Special Considerations

2005 EMT-Intermediate CurriculumBridge Course

Special Considerations

The pediatric

and geriatric patients


Nationwide over 30% of all patients transported are over

age 65


Leading Causes of Death or Disability:

• Heart disease

• Cancer

• Stroke

• Fractures

• Pneumonia

• Misuse of drugs

• Fall (leading cause of trauma related injuries)

• Mva's (2nd leading cause)


Who Is Elderly ?

• Society normally thinks of those who are over 65

• Patient considered elderly:

– Patient physically appears elderly

– Patient is middle aged with significant medical problems associated with elderly

– Patient is 65 years or older


Things To Consider

• After age 35 the effects of aging start affecting the body's ability to function

• Here are some of the things to consider when treating the elderly


Things To Consider

• The GEMS Diamond

• Remember the following when caring for older people:– Geriatric patients– Environmental assessment– Medical assessment– Social assessment


Aging Statistics

• 13% of people in the US are over age 65.

• “Baby Boomers” will increase this number.

• Expect to see an increase in emergency calls involving older patients.


Case Study

• Dispatched to a residence for an 84-year-old woman who has fallen

• Patient, Mrs. Reed, cannot get up.

Mrs. Reed


Case Study (continued)

• Mrs. Reed is on the kitchen floor.

• She is alert but weak.

• States she fell last night

• Has pain in left hip

• Vital signs are normal.

Mrs. Reed


Living Arrangements

• Most live at home.

• Women are more likely to live alone.

• Less than 5% are institutionalized.



• You conduct a GEMS exam:– Small amounts of food, home is

warm and clean– No significant medical history, no

medications– Son reports that mother lives

alone, no regular contact with friends

Mrs. Reed


Access to Essential Services

• Transportation

• Meal preparation

• Health care

• Social activities


Case Study Conclusion

• Mrs. Reed is transported to ED.

• Report to Social Services for potential follow up.

Mrs. Reed


Aging

• Number of people over age 65 is rising • Older people have many social and

environmental concerns.• We must understand and accept aging.• Family remains the most common residence

for the older population.


Leading Causes of Death in Older People

• Disease of the heart

• Cancer

• CVA/Stroke

• COPD

• Pneumonia


Case Study

• Dispatched for 79-year-old man with difficulty breathing

• Says he always gets winded easily and cannot catch his breath today

• Environment is clean and warm.

Mr. Brophy



• History of AMI, CHF, COPD, hypertension, diabetes

• Pulse = 112 beats/min• Respirations = 28 breaths/min• Blood pressure = 160/96 mm

Hg• ECG = A-fib• Pulse Ox = 92% on oxygen

Mr. Brophy



What factors influence how well Mr. Brophy can compensate for his illness?

How will aging affect these factors?

Mr. Brophy


The Aging Body:Integumentary System

• Wrinkles

• Thinner skin

• Decreased fat

• Gray hair


The Aging Body: Respiratory System

• Changes in airway

• Decreasing muscles of ventilation

• Increased residual volume

• Decreased sensitivity of chemoreceptors


Respiratory

• Dental prosthesis

• Pulmonary function can be reduced as much as 50 % by age 75

• Reduction in gas exchange through the pulmonary capillaries

• Increased respiratory rate

• Overall decrease in effectiveness


The Aging Body: Cardiovascular System

• Development of atherosclerosis

• Decreasing cardiac output

• Development of arrhythmias

• Changes in blood pressure


Cardiovascular

• Increase in PVR

• Between 30 and 80, resting cardiac output decreases about 30%

• Significant drop in organ perfusion

• Reduction of cardiac output by as much as 50 %


Cardiovascular

• Diminished ability to raise the heart rate

• Decrease in compliance of the ventricle

• Decrease response to hormone stimulation


Even without specific heart disease advanced aging

produces varying degrees of congestive

heart failure


The Aging Body:Nervous System

• Brain shrinkage

• Slowing of peripheral nerves

• Slowed reflexes

• Decreasing pain

sensation


Neurological and Sensory• Brain requires a continuous supply of

oxygen to function

• As much as a 45% loss of brain cells

• Also affected are the senses

• Response to stimuli is diminished

• Slowed reaction time

• Decreased response to pain


Renal System Changes

• Renal blood flow falls an average of 50% between the ages of 30 and 80

• Decline of renal function places the older patient at greater risk of renal failure


The Aging Body:Renal, Hepatic, and GI

Systems• Kidneys become smaller.

