Special Populations Review PDF

Special Populations Review Obstetrics Physiologic Maternal Changes During Pregnancy  Physiologic changes occurring throughout pregnancy can:  Alter normal response to trauma  Exacerbate or create medical conditions Physiologic Maternal Changes During Pregnancy  Significant changes...

Special Populations Review Obstetrics Physiologic Maternal Changes During Pregnancy  Physiologic changes occurring throughout pregnancy can:  Alter normal response to trauma  Exacerbate or create medical conditions Physiologic Maternal Changes During Pregnancy  Significant changes occur in the uterus.  Before pregnancy, the uterus: Weighs about 2.5 oz (70 gm) Has a fluid capacity of about 10 mL  At the end of the pregnancy, the uterus: Weighs as much as 2.24 to 2.6 lb (1100 to 1200 g) Has the capacity to hold about 5,000 mL Physiologic Maternal Changes During Pregnancy  Measurement of the fundus may indicate developmental problems:  Uterine growth problems  Breech position  Twins © Jones & Bartlett Learning. Physiologic Maternal Changes During Pregnancy  Pressure occurs on intestine and rectum  Smooth muscle in the GI tract relaxes  Stomach is not emptied as quickly  Kidneys increase in size and volume  Ureters increase in diameter  Hormones cause changes to the skin, hair, and eyes Physiologic Maternal Changes During Pregnancy  Circulatory changes  Blood volume increases up to 50% more to: Meet fetal metabolic needs Adequately perfuse maternal organs Help compensate for blood loss in delivery Physiologic Maternal Changes During Pregnancy  Circulatory changes (cont’d)  The number of red blood cells increases.  Clotting factors increase while fibrinolytic factors are depressed.  The size of the heart increases. Physiologic Maternal Changes During Pregnancy  The heart rate gradually increases by an average of 15 to 20 beats/min by term.  ECG changes may include: Ectopic beats Supraventricular tachycardia Slight left axis deviation Lead II changes Physiologic Maternal Changes During Pregnancy  Sensitivity to body position increases as gestation increases.  Lying supine can cause compression of the inferior vena cava.  If pressure is not relieved, cardiac output is decreased. Physiologic Maternal Changes During Pregnancy  The birthing position may stress the cardiovascular system.  The lithotomy position is standard in the United States. © Jones & Bartlett Learning. Physiologic Maternal Changes During Pregnancy  Respiratory changes  The diaphragm is pushed up by the uterus.  Maternal oxygen demand increases.  Progesterone does the following: Decreases threshold to carbon dioxide Causes the bronchi to dilate Regulates mucus production Physiologic Maternal Changes During Pregnancy  Respiratory changes (cont’d)  A decrease in: Expiratory reserve volume Functional residual capacity Residual volume  An increase in: Tidal volume Inspiratory reserve volume Physiologic Maternal Changes During Pregnancy  Maternal metabolism  Weight gain averages 27 lb (12.3 kg). Increased blood volume and intracellular and extracellular fluid Uterine growth Placental and fetal growth Increased breast tissue Increased proteins and fat deposits Physiologic Maternal Changes During Pregnancy  Maternal metabolism  Relaxin softens collagenous tissues and relaxes the ligamentous system.  The demand for carbohydrates increases. Physiologic Maternal Changes During Pregnancy  Physiologic changes occurring throughout pregnancy can:  Alter normal response to trauma  Exacerbate or create medical conditions Physiologic Maternal Changes During Pregnancy  Significant changes occur in the uterus.  Before pregnancy, the uterus: Weighs about 2.5 oz (70 gm) Has a fluid capacity of about 10 mL  At the end of the pregnancy, the uterus: Weighs as much as 2.24 to 2.6 lb (1100 to 1200 g) Has the capacity to hold about 5,000 mL Physiologic Maternal Changes During Pregnancy  Measurement of the fundus may indicate developmental problems:  Uterine growth problems  Breech position  Twins © Jones & Bartlett Learning. Physiologic Maternal Changes During Pregnancy  Pressure occurs on intestine and rectum  Smooth muscle in the GI tract relaxes  Stomach is not emptied as quickly  Kidneys increase in size and volume  Ureters increase in diameter  Hormones cause changes to the skin, hair, and eyes Physiologic Maternal Changes During Pregnancy  Circulatory changes  Blood volume increases up to 50% more to: Meet fetal metabolic needs Adequately perfuse maternal organs Help compensate for blood loss in delivery Physiologic Maternal Changes During Pregnancy  Circulatory changes (cont’d)  The number of red blood cells increases.  Clotting factors increase while fibrinolytic factors are depressed.  The size of the heart increases. Physiologic Maternal Changes During Pregnancy  The heart rate gradually increases by an average of 15 to 20 beats/min by term.  ECG changes may include: Ectopic beats Supraventricular tachycardia Slight left axis deviation Lead II changes Physiologic Maternal Changes During Pregnancy  Sensitivity to body position increases as gestation increases.  Lying supine can cause compression of the inferior vena cava.  If pressure is not relieved, cardiac output is decreased. Physiologic Maternal Changes During Pregnancy  The birthing position may stress the cardiovascular system.  