1 Special Health Care Needs
2 Prevalence Approximately 20% of the US population has some form of disability This patient population may pose distinct challenges in the prehospital setting Their conditions often have unique medical issues EMS providers must use different approaches for common issues
3 What to look for Recognize the basic elements of many disabilitiesUnderstand the disease’s pathophysiology and long-term management expectations
4 They have greater risksThis patient population is often at greater risks for Respiratory Failure Infections (urinary from long-term indwelling Foley catheters or respiratory from motor weakness or severe scoliosis)
5 Assessment Initial stabilization is primarily the same as any other patients Just keep the patient’s special needs in mind
6 Cerebral Palsy A non-progressive disorder of movement and postureCaused by a brain injury in early development Cerebral Palsy is NOT a disease It is a collection of symptoms
7 Issues affecting patient careMalnutrition due to swallowing and feeding problems Mental disabilities Seizures Urinary Incontinence Hearing Deficits Visual Deficits Speech Deficits Spasticity with joint contractures-some patients may have a baclofen pump implanted to control spasticity. Some patients may wear braces to support or correct musculoskeletal deformities
8 Positioning Remember to position cerebral palsy patients with supportive pads under areas of high pressure or in gaps between the body and the cot Never attempt to straighten a spastic extremity Splint extremities in their baseline position Blood pressure readings may be unreliable due to spastic extremities
9 Communicating with Cerebral Palsy patientsPatients may have dysarthria (difficult or unclear articulation of speech) Be prepared for the possibility of a communication device or communication board Be careful not to make assumptions regarding intelligence-many are highly intelligent Judge the patient’s ability to comprehend and interact on a case-by- case basis
10 Muscular Dystrophy A motor disorder associated with structural abnormalities of dystrophin proteins involved in muscle function Results in progressive weakness and motor dysfunction
11 Issues affecting patient careALL muscle function is affected Patients often require assistance with transfers Wheelchairs are common because the ability to ambulate is lost With disease progression comes respiratory compromise Patients can ultimately become ventilator dependent Respiratory muscles weaken causing difficulty swallowing which may lead to pneumonia Be on the look out for respiratory distress or impending failure
12 If you need to intubate Succinylcholine is contraindicated for patients with muscular dystrophy It is a toxin to unstable membranes in any patient who has myopathy It can be associated with rhabdomyolysis, pathogenic hyperkalemia and death Intubation without a paralytic may be an option Non-depolarizing agents like rocuronium may be used
13 Spina Bifida Results from incomplete neural tube developmentCan be caused by a folic acid deficiency in utero The extent of symptoms varies with the degree in which the spinal cord remains open
14 Issues affecting patient careSignificantly associated with lower extremity motor deficits and mobility issues Patients should use crutches or wheelchairs as mobility aids Identify the patients preference for transfer Be alert to increased risk of pressure ulcer formation Patients may not be able to identify ulcer formation due to sensory deficits or cognitive deficits Provide careful cushioning for transport A large percentage of Spina Bifida patients have a latex allergy
15 Ventricularperitoneal ShuntCommon in Spina Bifida patients but can be in other patient populations Used to drain cerebrospinal fluid Shunts can become a place of infection and increase intracranial pressure Children will be irritable, vomiting and have bulging fontanels Adults will be nauseous, vomit or complain of a headache or have a decreased alertness
16 Ventricularperitoneal ShuntConsider shunt failure in any vague symptoms or altered mental status Consider transport to a facility with neurosurgical capabilities
17 Down Syndrome Congenital disability – an extra copy of the 21st chromosome (trisomy 21) Mild to severe cognitive delay Has a pathological and physical manifestation
18 Issues affecting patient careAssociated with several medical problems Leukemia Early onset Alzheimer's Osteoporosis Sleep Apnea Cataracts Congenital Heart Defects
19 Medications in Down’s PatientsThey may be more sensitive to medications Dose with caution Contact medical control for any questions or concerns
20 Physical Features of Down’s PatientsDental Abnormalities Thickened and fissured lips or tongue Progressive protrusion of the mandible due to a large tongue in a small oral cavity Large tonsils and adenoids Small tracheal diameter-use an ET that is at least 2 sizes smaller than the recommended
21 Intubation of a Down’s PatientRecognize that this is a difficult airway and intubate only with a back up plan in place Combitube, King Airway and LMA devices put a great deal of pressure against the vertebral bodies in the upper cervical spine If possible maintain the airway with a BVM until you can reach the hospital for intubation
22 Spinal Immobilization of a Down’s PatientProne to atlantoaxial dislocation due to cervical spine instability Adopt a proactive approach to spinal stabilization Minimize cervical trauma
