Children with Special Health Care Needs

1. Children with Special Health Care Needs Lesson 8

2. 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.

3. 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.

4. 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 nat’l defn.).

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

6. 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.

7. 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.

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

9. Assessment - Breathing Children with congenital heart disease or chronic illness may be unable to compensate for even mild respiratory distress.

10. 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.

11. 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.

12. 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."

13. 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

14. Ask the Parents/Caregivers • Are there differences from normal abilities and behaviors now? • Were these changes the primary reason for calling EMS?

15. CUPS Assessment of Children with Special Needs Category Assessment Actions

16. Assessment Absent Airway Breathing Circulation AVPU = P or U Action Support and Transport Critical

17. Assessment Compromised Airway Breathing Circulation AVPU=V or P or Normal airway breathing and circulation, AVPU=A with other risk factors. Action Support and Transport Unstable

18. Assessment Compromised Airway Breathing Circulation AVPU=V or P or Normal ABC’s, AVPU=A with other risk factors. Action Support and Transport Potentially Unstable

19. Assessment 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. Stable

20. 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 SPECIAL TECHNOLOGY

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

22. 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.

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

24. 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.

25. 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.

26. 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.

27. 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

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

29. 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.

30. 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.

31. 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.

32. 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.

33. 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.

34. Tracheostomy - Management • Insert the tube with the curved end pointing down, • Confirm that the tube is positioned properly. • Evaluate the child’s respiratory status.

35. Tracheostomy - Management • Perform ventilations with a bag valve mask over the stoma or the mouth.

36. Tracheostomy - Management • Children with tracheostomies often have asthma. • Treat according to local protocol.

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

38. Home Ventilators - Settings • Home ventilators are set to control: • breathing rate • tidal volume • FIO2 • Peak Inspiratory Pressure (PIP) • Positive End Expiratory Pressure (PEEP)

39. Home Ventilators - Types • There are two types of home ventilators: • Pressure cycled ventilators • Volume ventilators

40. Home Ventilators - Modes • Home ventilators operate in two modes: • Intermittent Mechanical Ventilation (IMV) • Continuos Mechanical Ventilation (CMV)

41. 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

42. Constant Positive Airway Pressure- CPAP A mask covers the child’s mouth and nose, providing constant pressure, ensuring an open airway.

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

44. Central Intravenous Catheters There are two common types of catheters used for this purpose: • Broviac Catheters • Hickman or Mediport Catheters

45. 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. Central Intravenous Catheters

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

47. Pacemakers - Types There are three types of pacemakers: • Demand • Constant • Antiarrhythmia

48. 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. Pacemaker - Management

49. Problem Dislodged Leads Broken Leads Solution Treat symptoms as necessary, rapid transport. Treat symptoms, treat for shock, rapid transport. Pacemaker - Management

50. Feeding Catheters A feeding catheter provides a route for nutritional support when the child is unable to take food by mouth