1. EMS for children with special needs Carlos Villavicencio, MD, FAAP Clinical Assistant Professor, UW School of Medicine EMS Conference, February 4, 2011

2. Disclosures I have no financial conflicts of interest I have a son with CP

3. Objectives At the end of the presentation, participants should: 1.Recognize unique challenges in kids with special needs 2.Recognize common challenges in kids with special needs 3.Understand utility and layout of Emergency Information Form (EIF) 4.Recognize some unique situations and how to address them clinically

4. Definitions Who are children with special needs? Diagnoses CP Seizures CLD or Asthma Muscular Dystrophy

5. Definitions Devices Ventilators Feeding tubes Cincinnatichildrens.org VP shunt Blogs.naver.com/youjinch O 2 www.articles.complexchild.com Cincinnatichildrens.org

6. Definitions Who are children with special needs? Special Needs: Medications Complex Management Plans Particularly vulnerable and prone to complications

7. Some General Statistics www.cartoonstock.com

8. Seeking Emergency Care Age distribution Prehospital Emergency Care 2000; 4:19-23

9. Seeking Emergency Care Related or unrelated to underlying condition? Prehospital Emergency Care 2000; 4:19-23

10. Seeking Emergency Care Related or unrelated – by diagnosis Prehospital Emergency Care 2000; 4:19-23

11. Most Common Interventions RelatedUnrelated O2O2 C- collar Wounds Glucose (IV or PO) Peripheral IV Albuterol

12. www.demotination.com

13. Emergency Information Form - EIF http://www.aap.org/advocacy/eif.doc

14. Emergency Information Form - EIF http://www.aap.org/advocacy/eif.doc

15. Emergency Information Form - EIF http://www.aap.org/advocacy/eif.doc

16. Emergency Information Form - EIF http://www.aap.org/advocacy/eif.doc

17. Emergency Information Form - EIF http://www.aap.org/advocacy/eif.doc

18. Emergency Information Form - EIF http://www.aap.org/advocacy/eif.doc

19. Emergency Information Form - EIF http://www.aap.org/advocacy/eif.doc

20. Emergency Information Form - EIF http://www.aap.org/advocacy/eif.doc

21. Emergency Information Form - EIF http://www.aap.org/advocacy/eif.doc

22. Emergency Information Form - EIF http://www.aap.org/advocacy/eif.doc

23. Specific Conditions www.legacystation.com

24. Specific Conditions: Tracheostomies Focus on chronic tracheostomy Indications: Upper airway obstruction Pierre-Robin (congenital) vs. Acquired Chronic mechanical ventilation Inability to clear secretions Neuromuscular disease

25. Specific Conditions: Tracheostomies http://commons.wikimedia.org Cuffed Cuffless

26. Specific Conditions: Tracheostomies Obstruction Attempt suctioning using largest diameter possible for < 5 sec If still obstructed, urgently replace with new cannula

27. Tracheostomy sizing chart

29. Replacing a Tracheostomy Tube - Video http://www.tracheostomy.com

30. Specific Conditions: Replacing a Tracheostomy Steps: 1 Remove inner cannula 2 Insert obturator 3 Extend patient’s neck using shoulder roll 4 Insert tube into stoma in smooth, curved motion. No resistance should be felt. If excessive force used, can cause false track 5 Remove obturator 6 Confirm position, inflate cuffed tubes

31. Specific Conditions Gastrostomy Tubes http://tofs.org.uk

32. Complication: Gastrostomy tube dislodged Key emergency action: Can replace with foley Use same size or 1 smaller Don’t inflate balloon if <8wks from placement

33. Specific Conditions Cerebrospinal fluid shunts Most common is VPS Also VAS neuroanimations.com

34. Complication Clinical scenario: 4yo with shunt due to IVH as preemie now with 2 days of headache, vomiting Afebrile, decreased oral intake. Drowsy but arousable. Downward gaze. Moving all extremities equally

35. Complication: VPS Malfunction Key emergency action: Evaluation of shunt, assessment by neurosurgeon Most predictive? Vomiting Lack of fever Parental suspicion Typical pattern for given child

36. Questions?

37. Examples