23 Additional Info Challenges may not be evident upon initial assessmentTry to obtain as much information as possible from family or caregiver Ask open-ended questions to find out if there is anything else you need to be doing for this patient In group homes patient medication lists or recent medication administration documents are available Don’t delay care to obtain this information
24 Transport Take time to make sure feeding tubes, Foley catheters, and other medical devices are secured Be cautious not to pull any of these tubes out Secure tube with tape or gauze prior to movement Be aware of tubes at all times during transport
25 Patients as their own advocatesPatients often become experts in their own diseases Patients can be crucial resources Patient may become frustrated or distrust prehospital staff Engaging the patient in their care can help this
26 EMS Providers Always ask the patient about their condition if they communicate Always explain what you are doing and why Use a calm, reassuring voice and at a level appropriate for the patient’s cognition Choose your words carefully-certain terms have negative connotations (ex: person with a disability rather than a disabled person) Remember each person with a disability is different Being open-minded and thorough during assessment is crucial
27 Children with Special Health Care NeedsEMS Assessment and Treatment
28 Prevalence 11.2 million children in the US have special health care needs This includes children who have or are at risk for chronic physical, developmental, behavior, or emotional conditions These children may also require health services beyond that required of normal children
29 Children with Durable Medical EquipmentDME is a device that provides assistive or life-sustaining support (ex: wheelchair, walker, ventilator) Parents or full-time caregivers are often well-trained and can assist with managing equipment during transport
30 Parents as a Resource Parents are typically knowledgeable about their child’s medical history and condition Parents often understand how to operate and troubleshoot any DME their child relies on Rely on the parents to calm and soothe the child and guide you through the normal presentation for this patient
31 Treating Children with Special NeedsABC’s first Treat the child not the equipment If your equipment does not interfere with the child’s equipment go ahead and use your own
32 Communication Physical handicaps do not necessarily imply mental deficits Remember to communicate with the child...not over them Assess and communicate based on the developmental age not the chronological age
33 Go-Bag Families often have a bag prepared with the child’s spare equipment and supplies Bring this with you!
34 Tracheostomy ABC’s Assess the trach- Tube placementHas the obturator (stylet) been removed Is the inner cannula in place Has the de-cannulation plug or speaking valve been removed
35 Breathing with a Trach What is the rate AuscultateInspect the effort and adequacy of the chest rise What is the pulse ox What is the EtCO2 Attempt suctioning-ask the family for guidance
36 Trach Change If the suction catheter won’t advance consider a trach change Allow the family to help you-they are experts Follow your protocol Reassess the child often
37 Remember DOPE D=displaced, dislodged or damagedO=obstructed (mucus, food, blood, secretions) P=Pulmonary problems E=Equipment failure (bent tubing, ventilator malfunction, depleted oxygen supply)
38 Indwelling Central LineUsed to deliver nutrition or medications directly to the vein Types Tunneled Catheter: Broviac or Hickman Implanted Catheter: Mediport Peripheral Inserted Catheter: PICC
39 Emergencies with Indwelling Central LinesBlockage of the line Complete or partial accidental removal Complete or partial laceration of the line **These kids are high risk for blood stream or catheter infections- ALWAYS use strict sterile technique**
40 Blocked Line DO NOT attempt to force the catheter open Transport
41 Lacerated Line Clamp the line proximal to the lacerationUse a padded clamp DO NOT use the line Transport
42 Line is out or partially outDO NOT push the line back in Apply direct pressure to the skin site for any bleeding Stop any infusions Always bring the line with you to the hospital Estimate the blood loss Assess for signs and symptoms of an air embolism Transport
43 G-Tube/Feeding Tube Surgical feeding tubesGastrostomy Tube-passes through the abdomen into the stomach Jejunostomy Tube-passes through the abdomen into the small intestine Non-surgical feeding tubes are short term Nasogastric Tube-through the nose to the stomach Nasojejunal Tube-through the nose into the small intestine Orogastric Tube-through the mouth into the stomach
44 Complications with Gastrostomy TubesIrritation and bleeding at the entry site Obstruction is usually not an emergency but does require transport Dislodgement is not life-threatening but the tube should be replaced by a physician ASAP
45 Ventilators Complications may be from ventilator malfunction or worsening of the underlying disease Get the baseline data from the parents or caregiver Complications can occur from Respiratory failure Neurological disease causing impairment Airway control or respiratory effort
