Children With Special Healthcare Needs

Children With Special Healthcare Needs
1st Trimester March 2013 Continuing Education

Our agenda today System announcements
Children with special healthcare needs Children with special psychiatric needs (ALS) Strip o’ the month: Bradycardia (ALS) Drug o’ the month: Atropine

Special thanks to: The Alameda County (CA) Public Health Department

Introduction to Children With Special Health Care Needs (CSHCN)

CSHCN: Definition CSHCN (Children with Special Health Care Needs) –
Children who have or are at increased risk for a chronic condition physical developmental behavioral emotional and who also require health and related services of a type or amount beyond that are required by children generally. This definition was developed by an Emergency Medical Services for Children’s National Task Force on Children with Special Health Care Needs in 1997 – It reads as follows: Children with special health care needs are those who have or are at increased risk for a chronic physical, developmental, behavioral, or emotional condition and who also require health and related services of a type or amount beyond that required by children generally. From: Commentary in Pediatrics, Vol. 102, No.1, July 1998.

CSHCN: Epidemiology 12 million US children are considered “special needs,” which is 18% of all U.S. children From: 1994 National Health Interview Survey on Disability Estimated that 25% of children treated in pediatric EDs have special needs From: Pediatric Emergency Care, Vol 12, No. 3 June 1996 Conservatively, an estimated 12 million of all US children have special health care needs, which encompasses 18% of the pediatric population. These children have become frequent users of the emergency medical system comprising approximately twenty five percent of all pediatric emergency department visits.

CSHCN: Health Care Realities
Managed Care Complicated home care financially driven Parents forced to provide advanced care Societal Changes “Family-centered care” Disabled have right to be home Medical Advances Portable technology Improved techniques and medications In recent years, various health care changes have made it increasingly possible for special needs children, especially those who are technology dependent and developmentally delayed, to become a growing population within our communities. Managed Care has viewed home health care as a cost saving measure. The dollar amount to care for a special needs child in the home environment costs far less than it would to maintain that same child in a long-term care facility. Society has become more accepting of children who in past years were looked upon as “different… not belonging outside of an institution.” Praise, not public shunning, is now given to the caregiver who chooses to keep their special needs child at home. The concept of “family centered care” can provide endless happiness, love, and pampered care for a special needs child and his or her family. Advances in medicine have made it possible for pre-term infants, children with chronic illnesses or with a severe injury or disability to survive longer, and in many cases have more productive lives, than was possible in years past. In addition, equipment and monitors a child may depend on for survival have become portable and more manageable in the home setting. It is for these reasons that special needs children are becoming a growing part of our communities.

CSHCN: Equipment Technology-Assisted Children Feeding catheters
Colostomies Pacemakers Glucometers Nebulizers Apnea monitors Tracheostomies Ventilators/BiPAP Central venous catheters CSF shunts Vagal nerve stimulators A subset of special needs children with a chronic illness require technology assistance. This slide shows a list of possible technology you may encounter in a child with special needs. We will be discussing how to manage many of these various technologies today.

CSHCN: Important Points
Assess and manage ABCs as with any other child Listen to parents/caregivers They know problems and treatments very well Finally, remember that each child must ventilate, oxygenate and circulate in order to survive. Take into consideration the child’s chronic illness, but simultaneously manage the most life threatening problems. The child’s caregiver is part of the EMS team, utilize them for their vast amount of knowledge and have them continue assisting with the care of their child.

II. Common Chronic Pediatric Illnesses: Pulmonary Disorders and Airway Defects
We will be discussing the chronic pediatric medical conditions that you can expect to encounter. More detailed information about these conditions are in your SCOPE student’s manual.

Pulmonary Disorders and Airway Defects
Apnea Definition Respirations cease for > 20 seconds or Respirations cease for < 20 seconds with cyanosis or bradycardia Causes Obstructive, central, or mixed Affects both premature and full-term infants Apnea Characterized by periods of rapid breathing followed by periods of slow breathing or periods during which there is no visible breathing. It reflects immature neurological and respiratory control mechanisms. There are two definitions of apnea: An episode during which respirations cease for > 20 seconds. A cessation in respirations < 20 seconds accompanied by cyanosis, bradycardia and / or limpness. Obstructive apnea The most common form of childhood apnea, may be associated with choking or gagging as a result of gastro esophageal reflux. Obstructive apnea can also occur during sleep as a result of an upper airway abnormality or swelling, such as enlarged adenoids. With obstructive apnea, the infant makes a physical effort to breathe but no airflow is detected. Central apnea Occurs because of a central nervous system disorder such as encephalitis, brain stem infarction or tumor, neuromuscular disorders, or thoracic restrictive disorders. Central apnea can also be caused by an infection during the newborn period. With periods of central apnea, the infant shows no effort to breathe. Factors increasing the risk for apnea: Premature infants are at highest risk for experiencing an apenic event. Full term infants can also become apneic, although it is less common. Older children with neurological or brain abnormalities may also suffer from apneic events.