• Hepatic blood flow decreases.

• Production of enzymes declines.

• Salivation decreases.

• Gastric motility slows.



• Mr. Brophy appears to have a hard time hearing your questions.

• Does not respond to all of your requests

What are the sensory changes found in older patients?

Mr. Brophy


The Aging Body:Sensory Changes

• Vision distorts and eye movement slows.

• Hearing loss is more common.

• Taste decreases.



• Mr. Brophy reports feeling “down” lately.

• Lives alone and has few friends still around

Is this patient at risk for depression?

Mr. Brophy


The Aging Body:Psychological Changes

• Depression

• Anxiety

• Adjustment disorders



• When asked about medications, Mr. Brophy directs your attention to a shoebox.

How does the body react to medications with aging?

Mr. Brophy


The Aging Body:Musculoskeletal System

• Decreased muscle mass

• Changes in posture

• Arthritic changes

• Decrease in bone mass


The Aging Body:Immune System

• Less effective immune response

• Pneumonia and UTI are common.

• Increase in abnormal immune system substances


Immune System

• Pre-existing nutritional problems

• An increased susceptibility to infection


Case Study Conclusion

• Mr. Brophy is treated for exacerbation of COPD.

• Admitted to hospital, found to be on interacting medications

• On discharge, Mr. Brophy was given follow-up visits with a home care service.

Mr. Brophy


Thermoregulatory

• Diminished ability to maintain normal body temperature

• More susceptible to heat and cold related injuries


Chronic Medical Problems

• As the effects of illness and injury cumulate they result in a progressive reduction in the bodies ability to function

• As this progresses the body’s ability to withstand the introduction of disease, serious or even minor trauma is reduced


Assessing The Elderly Patient

• Difficult to separate the effects of aging / consequences of disease or injury

• The patient may fail to report significant symptoms

• Pain may be diminished or absent

• Chronic illness make assessment acute problems difficult


Assessing The Elderly

• Aging may change the individual's response to illness or injury

• There may be minimal or absent fever even in the presence of severe infection

• Decreased vision or hearing may diminish the patient's ability to hear or comprehend



• Vital signs may be altered by chronic medical problems, resulting in abnormal findings which are normal

• Social and emotional factors may have greater impact then in other age groups



Orientation should be evaluated using factors that are relative to that patient.

An elderly patient who does not work or keep a schedule may not have reason

to keep up with the day of the week



Be careful not to assume that the patient who has fallen simply tripped. Take into

consideration the possible underlying conditions that may be manifested



Knowledge of the medications the patient is taking will also aid in understanding

the condition of the patient and possible underlying causes of the incident at

hand



Elderly trauma victim’s die as a result of the same causes as trauma victims of

any age, but often due to their pre-existing physical condition, can die from

less severe injuries and more rapidly than younger patients


Physical Exam Considerations

• General

– Patient may fatigue easily

– Patients commonly multi-layer clothing

– Explain actions clearly

– Patient may minimize or deny symptoms

– Peripheral pulses may be difficult to evaluate


Respiratory Distress: Causes

• Pulmonary embolism

• In silent MI dyspnea may be only initial symptom

• Pulmonary edema

• Asthma/copd

• Respiratory infections

• Cancer


Cardiovascular Conditions


Syncope

• Carries a higher incidence of morbidity in-patients over 60 years of age

• Is a primary symptom of a silent MI


Myocardial Infarction

• Elderly are less likely to present with classic S/S

• Could present with syncope, dyspnea, abdominal or epigastric pain, and fatigue


Stroke (CVA)

• Strokes are more common in the elderly

• TIAs are also common in the elderly

– 1/3 of all patients who experience TIAs will have a major stroke

• TIAs are a common cause of syncope in the elderly


Called to an MVC

Arrive to find a 78F sitting in passenger side of car that struck a truck broadside

Pt is CAO X3, denies any pain/discomfort

Vs bp 140/80 p 80 r 24


Vehicular Trauma

• Estimated that more then 15 million licensed drivers are over age 65

• In 1990, more then 7600 deaths were attributed to vehicular crashes

• Risk of fatality from multiple trauma is estimated to be 3 times greater at age 70 then at age 20


Head Trauma

• Two thirds of the head-injured patients over age 65 who are unconscious on arrival at the ER do not survive

• Older patients are at significantly higher risk of cervical injury


Chest Injuries

• Any mechanism of injury suggesting thoracic trauma must be considered potentially lethal

