Download Special Populations

Special Populations
Pediatric Emergencies
Geriatric Emergencies
Topic Overview
• Injury Prevention
• Disaster Planning
• Pediatric Emergencies
–
–
–
–
–
–
Developmental Characteristics
Airway
Oxygen Therapy
Assessment
Common Medical Problems
Trauma
Topic Overview
– Child Abuse and Neglect
– Infants and Children with Special
Needs
– Family Response
– Provider Response
• Elderly Patients
Injury Prevention
• Evidence of a Problem
– Estimated 240-320 children in childcare
die / year
• Examples of Injuries
–
–
–
–
–
Eye injuries from glass
Severed thumb – 13 month old
10 month old left in bathtub with running water
Child struck by care after getting out of building
3 month old suffocated in a crib with diaper bag
over face
Injury Prevention
• Strategies
– Five Point Injury Prevention Plan
•
•
•
•
•
Never underestimate what a child can do
Teach Safety
Recognize what is age-appropriate
Create a safe environment
Supervise children carefully
Injury Prevention
• Age Appropriate Safety Guidelines
– Infants (Birth – 1 YOA)
– Toddlers & Preschoolers (1 – 5 YOA)
– Older Children (5-9 YOA)
Injury Prevention
• Children’s Medical Information
–
–
–
–
Physician’s name & phone number
Health plan – numbers & contact number
Emergency contacts
Medical conditions – type & current
treatment, allergies
– Current meds – scripts, OTCs, vitamins
Injury Prevention
• Medication Administration
– Avoid telling children
• “it tastes like candy”
• “it is a treat”
– Be diligent
• If you must give a med ensure the following:
–
–
–
–
In original container
Has an expiration date & med has not expired
Has instructions for administration
Four Rights
» Right Child
» Right Med
» Right Dose
» Right Time
• Store all meds out of reach of children
Injury Prevention
• Basic Fire Facts
– Seniors over 70 / Children under 5 YOA at
greatest risk of fire death
• Children under 5 YOA risk 2X of average population
• 2000 United States Fire Administration (USFA)
report:
– U.S. has one of highest fire death rates in
industrialized world
» U.S. death rate 14.9 deaths per million population
» 1998 – 4,400 deaths & 25,100 injured annually
Injury Prevention
– Fire kills more Americans than all natural
disasters combines annually
– 3rd leading cause of accidental death in the home
» ~ 80% of all fire deaths occur in residences
– ~ 2 million fires reported annually
Injury Prevention
• Fires in 1 0r 2
story dwelling most
often start:
–
–
–
–
–
23.5% - kitchen
12.7% - bedroom
7.9% - living room
7.1% - chimney
4.7% - laundry room
• Apartment Fires
–
–
–
–
–
46.1% - kitchen
12.3% - bedroom
6.2% - living room
3.3% - laundry room
2.4% - bathroom
Injury Prevention
• Fire-prevention techniques
– Install a smoke alarm
• ~88% of U.S. homes have at least 1
–
–
–
–
– Increasing numbers of them non-functioning
Teach children to never cook alone
Turn pot handles toward center of stove
Never put anything over a lamp
Teach children to:
• never touch radiators or heaters
• never stand to close to a fireplace or wood stove
• never touch matches, lighters or candles
Injury Prevention
– Establish & teach children to about gathering
points in case of fire
• Identify more than one location
– Good locations
» At mailbox
» Neighbor’s porch
» Nearby fire hydrant
• Fire drills
• For more information visit the United
States Fire Administration website
– www.usfa.fema.gov/kids
Injury Prevention
• PediScan Checklist (see handout)
– Brady Pediatric Emergencies, The First
Five Minutes
• Designed for both home & childcare
facilities
• Key to success
– Establish a systematic method for checking your
child’s environment
Injury Prevention
• First Aid Kits
• Special kits for childcare
– Always get assistance from:
• National Poison Control Center
– 1-800-222-1222
• Regional Center
– 1-800-Poison1
Disaster Planning
• Determining Preparedness
– Do you have a plan?
• Do you have an organized method of evacuation?
– Where to begin:
• Types of natural disasters in your area
• Ask yourself these questions:
–
–
–
–
–
–
Local warning system?
Designated area in home?
Evacuation plan if needed?
Have children been taught about plan?
Access to local shelter?
ID system for children in case of separation?
Disaster Planning
– Disaster kit?