Pulmonary Disorders and Airway Defects
Cystic Fibrosis Overview Affects 30,000 Americans Autosomal recessive disorder Mucus builds up in lungs Signs and symptoms Increased respiratory rate Increased oxygen requirement Paleness or cyanosis Management Give active form of the abnormal protein product Chest therapy with bronchial or postural draining Antibiotics Bronchodilators

III. Cardiovascular Defects

Cardiovascular Defects
Congenital Heart Defects (CHDs) 1 in 1,000 live births Two types 1. Acyanotic 2. Cyanotic Congenital heart disease occurs in approximately 8 in 1,000 live births. When infants are born with a severe cardiac anomaly, interventions are primarily directed towards home health care until definitive surgery can be performed or towards supportive treatment in the home of a child whose defect cannot be surgically repaired. There are two types of cardiac defects: Acyanotic lesions account for the majority of congenital heart disease. With acyanotic defects, there is no mixing of poorly oxygenated blood in the systemic circulation. Cyanotic heart defects result when blood from the veins and the arteries mix in the heart, causing constant low blood oxygen levels. The degree of cyanosis may vary with age, activity, or both. The severity of the defect depends on the presence of an opening between the right-sided pulmonary circulation and the left-sided systemic circulation. This concept is called shunting, which allows unoxygenated blood to mix with oxygenated blood.

Acyanotic Heart Defects Account for the majority of CHD in children Mixing of desaturated blood in the systemic arterial circulation Oxygen saturation is in the normal range Generally septal defects, obstructions to the flow of blood, and incomplete heart development.

Signs/Symptoms of Acyanotic Heart Disease Increased respiratory rate Increased heart rate Heart murmur Signs of heart failure Rales on lung exam Palpable liver edge Swollen extremities

Types of Acyanotic Heart Defects VSD (most common) Ventral Septal Defect Defect in wall that separates ventricles ASD Atrial Septal Defect Patent ductus arteriosus Fetal blood passage doesn’t close after birth Obstructive lesions Narrows the aorta or valves Examples of acyanotic lesions include: ASD (Atrial Septal Defect) - a defect in the septum that separates the upper two chambers, or atria, of the heart. VSD (Ventricular Septal Defect) – a defect in the septum that separates the lower two chambers, or ventricles, of the heart. Pulmonary Stenosis - a narrowing of the valve that allows blood to flow from the right ventricles to the lungs. Aortic Stenosis – is a malformed aortic valve where one or more of the normally three leaflets are missing. AV (Arterioventricular) Canal Defect – occurs between the atrium and ventricles. The tricuspid and mitral valves form abnormally into one single valve, which crosses the defect. Coarctation of the aorta – a constricted or pinched aorta resulting in an obstructed blood flow from the heart to the rest of the body.

Cyanotic Heart Defects Blood from arteries and veins mix in the heart Typical oxygen saturation—70% to 90% on room air Palliative procedures often performed at birth Caregivers/medical control may advise that you avoid administration of O2 unless O2 saturation is below usual Otherwise, never withhold oxygen! Cyanotic heart defects result when blood from the veins and the arteries mix in the heart, causing constant low blood oxygen levels. The degree of cyanosis may vary with age, activity, or both. The severity of the defect depends on the presence of an opening between the right-sided pulmonary circulation and the left-sided systemic circulation. This concept is called shunting, which allows unoxygenated blood to mix with oxygenated blood.

Signs/Symptoms of Cyanotic Heart Disease Cyanosis Increased respiratory rate, retractions Increased heart rate Poor perfusion Diminished peripheral pulses Poor feeding, sweats with feeds

Types of Cyanotic Heart Defects Hypoplastic Left Heart Syndrome Transposition of the great arteries Tetrology of Fallot Tricuspid Atresia Pulmonary Atresia Truncus Arteriosus Cardiac Arrhythmias Some of the more common types of cyanotic cardiac defects include: Tetralogy of Fallot – encompass 4 different defects: a VSD, pulmonary stenosis, an abnormally muscular right ventricle, and the aorta lying directly over the VSD. Hypoplastic left heart – can be described as an underdeveloped left ventricle combined with an aortic and / or mitral valve stenosis or atresia. Transposition of the great arteries – results when there is a reversal of the pulmonary artery (which normally carries venous blood flow) and the aorta (which normally carries oxygenated blood from the left ventricle to the body.) Since the aorta is abnormally connected to the right ventricle, it returns unoxygenated blood to the body. Subsequently, the pulmonary artery, which is now abnormally attached to the left ventricle, now carries oxygenated blood to the lungs.

