Special PopulationsSpecial PopulationsSpecial PopulationsSpecial PopulationsPediatric EmergenciesPediatric EmergenciesGeriatric EmergenciesGeriatric 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 120 to 160• Infant 0-5 months 90 to 140• Infant 6-12 months 80 to 140• Toddler 1-3 years 80 to 130• Preschooler 3-5 years 80 to120• School-age 6-12 years 70 to110• Adolescent 12-18 years 60 to105

Infants & Children– Normal Respiration Rate Ranges

• Newborn 30 to 50• Infant 0-5 months 25 to 40• Infant 6-12 months 20 to 30• Toddler 1-3 years 20 to 30• Preschooler 3-5 years 20 to 30• School-age 6-12 years 15 to 30• Adolescent 12-18 years 12 to 20

Infants & ChildrenBlood Pressure Ranges

Systolic Diastolic

Under 3 yoa

Approx. 80 plus 2 x age

Approx. 2/ 3 systolic

Preschooler 3-6 yoa

average 99 (79-116)

average 65

School-age 6-12 yoa

average 105 (80-122)

average 57

Adolescent 12-18 yoa

average 115 (94-140)

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-

to-head

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

head-to-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

GeriatricsGeriatricsGeriatricsGeriatrics

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 pain & altered sense of taste & smell

Underestimates severity of problems

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 temperature-regulating 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