» Battery powered flashlights (extra batteries)
» Battery powered radio (extra batteries)
» Cash (quarters)
» List of emergency numbers
» Bottled water
» Infant formula & bottles (if appropriate)
» Diapers
» Extra set of keys
» Blanket
» Large plastic bags
» Children’s books, puzzles, stuffed toys, crayons,
etc.
» Cell phone (if available)
– Emergency notification cards for each child?
Disaster Planning
– Available resources
• FEMA – extensive information at
www.fema.gov
• FEMA site for children to get interactive
information www.femaforkids.gov
• American Red Cross www.redcross.org
• Emergency Medical Services for Children
National Resource Center www.ems-c.org
• Institute for Business & Home Safety
www.ibhs.org
• Insurance Information Institute
www.iii.org/individuals/disasters
Infants & Children
Infants & Children
• Focused History, Vitals & Detailed
Physical
– Normal Pulse Ranges
•
•
•
•
•
•
•
Newborn
Infant 0-5 months
Infant 6-12 months
Toddler 1-3 years
Preschooler 3-5 years
School-age 6-12 years
Adolescent 12-18 years
120 to 160
90 to 140
80 to 140
80 to 130
80 to120
70 to110
60 to105
Infants & Children
– Normal Respiration Rate Ranges
•
•
•
•
•
•
•
Newborn
Infant 0-5 months
Infant 6-12 months
Toddler 1-3 years
Preschooler 3-5 years
School-age 6-12 years
Adolescent 12-18 years
30 to 50
25 to 40
20 to 30
20 to 30
20 to 30
15 to 30
12 to 20
Infants & Children
Blood
Pressure
Ranges
Under 3 yoa
Preschooler
3-6 yoa
School-age
6-12 yoa
Adolescent
12-18 yoa
Systolic
Diastolic
Approx. 80 plus 2
x age
average 99 (79116)
average 105 (80122)
average 115 (94140)
Approx. 2/3
systolic
average 65
average 57
average 59
Birth to 1 YOA
Newborns & Infants
• Working with children
–
–
–
–
Little anxiety with strangers
Parental separation is stressful
Dislike masks (oxygen)
Need warmth
• Warm hands, stethoscope
– If listening to lungs, do it early
– Get respiratory rate from a distance
– Detailed head-to-toe assessment done toe-tohead
Toddlers
• Toddlers – 1 to 3 yoa
• Toddlers dislike
–
–
–
–
Being touched
Separated from parents
Being undressed
Masks on face (oxygen
• Tend to think illness/injury is punishment
• Perform head-to-toe assessment toe-to
head
Preschool
• Preschoolers – 3 to 6 yoa
• Dislike
– Same dislikes as toddlers
– Generally
• afraid of blood & pain
• modest
– Fear permanent injury
– See injury/illness as a punishment
– Good imagination (magical thoughts)
School Age
• School Age – 6 to 12 yoa
• Generally
– Afraid of permanent injury &
disfigurement
– Modest
– Can perform a traditional detailed headto-toe assessment
Adolescent
• Adolescent – 12-18 yoa
• Still fearful of permanent injury &
disfigurement
• Treat as a adult
• Maintain their modesty
• Can perform a head-to-toe
assessment as appropriate
Airway Differences
Between Adults & Children
Patient Assessment
• General Impression
– Observe
•
•
•
•
•
•
•
Mental status
Breathing
Color
Quality of cry or speech
Emotional state
Response to your presence
Tone & body position
Patient Assessment
• General Impression
– Observe
• Interaction with environment & parents
–
–
–
–
–
Normal behavior for age?
Playing &/or moving around?
Attentive?
Eye contact?
Recognize & respond to parents?