The lithotomy position is standard in the United States. © Jones & Bartlett Learning. Physiologic Maternal Changes During Pregnancy  Respiratory changes  The diaphragm is pushed up by the uterus.  Maternal oxygen demand increases.  Progesterone does the following: Decreases threshold to carbon dioxide Causes the bronchi to dilate Regulates mucus production Physiologic Maternal Changes During Pregnancy  Respiratory changes (cont’d)  A decrease in: Expiratory reserve volume Functional residual capacity Residual volume  An increase in: Tidal volume Inspiratory reserve volume Physiologic Maternal Changes During Pregnancy  Maternal metabolism  Weight gain averages 27 lb (12.3 kg). Increased blood volume and intracellular and extracellular fluid Uterine growth Placental and fetal growth Increased breast tissue Increased proteins and fat deposits Physiologic Maternal Changes During Pregnancy  Maternal metabolism  Relaxin softens collagenous tissues and relaxes the ligamentous system.  The demand for carbohydrates increases. Supine Hypotensive Syndrome  Uterus may compress the inferior vena cava.  May diminish or occlude venous blood return to the heart  Can result in significant hypotension and fetal distress Supine Hypotensive Syndrome  Management includes:  Placing the patient in the left lateral recumbent position.  Treating underlying causes.  Monitoring blood pressure and other vital signs.  Obtaining an ECG. Cardiac Conditions  Determine the nature and treatment of any heart condition.  Cardiac medications  Diagnosed with dysrhythmias or heart murmurs  History of rheumatic fever  Born with congenital heart defect  Episodes of dizziness, light-headedness Hypertensive Disorders  Chronic hypertension  Gestational hypertension  Blood pressure equal to or greater than 140/90 mm Hg  Develops after the 20th  Increased risk for stroke or week of pregnancy other cardiovascular  Resolves spontaneously problems Hypertensive Disorders  Preeclampsia  Risk factors include: First pregnancy before age 20 years Women with advanced maternal age History of multiple pregnancies Hypertension Renal disease Diabetes Hypertensive Disorders  Preeclampsia (cont’d)  Manifests after 20th week with a triad of symptoms including: Edema Gradual onset of hypertension Protein in the urine Hypertensive Disorders  Preeclampsia (cont’d)  May require emergency hypertensive medications  Other conditions that may accompany preeclampsia: Liver or renal failure Cerebral hemorrhage Abruptio placenta HELLP syndrome Seizures  Treatment is difficult because drugs may cause fetal distress.  Magnesium sulfate is recommended.  Potential complications may include:  Abruptio placenta  Hemorrhage  Disseminated intravascular coagulation Diabetes  Gestational diabetes mellitus: inability to process carbohydrates during pregnancy  Treatment consists of:  Diet control  Oral hypoglycemic medications Diabetes  Diabetes may be affected by pregnancy.  Patients with a history of diabetes should have a blood glucose level test. Respiratory Disorders  Shortness of breath or general dyspnea is one of the most common complaints.  Often caused by hormone-related changes  Asthma is a common condition that complicates pregnancy. Respiratory Disorders  Maternal asthma complications:  Fetal asthma complications:  Premature labor  Premature birth  Preeclampsia  Low birth rate  Respiratory failure  Growth retardation  Vaginal hemorrhage  Fetal death  Eclampsia Pathophysiology of Bleeding Related to Pregnancy  Abortion  Expulsion of the fetus before the 20th week of gestation  Classified as: Spontaneous abortion (miscarriage) Elective (intentional) abortion Pathophysiology of Bleeding Related to Pregnancy  Habitual abortions: three or more consecutive miscarriages  Causes include: Ovarian issues Uterine malformations Cervical conditions Infections Pathophysiology of Bleeding Related to Pregnancy  Threatened abortion: abortion attempting to take place  It is characterized by vaginal bleeding in the first half of pregnancy.  It can progress, or it may subside.  The prehospital role is transport and support. Pathophysiology of Bleeding Related to Pregnancy  Imminent abortion: spontaneous abortion that cannot be prevented  Signs and symptoms include: Severe abdominal pain Vaginal bleeding Cervical dilation  Maintain blood pressure and prevent hypovolemia. Pathophysiology of Bleeding Related to Pregnancy  Imminent abortion (cont’d)  Treatment includes: Establishing an IV line of normal saline Administering 100% supplemental oxygen Obtaining an ECG Providing emotional support with rapid transport Watching for signs of shock Pathophysiology of Bleeding Related to Pregnancy  Incomplete abortion: Part of the products of conception remains in the uterus.  Vaginal bleeding will be continuous.  Watch for signs and symptoms of shock.  Start an IV line of normal saline.  Consult medical control.  Collect all products of conception. Pathophysiology of Bleeding Related to Pregnancy  Missed abortion: The fetus dies during the first 20 weeks of gestation but remains in utero.  Provide emotional support and transport.  On examination: The uterus feels like a hard mass. The fetal heartbeat cannot be heard. Pathophysiology of Bleeding Related to Pregnancy  Septic abortion: The uterus becomes infected following abortion.  