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Children with Special Health Care

NeedsLesson 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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CSHCNChildren 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.).

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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 child’s 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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UnstableAssessmentCompromised

• Airway• Breathing• Circulation• AVPU=V or P or• Normal airway

breathing and circulation, AVPU=A

with other risk factors.

Action

Support and Transport

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Potentially Unstable

AssessmentCompromised

• Airway• Breathing• Circulation• AVPU=V or P or• Normal ABC’s,

AVPU=A with other risk factors.

Action

Support and Transport

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StableAssessment

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.

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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

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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 child’s 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 child’s 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 child’s 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

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.

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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 TubesUsed 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 don’t function correctly– Cyanotic heart disease– Heart doesn’t 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 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.

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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.