1. NYS DOH EMSC PPCC 1 Children with Special Health Care Needs Lesson 8

2. NYS DOH EMSC PPCC 2 You respond for a child with difficulty breathing at home. On arrival, you find a 4 year old laying on a hospital bed amidst a gaggle of tubes and monitors. Your RFI reveals an alert child with rapid breathing rate and effort, pale skin and gurgling sounds. The child has a tracheostomy from which the gurgling originates. Mother states that a new nurse was on duty when the trouble began. The new nurse had trouble operating the suction unit and called mother to return home and called 911 as well.

3. NYS DOH EMSC PPCC 3 Mother is visibly upset and frustrated, because the pulse oximeter has been fluctuating between 91 and 94%. Mother asks to use your suction unit, and is successful in clearing the excess mucous in a matter of seconds. Immediately, the child looks more relaxed, has easier breathing and the pulse oximeter reads 98%. At the request of mother, you transport the child to the hospital.

4. NYS DOH EMSC PPCC 4 CSHCN Children with special health care needs (CSHCN) refers to children who have or are suspected of having a serious or chronic condition of: physical, developmental, behavioral, or emotional health that requires health- related services of a type or amount beyond that generally required by children (based on nat’l defn.).

5. NYS DOH EMSC PPCC 5 Technology-Assisted Technology-assisted children refers to those children who depend on medical devices to support bodily function.

6. NYS DOH EMSC PPCC 6 Why is this Population Increasing? Increased survival rates from children suffering from critical injuries or disease. Advances in medical technology allow more children into the mainstream. More plentiful support services has decreased the time spent in hospitals for these children.

7. NYS DOH EMSC PPCC 7 Assessment: General Points Use RFI and Initial Assessment Steps The baseline of these children may be different from others in their age group. Ask the family member or caregiver if there are deviations from this child’s normal state.

8. NYS DOH EMSC PPCC 8 Assessment - Airway Children with special needs are susceptible to airway obstruction. Technology-assisted children are at risk of device failure.

9. NYS DOH EMSC PPCC 9 Assessment - Breathing Children with congenital heart disease or chronic illness may be unable to compensate for even mild respiratory distress.

10. NYS DOH EMSC PPCC 10 Assessment - Circulation Signs of hypoperfusion may be masked because the baseline heart rate of the child may be accelerated. Look for other signs including AMS.

11. NYS DOH EMSC PPCC 11 Always Urgent CSHCN Child who has respiratory distress or signs of hypoperfusion is treated as an urgent condition. Transport ASAP with oxygen. Additional assessment while en route.

12. NYS DOH EMSC PPCC 12 Delayed Mental Development Assessment Concerns Use a sensitive approach: Ask for the child's name and use it. If necessary, use "special child" rather than terms like "retarded" or "slow."

13. NYS DOH EMSC PPCC 13 Ask the Parents/Caregivers Determine the child's normal abilities and behavior in the following areas: mental status interaction with parents and strangers verbal abilities ability to sit, stand, and walk muscle tone and strength

14. NYS DOH EMSC PPCC 14 Ask the Parents/Caregivers Are there differences from normal abilities and behaviors now? Were these changes the primary reason for calling EMS?

15. NYS DOH EMSC PPCC 15 CUPS Assessment of Children with Special Needs Category Assessment Actions

16. NYS DOH EMSC PPCC 16 Critical Assessment Absent Airway Breathing Circulation AVPU = P or U Action Support and Transport

17. NYS DOH EMSC PPCC 17 Unstable Assessment Compromised Airway Breathing Circulation AVPU=V or P or Normal airway breathing and circulation, AVPU=A with other risk factors. Action Support and Transport

18. NYS DOH EMSC PPCC 18 Potentially Unstable Assessment Compromised Airway Breathing Circulation AVPU=V or P or Normal ABC’s, AVPU=A with other risk factors. Action Support and Transport

19. NYS DOH EMSC PPCC 19 Stable Assessment Normal Airway Breathing Circulation AVPU=V or A Action CSHCN or technologically dependent children often have the potential to abruptly deteriorate. For this reason, they are not considered stable.

20. NYS DOH EMSC PPCC 20 SPECIAL TECHNOLOGY EMTs and Paramedics will encounter various people who assist these children. Tracheostomy Tubes Home Ventilators CPAP Devices Central Intravenous Catheters Pacemakers Feeding Catheters CSF Shunts Colostomies and Illeostomies

21. NYS DOH EMSC PPCC 21 Tracheostomy A surgical opening into the trachea through which a tracheostomy tube can be passed. The child then breathes through this opening.