Patient Assessment
• Approach to Evaluation
– As soon as you see the patient, check:
•
•
•
•
MOI
Surroundings
Healthy or sick in appearance
Assess respirations, perfusion
– When you reach the child,
• Assess breathing (stethoscope)
• Assess circulation
– Detailed assessment
Pediatrics
• Common Medical Problems
– Partial airway obstruction
•
•
•
•
Stridor, crowing or noisy respirations
Retractions on inspiration
Pink mucous membranes & nail beds
Alert
– Complete Airway Obstruction
•
•
•
•
No crying or speech
Initial difficulty breathing that worsens
Cough becomes weak & ineffective
Altered mental status
Pediatrics
– Early Respiratory Distress
• Nasal flaring
• Retractions
•
•
•
•
•
•
•
– Intercostal,
supraclavicular, subcostal
Stridor
Audible wheezing
Grunting
Respiratory rate >60
Cyanosis
Decreased muscle tone
Excessive use of accessory
muscles
• Poor peripheral perfusion
– Respiratory Arrest
•
•
•
•
•
Respiratory rate <10
Little or no muscle tone
Unconsciousness
Slow/absent heart rate
Weak/absent pulse
Infants & Children
• Croup (laryngotracheobronchitis)
–
–
–
–
–
Viral infection of upper airway
Most often in children 6 months - 4 YOA
Mostly in fall & winter
Edema of the larynx
Signs & Symptoms
•
•
•
•
slow onset
child generally wants to sit upright
barking cough
Fever (100-101oF)
Infants & Children
• Croup (Care)
– Position of comfort
– Cool humidified air (oxygen if available)
– Check for
•
•
•
•
inspiratory stridor
nasal flaring
tracheal tugging
tracheal retraction
– Activate EMS if airway becomes
obstructed
Infants & Children
• Epiglottitis
– Acute infection & inflammation of the
epiglottis
– Bacterial infection (usually Haemophilus
influenza)
– Usually children over 4 YOA
Infants & Children
– Signs & Symptoms
•
•
•
•
•
•
•
•
•
Rapid onset
Prefers to sit up
Brassy cough (not a barking cough)
High fever (102-104oF)
Occasional stridor
Pain upon swallowing, sore throat
Shallow breathing & Dyspnea
Drooling
Epiglottis red & swollen (do not attempt to
visualize)
Infants & Children
• Epiglottitis (Care)
– Position of comfort
– Cool humidified air (oxygen if available)
– Activate EMS ASAP
Pediatrics
– Signs of
Respiratory
Distress
Pediatrics
• Emergency Care
– Oxygen
• High flow oxygen
– Blow by technique
Pediatrics
• Emergency Care - Respiratory
Emergencies
– Ventilate if respiratory distress severe
•
•
•
•
•
Altered mental status
Cyanosis
Poor muscle tone
Respiratory rate <10
Respiratory arrest
Pediatrics
• Common Medical Emergencies
– Seizures
– Altered mental status
– Poisoning
• Rule our trauma
– Fever
– Shock
Pediatrics
– Near Drowning
• Ventilation is top priority
• Consider possibility of trauma, hypothermia
& drug ingestion
• Activate EMS for any submersion
– Some patients deteriorate minutes to hours later
Pediatrics
– Blunt trauma – most common type of
pediatric injury
• Motor vehicle crashes
– Unrestrained passenger
» (head and neck injuries)
– Restrained passenger
» (abdominal & lower extremity injuries
• Struck while riding bicycle
– (head, spine, abdominal injuries)
• Pedestrian struck by vehicle
– (abdominal, femur, head injuries)
Pediatrics
• Falls from height
– Head and neck injuries
• Diving into shallow water
– Head and neck injuries
• Burns
• Sports injuries
• Child abuse
Pediatrics
• Blunt Trauma
– Specific types & problems
• Head
–
–
–
–
Airway maintenance critical
Head injury common
Can result in respiratory arrest
Nausea and vomiting – very common
• Chest
– Children’s ribs less rigid
» Results in injury to internal organs without
external wounds
Pediatrics
• Abdomen
– Pediatric injuries more common than adult
• Extremities
– Managed the same as adults
• Burns
– Managed the same as adults
– General Care
•
•
•
•
Establish airway with jaw thrust
High flow oxygen
Immobilize spine
EMS activation
Pediatrics
• SIDS
– Sudden Infant Death Syndrome
• Sudden death without identifiable cause in
infant < one year of age
• Cause not well understood
• Most common time of discovery – early
morning
Pediatrics
• SIDS
– Care
• Try to resuscitate unless rigor mortis or
lividity present
• Avoid comments that blame parents
• Expect parents to feel remorse and guilt
• Activate EMS
Pediatrics/Geriatrics
• Abuse
– Improper or excessive action so as to
injure or cause harm
• Neglect
– Giving insufficient attention or respect
to someone who has a claim to that
attention
• You must be aware of Physical Abuse
and Neglect to recognize it
Abuse
• Bruising
– Various stages of
healing
– Target zones
Abuse
• Head injuries –
most lethal
– Shaken baby
syndrome
• Musculoskeletal
injuries
• Burns
Neglect
• Signs & Symptoms
–
–
–
–
Lack of adult supervision
Appearance of malnutrition
Unsafe living environment
Untreated chronic illness
• Characterized by failure to provide
for a child’s basic needs
Neglect
• Types
– Physical Neglect
•
•
•
•
•
Refusal of or delay in seeking health care
Abandonment
Expulsion from the home