• Injuries to the heart, aorta, and major blood vessels are a greater risk to the older patient


Abdominal Injuries

• Abdominal injuries are often less apparent in the elderly and require a greater index of suspicion

• Elderly patients less likely to tolerate surgery / more likely to develop postoperative complications


Musculoskeletal Injuries

• Remember that the older patient may have decreased perception of pain

• Pelvic fractures are highly lethal in the elderly

• The mortality rate associated with skeletal injuries is largely due to complications secondary to the initial injury


Falls

• Estimated one third of the older population falls each year

• 1 in 4 are hospitalized for injuries

• Of hospitalized 50% die within 12 months

• Fractures most common fall related injury


Medications in the Elderly

• Accidental drug overdose and medication noncompliance account for approximately 30% of all hospital admissions related to drug induced illness in older people


Common Reasons for These Medication Mishaps Include:

• Noncompliance

• Confusion

• Vision impairment

• Self selection

• Multiple prescriptions from multiple physicians

• Forgetfulness

• Excessive dosing or improper mixing of over the counter medications

• Changes in habits that affect drug metabolism


Geriatric Abuse/neglect

It is estimated that between 1 and 4 percent of the geriatric population

suffers from some form of abuse or neglect


Some Things to Watch for Are:

• Inconsistencies in history

• Unexplained trauma

• History inconsistent with complaint

• Visible signs

• Contusions, lacerations, abrasions


• Fractures, sprains, dislocations

• Burns

• Over-sedation

• Dehydration

• Poor hygiene

• Malnutrition


SUMMARY of the Geriatric Patient

• Take into consideration the changes caused by the normal aging process in assessing the ill or injured elderly patient

• Carefully assess the patients’ mental status and compare with what is considered to be normal for the patient


• Carefully assess the patient taking into consideration the affects of chronic conditions the patient has and any medications the patient is taking

• Treat the elderly patient aggressively and support vital functions


The Pediatric Patient

Do you remember your first kiss?


Who Is the Pediatric Patient???

• Newly-born to • 18 years old


PAT: Respiratory Distress

Circulation to SkinNormal

Work of BreathingIncreased

AppearanceNormal


PAT: Respiratory Failure

Circulation to SkinNormal or abnormal

Work of BreathingIncreased or Decreased

AppearanceAbnormal


PAT: Shock

Circulation to SkinAbnormal

Work of BreathingNormal

AppearanceAbnormal


PAT: Primary Central Nervous System (CNS) Dysfunction or

Metabolic Abnormality

Circulation to SkinNormal

Work of BreathingNormal

AppearanceAbnormal


Common Medical Emergencies

• Respiratory

• Cardiovascular

• Metabolic abnormalities

• Neurological crises

• Life-threatening infections


Peculiarities of the Pediatric Lung

• High proportion of mucus glands

• Incomplete development of airway cartilage

• Small peripheral airways compared to adult lung



• Less compliant than adult lung, while chest is more compliant

• Airways smaller in boys than in girls

• More capability of regenerating than adult lung

• Tongue is relatively large, likely to obstruct airway



• Larynx is high:– C2 in neonate– C3-4 in child– C5-6 in adult

• Narrowest at the cricoid ring

• Young infants are often obligate nose breathers


Clinical Signs of Respiratory Distress

• Tachypnea - rapid respirations– What’s normal?

• Dyspnea - labored respirations– Retractions– Accessory muscles– Nasal flaring– Expiratory grunting



• Abnormal sounds– Stridor– Wheezing– Cough– Rales, rhonchi, “crackles”– Absent breath sounds - silent chest is an

ominous sign



• Preferred position– Upright except in

infants or the unconscious child

• Initial tachycardia - fast heart rate

• Later bradycardia - slow heart rate

• Cardiac arrest



• Initial anxiety and irritability

• Later lethargy and coma



• Cyanosis - blue skin tone– Indicates presence of hemoglobin which is

not carrying oxygen– Can be masked by severe anemia– Peripheral cyanosis may result from shock– May not be obvious in newly born until

oxygen level is very low


Respiratory Failure

• End state of any of the causes of respiratory distress

• Failure of respiratory drive – Apnea due to drug overdose– Head trauma


Causes of Respiratory Crisis

• Asthma • Bronchiolitis • Croup• Epiglottitis• Foreign body

aspiration

• Laryngeal edema as part of anaphylaxis

• Smoke inhalation• Fractured larynx due

to trauma• Birth defects• Sids


Treatment of Pediatric Respiratory Patients

Assess the child’s breathing


• Conscious child:

• Observe as much as possible without touching

• Minimize handling the child

General Treatment for all Respiratory Distress

How agitation affects breathing: A child with respiratory problems who is agitated or frightened by EMTs will begin breathing harder and faster. This leads to increased resistance in the air passages, which in turn worsens breathing problems.