History includes fever and bad-smelling vaginal discharge after abortion.  Physical examination shows fever and abdominal tenderness. Pathophysiology of Bleeding Related to Pregnancy  Septic abortion (cont’d)  Prehospital management includes: Establishing an IV line of normal saline Administering 100% supplemental oxygen ECG monitoring Rapid transport Fluid administration Pathophysiology of Bleeding Related to Pregnancy  Third-trimester bleeding  Greatest danger of hemorrhage A large volume of blood is present. Compensatory mechanisms function as a result of pregnancy. Pathophysiology of Bleeding Related to Pregnancy  Ectopic pregnancy  The ovum implants somewhere besides uterus.  The patient usually presents with: Severe abdominal pain Hypovolemic shock  Should be considered for all female patients of child-bearing age with severe lower abdominal pain.  Treat for shock and provide rapid transport. Pathophysiology of Bleeding Related to Pregnancy  Abruptio placenta  Premature separation of the placenta from the uterine wall © Jones & Bartlett Learning. Pathophysiology of Bleeding Related to Pregnancy  Abruptio placenta (cont’d)  Patient will report: Sudden onset of severe abdominal pain No longer feeling the fetus moving Vaginal bleeding with dark red blood Pathophysiology of Bleeding Related to Pregnancy  Abruptio placenta (cont’d)  Physical examination may reveal: Signs of shock Tender abdomen and rigid uterus Absent fetal heart sounds Pathophysiology of Bleeding Related to Pregnancy  Placenta previa  Placenta is implanted low in the uterus and obscures the cervical canal. © Jones & Bartlett Learning. Pathophysiology of Bleeding Related to Pregnancy  Placenta previa (cont’d)  Painless vaginal bleeding with bright red blood.  Uterus is soft and nontender. Assessment of Bleeding Related to Pregnancy  Try to determine the nature of the bleeding.  Use OPQRST to elaborate on the chief complaint of labor pain.  Identify changes in orthostatic vital signs.  Look for positive Grey Turner or Cullen sign. Management of Bleeding Related to Pregnancy  Keep the woman lying on her left side.  Administer 100% supplemental oxygen.  Provide rapid transport.  Start an IV line of normal saline.  Obtain an ECG and baseline vital signs.  Loosely place trauma pads over the vagina. Cephalic Presentation  The newborn’s head is overly extended, creating a face presentation at birth.  Brow presentation  Occiput-posterior presentation  Military presentation Cephalic Presentation  If the newborn’s head cannot be externally rotated or the delivery cannot be completed:  Support the woman and fetus.  Provide rapid transport. Breech Presentations  A different part of the body besides the head leads the way through the birth canal.  Types:  Frank  Incomplete  Complete © Jones & Bartlett Learning. Breech Presentations  If buttocks are presenting and delivery is imminent:  Position the woman with buttocks at edge of bed or stretcher, legs flexed.  Allow newborn’s buttocks and trunk to deliver spontaneously.  Once the legs are clear, support the body.  Lower the newborn slightly. Breech Presentations  Once the hairline is spotted, grasp the newborn’s ankles and lift upward.  If the head does not deliver within 3 minutes, the newborn may suffocate.  Do not try to forcibly pull the newborn out. Breech Presentations  Other presentations are rare.  Footling breech  Transverse presentation  In abnormal presentations, do not attempt delivery in the field. © Jones & Bartlett Learning. Shoulder Dystocia  Difficulty in delivering the shoulders.  If the shoulders cannot clear the birth canal, the fetus cannot breathe.  A major concern for the newborn is brachial nerve plexus damage. Shoulder Dystocia  McRoberts maneuver  Hyperflex the woman’s legs tightly to the abdomen.  You may need to apply pressure to the lower abdomen and gently pull on the fetus’s head. Nuchal Cord  The umbilical cord becomes wrapped around the newborn’s neck during delivery.  Slip a finder under the cord and gently attempt to slip it over the shoulder and head.  If unsuccessful, cut the cord. Prolapsed Umbilical Cord  The cord emerges before the fetus.  Shuts off the oxygenated blood supply from the placenta  Leads to fetal asphyxia © Jones & Bartlett Learning. Prolapsed Umbilical Cord  Keep the woman supine with hips elevated.  Administer 100% supplemental oxygen.  Have the woman pant with each contraction.  Gently push the presenting part back up the vagina until it no longer presses on the cord. Prolapsed Umbilical Cord  Maintain pressure while another paramedic covers the exposed cord with dressings.  Maintain that position throughout urgent transport. Postpartum Hemorrhage  Can be either early or late hemorrhage.  Early: bleeding within 24 hours of delivery  Late: bleeding occurring from 24 hours to 6 weeks after delivery  Blood loss exceeds 500 mL during first 24 hours after birth. Postpartum Hemorrhage  Causes of postpartum hemorrhage include:  Lacerations  Prolonged labor or multiple baby delivery  Retained products of conception  Multiple pregnancy  Placenta previa  Full bladder Postpartum Hemorrhage  Continue uterine massage.  Encourage the woman to breastfeed.  Notify the receiving facility of status.  Transport immediately.  Add a large-bore IV line en route.  