IV. Down Syndrome

Down Syndrome Down Syndrome (Trisomy 21) Chromosomal abnormality
Affects 1 in 800 births Highest risk: women > 35 years At risk for medical complications of multiple systems Trisomy 21 more commonly known as “Down Syndrome” is one of the more common chromosomal abnormalities. Occurs in 1 in 800 births While the women at highest risk are over 35 years, most of these births occur in women in their 20s due to higher birth rates in that age group New methods for screening pregnancies has lowered the incidence of Down Syndrome Children with Down Syndrome have a number of medical problems affecting most of the major organ systems.

Down Syndrome Signs/Symptoms of DS Large tongue Short neck Obesity
Short stature Loose ligaments Epicanthal folds Children with Down Syndrome have the following features Large tongue Short neck Obesity Short stature Loose ligaments Epicanthal folds The large tongue and short neck may make managing these children’s airways more difficult.

Down Syndrome Conditions Associated with DS Congenital heart disease
VSD, ASD, AV canal Orthopedic conditions Atlantoaxial subluxation Neurologic Conditions Epilepsy Airway and Respiratory problems Dental and speech abnormalities The most concerning medical problem for children with Down’s Syndrome is congenital heart disease. These children have endocardial cushion defects that include: VSDs ASDs Arteriovenous Canal (AV canal) Orthopedic conditions are common. The most concerning is atlantoaxial subluxation which can be seen on x-ray. This condition can theoretically lead to a spinal cord dissection at C1 Other problems include dental issues, seizure disorders, and mental retardation. The level of MR varies. Some are slightly MR while others are profoundly MR.

V. Traumatically Disabled Children

Traumatically Disabled Children
Unintentional injuries are the leading cause of morbidity and mortality Traumatic brain injuries Risk of seizures May need CSF shunt/feeding tube/wheelchair Spinal cord injuries Difficulty regulating body temperature Pressure sores are serious concerns Disabled child may be unaware he or she is injured High risk of abuse Unintentional injury is the number one killer of children ages 14 and under. Each year, nearly 6,700 children are killed and more than 50,000 are permanently disabled by preventable injuries. Brain injuries result from injuries to the head and / or anoxia. Spinal cord injuries may result from trauma but also may be due to a tumor compressing a section of the cord.

VI. Neurologic Diseases

Neurologic Diseases Causes of Seizures Epilepsy Traumatic brain injury
Genetic/metabolic defect Congenital brain abnormality Including mental retardation Tumor Causes of non-febrile seizures can include: Epilepsy – is a diagnoses given to a child who has a history of has seizure episodes Post anoxic brain injury – severe anoxia and cerebral edema can result in brain injury which can cause seizures Genetic defect – results from a chromosomal abnormality Congenital abnormality –is a defect occurring in utero Extrinsic drugs –which include overdoses on OTC or prescription medications. Brain tumor – new-onset seizure activity in the non-febrile child may be the first symptom of an undiagnosed brain tumor

Neurologic Diseases Generalized Seizures Tonic clonic or grand mal
Duration seconds to minutes Most common type of seizure Absence Vacant, blank stare May occur many times a day Myoclonic Infantile spasms Difficult to control There are two categories of seizure disorders: Generalized seizure activity and Partial seizure activity. Generalized seizure activity – Grand mal or clonic – tonic activity: the most common type of seizure activity. The child may experience an aura then rigid muscles interspersed with rhythmic jerking. The seizure ends with complete relaxation, which may lead to incontinence. Seizure activity usually ends within 5 minutes followed by a post-ictal period. In this stage the child may sleep or be very lethargic. Absence: (formally known as petite mal seizures) are less common. A normally behaving child will suddenly stop all activity and develop a vacant look or blank stare, and become unaware of everything. Absence seizures are seen more in older children and adolescents and may occur as many as 100 times a day. Myoclonic: seizure activity is characterized by sudden startle-like episodes when the body flexes or extends briefly. It commonly starts around 3 to 6 months of age. Myoclonic seizures often occur in clusters of 8 – 10, multiple times a day. These seizures are difficult to control and are associated with a poor outcome.