Refusal to allow a runaway to return home
Inadequate supervision
Neglect
– Educational Neglect
• The allowance of chronic truancy
• Failure to enroll a child of mandatory school age in
school
• Failure to attend to a special need
– Emotional Neglect
• Marked inattention to a child’s need for affection
• Refusal of or failure to provide needed psychological
care
• Spouse abuse in child’s presence
• Permission of drug or alcohol use by a child
Neglect
• Assessment of child neglect requires
– Consideration of cultural values &
standards
– Recognition that the failure to provide
the necessities of life may be related to
poverty
Sexual Abuse
• Includes:
–
–
–
–
Fondling a child’s genitals
Intercourse, incest, rape, sodomy
Exhibitionism
Commercial exploitation through
prostitution or the production of
pornographic materials
• Believed to be most under-reported
form of child maltreatment
Emotional Abuse
• Includes:
– Acts or omissions by the parents or
other caregivers that have caused or
could cause, serious behavioral,
cognitive, emotional, or mental disorders
– Emotional abuse is almost always
present when other forms of abuse are
identified
Emotional Abuse
• In some states:
– The acts of parents or other caregivers alone,
without any harm evident in the child’s
behavior or condition, are sufficient to warrant
child protective services (CPS) intervention.
• Confinement of a child in a closest
• Habitual scapegoating
• Belittling
– Difficult to prove without evidence of harm to
child
Handling Abuse & Neglect
• Do Not accuse anyone face to face
• Required Reporting
– Follow state laws & local regulations
– Document objective information
• What you SEE and HEAR, not just what you
think
Geriatrics
The Elderly
• Epidemiology and Demographics
– Population Characteristics
• Geriatrics – 65 and older
• Old-Old – 85 and older
• 1960-1990 Geriatric population of U.S.
doubled
• Late 1998
– More than 34 million
– ~400,000 aged 95 and older
– Estimate – 2040, elderly will represent ~20% of
population
Elderly
• Social Issues
– Post retirement can be up to 1/3 of
average life span
• Transitions include –
– Reduced income
– Relocation
– Loss of friends, family members, spouse
or partner
Elderly
• Living Environments
– Age 85 and older
• 78% women
• Pathophysiology of Elderly Patient
– Multiple System Failure
• On average
– Comorbidity
» More than one disease at a time
» Up to 6 medical disorders may exist
• Disease in one system causes deterioration
of other systems
The Elderly
• Common Complaints
–
–
–
–
–
–
Fatigue and weakness
Dizziness / vertigo / syncope
Falls
Headaches
Insomnia
Dysphagia (inability to shallow or difficulty
swallowing)
– Loss of appetite
– Inability to void
– Constipation / diarrhea
The Elderly
• Changes involved in aging lead to different
presentations
– Pneumonia
• “Classic Fever” common
• Chest pain and cough less common
• Many cases due to aspiration not infection
– Pharmacology
• 65 and over use over 1/3 of all prescription drugs in
U.S.
– Average 4.5 meds / day
– Does not include OTCs, vitamin supplements or herbal
remedies
The Elderly
• Pharmacology
– If not correctly monitored,
polypharmacy can lead to multiple
problems
• Sensitivity to drugs increases with age
• More adverse drug reactions, drug-drug
interactions and drug-disease interactions
• Drugs concentrate more readily in the
plasma and tissues causing toxicity in elderly
patients
The Elderly
• Mobility and falls
– Contributing factors
•
•
•
•
•
•
•
Poor nutrition
Difficulty with elimination
Poor skin integrity
Greater disposition for falls
Loss of independence and/or confidence
Depression from “felling ill”
Isolation and lack of social network
Communication Changes & Implications
Sensory Change
Result
Strategy
Clouding & thickening
of lens
Cataracts, poor vision,
especially peripheral
vision
Position yourself in
front of patient
Shrinkage of
structures in ear
Deceased hearing,
especially high
frequencies, loss of
balance
Speak clearly, check
hearing aids, write
notes if necessary
Deterioration of teeth
& gums
Painful dentures, don’t
wear them, so
difficulty speaking
Ask patient to put
dentures in, write
answers
Lowered sensitivity to Underestimates
pain & altered sense of severity of problems
taste & smell
Ask questions aimed at
functional impairment
The Elderly
• General Health Assessment
– Factors in Forming a General Impression
•
•
•
•
•
•
Living situation
Level of activity
Network of social support
Level of independence
Medication history
Sleep patterns
– Try to distinguish the chief complaint
from the primary problems
The Elderly
• Patient history – takes more time
• More prone to environmental problems
– Age-related alternations in temperatureregulating mechanism, coupled with in sweat
glands
• Altered Mental Status
– Do Not assume that a confused, disoriented
patient is “just senile”
– Do Not assume that an altered mental status is
a normal age-related change.