Do not pack dressings into the vagina. Trauma and Pregnancy  Trauma is the leading cause of maternal death in the United States.  Abdominal trauma occurs from the same mechanisms in pregnant women as nonpregnant women. Pathophysiology and Assessment Considerations  Anatomic changes are important in trauma.  Abdominal contents compress into the upper abdomen.  The diaphragm elevates by about 1.5 inches.  The peritoneum maximally stretches. Pathophysiology and Assessment Considerations  First trimester  The uterus is well protected and rarely damaged from trauma.  Second and third trimesters  The uterus extends into the abdomen and becomes more vulnerable to trauma. Pathophysiology and Assessment Considerations  Pregnant patients will have different signs or responses to trauma.  It may be more difficult to interpret tachycardia.  Signs of hypovolemia may be hidden.  The patient has a higher chance of bleeding to death in case of pelvic fractures.  A respiratory rate less than 20 breaths/min is not adequate. Considerations for the Fetus and Trauma  Fetal injury can occur from:  Rapid deceleration  Impaired fetal circulation  If a pregnant woman has massive bleeding, maternal circulation will reroute blood from the fetus. Considerations for the Fetus and Trauma  The fetal heart rate is the best indication of fetal status after trauma.  A normal fetal heart rate is between 120 and 160 beats/min.  A rate slower than 120 beats/min indicates fetal distress and a dire emergency. Management of the Pregnant Trauma Patient  You can only treat the woman directly.  Transport a pregnant woman on her left side if no spinal injury is suspected. © Jones & Bartlett Learning. Management of the Pregnant Trauma Patient  Ensure an adequate airway.  Administer oxygen.  Assist ventilations when needed and provide a higher-than-usual minute volume.  Control external bleeding and splint fractures. Management of the Pregnant Trauma Patient  Start one or two IV lines of normal saline.  Transport the patient in the lateral recumbent position.  Management of the Pregnant Trauma Patient  Maternal cardiac arrest  Provide CPR and ALS as you would for any other trauma patient.  CPR and ventilator support may keep the fetus viable, even if the mother is already dead. Neonate Arrival of the Newborn  Obtain patient history and prepare environment.  Minimum needs: Warm, dry blankets Bulb syringe Two small clamps or ties A pair of clean scissors Arrival of the Newborn  If delivery in ambulance:  Use blankets.  Confirm ABCs.  Place newborn on mother’s chest.  Suction mouth, then nose.  Keep newborn at level of © Jones & Bartlett Learning. mother. Arrival of the Newborn  Clamp and cut the umbilical cord.  Primary survey simultaneous with treatment interventions  Examine skin, head, and eyes for irregularities.  Inspect umbilical cord for abnormalities. Arrival of the Newborn  Newborns are at risk for hypothermia.  Place on prewarmed towels or radiant warmer  Dry the head and body thoroughly  Remove wet towels and cover with a dry towel  Cover the head with a cap Arrival of the Newborn  All babies are cyanotic right after birth  If the newborn remains vigorous and begins to turn pink in the first 5 minutes:  Maintain ongoing observation.  Continue thermoregulation with direct skin-to-skin contact with mother. The Apgar Score  Helps record condition at birth  If score is less than 7, redo every 5 minutes until 20 minutes after birth. Algorithm for Neonatal Resuscitation  Follow current neonatal resuscitation guidelines.  First 60 seconds: Initial steps, reevaluation, and ventilation should occur.  Additional oxygen may be necessary if the target preductal oxygen saturation value has not been reached. Algorithm for Neonatal Resuscitation  If the newborn’s pulse rate is apneic or less than 100 beats/min, begin PPV.  Begin chest compressions if the newborn’s pulse rate is less than 60 beats/min.  If ventilation and chest compression do not improve the bradycardia, administer epinephrine preferably via IV line.  Resuscitation Algorithm for Neonatal Reprinted with permission. Web-based Integrated 2015 American Heart Association Guidelines for CPR & ECC. Part 13: neonatal resuscitation. © 2015 American Heart Association, Inc. Bradycardia  Most frequently occurs due to inadequate ventilation  Often responds to effective PPV  Morbidity and mortality are determined by:  Underlying cause  How quickly it is corrected Bradycardia  Assessment and management  Heart rate less than 100 beats/min: Provide PPV  If still less than 60 beats/min: Begin chest compressions  If still less than 60 beats/min: Administer epinephrine. Repeat every 3 to 5 minutes for persistent bradycardia. Meconium-Stained Amniotic Fluid  Carries a high risk of morbidity  If newborns inhale meconium-stained amniotic fluid, airway may become plugged.  Atelectasis  Persistent pulmonary hypertension  Hypoxemia  Aspiration pneumonitis  Pneumothorax Meconium-Stained Amniotic Fluid  To decrease risk of persistent pulmonary hypertension:  Ensure a clear airway.  Keep newborn warm.  Minimize stimulation.  