Neurologic Diseases Partial Seizures Simple partial Complex partial
One part of brain involved Child awake and aware Involves one limb or one side of body Can progress to generalized seizure Complex partial Child unconscious Affects one side of the body Psychomotor partial Repetitive fine-motor activity Most common; one part of the brain Partial seizures. This type of seizure activity is limited to one part of the brain. The presentation of the seizing child depends on the location of the abnormal electrical activity. Simple complex seizures - the child is aware during his / her seizure activity Complex partial seizures – are associated with a loss of consciousness Psychomotor seizures –are describes as repetitive fine motor actions such as lip smacking, eye blinking, or mumbling. The length of the seizure usually lasts a few minutes, yet it may progress to grand mal seizures.

Neurologic Diseases Management of Seizures Antiepileptic medications
Most common treatment Home Valium per rectum For frequent and/or prolonged seizures Can NOT give unless you are trained to do so and with approval of medical control Vagal nerve stimulators Ketogenic diet For intractable seizures The mainstay of therapy includes antiepileptic medications. There are new generations of these medications and a child may be on more than one. For those children who have frequent or prolonged seizure activity, parents may have rectal valium at home and can administer this if a child has a seizure lasting more than a few minutes. Ask parents about use of these treatment modality. A relatively new treatment modality are vagal nerve stimulators. These are used in patients with epilepsy who are refractory to oral medications This is implanted into the child’s chest and sends off a discharge to stop seizures And rarely, a child with intractable seizures is on a ketogenic diet. A child is put on this very restrictive high fat diet where the goal is to make ketones. Any sugar (as in IVF with D5) will put them out of their ketotic state. Discuss with parents before starting fluids with dextrose.

Neurologic Diseases Hydrocephalus
Excessive build-up of CSF within the cavities of the brain Causes Congenital hydrocephalus (occurs before birth) Acquired hydrocephalus (occurs after birth) Hydrocephalus An excessive build up of cerebral spinal fluid (CSF) within the cavities of the brain known as the ventricles. Causes of hydrocehpalus include Congenital (existing before birth – such as Spina Bifida), or acquired, which occurs after birth. Acquired hydrocephalus can result from trauma, scar tissue formation, post head injury or meningitis.

Neurologic Diseases Management of Hydrocephalus CSF shunts
Ventriculoparietal shunt most common type Shunt complications Shunt malfunction, obstruction Infection Signs and symptoms of shunt malfunction Headache Nausea/Vomiting Diminished mental status Bradycardia, hypertension, irregular respirations “Sundown eyes” Management Includes the placement of a CSF shunt to drain off excessive CSF in order to prevent increased intracranial pressure and death. The most common type is a ventriculoparietal shunt. Fluid is drained from the ventricle in the brain to the peritoneum. Sometimes a child may have a ventriculoatrial shunt which trains fluid into the atrium of the hear. CSF Shunts are highly prone to complications. The most common are shunt obstruction or malfunction. This is where the shunt becomes blocked either by excessive protein in the fluid or a disconnection in the tubing or a kink in the tubing. Infection is much less common and is usually seen within 2 months after placement or revision. Other complications include CSFoma in the abdomen and periotonitis. Signs and symptoms include: Headache Vomiting Decreased mental status Cushing’s triad—bradycardia, hypertension and irregular respirations Sundowning—this is where the cranial nerve 3 is compressed by the increased intracranial pressure such that the patient cannot look up so the pupils look like the sun at sundown

Neurologic Diseases Mental Retardation Developmental Delay IQ < 70
Non-progressive disorder Cause is prenatal problem, brain injury, or genetic syndrome Requires special education Developmental Delay Results from prolonged illness or prematurity Potential to “catch up” Developmental Delay Usually results from a prolonged illness or prematurely. These children have the potential to “catch up” and to eventually progress normally with their growth and development. Mental retardation Affects an estimated 1 to 3% of the population. May occur as a result of a prenatal problem or from an injury or disease that occurs during the developmental years. A non-progressive disorder or slowness in development defined as an IQ < 70 and an inability to adapt to his or her surroundings. Ability to adapt to their surroundings is impaired. Treatment is focused on special education and training to develop the child’s potential to the fullest.

