Special Populations Pediatric Emergencies Geriatric Emergencies Topic Overview

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 2 X 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 – 3 rd 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 0 r 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 • Pedi. Scan 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 -Poison 1

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 130 80 to 120 70 to 110 60 to 105

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 15 to 30 12 to 20

Infants & Children

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 -101 o. F)

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 -104 o. F) 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