Refresher Class Session - M

Special PopulationsElder/child abusePatients with special needs

1

Introduction

People over the age of 65 make up the fastest-growing segment of the population. Almost 40 million in 2008, or 12.8 of the

population. Changes in physiology due to aging have an

effect on pathophysiology as compared to younger adults.

Geriatric patients typically have more than one disease and take more than one medication

2

Introduction

Cardiovascular disease is leading cause of death, followed by cancer, strokes, and COPD.

They use 1/3 of all prescriptions. The average geriatric patient takes 4.5

medications per day.

3

Pathophysiology

Human body changes with age: cellular, organ, and system functions

Change in normal physiology starts around age 30

Process can be slowed with diet and exercise, but it cannot be stopped entirely.

4

Pathophysiology

Cardiovascular system Degenerative process to the myocardium Damage to valves Thickening of the walls Loss of artery elasticity Decrease in baroreceptor activity

5

Pathophysiology

Respiratory system Size and strength of respiratory muscles

decrease Alveolar surfaces degrade, impairing gas

exchange Chemoreceptors begin to fail More turbulent airflow through the bronchioles

6

Pathophysiology

Nervous system Nerve cells degenerate and die as early as mid-

20s Reflexes slow, proprioception falters Brain atrophies with resultant increase in CSF Regulation of basal bodily functions becomes

less sensitive

7

Pathophysiology

Gastrointestinal system Sense of taste and smell diminished Cardiac sphincter becomes weaker Hepatic function decreases Lining of GI system degenerates, resulting in

lesser absorption of nutrients

8

Pathophysiology Endocrine system

Hormones that elevate blood pressure and those that regulate fluid balance become deranged

Stimulation of adrenergic sites diminishes due to failure of sensitivity of receptor cells

Musculoskeletal system Loss of minerals from the bones Vertebral disks narrow Joints lose flexibility Synovial fluid thickens

9

Pathophysiology

Renal system Decrease in nephrons, kidneys shrink Diminished ability to filter blood Fluid and electrolyte disturbances

Integumentary system Skin becomes thinner from a loss of

subcutaneous layer Replacement cells generate more slowly Sense of touch dulled, less perspiration Less effectiveness as an external barrier

10

Bucket next to bed Home O2 setup

Medications at scene Tripod Position Abnormally hot/cold room

11

Clues to Illness Found in the Scene Size-Up

Pain May not complain of pain due to preexisting conditions May not feel pain due to disease process ie diabetes Prickling/burning pain = superficial structures; aching-type

pain = internal organs Fainting may indicate a serious illness

Mental Status Hypoxia causes agitation and aggression High CO2 causes confusion and disorientation Sudden onset of AMS is not normal - -indicates serious

illness or injury12

Special Considerations in the Primary Assessment of the Geriatric Patient

Airway High incidence of choking and aspiration of food Cervical arthritis makes head-tilt/chin lift difficult Loose dentures may cause airway obstruction

Breathing Expect higher resting rates Lower tidal volume = risk of early onset of hypoxia Retractions less likely

Circulation Expect higher resting heart rate (unless on meds) Irregularly Irregular pulse may be normal

Skin Normally dry and less elastic; Turgor not reliable subcutaneous fat & skin vessel >> to ”urban hypothermia” Fever less common

13

Special Considerations in the Primary Assessment of the Geriatric Patient

Emergency Medical Care

Manual cervical spine considerations Assess and maintain the airway Determine breathing adequacy

High-flow via NRB with adequate breathing High-flow via PPV @ 10-12/min if inadequate Maintain saturation >95%

Assess circulatory components Pulse check, skin characteristics Control major bleeds

14

Emergency Medical Care

Initiate transport with ALS intercept Position the patient

Sitting up if able to maintain own airway Lateral recumbent with altered mentation Supine if immobilized

Constantly monitor airway, breathing, and circulation

Mental status changes key to determining improvement or deterioration

15

Summary

Geriatric patients, like pediatric patients, have an altered physiology that needs to be considered given illness and injuries.

The normal decline in the body systems render them susceptible to a multitude of emergencies.

Carefully manage and closely watch elderly patients, as they may deteriorate suddenly.

16

Special Challenges

17

Introduction

Due to lifestyle changes and medicine, the life span of humans is lengthening.

Advances in medicine allow technology to go home with the patient.

Congenital disease patients live longer at home, due to medicine.

EMS may not know what the medical technology is, but they must always know what to do.

18

Epidemiology

No specific registry nor definition for what “specially challenged” is.

Underreporting is also believed to occur, especially with abuse.

Over 3 million pediatric abuse cases and over half a million elder abuse cases.

8 million disabled people are receiving health care from professional providers.