Neurologic Diseases Spina Bifida (Myelomeningocele)
Failure of the spinal cord to fuse during pregnancy Characteristics depends on level of lesion Paralysis Hydrocephalus Delay in motor development Loss of bladder function/UTIs Normal intelligence Considered to have latex allergy Spina Bifida (also called myelomeningocele) Affects about 1 in every 1000 infants born in the US. An incomplete malformation, or incomplete closure, of the spinal column that occurs around the third week in utero. Nerves will not develop below the area of malformation, which often results in lower extremity paralysis or loss of sensation as well as bowel and bladder dysfunction. Many children with spina bifida may need to have their bladder catheterized several times a day, which can cause frequent urinary tract infections and urosepsis. Hydrocephalus occurs in 60 – 90% of these children because the open spine allows the lower portion of the brain to slip through the opening of the spinal column into the spinal canal. Even though children with Spina Bifida may have motor delays or dysfunction, the majority often have average to above average intelligence. Highest risk group for having a latex sensitivity or LATEX ALLERGY. It has become a standard practice avoid use of any products containing LATEX when working with these children.

Neurologic Diseases Cerebral Palsy (CP) Characteristics
Damage to brain center controlling muscle control Multiple types Congenital or acquired Often occurs in very-low-birth-weight babies Hypertonic, contracted limbs 50% have seizure disorder Two-thirds have mental retardation

Neurologic Diseases Cerebral Palsy Management Braces Wheelchairs
Oral medications Baclofen intrathecal pumps

VII. Hematology and Oncology Diseases

Hematology and Oncology Diseases
Sickle Cell Anemia (SCA) An inherited hemoglobinopathy that causes sickling of RBCs Characteristics Pain,“vaso-occlusive crisis” Splenic sequestration Aplastic crisis Sepsis

Hematology and Oncology Diseases
Hemophilia An inherited disorder in which a factor needed for clotting blood is either too low or missing Incidence 15,000 in U.S. (mostly males) 60% severe form 15% moderate form 25% mild form Characteristics Prolonged bleeding Factor routinely administered at home Seemingly minor injury can be serious Hemophilia An inherited disorder where one of the factors needed for clotting is either missing or very low. It is estimated that more than 15,000 people in the US have hemophilia. The hemophilia gene is carried by females on one of their X-chromosomes and may be passed along to their male offspring. Males, unlike females, only have one X chromosome. There are varying degrees of severity of hemophilia, which may be mild, moderate or severe. Uncontrollable bleeding may occur after trauma, surgery, a minor injury, or for no apparent reason.

X. Musculoskeletal Disorders

Musculoskeletal Disorders
Osteogenesis Imperfecta “Brittle bone” disease Incidence: 20,000–50,000 people in U.S. Etiology Genetic disorder Defective collagen synthesis Multiple types, differing severity Characteristics Bones fracture easily Weak musculature Growth retardation Head disproportionately large for body Osteogenesis Imperfecta (OI), or “brittle bone disease” A genetic disorder characterized by bones that break easily, often from little or no apparent reason. Most forms of OI are caused by a genetic defect that affects the production of collagen, which is the major protein of the body’s connective tissue. Approximately 20,000 to 50,000 people in the US are known to have OI. The characteristics of OI vary greatly from one child to another – even with the same form of OI. Osteogenesis Imperfecta General Characteristics: Small stature – appear younger than their true age. The child in this slide is actually 12 years old and when this picture was taken, he already had a history of over 365 fractures. Bones that easily fracture Possible hearing loss Loose joints Poor muscle development in the arms and legs Barrel shaped chest, which can cause respiratory problems Spinal curvatures Dental problems triangular faces Note: the child in this picture is 12 years old! He had had over 365 fractures in his lifetime!

Musculoskeletal Disorders
Muscular Dystrophy Cause Most common type is Duchenne’s Flaw in muscle protein Muscle-wasting disease Most are inherited Characteristics Motor skills deteriorate Cardiomyopathy Shortened lifespan Muscular dystrophy (MD) A group of genetic muscle-wasting diseases that is caused by a flaw in muscle protein genes. MD is generally inherited. Progressive weakness and degeneration of the skeletal or voluntary muscles, which control movement, are the main characteristics of MD. The muscles of the heart and some other involuntary muscles may also be affected. As the disease progresses, muscles become profoundly weak. Eventually lung capacity may decrease, resulting in an increased susceptibility to lung infections. Severe respiratory and heart problems mark the disease’s final stages, which is in adolescence or the early 20’s in the case of Duchenne's MD. There is no cure for MD, however supportive therapies are available. The two most common forms of MD that present during childhood: Spinal Muscular Atrophy is a weakening of the spinal muscular usually resulting in death before the child’s first birthday unless supportive airway interventions are taken, such as ventilatory support through a tracheostomy tube. The most common form of childhood MD is Duchenne's Muscular Dystrophy. It occurs in one out of every 5,000 boys born. Symptoms usually occur between the ages of 2 and 6 years.