22. NYS DOH EMSC PPCC 22 Reasons for a Tracheostomy To bypass an airway obstruction caused by birth defect, surgery, or trauma. To allow for long-term ventilator use. To access and remove excessive secretions.

23. NYS DOH EMSC PPCC 23 Single Cannula Tracheostomy Tube Used on all newborns and most pediatric patients. Has one single passage used for both air flow and suctioning.

24. NYS DOH EMSC PPCC 24 Double Cannula Tracheostomy Tube Features a removable inner cannula that fits inside an outer cannula. Inner cannula must be in place to ventilate the patient Outer cannula keeps the stoma open while the inner is removed for cleaning.

25. NYS DOH EMSC PPCC 25 Fenestrated Tracheostomy Tube Allows the child to breathe through either the tube or the mouth. Teaches the child to breathe through the mouth. Allows for speech.

26. NYS DOH EMSC PPCC 26 Cuffed Tracheostomy Tube Cuffed tubes are used to eliminate or reduce airflow through the mouth and nose. Cuffs may be either foam or balloons. Used for adults or older children.

27. NYS DOH EMSC PPCC 27 Tracheostomy Emergencies EMTs may be called on to respond to children with tracheostomies for the following reasons: –obstruction of the tube –displacement of the tube –psychological care of the patient or care giver

28. NYS DOH EMSC PPCC 28 Tracheostomy Emergencies EMTs should follow assessment priorities with additional focus on the airway: Always consider obstructed airway. Check and recheck. May need suctioning repeatedly.

29. NYS DOH EMSC PPCC 29 Tracheostomy - Management To correct respiratory distress for a patient with a tracheostomy: –place a rolled towel under the child’s shoulders, –make sure the tracheostomy tube is properly seated and the obturator/ decannulation plug has been removed.

30. NYS DOH EMSC PPCC 30 Tracheostomy - Management Attempt assisted ventilation through the tracheostomy tube. If the child is on a home ventilator, remove it and manually ventilate the child with a bag- valve device.

31. NYS DOH EMSC PPCC 31 Tracheostomy - Management Suction the tracheostomy tube –Ask the parent or caregiver for the proper supplies. –Select a catheter small enough pass through the tube. –Set the suction at 100 mm/Hg or less.

32. NYS DOH EMSC PPCC 32 Tracheostomy - Management –Pre oxygenate the patient. –Loosen secretions with normal saline. –Insert catheter 2 inches into the tube. –Suction for no more than 10 seconds while removing the catheter. –Monitor pulse and condition.

33. NYS DOH EMSC PPCC 33 Tracheostomy - Management Attempt to remove/ replace the tube –obtain a replacement tube. –If the existing tube has a balloon cuff, deflate it. –Cut the ties that hold the tube in place and remove the tube.

34. NYS DOH EMSC PPCC 34 Tracheostomy - Management –Insert the tube with the curved end pointing down, –Confirm that the tube is positioned properly. –Evaluate the child’s respiratory status.

35. NYS DOH EMSC PPCC 35 Tracheostomy - Management Perform ventilations with a bag valve mask over the stoma or the mouth.

36. NYS DOH EMSC PPCC 36 Tracheostomy - Management Children with tracheostomies often have asthma. Treat according to local protocol.

37. NYS DOH EMSC PPCC 37 Home Ventilators Children who depend on home ventilators have a problem with their respiratory drive or respiratory effort.

38. NYS DOH EMSC PPCC 38 Home Ventilators - Settings Home ventilators are set to control: –breathing rate –tidal volume –FIO 2 –Peak Inspiratory Pressure (PIP) –Positive End Expiratory Pressure (PEEP)

39. NYS DOH EMSC PPCC 39 Home Ventilators - Types There are two types of home ventilators: –Pressure cycled ventilators –Volume ventilators

40. NYS DOH EMSC PPCC 40 Home Ventilators - Modes Home ventilators operate in two modes: –Intermittent Mechanical Ventilation (IMV) –Continuos Mechanical Ventilation (CMV)

41. NYS DOH EMSC PPCC 41 Home Ventilators - Management Possible causes of emergencies involving home ventilators include: –equipment failure –problems with the oxygen supply –an obstruction in the ventilator tubing –an obstruction in the tracheostomy tube –a medical condition

42. NYS DOH EMSC PPCC 42 Constant Positive Airway Pressure - CPAP A mask covers the child’s mouth and nose, providing constant pressure, ensuring an open airway.