19

Pathophysiology

Mental Illness Mild to severe disabilities Commonly include the following features

• Cognitive disabilities• Speech impediments• Behavioral disorders• Movement disorders

20

Causes of Mental Retardation

Down Syndrome Fragile X Syndrome Autism Fetal Alcohol Syndrome Phenylketonuria (PKU) hypothyroidism Rett Syndrome

21

Pathophysiology

Disabilities A problem of the patient that was caused by a

disease Results in sustained medical care for the person

Common disabilities seen in EMS include:• Paralysis• Obesity• Traumatized patients

22

Pathophysiology

Disabilities – Paralysis Loss of function of single or multiple muscles Damage to nervous system (spinal cord) Neuromuscular diseases

23

Pathophysiology

Disabilities – Obesity Over 40% of U.S. population is obese Obesity may be due to lifestyle choices or

medical conditions Obesity creates a multitude of secondary

emergencies Obesity also creates a patient handling and

movement concern for EMS

24

Effects of Excess Weight on Organ Systems

25

Pathophysiology

Disabilities – Traumatized patients Head and/or brain trauma Commonly there are residual effects

• Mild – speech or gait impairments• Severe – unresponsive, seizures, technology

dependent Most patients fall between these two extremes

26

Pathophysiology Technology Assistance/Dependency

Medical equipment designed for patient care• Enhance quality of life• Sustain life

EMS must remain aware of common types of equipment

Some EMS systems track where patients live who are technology dependent

27

Technology dependent patients;Infants and Children

with Special Needs

28

Pathophysiology

Vascular Access Devices Devices implanted into the skin Allow for ongoing or multiple medication

administrations into the patient's vascular system Dialysis

Replaces kidney function Hemodialysis – done at facility Peritoneal dialysis – done at home

29

Pathophysiology Home Mechanical Ventilators

Assist or provide total ventilatory needs to a patient who cannot maintain own ventilatory effort

Negative and positive pressure units Controls include rate, volume, and occasionally

oxygen levels Alarms (may be reason EMS is summoned)

• High pressure alarm• Low pressure alarm• Apnea alarm• Low FiO2 alarm

– “Fraction of inspired oxygen,” which refers to the amount of oxygen the patient in breathing in.

30

Pathophysiology

CPAP and BiPAP Designed to provide “back pressure” via mask

that attaches to face Helps to keep small bronchioles open during

breathing, and the airway open during sleep Commonly found with obese patients and certain

chronic lung diseases

31

Children with Special Needs

Premature babies with lung disease Heart disease Neurologic disease Chronic disease or altered function since birth

32

Apnea Monitor Monitors patient's breathing status Some monitor heart rate Common to neonates and infants Audible alert for when patient stops breathing

Tracheostomy Tube Provides artificial opening into airway Placed through anterior neck Bypasses mouth and nose

33

Pathophysiology Technology Assistance/Dependency

34

The EMT can ventilate a patient with a tracheostomy by attaching the bag-valve device to the tracheostomy tube's 15/22 mm adapter.

A tracheostomy tube for older children and adults has an outer cannula and an inner cannula

Tracheostomy Tube

35

Tracheostomy Tube Complications

Obstruction Bleeding Air leak Dislodged tube Infection

Maintain open airway. Suction. Maintain a position of comfort. Transport.

36

37

Home Artificial Ventilation

The tubing from the home ventilator attaches to the

patient's tracheostomy tube.

Assure airway.

Artificially ventilate with oxygen.

Transport.

Central Intravenous Lines

IVs that are very long Tip in vein near heart

Complications Cracked line Infection Clotting off Bleeding

If bleeding is present, apply pressure. Transport.

38

Gastrostomy Tubes

Gastrostomy Tubes (Feeding Tubes) Provide nutrition to patients who cannot chew “Enteral feeding” or “tube feeding” Types

• NG tube – nose to stomach• OG tube – mouth to stomach• G-tube – through skin to stomach• J-tube – through skin to jejunum

39

Gastrostomy Tube

Tube placed directly into stomach for child who usually cannot be fed by mouth

40

Managing GastrostomyTubes

Assess for mental status changes. Assure patent airway. Suction as needed. Provide high-concentration oxygen. Transport patient sitting or lying on right side

with head elevated.

41

Intraventricular Shunt Medical illnesses or anatomic defects that allow

excessive CSF to accumulate Increased CSF can cause damaging ICP issues

Tube running from brainto abdomen to drain excess cerebrospinal fluid.

Assure airway. Ventilate as needed. Transport.

42

Family Response

43

Family Response

When you care for an injured or ill child, you must also care for the child’s family.

Parent may react with anger/hysteria toward EMT–B.

Calming the parent calms the child. Parent is concerned about child's injury/illness

as well as child’s fear/pain. Response worsened by feeling of helplessness.