Administer supplemental oxygen when necessary. Meconium-Stained Amniotic Fluid  Assessment and management  If depressed: Start PPV. Intubation and suctioning may be required to remove an obstruction. Meconium-Stained Amniotic Fluid  Assessment and management (cont’d)  If the newborn is not responding well to the care outlined in the neonatal resuscitation algorithm: Suspect airway occlusion or pneumothorax. Minimize hypothermia. Reassess frequently. Premature and Low Birth Weight Infants  Premature: Delivered before 37 weeks of gestation  Increased mortality  Associated morbidities © American Academy of Orthopaedic Surgeons. Premature and Low Birth Weight Infants  Low birth weight—newborns weighing less than 5.5 lb (2,500 g)  Morbidity and mortality are related to degree of prematurity. Premature and Low Birth Weight Infants  To determine prematurity, rely on:  Physical features  Information from family about gestational dating  Information related to maternal or fetal complications Premature and Low Birth Weight Infants  To optimize survival in the field:  Provide cardiorespiratory support.  Provide thermoneutral environment.  Use only minimum pressure necessary to move chest when providing PPV. Premature and Low Birth Weight Infants  Assessment and management  Management focuses on: Clearing airway Gentle stimulation Administering supplemental oxygen and PPV if needed Providing chest compressions Maintaining a warm environment Seizures in the Newborn  Suggest the presence of neurologic disorder  Usually related to an underlying abnormality  Prolonged seizures may cause brain injury. Seizures in the Newborn  Types of seizures:  Subtle seizure  Tonic seizure  Spasm  Myoclonic Seizures in the Newborn  Assessment and management  Evaluate prenatal and birth history.  Perform a careful physical exam.  Obtain vital signs and oxygen saturation.  Provide additional oxygen, assisted ventilation, blood pressure evaluation, and IV access. Seizures in the Newborn  Assessment and management (cont’d)  If blood glucose level is less than 40 mg/dL, give an IV bolus of 10% dextrose solution.  Monitor respiratory status and oxygen saturation.  Maintain normal body temperature.  Keep family informed as you transport. Hypoglycemia  Blood glucose level of less than 45 mg/dL  May result in:  Seizures  Brain damage Hypoglycemia  Risk factors:  Disorders related to decreased glycogen stores  Increased use of glucose Vomiting  Common in newborns  Persistent or bilious vomiting in first 24 hours may indicate:  Upper digestive tract obstruction  Increased intracranial pressure  Vomitus aspiration may cause respiratory insufficiency or airway obstruction. Vomiting  Sudden, unexpected, and forceful vomiting may occur in conjunction with:  Asphyxia  Meningitis  Hydrocephalus Vomiting  Assessment and management  Stomach may be distended.  May have a fever or hypothermia  May also note: Temperature instability Apnea/bradycardia Abdominal tenderness/guarding Vomiting  Assessment and management (cont’d)  Start management with ABCs.  Consider decompressing the stomach.  Do not administer antiemetics.  May need fluid resuscitation if dehydrated  Place newborn on the side when transporting. Diarrhea  Assessment and management  Estimate: Number and volume of loose stools Decreased urinary output Degree of dehydration  Patient management begins with ABCs. Neonatal Jaundice  Considered pathologic when:  Clinically visible in first 24 hours  Serum bilirubin increases more than 5 mg/dL/d.  Bilirubin exceeds 12 mg/dL.  Conjugated bilirubin makes up greater than 20% of total serum bilirubin concentration.  Clinical jaundice persists for more than 1 week in full-term infants or for more than 2 weeks in preterm infants. Neonatal Jaundice  Assessment and management  Transport is essential.  Start on IV fluids if neonate shows significant clinical jaundice.  Communicate with medical control. Thermoregulation  Thermoregulation limited in newborns  Average normal temperature of newborn—37°C (99.5°F)  Range for neonate—36.6°C to 37.2°C (97.9°F to 99°F) © Jones & Bartlett Learning. Fever  Rectal temperature greater than 38°C (100.4°F)  Newborn may not always present with fever in an illness or infection.  May be caused by overheating or dehydration Fever  Limited ability to control their temperature.  Signs and symptoms include:  Irritability  Somnolence  Decreased feeding  Warm to touch Fever  Assessment and management  Examine for rashes.  Obtain history.  Note increased respiratory rate and work of breathing. Courtesy of Centers for Disease Control and Prevention. Fever  Assessment and management (cont’d)  Obtain vital signs and ensure adequate oxygenation and ventilation.  Cool the patient. Pathophysiology of Congenital Heart Disease  Congenital heart disease (CHD)  Most common birth defect  Can present with varying degrees of cardiorespiratory compromise Pathophysiology of Congenital Heart Disease  Noncyanotic disease (pink defects)  Oxygenated blood is shunted from the left side of the heart to the right side.  Called a left-to-right shunt Pathophysiology of Congenital Heart Disease  Atrial septal defect  Abnormal opening exists in the wall separating the atrial chambers of the heart.  Ventricular septal defect:  Abnormal opening exists in the wall separating the right and left ventricles. Pathophysiology of Congenital Heart Disease  Patent ductus arteriosus:  Ductus arteriosus does not close after birth.  If left untreated, patient could develop heart failure. © Jones & Bartlett Learning. Pathophysiology of Congenital Heart Disease  Cyanotic disease  Deoxygenated blood from the right side of the heart mixes with the left side.  