46 Troubleshooting Vent AlarmsLow pressure/apnea=loose or disconnected circuit; leak in circuit; leak around trach site Low power=internal battery depleted High pressure=plugged or obstructed airway; coughing/bronchospasms Setting error=settings are incorrectly adjusted Power switchover=unit switched from AC to internal battery
47 Urinary Drainage CathetersUsed to drain urine Can become blocked or dislodged Can be a source of bleeding Foleys: from the urethra to the bladder Nephrostomy: from the skin directly into the kidney Suprapubic: from the skin directly into the bladder Ureterostomy: from the skin into the ureter
48 Blocked Urinary Drainage CatheterFlush once with 5 ml of Normal Saline DO NOT flush more than one time If blockage remains Transport
49 Lacerated Urinary Drainage CatheterDO NOT remove Tape in place and avoid dislodgement Allow to continue to drain Transport
50 Partially out Urinary Drainage CatheterDO NOT push the line back in Secure to the skin and avoid complete dislodgement Transport
51 Completely Out Urinary Drainage CatheterCover the opening with a sterile gauze Transport
52 Blood in the Urinary Drainage CatheterAllow the catheter to drain Secure the catheter to the skin to prevent dislodgement Transport
53 Hemodialysis Used to filter and clean the blood in patients with renal failure Types of lines: Hemodialysis catheter=external tubing from a large artery to the skin Hemodialysis graft=gortex tubing under the skin to an artery and vein
54 Emergencies Infection in the line Bleeding from the lineComplete or partial dislodgement from trauma **Children are always at risk for blood and catheter infections. ALWAYS use strict sterile technique**
55 Blocked Hemodialysis LineDO NOT MANIPULATE Transport
56 Lacerated Hemodialysis LineClamp the lime proximal to the laceration Use padded clamp DO NOT USE THE LINE transport
57 Hemodialysis Line our or Partially OutDO NOT push the line back in Apply direct pressure to the skin site for any bleeding Stop any infusions Always bring the line with you to the hospital Estimate any blood loss Assess for signs and symptoms of an air embolism DO NOT USE FOR IV ACCESS Transport
58 Peritoneal Dialysis CatheterRun from the skin into the peritoneum Dialysis is done using the peritoneal lining as the dialysis membrane Fluid is placed in the peritoneum and left for hours or overnight It is then drained removing extra electrolytes, acid, etc. Usually done at home
59 Emergencies Infection in the abdomen (peritonitis)Catheter site infection Catheter fractures Bleeding from the catheter Complete or partial dislodgement
60 Catheter Exit Site InfectionsDrainage with blood and/or pus from the exit site Associated with redness, tenderness, overgrown granulation tissue and swelling
61 Peritonitis Staphylococcus AureusCaused by touch or contamination with respiratory secretions Abdomen is painful, tender and distended Peritoneal fluid is cloudy Fever Nausea and Vomiting
62 Blocked Peritoneal Dialysis CatheterDO NOT MANIPULATE Transport the patient
63 Fractured Peritoneal Dialysis CatheterClamp the line proximal to the fracture Use a padded clamp DO NOT USE THE LINE Transport
64 Out or Partially Out Peritoneal Dialysis CatheterDO NOT push the catheter back in Apply direct pressure to the skin site if bleeding Stop any infusions Always bring the catheter with you to the hospital
65 Leaking Peritoneal Dialysis CatheterCover with a sterile gauze Transport
66 Apnea Monitors ABC’s Obtain a pulse ox Treat appropriately
67 Shunts Catheter is inserted into the ventricles of the brain and threaded under the skin from the skull to the right ventricle (VA Shunt) or the peritoneum of the abdomen (VP Shunt) Drains excessive cerebral spinal fluid that would other wise build up in the brain
68 Consider a Shunt Malfunction In:Altered mental status Irritable with no explanation Listless Increased sleep unexplained High-pitch cry Nausea and Vomiting with no explanation Fever with no explanation Headaches Blurred Vision Difficulty walking Apnea Bradycardia or other arrhythmias Seizures Redness along the shunt track Rapid worsening of mental status
69 Internal Pacemakers/DefibrillatorsWhat is the underlying cardiac condition? What is the baseline rate and rhythm? How long has the unit been in place?
70 Internal Pacemakers/DefibrillatorsThe device can easily be felt near the clavicle Never place defibrillator or pacing pads directly over the unit Remember the battery life is 3-5 years
71 Vagal Nerve StimulatorsSurgically implanted in the chest with electrodes to the vagal nerve in the left side of the neck Uses electrical energy to dissipate seizures Was there a recent trauma? When was the device implanted? When was the device last checked? What are the current settings? Any changes in recent seizure activity?
72 Colostomies and IleostomiesA portion of the large or small intestine is attached to the abdominal wall AN external bag is in place to collect digestive waste
73 Colostomies and IleostomiesCheck the ostomy site for infection Assess carefully for signs and symptoms of dehydration or shock If the bag breaks the caregiver can usually help replace it If no bag is available circle the ostomy with moist gauze and attain any available bag that will substitute until a proper bag is obtained
74 For more information: https://www.ems1.com/ems-products/neonatal- pediatric/articles/ Children-with-special-health-care-needs- EMS-assessment-and-treatment-tips/ assessment-of-patients-with-physical-disabilities https://www.ncems.org/pdf/CYSHCNPrehospitalGuidelinesJuly2009.p df