43. NYS DOH EMSC PPCC 43 Central Intravenous Catheters Used to deliver nutrients or special medications into a central line. Located on the chest, neck, groin, or arm.

44. NYS DOH EMSC PPCC 44 Central Intravenous Catheters There are two common types of catheters used for this purpose: Broviac Catheters Hickman or Mediport Catheters

45. NYS DOH EMSC PPCC 45 Central Intravenous Catheters Problem Bleeding or broken catheter Obstructed Fever Solution Control bleeding with direct pressure and transport, clamp catheter end. Transport, request ALS to clear obstruction. Transport immediately.

46. NYS DOH EMSC PPCC 46 Pacemakers Pacemakers regulate heart rate. A pacemaker is needed if the natural heart rate is not fast enough to ensure adequate perfusion.

47. NYS DOH EMSC PPCC 47 Pacemakers - Types There are three types of pacemakers: Demand Constant Antiarrhythmia

48. NYS DOH EMSC PPCC 48 Pacemaker - Management Problem Pacemaker failure Failure to compensate Solution Transport immediately, request ALS back-up, treat for shock as indicated.

49. NYS DOH EMSC PPCC 49 Pacemaker - Management Problem Dislodged Leads Broken Leads Solution Treat symptoms as necessary, rapid transport. Treat symptoms, treat for shock, rapid transport.

50. NYS DOH EMSC PPCC 50 Feeding Catheters A feeding catheter provides a route for nutritional support when the child is unable to take food by mouth

51. NYS DOH EMSC PPCC 51 Surgical Feeding Catheters Used for long term support of the child. –Gastrostomy Tube(GT) –Jejunostomy Tube(JT) –Gastrostomy Button

52. NYS DOH EMSC PPCC 52 Nonsurgical Feeding Tubes Used for temporary support of the child –Nasogastric Tube (NGT) –Nasojejunal Tube (NJT) –Orogastric Tube (OGT) –Orojejunal Tube (OJT)

53. NYS DOH EMSC PPCC 53 Feeding Tubes - Management Problem Bleeding Leaking Broken Dislodged Solution Control bleeding at site. Treat skin irritation Monitor, transport

54. NYS DOH EMSC PPCC 54 CSF Shunts A special Catheter to drain cerebrospinal fluid (CSF) from the brain. Runs under the skin from the skull to the chest or abdomen.

55. NYS DOH EMSC PPCC 55 CSF Shunt Concerns Altered mental status Listlessness Increased sleep Nausea or vomiting Fever Headaches Difficulty walking Initiate transport Continually assess and reassess ABCs Request ALS when the child has - Periods without breathing - Seizures - Rapid AMS

56. NYS DOH EMSC PPCC 56 Colostomies and Ileostomies A portion of the small or large intestine is attached to a surgical opening in the abdominal wall and a bag is placed to collect digestive waste.

57. NYS DOH EMSC PPCC 57 Congenital Heart Disease Children may be born with structural defects of the heart: –Heart valve problems –Arteries don’t function correctly –Cyanotic heart disease –Heart doesn’t fire properly

58. NYS DOH EMSC PPCC 58 Congenital Heart Disease - Mgmt EMTs should consider: –These children will have low blood oxygen levels. –Hypoperfusion (shock) is severely life threatening. –Children with irregular pulses should be rapidly transported and constantly monitored.

59. NYS DOH EMSC PPCC 59 Children with Mobility Problems Mobility problems may be caused by spasticity or paralysis. –Spasticity is a condition where muscles and tendons become tight, restricting movement of joints and extremities. –Paralysis is the inability to move a portion of the body.

60. NYS DOH EMSC PPCC 60 Children with Chronic Illnesses Children with chronic illness may have medical emergencies for other reasons: –They may experience an unrelated illness or a traumatic injury. –They may suffer a sudden worsening of the underlying chronic condition.

61. NYS DOH EMSC PPCC 61 Children with Chronic Illnesses - Special Considerations The child’s baseline vitals may be different from others his/her own age. The child may have a decreased tolerance. The child may have received significant medical care prior to EMS’ arrival. The parent/caregiver can provide valuable information.

62. NYS DOH EMSC PPCC 62 Summary CSHCN - Technology Assisted children present unique challenges for EMTs. Modify RFI and Initial Assessment steps Focus on any condition of the airway, respiratory or circulatory system. Take nothing for granted. Parent/caregiver is key in assessment.