Known as a right-to-left shunt Pathophysiology of Congenital Heart Disease  Pulmonary stenosis  Pulmonic valve near right ventricle becomes damaged.  Patient will present with: Jugular vein distention Cyanosis Right ventricular hypertrophy Pathophysiology of Congenital Heart Disease  Truncus arteriosus  Pulmonary and aorta arteries are combined.  Increases blood flow into the lungs  Will require surgical intervention © Jones & Bartlett Learning. Pathophysiology of Congenital Heart Disease  Tricuspid atresia  Tricuspid valve is missing.  Results in an undersized or absent right ventricle  Will have decreased blood flow into the lungs © Jones & Bartlett Learning. Pathophysiology of Congenital Heart Disease  Hypoplastic left heart syndrome  Left side of heart is completely underdeveloped.  Heart transplant may be needed if a surgical procedure cannot be performed or fails. Pathophysiology of Congenital Heart Disease  Tetralogy of Fallot (ToF)  Combination of four heart defects: Ventricular septal defect Pulmonary stenosis Right ventricular hypertrophy Overriding aorta  Open heart surgery is required. Pathophysiology of Congenital Heart Disease  Transposition of the great arteries (TGA)  Blood goes to the lungs, then returns to the lungs.  Blood from the body goes to the heart and returns to the body. © Jones & Bartlett Learning. Pathophysiology of Congenital Heart Disease  Total anomalous pulmonary venous return (TAPVR)  Four pulmonary veins connect to the right atrium instead of the left atrium.  Results in diminished oxygen and increased load on right ventricle  Assessment and Management of Congenital Heart Disease  Rapid detection and transport are mandatory.  Communication with medical control is critical. Pediatrics The Respiratory System  Smaller tidal volume, double metabolic oxygen demand  Smaller functional residual capacity  Faster breathing The Cardiovascular System  Children rely on pulse rate to:  Compensate for decreased oxygenation  Maintain cardiac output Primary Survey  Use the PAT to form a general impression. Used with permission of the American Academy of Pediatrics, Pediatric Education for Prehospital Professionals, © American Academy of Pediatrics, 2000. Primary Survey  Appearance  Often the most important factor in determining the severity of illness, need for treatment, and response to therapy © Photos.com/Getty.  Appearance (cont’d) Primary Survey life-support interventions and transport.  A child with a grossly abnormal appearance requires immediate Courtesy of Health Resources and Services Administration (HRSA), Maternal and Child Health Bureau (MCHB), Emergency MedicalServices for Children (EMSC) Program. Primary Survey  Work of breathing  Reflects attempt to compensate for abnormalities in oxygenation, ventilation Hands-on Primary Survey  Airway  Determine whether airway is open and patient has adequate chest rise with breathing.  If there is potential obstruction, position airway and suction as necessary. Hands-on Primary Survey  Breathing  Calculate the respiratory rate.  Auscultate breath sounds.  Check pulse oximetry. Hands-on Primary Survey  Circulation  Integrate information from PAT.  Listen to the heart or feel pulse for 30 seconds. Double the number to get pulse rate.  After checking the pulse rate, do a hands-on evaluation of skin CTC. Hands-on Primary Survey  Disability  Use the AVPU scale or Pediatric Glasgow Coma Scale to assess level of consciousness. Assess pupillary response. Evaluate motor activity.  Combine this information with PAT to determine neurologic status. Hands-on Primary Survey Hands-on Primary Survey  Exposure  Perform a rapid exam of the entire body.  Avoid heat loss, especially in infants.  Cover child as soon as possible. Transport Decision  Transport immediately for trauma with:  Serious MOI  Physiologic abnormality  Significant anatomic abnormality  Unsafe scene  Attempt vascular access en route. Secondary Assessment  Attempt to take the child’s blood pressure on the upper arm or thigh.  Minimal systolic blood pressure = 70 + (2 × Age in years) Secondary Assessment  Pediatric pain  When assessing pain: Consider developmental age. Discuss child’s pain with caregivers. Use pain scales with pictures. Secondary Assessment  Pediatric pain (cont’d)  Consider pharmacologic methods: Acetaminophen Opiates Benzodiazepines Nitrous oxide  Weigh benefits and risks of administration. Reassessment  Includes the following:  PAT  Patient priority  Vital signs  Assessment of interventions  Reassessment of focused exam areas Respiratory Arrest, Distress, and Failure  Determining severity of illness will indicate urgency of treatment and transport.  Obtain SAMPLE history on scene or during transport. Shock  Compensated shock  Critical abnormalities of perfusion  Body is able to maintain adequate perfusion to vital organs.  Intervention is needed to prevent child from decompensating. Shock  Decompensated shock  State of inadequate perfusion  Child will be profoundly tachycardic and show signs of poor peripheral perfusion.  Hypotension is a late and ominous sign.  