XI. Tips for Chronic Conditions

Tips for Chronic Conditions
Medical Identification Jewelry Parents trained in child’s care Often part-time home health care assistance DNR forms—Follow local protocols EMS Outreach Program EMS Notification The child may be wearing medical identification jewelry. This bracelet contains brief pertinent medical information including allergies and a phone number to call for a more detailed account of the child’s history. Prior to discharge from the hospital, the child’s primary caregiver(s) is thoroughly trained in all aspects of the child’s care. The parents are also trained in what to do in various emergencies. The child may have a DNR form. If this is the case, review this form to see if it falls within your state DNR protocols. If it does not and the child is in or pending arrest, contact medical control for further guidance. Caregivers are encouraged to alert their local EMS system as to the special needs of their child or to participate in a prehospital notification program such as EMS Outreach – started in Washington CD - or S.K.I.P., piloted in West VA. Such programs better prepare EMS providers to care for these children, especially if a child is technology assisted. Courtesy of the MedicAlert Foundation®. © 2006, All Rights Reserved. MedicAlert® is a federally registered trademark and service mark.

Tips for Chronic Conditions
Assess and manage ABCs as with any other child Listen to parents/caregivers They know problems and treatments very well Finally, remember that each child must ventilate, oxygenate and circulate in order to survive. So take a step back and focus on managing the child’s ABC’s in order to prevent becoming overwhelmed with a child’s diagnosis or technology. Take into consideration the child’s chronic illness, but simultaneously manage the most life threatening problems. The child’s caregiver is part of the EMS team, utilize them for their vast amount of knowledge and have them continue assisting with the care of their child.

A Different Look Why CSHCN Caregivers Call 9-1-1
97 of 100 CSHCN families surveyed have sought emergency care 75 sought emergency care three or more times CSHCN require EMS services because: Home health care equipment fails Caregivers panic No improvement with therapy Child in respiratory or cardiac distress/arrest

A Different Look Differences to Consider
Medical issues vs. equipment issues Atypical baseline vital signs May be smaller than same age peers May be developmentally delayed

A Different Look General Approach Ask “What is normal for your child?”
Respect caregiver’s opinion on child’s condition. Many know as much as the doctors do about their child’s illness. Treat the child, not the technology. Simple illnesses can be life-threatening . Caregivers are experienced with the medical system.

II. The ABCDEs: Interventions Using Special Technology

AIRWAY: Tracheostomies

Airway Tracheostomy An artificial airway passed through a surgical opening (stoma) in the anterior aspect of the neck and into the trachea

Airway Tracheostomy Indications: To bypass an upper-airway obstruction
To provide long-term mechanical ventilation To facilitate clearance of excess secretions

Airway Tracheostomy Types and Features Single Lumen Fenestrated
Double Lumen

Airway Interventions: Position of comfort Humidified air or O2
Nebulized 1:1000 epinephrine, if protocols allow If child is in extremis, consider endotracheal intubation

Airway Alleviating Respiratory Distress Position Suction Oxygen Repeat
An emergency tracheostomy tube change may be necessary.

Airway When to ventilate manually Upon removal from ventilator
Consider before/after suctioning or trach change Signs of respiratory distress or failure

Airway Causes of Tube Obstruction Improper airway positioning
Improper insertion of the trach tube Creation of a “false track” Mucous plug Failure to remove obturator after tube insertion

Breathing Interventions Disconnect patient from the ventilator
Began manual ventilation Assess for chest rise, breath sounds If no improvement, check for tracheostomy-tube obstruction If improved, consider ventilator issue Prepare for transport

CIRCULATION: Central Venous Catheters

Circulation Purpose of Central Venous Catheters
Administration of Medications Delivery of chemotherapy Nutritional support Infusion of blood products Blood draws

Circulation Types of Catheters Broviac, Hickman, Groshong
-Tunneled central venous catheters - Proximal tip in the subclavian vein - External access Port-a-Cath/Med-a-Port/PAS Port - Catheter system is completely beneath skin Percutaneous Intravenous Catheter (PICC) - Proximal tip in central vein - Looks like a PIV

DISABILITY

Disability Interventions Assessment of neurological status Position
Oxygen Maintain body temperature ALS: IV, fluids, IO ALS: Consider inotropes for shock if unresponsive to fluid resuscitation Assessment of neurological status Ask caregiver to compare child’s present status to baseline

Disability Cause of symptoms: Shunt infection Meningitis Encephalitis
If child presents with a fever or redness along the shunt tubing, suspect a shunt infection Meningitis Encephalitis

Disability CSF Shunts Types:
A CSF shunt is a catheter with one end in a ventricle of the brain and the other end in the abdomen or atrium that drains excess CSF or bypasses a blockage of CSF. Types: Ventriculoperitoneal Ventriculoatrial

Disability Concern The shunt could be damaged or disconnected. This can result in increased intracranial pressure.