• Keep close to parent in position of comfort

• Oxygen

• DO NOT attempt IV

General Treatment


• Obtain brief history

• Perform limited physical exam - as tolerated

• Do not examine or instrument the oral cavity

• Administer any specific therapy indicated for child’s illness

General Treatment


• Unconscious child:

• Open airway

• Suction

• Ventilate with oxygen immediately

• Coordinate with child’s effort

• Watch for chest movement with bagging

General Treatment


• Watch for improvement– The child who remains blue and

bradycardic is inadequately ventilated until proven otherwise

General Treatment


Watch the pupils:

• Low blood oxygen can cause the child’s pupils to become enlarged. If the child is responding to oxygen, the pupils may get smaller.


• Airway problems are common and potentially lethal in children

• Invasive techniques should be reserved primarily for children whose severe airway compromise has led to loss of consciousness.

Summary


Cardiovascular Crisis

• Cardiac arrest is almost always a complication of respiratory failure, not primary cardiac disease; mortality is high

• Shock and bradycardia are most frequently encountered cardiovascular abnormalities


Summary

• Primary cardiac disease is uncommon in children; hypoxia, acidosis and other metabolic derangement's are much commoner causes of cardiac symptoms


Metabolic Crisis - Dehydration

• More frequently seen in children than in adults

• Increased frequency of infections

• Tendency to develop vomiting and diarrhea with viral illness

• Tendency to develop higher fever than adults


Signs and Symptoms

• Dry mucous membranes

• Absence of tears

• Reduced skin turgor

• Depressed anterior fontanel

• Sunken eyeballs

• Rapid respirations


Signs and Symptoms

• Hypotension (orthostatic)

• Increased pulse rate


Therapy of Dehydration

• Definitive therapy varies with degree of dehydration

– <10% can often be treated with oral fluids

– >10% generally requires IV rehydration


Treatment

• Abc's

• Oxygen

• Consider IV

• Notify hospital


You are called to an unresponsive newly born. Upon arrival you find a 1

month old child with decreased LOC, signs of

dehydration.


Glucose Abnormalities

• Hypoglycemia– More common in children than adults,

especially in newly born and insulin dependent diabetics


Signs and Symptoms

• Anxiety• Sweating• Tachycardia• Tremors• Headache• Depressed level of

consciousness• Seizures

• Frequent urination• Excessive thirst• Vomiting, abdominal

pain• Fruity odor to breath

if child is ketotic (not all are)


Signs and Symptoms

• Signs of dehydration

• Kussmaul respirations

• Lethargy, coma, seizure


Signs and Symptoms

• In neonates

• Tachypnea or apnea

• Jitteriness

• Color changes

• NO visible signs at all


Treatment

• Check chemstrip <60% treat

• Administer sugar-containing fluid by mouth if child is conscious and able to tolerate oral intake

• 1 - 2 cc/kg D25 if IV access is available


Treatment

• Remember that prolonged significant hypoglycemia can result in permanent CNS injury or death

• If in doubt give sugar

• Repeat chemstrip q 10 - 15 minutes


Neurological Crisis

• Seizures– Abnormal electrical discharge from the

brain; often results in motor activity but may be manifested as a period of unawareness or visual or auditory hallucinations


Causes of Seizures

• Febrile convulsions– Most common in children 6 months to 6

years

• CNS infections – Meningitis– Encephalitis– Brain abscess


Causes of Seizures

• Toxic ingestion– Lead, cocaine, PCP, amphetamine, aspirin

• Withdrawal from:– Narcotics, benzodiazepines, cocaine


Causes of Seizure

• Metabolic

• Trauma

• Epilepsy

• Brain tumor

• Stroke


Treatment for Seizure

• ABC’s

• Oxygen

• Support ventilation

• Protect child from injury

• Check chemstrip

• Consider anticonvulsant therapy if seizure continues


Neurological Crisis

• Coma– A disturbance of consciousness in which

patient becomes unaware and unresponsive to stimuli


Common Causes of Coma

• Hypoglycemia, diabetic ketoacidosis

• Meningitis, encephalitis

• Cerebral hypoxia/ischemia

• Cerebral edema

• Intoxication/drug overdose


Common Causes of Coma

• Reye syndrome

• Epilepsy

• Severe hypothermia or hyperthermia

• Intracranial hemorrhage or contusion

• Brain tumor

• Increased ICP


Reye Syndrome

• Cause unknown– Associated with influenza, – Chicken pox, – Use of aspirin– Gastroenteritis

