Children with Special Health Care Needs

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Children with Special Health Care Needs

• Lesson 8

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• 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.

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• 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.

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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 natl
  defn.).

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Technology-Assisted

• Technology-assisted children refers to those
  children who depend on medical devices to support
  bodily function.

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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.

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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 childs normal state.

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Assessment - Airway

• Children with special needs are susceptible to
  airway obstruction.
• Technology-assisted children are at risk of
  device failure.

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Assessment - Breathing

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

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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.

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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.

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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."

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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

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Ask the Parents/Caregivers

• Are there differences from normal abilities and
  behaviors now?
• Were these changes the primary reason for calling
  EMS?

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CUPS Assessment of Children with Special Needs

• Category
• Assessment
• Actions

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Critical

• Assessment
• Absent
• Airway
• Breathing
• Circulation
• AVPU P or U

• Action
• Support and Transport

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Unstable

• Assessment
• Compromised
• Airway
• Breathing
• Circulation
• AVPUV or P or
• Normal airway breathing and circulation, AVPUA
  with other risk factors.

• Action
• Support and Transport

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Potentially Unstable

• Action
• Support and Transport

• Assessment
• Compromised
• Airway
• Breathing
• Circulation
• AVPUV or P or
• Normal ABCs, AVPUA with other risk factors.

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Stable

• Assessment
• Normal
• Airway
• Breathing
• Circulation
• AVPUV or A

• Action
• CSHCN or technologically dependent children often
  have the potential to abruptly deteriorate. For
  this reason, they are not considered stable.

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SPECIAL TECHNOLOGY

• Tracheostomy Tubes
• Home Ventilators
• CPAP Devices
• Central Intravenous Catheters
• Pacemakers
• Feeding Catheters
• CSF Shunts
• Colostomies and Illeostomies

• EMTs and Paramedics will encounter various people
  who assist these children.

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Tracheostomy

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

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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.

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Single Cannula Tracheostomy Tube

• Used on all newborns and most pediatric patients.
• Has one single passage used for both air flow
  and suctioning.

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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.

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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.

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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.

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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

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Tracheostomy Emergencies

• EMTs should follow assessment priorities with
  additional focus on the airway
• Always consider obstructed airway.
• Check and recheck.
• May need suctioning repeatedly.

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Tracheostomy - Management

• To correct respiratory distress for a patient
  with a tracheostomy
• place a rolled towel under the childs shoulders,
• make sure the tracheostomy tube is properly
  seated and the obturator/ decannulation plug has
  been removed.

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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.

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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.

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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.

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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.

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Tracheostomy - Management

• Insert the tube with the curved end pointing
  down,
• Confirm that the tube is positioned properly.
• Evaluate the childs respiratory status.

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Tracheostomy - Management

• Perform ventilations with a bag valve mask over
  the stoma or the mouth.

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Tracheostomy - Management

• Children with tracheostomies often have asthma.
• Treat according to local protocol.

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Home Ventilators

• Children who depend on home ventilators have a
  problem with their respiratory drive or
  respiratory effort.

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Home Ventilators - Settings

• Home ventilators are set to control
• breathing rate
• tidal volume
• FIO2
• Peak Inspiratory Pressure (PIP)
• Positive End Expiratory Pressure (PEEP)

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Home Ventilators - Types

• There are two types of home ventilators
• Pressure cycled ventilators
• Volume ventilators

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Home Ventilators - Modes

• Home ventilators operate in two modes
• Intermittent Mechanical Ventilation (IMV)
• Continuos Mechanical Ventilation (CMV)

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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

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Constant Positive Airway Pressure- CPAP

• A mask covers the childs mouth and nose,
  providing constant pressure, ensuring an open
  airway.

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Central Intravenous Catheters

• Used to deliver nutrients or special medications
  into a central line.
• Located on the chest, neck, groin, or arm.

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Central Intravenous Catheters

• There are two common types of catheters used for
  this purpose
• Broviac Catheters
• Hickman or Mediport Catheters

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Central Intravenous Catheters

• Solution
• Control bleeding with direct pressure and
  transport, clamp catheter end.
• Transport, request ALS to clear obstruction.
• Transport immediately.

• Problem
• Bleeding or broken catheter
• Obstructed
• Fever

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Pacemakers

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

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Pacemakers - Types

• There are three types of pacemakers
• Demand
• Constant
• Antiarrhythmia

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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.

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Pacemaker - Management

• Problem
• Dislodged Leads
• Broken Leads

• Solution
• Treat symptoms as necessary, rapid transport.
• Treat symptoms, treat for shock, rapid transport.

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Feeding Catheters

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

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Surgical Feeding Catheters

• Used for long term support of the child.
• Gastrostomy Tube(GT)
• Jejunostomy Tube(JT)
• Gastrostomy Button

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Nonsurgical Feeding Tubes

• Used for temporary support of the child
• Nasogastric Tube (NGT)
• Nasojejunal Tube (NJT)
• Orogastric Tube (OGT)
• Orojejunal Tube (OJT)

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Feeding Tubes - Management

• Problem
• Bleeding
• Leaking
• Broken
• Dislodged

• Solution
• Control bleeding at site.
• Treat skin irritation
• Monitor, transport
• Monitor, transport

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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.

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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

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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.

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Congenital Heart Disease

• Children may be born with structural defects of
  the heart
• Heart valve problems
• Arteries dont function correctly
• Cyanotic heart disease
• Heart doesnt fire properly

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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.

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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.

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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.

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Children with Chronic Illnesses - Special
Considerations

• The childs 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.

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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.