1 children with special health care needs. 2 objectives discuss assessment techniques for children...
TRANSCRIPT
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Children with Special Health Care Needs
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Objectives
• Discuss assessment techniques for children with special health care needs (CSHCN)
• Describe complications and key interventions for selected special needs children
• Outline management priorities for technology-dependent children with complications of indwelling devices
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14-month-old child
• You are called to the home of a 14-month-old child whose mother reports that he has trouble breathing and refuses to eat.
• Child born three months prematurely and was on a ventilator for his first 4 months
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14-month-old child
AppearanceAlert, irritable
Work of BreathingRetractions, grunting, nasal flaring
Circulation to SkinNormal
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Initial Assessment
• Airway - Open, no stridor• Breathing - RR 60 breaths/min,
wheezing, SaO2 88% on 2L home oxygen
• Circulation - HR 140 beats/min; CRT 2 seconds; BP not obtained
• Disability - AVPU=A• Exposure - No sign of trauma
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What makes assessment of this CSHCN child challenging?
How ill is this child?
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• Child may have chronic respiratory distress
• Establish a baseline status
• Interview caregiver to distinguish chronic from acute problems
What are your initial treatment and transport priorities for this patient?
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Treatment Priorities• Provide oxygen 15 L/min as
tolerated • Suction airway • Prepare to assist ventilation
with BVM • Obtain further history • Transport to facility familiar
with child’s care
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Treatment Priorities
BLS priorities plus…• Albuterol 2.5 mg
by nebulizer, or by MDI with face mask, 1-2 puffs
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• Patient transported on oxygen 15L/min by face mask
• Respiratory status improved on arrival to hospital
• Admitted with diagnosis of pneumonia
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7-year-old child
• You are called to the home of a 7-year-old child with trouble breathing.
• He is lying in a hospital-style bed, with a ventilator and suction machine on the nightstand.
• He is being ventilated through a tracheostomy tube.
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7-year-old child
AppearanceListless, poor muscle tone
Work of BreathingNo chest rise visible
Circulation to SkinPale skin color
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What immediate action should be taken to manage this child?
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Immediate Management
• Disconnect the ventilator, and begin ventilation using bag-valve device via the tracheostomy tube
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Initial Assessment
• Child is not breathing spontaneously• There is resistance to bagging• Poor chest rise with bag-valve-tracheostomy
ventilation• HR 160 beats/min by palpation of femoral pulse
What is going on with this patient?
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• This child has an obstructed tracheostomy tube, a common complication of tracheostomy tube placement
• Usually due to mucus plugging
• Caregivers will often have attempted to clear tracheostomy prior to 911 call
What are your management priorities now?
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Treatment Priorities
• Suction the tracheostomy tube• Instill 2 ml normal saline
into tube prior to suctioning
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Treatment Priorities
• Attempt to ventilate again• If no chest rise, remove
tracheostomy tube • Begin BVM ventilation
over the mouth, while partner covers stoma
• If no chest rise, ventilate using small mask over the stoma
• Rapid transport
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Treatment Priorities
• If no chest rise after suctioning tube, immediately remove and replace the tracheostomy tube
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Treatment Priorities
• Parents may have replacement tracheostomy tube
• Endotracheal tube may be substituted• Use tube of same internal diameter as
tracheostomy tube• Insert into stoma 1/2 the length used for oral
intubation• Begin bagging via the newly inserted tube
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• Tracheostomy tube suctioned • Good chest rise with bagging • HR decreases to 90 beats/min• Child becomes alert and interactive
This child also has a feeding tube in place.What are some potential complications of
this device?
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• A feeding tube is used for nutritional supplementation when the child cannot take adequate nourishment by mouth
• Common complications include:
• Dislodged tube
• Leakage of stomach/bowel contents around the tube
• Infection of the insertion site
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Conclusion
• CSHCN encounters are becoming more common.
• Baseline assessment requires assistance and information from the caregiver.
• Technology-assisted children may present with complications unique to the presence of indwelling devices.