care
 Initiate transport with ALS intercept
 Position the patient based on condition and
medical equipment
 Consider immobilization needs
 Constantly monitor airway, breathing, and
circulation
 Try to use medical equipment if it is portable and
working correctly
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Summary
 Patients with special needs are those who
usually have some medical technology helping
them with life.
 When this equipment malfunctions, typically it is
EMS that is called.
 The role of the EMT is to manage the patient's
problem(s), incorporating this technology into
their assessment and management.
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Abuse and Neglect
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Abuse
Improper or excessive action so as to
injure or cause harm
Child Abuse
(NJ EMS Field Guide)
Child abuse is the physical, sexual, or
emotional harm or risk of harm to a child
under the age of 18.
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Pathophysiology
 Abuse
 Child abuse
• Physical, emotional, sexual
 Elder abuse
• Physical, emotional, sexual
 Passive versus active
• Neglect
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Neglect
Giving insufficient attention or respect to
someone who has a claim to that attention
Neglect
(NJ EMS Field Guide)
Neglect occurs when a parent or Caregiver
fails to provide proper supervision or
adequate food, clothing, shelter, education,
or medical care although financially able or
assisted to do so.
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Physical abuse
of an elderly
person can
have dire
consequences
because of the
patient's
frailty.
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Signs of Abuse
 Multiple bruises in different
stages of healing
 Injury not consistent with mechanism described
 Injury matches item used to
cause it Fresh burns
 Parents seem not to care as much as they
should
 Conflicting stories
 Child afraid to describe how injury occurred
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What does abuse look like
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Hand Marks
Bruising of the ear from being pulled.
Bruising of the ear from being "boxed”
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Loop mark bruises inflicted by a doubled-over cord.
Bruises
inflicted with
belt.
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Handling Abuse and Neglect
 Head injuries are most lethal.
 Shaken baby syndrome
 Do not accuse anyone in the field.
 Required Reporting
 Follow state laws and local regulations.
 Document objective information (what you SEE
and HEAR, not what you merely THINK).
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Reporting Child Abuse
 If you suspect child abuse, or a child tells you
about abuse, don’t delay.
 You must report it! Everyone in New Jersey is
required to report suspected abuse.
 To make a report, call the NJ Division of Youth
and Family Services’ toll-free Child Abuse
Hotline 24 hours a day, 7 days a week:
1-877-NJ-ABUSE (1-877-652-2873)
TTY 1-800-835-5510.
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Reporting FAQs
 Do callers have immunity from civil or criminal
liability?
 Any person who, in good faith, makes a report of
child abuse or neglect or testifies in a child abuse
hearing resulting from such a report is immune from
any criminal or civil liability as a result of such action.
Calls can be placed to the hotline anonymously.
 Is it against the laws of New Jersey to fail to report
suspected abuse/neglect?
 Any person who knowingly fails to report suspected abuse
or neglect according to the law or to comply with the
provisions of the law is a disorderly person.
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Reporting Elder Abuse
 The Office of the Ombudsman for the
Institutionalized Elderly investigates and responds
to complaints of abuse, neglect, and exploitation
of individuals 60 years of age and older who
reside in licensed facilities within New Jersey, both
public and private.
 To make a report, call:
1-877-582-6995
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Prevention of Domestic Violence Act
Applies
 To a person 18 years of age or older or a person who is an
emancipated minor that has been subjected to domestic violence by a
spouse, former spouse, or any other person who is a present or
former household member.
 If you or the abuser are the parents of any children, whether or not you
have ever lived together;
 If you are pregnant with the abuser’s child;
 If you and the abuser now live together or have lived together in the
past; or you and the abuser now have or did have, at one time, a dating
relationship.
 You and the abuser do not have to be married or be
girlfriend/boyfriend. He or she can be a family member, your gay or
lesbian partner, your roommate, your caretaker, or any other adult who
lives with you now or has lived with you.
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NJ State EMS Field Guide
http://njems.rutgers.edu/cdr/jsp/field_guide.jsp
Google: NJ State EMS Field Guide
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