Start resuscitation on scene. Hypovolemic Shock  Most common cause of shock in infants and young children  Loss of volume due to illness or trauma  Early signs may include: Tachycardia Pale or mottled skin Cool extremities Hypovolemic Shock  Management  Position of comfort  Supplemental oxygen  Keep the child warm.  Direct pressure to stop external bleeding  Volume replacement Hypovolemic Shock  With compensated shock, you can attempt IV or intraosseous (IO) access en route. © Jones & Bartlett Learning.  Bradydysrhythmias Reprinted with permission. Web-based Integrated 2015 American Heart Association Guidelines for CPR and ECC—Part 12: Pediatric Advanced Life Support © 2015 American Heart Association, Inc. Reprinted with permission. Web-based Integrated 2015 American Heart Association Guidelines for CPR and ECC—Part 12: Pediatric Advanced Life Support © 2015 American Heart Association, Inc. Pediatric Cardiac Arrest Algorithm Traumatic Brain Injury (TBI)  Head trauma is common in childhood.  Small number of children who appear to be at low risk may have an intracranial injury.  Evaluate any child with head injury for signs of potential abuse. Traumatic Brain Injury (TBI)  Epidural hematoma  Subdural hematoma  Hemorrhage into space  Hemorrhage into space between the dura and skull between dura and  Child abuse accounts for arachnoid membranes significant number of cases  Suspect abuse until proven in infants and children. otherwise. Traumatic Brain Injury (TBI)  Management includes stabilization of airway, breathing, and circulation.  Perform frequent neurologic checks. Brief Resolved Unexplained Event (BRUE)  Episode during which an infant:  Becomes pale or cyanotic;  Chokes, gags, or has an apneic spell; or  Loses muscle tone  Causes range from benign to serious diagnoses. Brief Resolved Unexplained Event (BRUE)  Provide life support with signs of cardiorespiratory compromise or altered mental status.  Transport all infants with a history of BRUE. Pediatric Trauma Emergencies  Anatomy and physiology make injury patterns and responses different from those seen in adults.  Developmental stage will affect response. Pathophysiology of Traumatic Injuries  Blunt trauma is the MOI in most pediatric injury cases.  Less muscle and fat mass leads to less protection against forces transmitted. Pathophysiology of Traumatic Injuries  Falls are common.  Injury will reflect child’s anatomy and height of fall.  Falls from a standing position usually result in isolated long bone injuries.  High-energy falls result in multisystem trauma.  Injuries from bicycle handlebars typically produce intraabdominal compression injuries. Pathophysiology of Traumatic Injuries  Motor vehicle crashes can result in a variety of injury patterns depending on restraints and position in car.  For unrestrained passengers, assume multisystem trauma.  Suspect spinal fractures with chest or abdominal bruising in a seat belt pattern. Assessment and Management of Traumatic Injuries  Begin with a thorough scene size-up.  Use PAT to form a general impression.  If findings are grossly abnormal, move to ABCs.  Initiate life support interventions. Assessment and Management of Traumatic Injuries  Pneumothorax may be present with penetrating trauma of the chest or upper abdomen.  Perform needle decompression.  Signs and symptoms may include: Tachycardia Jugular vein distention Pulsus paradoxus Assessment and Management of Traumatic Injuries © American Academy of Orthopaedic Surgeons. © American Academy of Orthopaedic Surgeons. Assessment and Management of Traumatic Injuries  Any trauma patient should be considered at risk for developing shock.  Once ABCs are stabilized, continue assessment of disability with AVPU. Assessment and Management of Traumatic Injuries  Place a cervical collar, and immobilize on a long backboard as indicated.  Perform rapid exam to identify all injuries.  Cover the child with blankets.  Treat any fractures. Transport Considerations  Some traumas are load-and-go because of severe injuries and unstable condition.  For these situations:  Perform lifesaving steps on scene or en route.  Transfer quickly per local trauma protocols. Transport Considerations  All trauma victims with suspected spinal injury require spinal stabilization.  Do not place a collar that is too big on a child. © Mark C. Ide. Geriatrics Geriatric Anatomy and Physiology  Aging process begins in the late 20s, early 30s.  Organ and tissue aging may be accelerated by:  Genetics  Preexisting disease  Diet and activity levels  Toxin exposure  Geriatric Anatomy and Physiology  Aging rate varies from person to person.  Decrease in functional capacity is normal. Courtesy of the National Cancer Institute. Changes in the Respiratory System  Respiratory capacity undergoes a large reduction with age.  Vital capacity decreases, and residual volume increases.  Changes in blood flow distribution in the lungs result in declining PaO2. Changes in the Respiratory System  Decreased sensitivity/CNS response to arterial blood gases changes  Limited lung volume and maximal inspiratory pressure  Limited chest expansion Changes in the Respiratory System  The ability to modify respiratory rate/tidal volume in response to changes is limited.  Defense mechanisms are less effective. Changes in the Cardiovascular System  The cardiovascular system decreases in efficiency with age.  