Disability Causes of Complications: Brain infection
Shunt obstruction (resulting in a dangerous build-up of fluid in the skull) Shunt malfunction Peritonitis

Children with Special Healthcare Needs
Cerebrospinal fluid shunts Emergency care Vomit, aspiration Suction O2 Assist breathing, intubate Blood sugar Treat seizures

Shunt Drainage Routes Routes of drainage of ventriculoperitoneal (VP) and ventriculoatrial (VA) shunts VP shunts drain CSF from cerebral ventricles to peritoneal cavity by catheter tubing implanted superficially over rib cage Lower end of peritoneal catheter lies free in abdomen VA shunts drain CSF by a convenient neck vein such as jugular and superior vena cava to right atrium

External Shunt Infection External shunt infection in premature infant with poor nutritional status

EXPOSURE

Exposure Interventions
Assess neurovascular status distal to the injury. Gently place on a long-board splint. Avoid taking the blood pressure of a child with osteogenesis imperfecta. Do not use a hare traction splint or MAST trousers.

IMPORTANT POINTS Cover the child to maintain normal body temperature
Respect the child’s privacy

IMPORTANT POINTS Carefully examine for injuries
Assessment may be difficult due to developmental level CSHCN are at high risk for abuse Report any suspicious injuries to the proper agency.

II. SAMPLE History: Feeding Catheters

Feeding Catheters Nasogastric Tube (NGT):
Catheter placed through the nose into stomach For supplementation in children who cannot take enough by mouth Short-term use Can use to decompress stomach

Feeding Catheters Gastrostomy Feeding Tube (GT):
Catheter surgically or endocopically placed into stomach or Jejunum Provides long-term nutritional support

Feeding Catheters Feeding Catheter Complications:
Gastric contents can leak, causing irritation Tube obstructed Tube dislodged Abdominal distention

I. Moving Children with Special Needs

Communication Challenges: Language barriers
Is the person with the child the primary caregiver? Assess child’s ability to understand. Developmental delay Visual/auditory deficits

Communication Management: Use a soothing voice to provide comfort.
Explain each movement. Ask the caregiver for a medical summary card. Oftentimes, the caregiver may be too stressed to remember vital information.

Environment Challenges:
The scene and the child’s response to that environment can be a great source of tension and anxiety. Multiple providers can create fear. Multiple voices can cause confusion.

Environment Management: Limit the number of providers.
Ask one person to speak and interact with the child. Decrease chaos. Keep the noise down.

TRANSPORT AND TRANSFER

Transport Anxiety in child. Child may resist being restrained.
Challenges: Anxiety in child. Child may resist being restrained. Brittle bones and muscle contractures can easily lead to injuries during transport. Do not pull on extremities!

Transfer Management Make secure, firm contact
Suggest that family member move child. Allow the child to lay in a comfortable position. Use padding around buckles and contractures. Do not pull on extremities!

Stabilization Secure and transport child in own special restraint device if: No suspicion of cervical injury. Child is not critically ill. Device doesn’t impede assessment and treatment. Device can be properly secured in ambulance.

Destination Decisions
Challenges: Parents’ confidence in EMS system* 82% very confident in EMS care and home hospital 77% uneasy/not confident in community hospital care 98% very confident in “home” hospital care Parents trust but not transport decisions! *100 CSHCN families surveyed in 2000

Children with Special Behavioral and Emotional Needs
Behavioral emergencies involving children present special challenges to EMS. Aggressive behavior may really be symptom of an underlying disorder or disability. Parents of mentally ill children often overwhelmed and isolated from community and social support network. Family may hesitate to call 911 because of fear of stigma or misinterpretation by EMS personnel.

EMS Response Volatile situations require shift from common EMS response to integrated community collaboration and adaptive “out-of-the-box” decision making. 911 call may be from a mother or school staff member desperate for help with “out-of-control” child. Immediate link to pediatric or mental health professionals may de-escalate the child’s psychiatric emergency and ensure continuity of care. Unfortunately many EMS system policies, procedures, guidelines, and training do not include these options.