44

Family Response

Encourage the parent to be involved in child’s care (e.g., holding oxygen mask, cup, or tubing).

Have the parent help calm child. Parents of “high-tech kids” are medical experts

on their child’s condition. In general, other parents may not have medical

training, but they are experts on their children and what will calm them.

45

Assessment Findings During your assessment, ask about the medical

equipment Where do I get the best information regarding this

equipment? What does this device do for the patient? Can I replicate its function should it fail? Will this equipment change assessment findings? Has this ever occurred before? What fixed it? Has anyone attempted to remedy the problem? Do I have movement or handling issues with this

equipment?

46

Emergency Medical Care

Manual cervical spine considerations Assess and maintain the airway Determine breathing adequacy

High-flow via NRB with adequate breathing High-flow via PPV @ 10-12/min if inadequate Maintain saturation >95%

Assess circulatory components Pulse check, skin characteristics

47

Emergency Medical Care

Initiate transport with ALS intercept Position the patient based on condition and

medical equipment Consider immobilization needs

Constantly monitor airway, breathing, and circulation

Try to use medical equipment if it is portable and working correctly

48

Summary

Patients with special needs are those who usually have some medical technology helping them with life.

When this equipment malfunctions, typically it is EMS that is called.

The role of the EMT is to manage the patient's problem(s), incorporating this technology into their assessment and management.

49

Abuse and Neglect

50

AbuseImproper or excessive action so as to injure or cause harm

51

Child abuse is the physical, sexual, or emotional harm or risk of harm to a childunder the age of 18.

Child Abuse (NJ EMS Field Guide)

Pathophysiology

Abuse Child abuse

• Physical, emotional, sexual Elder abuse

• Physical, emotional, sexual Passive versus active

• Neglect

52

NeglectGiving insufficient attention or respect to someone who has a claim to that attention

53

Neglect occurs when a parent or Caregiver fails to provide proper supervision or adequate food, clothing, shelter, education, or medical care although financially able orassisted to do so.

Neglect (NJ EMS Field Guide)

Physical abuse of an elderly person can have dire

consequences because of the

patient's frailty.

54

Signs of Abuse

Multiple bruises in different stages of healing

Injury not consistent with mechanism described Injury matches item used to

cause it Fresh burns Parents seem not to care as much as they

should Conflicting stories Child afraid to describe how injury occurred

55

What does abuse look like

56

Hand Marks

Bruising of the ear from being pulled.Bruising of the ear from being "boxed”

57

Loop mark bruises inflicted by a doubled-over cord.

Bruises inflicted with

belt.

58

Handling Abuse and Neglect

Head injuries are most lethal. Shaken baby syndrome

Do not accuse anyone in the field. Required Reporting

Follow state laws and local regulations. Document objective information (what you SEE

and HEAR, not what you merely THINK).

59

Reporting Child Abuse

If you suspect child abuse, or a child tells you about abuse, don’t delay.

You must report it! Everyone in New Jersey is required to report suspected abuse.

To make a report, call the NJ Division of Youth and Family Services’ toll-free Child Abuse Hotline 24 hours a day, 7 days a week:

1-877-NJ-ABUSE (1-877-652-2873)

TTY 1-800-835-5510.60

Reporting FAQs

Do callers have immunity from civil or criminal liability? Any person who, in good faith, makes a report of

child abuse or neglect or testifies in a child abuse hearing resulting from such a report is immune from any criminal or civil liability as a result of such action. Calls can be placed to the hotline anonymously.

Is it against the laws of New Jersey to fail to report suspected abuse/neglect? Any person who knowingly fails to report suspected abuse

or neglect according to the law or to comply with the provisions of the law is a disorderly person.

61

Reporting Elder Abuse

The Office of the Ombudsman for the Institutionalized Elderly investigates and responds to complaints of abuse, neglect, and exploitation of individuals 60 years of age and older who reside in licensed facilities within New Jersey, both public and private.

To make a report, call:

1-877-582-6995

62

Prevention of Domestic Violence Act

Applies To a person 18 years of age or older or a person who is an

emancipated minor that has been subjected to domestic violence by a spouse, former spouse, or any other person who is a present or former household member.

If you or the abuser are the parents of any children, whether or not you have ever lived together;

If you are pregnant with the abuser’s child; If you and the abuser now live together or have lived together in the

past; or you and the abuser now have or did have, at one time, a dating relationship.

You and the abuser do not have to be married or be girlfriend/boyfriend. He or she can be a family member, your gay or lesbian partner, your roommate, your caretaker, or any other adult who lives with you now or has lived with you.

63

64

NJ State EMS Field Guide

http://njems.rutgers.edu/cdr/jsp/field_guide.jsp

Google: NJ State EMS Field Guide