• Occurs in children 5 - 15 years

• Fall and winter


Reye Syndrome

• Should be considered a serious disease

• Respiratory failure

• Cardiac arrhythmias

• Acute pancreatitis


Treatment of Coma

• Abc's

• Oxygen

• En route focused assessment– Check for signs of trauma, rash, bruises,

patients breath,


Treatment of Coma - History

• Has child had recent symptoms of infection?

• Has child sustained any trauma recently?

• Has he access to medications, alcohol, or household toxins?



• Does he have diabetes or any history of blood sugar abnormalities?

• Has he has unexplained headaches or vomiting?

• What medications does he normally take?



• Did his diminished responsiveness develop gradually following a period of increasing lethargy or was it of sudden onset with no premonitory signs?

• Has he had any periods where he stopped breathing or appeared cyanotic?


You are called to an 18 month old child who is said to be unresponsive. The mother tells you that the child has

had a cold for a few days, today developed a fever and rapid breathing,

she is having difficulty waking the child.


Your initial assessment reveals a pale child with poor muscle tone, who

does not appear responsive to his

surroundings.


How will you care for this child?


Life-threatening Infections

• Young children are particularly prone to serious infections– Immune systems are not fully developed– No sense of hygiene and explore the world

with their mouth– Day care settings greater exposure to a

variety of pathogens


Life-threatening Infections

• Recognition - consider in any child that presents with – Altered mental status,– Cardiovascular compromise– Respiratory compromise– Normal, high or low body temperature


Sepsis

• Illness resulting from invasive infection, including spread of pathogens or toxins via the blood stream; usually due to bacteria but may result from overwhelming viral or fungal infection

• Some endocrine diseases, e.G. Diabetes or disorders of metabolism can mimic sepsis syndromes


Meningitis

• Infection of the meninges and cerebrospinal fluid

• Most serious forms result from bacterial infection

• Highly contagious


Signs and Symptoms of Meningitis

• Fever

• Irritability, lethargy

• Headache

• Vomiting

• Seizures

• Stiff neck

• Recent ear infection


Signs and Symptoms

• Dehydration

• Decreased LOC

• Mottling, color changes

• Bulging fontanel


Serious bacterial infection (SBI)

• Any invasive bacterial infection e.g. pneumonia, meningitis, sepsis.

• Unsuspected trauma, as in nonaccidental trauma/child abuse can present as SBI.


SBI Symptoms

• Listlessness • Lethargy• Decreased oral intake• Floppiness• Moaning Cry• Decreased activity

level• Labored or rapid

breathing

• High-pitched cry• Decreased urine

output.• Grunting• Vomiting• Poor Color• Bilious vomiting• Elevated temperature• Hypothermia


Treatment for life-Threatening Infections

• ABC’s• Oxygen• Respiratory support• If febrile cool• History -

– Very important!– if the child was well 3 hours ago and is now

very ill, SBI is likely• Transport


One “Pill” Killers

• Theophylline• I mipramine

(tricyclics)• Clonidine• Camphor• Verapamil• Propanolol


Trauma in Oregon 1997 -1998

• 3090 children infant to 18 years

• 444 children died

• 210 deaths related to MVCs

• 45 from suicide

• 60 occurred due to violence

• boys were injured twice as often as girls


Oregon Trauma System

• 8.4% of injuries were intentional • 91.6% of injuries were unintentional.• 1208 children were tested for blood alcohol. • 270 tested positive. • 163 were involved in a motor vehicle crash, • 27 were injured by a cutting or piercing object• 21 by firearms.


Oregon Trauma System

• 575 children were tested for drugs.

• 172 tested positive for one or more drugs.

Cannabis 60.5%, amphetamine 14.8%, Opiates 9.0%, Benzodiazepine 7.1%, Cocaine 4.8%, Barbiturate 2.9%, Other 1.0%.


References

• Cristofani, C. B., J. Fairchild, and W. B. Long. Pediatric Prehospital Care Courses. Oregon Emergency Medical Services for Children, 1990.

• TRIPP Instructor course

Special Considerations

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