Common Behavioral Emergencies in Children
Major psychiatric disorders that may predispose to behavioral emergencies in children include mood disorders (e.g., depression, bipolar disorder); thought disorders (e.g., schizophrenia); developmental disorders (e.g., autism); anxiety disorders (e.g., posttraumatic stress disorder); other disorders such as attention deficit hyperactivity disorder.

EMS considerations EMS can assist and advocate for child and the family during a behavioral emergency. Family of a child with behavioral problems lives in fear of restraints, hospitalizations, false accusations. Understanding emotional fatigue, physical exhaustion, and chronic life disruptions of families is is integral to addressing their needs.

EMS Considerations Families of children with psychiatric disorders often have competing fears: Love for their child Fear of a violent outburst by the child toward the family Fear of the violence that may occur if the child needs to be restrained by the police or EMS providers.

For more information on pediatric psych issues and EMS response:

Rhythm O’ the Month Bradycardia

Sinus Bradycardia - Causes
Decrease in sympathetic tone on the AV node (increase in parasympathetic tone) Pressure on fontanels in infants Intracranial swelling Glottic irritation from ET tubs, gagging, emesis Disease of the SA node Hypothermia, Hypoxia

Sinus Bradycardia Administration of digitalis, propranolol (Inderal), verapamil, and quinidine Common in acute inferior AMI - Involves the right coronary artery which supplies the SA node with blood

Sinus Bradycardia in Children
Life threatening, especially in newborns and infants. Often a respiratory issue Newborn Dry, stimulate, suction first Then oxygen, ventilation CPR if heart rate remains under 60 Babies/children Treat respiratory issues unless child has known cardiac issue

Sinus Bradycardia Treat the patient, not the monitor!
Bradycardia is also common during sleep, rest and in trained athletes!

Sinus Bradycardia Ultimate clinical significance…..
Decreased heart rate/BP which leads to decreased CARDIAC OUTPUT

Sinus Bradycardia Treatment Modalities
Asymptomatic – pulse and adequate BP (>100 systolic) Routine Medical Care IV, O2, monitor Position of Comfort

Sinus Bradycardia Symptomatic
Hemodynamic Instablity (BP <100 systolic) Syncope, hypotension, altered mentation Chest pain, palpitations, diaphoresis Difficulty in breathing Poor skin vitals and perfusion

Symptomatic Bradycardia - ALS
Do not delay pacing while getting ready for Atropine Pace at 70. Increase MA until pulse matches. While pacing, consider Versed, 2.5 mg slow IVP. If necessary, Dopamine to maintain SBP and pulse >60.

Sinus Bradycardia Hypotension Leads to decreased cardiac output
Palpitations Because of SA node’s increased relative refractory period permits refractory firing

Sinus Bradycardia Chest Pain Heart disease already exists
Coronary blood flow is decreased

Sinus Bradycardia Bottom Line: TREAT THE UNDERLYING CAUSE TO ABOLISH THE DYSRHYTHMIA AND INCREASE THE RATE

Drug O’ the Month Atropine!

Atropine Indications Symptomatic bradycardia.
NO LONGER USED: asytole or PEA Nerve agent exposure Organophosphate poisoning

Adverse Reactions Dry mouth, hot skin, intense facial flushing
Blurred vision or dilation of the pupils with subsequent photophobia Tachycardia Restlessness May cause paradoxical bradycardia if the dose administered is too low or pushed to slowly

Contraindications Acute MI Myasthenia Gravis GI Obstruction
Closed angle glaucoma Known sensitivity to atropine, belladonna alkaloids or sulfates (NOT sulfa)

How Atropine Works Increases firing of the SA node.
Increases conduction through the AV node. Opposes the action of the vagus nerve. Blocks acetylcholine receptor sites Decreases bronchial secretions.

Atropine Dosage Symptomatic Bradycardia
Adult: 0.5 mg IV/IO every 3 to 5 minutes to a max dose of 0.04 mg/kg. Don’t delay pacing for Atropine. Peds: Oxygen/ventilation first. Then Epi! If that doesn’t work then 0.02 mg/kg (min of 0.1 mg/dose; max of 0.5 mg/dose). Repeat once in 5 minutes

Dosage Nerve Agent or Organophosphate Poisoning
Adult: 2 mg IVP repeated if needed every 5 minutes until symptoms dissipate Peds: 0.02 mg/kg IV/IM every 5 minutes as needed until symptoms dissipate

Special Children, Special Care
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