The Elderly
• Altered Mental Status Triggers
–
–
–
–
–
–
–
–
–
Decreased blood sugar levels
Medical & traumatic head injury
Hear rhythm disturbances & heart attack
Dementia
Infection
Medication
Decreased blood volume
Respiratory disorders & hypoxia
Hypothermia or hyperthermia
The Elderly
– In assessing altered mental status
• Presume patient to have been mentally alert unless
proven otherwise
– Obtain blood glucose ASAP to exclude
hypoglycemia/hyperglycemia as a cause for
altered mental status
– Be careful to avoid transmitting an illness to an
elderly patient, even a mild cold
– Treat seizures as life-threatening (activate
EMS ASAP)
The Elderly
• Dyspnea
–
–
–
–
–
–
Chronic bronchitis
Pulmonary embolism, pulmonary edema
Pneumonia
Asthma
Emphysema
Congestive heart failure or AMI
• AMI is less likely to present with classic symptoms
– Abnormal or disordered heart rhythm may be only
clinical finding
– Heart sounds generally softer
The Elderly
• Dementia/Delirium
– 15% of all patients over 65 have some
degree of dementia or delirium
– Dementia
• Chronic global cognitive impairment, often
progressive and/or irreversible
– Best known form is Alzheimer’s
– Delirium
• Global mental impairment of sudden onset
and self-limited duration
The Elderly
• Dementia
– Chronic, slowly
progressive
– Irreversible disorder
– Greatly impairs memory
– Global cognitive deficits
– Most common-Alzheimer’s
– Does not require
immediate treatment
• Delirium
– Rapid onset, fluctuating
course
– May be reversed,
especially if treated
– Greatly impairs
attention
– Focal cognitive deficits
– Most common causes
• Systemic disease
• Drug toxicity
• Metabolic changes
– Requires immediate
attention
The Elderly
– In distinguishing dementia and delirium, error
on the side of delirium
• Gastrointestinal complaints – treat as
serious
– Causes
• Tumors, prior abdominal surgeries, medications,
vertebral compression fractures
– Look for diffuse abdominal pain, bloating,
nausea, vomiting, distended abdomen,
hypoactive/absent bowel sounds
The Elderly
• Generalized itching can be a sign of
systemic diseases, particularly liver
and renal disorders
– Antihistamines and corticosteroids are
2-3 times more likely to provoke
adverse reactions in elderly
• UTIs (Urinary tract infections) can
easily lead to urosepsis (septicemia)
– Mortality rate – 30%
The Elderly
• Hypothermia
– Elderly often do not shiver
– Treat even apparently mild cases as an
emergency
• Hyperthermia
– Additional risk factors in elderly
• Altered sensory output, inadequate fluid intake,
decreased thermoregulatory control, commonly
prescribed meds (antihistamines, tricyclic
antidepressants) inhibit sweating, concomitant
medical disorders, use of diuretics
The Elderly
• Specific Injuries
– Common fractures
•
•
•
•
•
Hip and/or pelvis
Proximal humerus
Distal radius
Proximal tibia
Thoracic and lumbar bodies
– Burns
• 60 and over more likely to suffer death
from burns (except neonates and infants)
The Elderly
• Unless patient is openly intoxicated,
discovery of alcohol abuse often
depends on a thorough history
• Do Not rule out fire arms among
elderly
• Trauma
– Remember blood pressure and pulse
readings can be deceptive indicators of
hypoperfusion
The Elderly
• Geriatric Abuse
– A syndrome in which an elderly patient
has received serious physical or
psychological injury from family
members or other caregivers
• Average abused patient – over 80
• Multiple medical problems
– DO NOT confront the family
• Report suspicions to EMS