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Children with Special Health Care Needs. Lesson 8.

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slide2
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.

slide3
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.

cshcn
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.).

technology assisted
Technology-Assisted
  • Technology-assisted children refers to those children who depend on medical devices to support bodily function.
why is this population increasing
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.
assessment general points
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.
assessment airway
Assessment - Airway
  • Children with special needs are susceptible to airway obstruction.
  • Technology-assisted children are at risk of device failure.
assessment breathing
Assessment - Breathing

Children with congenital heart disease or chronic illness may be unable to compensate for even mild respiratory distress.

assessment circulation
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.

always urgent cshcn
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.

delayed mental development assessment concerns
Delayed Mental DevelopmentAssessment 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."
ask the parents caregivers
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
ask the parents caregivers14
Ask the Parents/Caregivers
  • Are there differences from normal abilities and behaviors now?
  • Were these changes the primary reason for calling EMS?
critical
Assessment

Absent

Airway

Breathing

Circulation

AVPU = P or U

Action

Support and Transport

Critical
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

Unstable
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

Potentially Unstable
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.

Stable
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

SPECIAL TECHNOLOGY
tracheostomy
Tracheostomy

A surgical opening into the trachea through which a tracheostomy tube can be passed. The child then breathes through this opening.

reasons for a tracheostomy
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.
single cannula tracheostomy tube
Single Cannula Tracheostomy Tube
  • Used on all newborns and most pediatric patients.
  • Has one single passage used for both air flow and suctioning.
double cannula tracheostomy tube
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.
fenestrated tracheostomy tube
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.
cuffed tracheostomy tube
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.
tracheostomy emergencies
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
tracheostomy emergencies28
Tracheostomy Emergencies

EMTs should follow assessment priorities with additional focus on the airway:

  • Always consider obstructed airway.
  • Check and recheck.
  • May need suctioning repeatedly.
tracheostomy management
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.
tracheostomy management30
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.
tracheostomy management31
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.
tracheostomy management32
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.
tracheostomy management33
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.
tracheostomy management34
Tracheostomy - Management
  • Insert the tube with the curved end pointing down,
  • Confirm that the tube is positioned properly.
  • Evaluate the child’s respiratory status.
tracheostomy management35
Tracheostomy - Management
  • Perform ventilations with a bag valve mask over the stoma or the mouth.
tracheostomy management36
Tracheostomy - Management
  • Children with tracheostomies often have asthma.
  • Treat according to local protocol.
home ventilators
Home Ventilators
  • Children who depend on home ventilators have a problem with their respiratory drive or respiratory effort.
home ventilators settings
Home Ventilators - Settings
  • Home ventilators are set to control:
    • breathing rate
    • tidal volume
    • FIO2
    • Peak Inspiratory Pressure (PIP)
    • Positive End Expiratory Pressure (PEEP)
home ventilators types
Home Ventilators - Types
  • There are two types of home ventilators:
    • Pressure cycled ventilators
    • Volume ventilators
home ventilators modes
Home Ventilators - Modes
  • Home ventilators operate in two modes:
    • Intermittent Mechanical Ventilation (IMV)
    • Continuos Mechanical Ventilation (CMV)
home ventilators management
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
constant positive airway pressure cpap
Constant Positive Airway Pressure- CPAP

A mask covers the child’s mouth and nose, providing constant pressure, ensuring an open airway.

central intravenous catheters
Central Intravenous Catheters
  • Used to deliver nutrients or special medications into a central line.
  • Located on the chest, neck, groin, or arm.
central intravenous catheters44
Central Intravenous Catheters

There are two common types of catheters used for this purpose:

  • Broviac Catheters
  • Hickman or Mediport Catheters
central intravenous catheters45
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.

Central Intravenous Catheters
pacemakers
Pacemakers

Pacemakers regulate heart rate. A pacemaker is needed if the natural heart rate is not fast enough to ensure adequate perfusion.

pacemakers types
Pacemakers - Types

There are three types of pacemakers:

  • Demand
  • Constant
  • Antiarrhythmia
pacemaker management
Problem

Pacemaker failure

Failure to compensate

Solution

Transport immediately, request ALS back-up, treat for shock as indicated.

Transport immediately, request ALS back-up, treat for shock as indicated.

Pacemaker - Management
pacemaker management49
Problem

Dislodged Leads

Broken Leads

Solution

Treat symptoms as necessary, rapid transport.

Treat symptoms, treat for shock, rapid transport.

Pacemaker - Management
feeding catheters
Feeding Catheters

A feeding catheter provides a route for nutritional support when the child is unable to take food by mouth

surgical feeding catheters
Surgical Feeding Catheters
  • Used for long term support of the child.
    • Gastrostomy Tube(GT)
    • Jejunostomy Tube(JT)
    • Gastrostomy Button
nonsurgical feeding tubes
Nonsurgical Feeding Tubes

Used for temporary support of the child

  • Nasogastric Tube (NGT)
  • Nasojejunal Tube (NJT)
  • Orogastric Tube (OGT)
  • Orojejunal Tube (OJT)
feeding tubes management
Problem

Bleeding

Leaking

Broken

Dislodged

Solution

Control bleeding at site.

Treat skin irritation

Monitor, transport

Monitor, transport

Feeding Tubes - Management
csf shunts
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.
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

CSF Shunt Concerns
colostomies and ileostomies
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.
congenital heart disease
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
congenital heart disease mgmt
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.
children with mobility problems
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.
children with chronic illnesses
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.
children with chronic illnesses special considerations
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.
summary
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.