Heart hypertrophies Changes in the Cardiovascular System  Arteriosclerosis adds to systolic hypertension  Diabetes  Atherosclerosis  Renal compromise © Jones & Bartlett Learning. Changes in the Cardiovascular System  Vascular stiffening occurs as collagen and elastin production changes with age.  In aortic sclerosis, the aortic valve thickens from fibrosis and calcification.  Peripheral vessel walls lose elasticity. Changes in the Cardiovascular System  The heart’s electrical conduction system undergoes changes over time.  The number of pacemaker cells decreases with age.  Bradycardia can occur.  Failure of the SA node can lead to atrial dysrhythmias. Changes in the Cardiovascular System  Aging makes the cardiovascular system more vulnerable to dysfunction.  Potential cardiac compromises should be recognized and treated quickly. Changes in the Nervous System  A neurologic exam will reflect aging-related changes in the nervous system.  The brain decreases in weight and volume. Changes in the Nervous System  As mental function declines, so does the regulation of:  Respiratory rate and depth  Pulse rate  Blood pressure  Hunger and thirst  Temperature Sensory Changes  Most sensory organs decline with age.  Do not assume geriatric patients are deaf or blind.  Vision changes may begin as early as 40 years. Cataracts Glaucoma Sensory Changes  Visual acuity decreases even without disease  Difficulty seeing at night  Inability to adjust to rapid changes  Presbyopia (far-sightedness)  Difficulty differentiating between colors Sensory Changes  Gradual hearing loss is common.  Hearing aids:  Consist of a microphone and an amplifier  May fit in the ear canal  Mainly battery operated © Maxx-Studio/Shutterstock. Sensory Changes  Ménière disease: hearing-related impairment  Onset in middle age  Symptom cycles last several months: Vertigo Hearing loss and tinnitus Pressure in ear Sensory Changes  Other sensory changes:  Changes in appetite  Decrease in sense of touch  Sense of smell last to diminish Sensory Changes  Changes may make it difficult to produce speech that is loud enough, clear, and well spaced.  Sense of body position may become impaired. Changes in the Digestive System  Changes may be first noted in the mouth.  Fewer taste buds  Reduction of saliva  Dental loss Changes in the Digestive System  Ill-fitting dentures may cause risk of:  Choking  Heartburn  Abdominal pain Changes in the Digestive System  Gastric secretions are reduced.  Heart burn  Indigestion  Acid reflux Changes in the Digestive System  Slight changes in small and large bowel functions from aging  The rectal sphincter decreases in size and strength, causing incontinence.  Slowing peristalsis causes increased constipation. Changes in the Digestive System  Constipation also caused or worsened by:  Some medications  Diet changes  Decreased physical activity  Can cause straining bowel movements Changes in the Digestive System  Hepatic enzyme changes: some activity declines and others’ increases.  Enzyme systems that detoxify drugs decline.  Taking numerous medications increases the risk for hepatic damage or drug toxicity. Changes in the Renal System  Kidneys decline in weight with age.  Loss of functioning nephron units  Small effective filtering surface Changes in the Renal System  Aging kidneys respond slowly to sodium deficiency, causing electrolyte imbalance.  Rapid development of severe dehydration  Exacerbated by decreased thirst mechanism Changes in the Renal System  At risk of overhydration with large sodium loads  Lower glomerular filtration rate.  The patient is prone to serious or lethal hyperkalemia if he or she becomes acidotic or the potassium load is increased. Changes in the Endocrine System  Greater risk for developing type 2 diabetes.  Difficulty metabolizing carbohydrates  Comorbid disorders (medications can affect glucose metabolism) Changes in the Endocrine System  Increase in ADH as people age:  Causes electrolyte and fluid imbalances  May present as pedal or other peripheral edema  Menopause: decrease in hormone secretion Changes in the Immunologic System  Every immune system function is affected by aging.  More prone to infection and secondary complications.  Infections manifest differently in older people. Changes in the Integumentary System  Wrinkling and resiliency loss in skin  Thinner, drier, less elastic, more fragile skin  Subcutaneous fat thinner, bruising  Decreasing elastin and collagen  Skin more prone to tenting in skin turgor tests Changes in the Integumentary System  Sebaceous glands produce less oil, so the skin is drier.  Decreased sweat gland activity  Thinner or no hair  Gray or white hair Changes in the Integumentary System  Blood vessels are affected by atherosclerosis, providing less oxygenated blood to the skin.  Production of new skin takes longer  Thin and brittle fingernails and toenails Homeostatic and Other Changes  Homeostatic capabilities decrease with age.  Thirst mechanism  Temperature regulating mechanism  Blood glucose regulatory system Changes in the Musculoskeletal System  Decrease in bone mass in men and women  Causes brittle, easily breakable bones  Joint problems  Tendons and ligaments lose elasticity  Synovial fluids thicken  Cartilage decreases Changes in the Musculoskeletal System  Height decreases, posture changes.  Arthritic joints increase.  Muscle mass and strength decrease.  Muscles atrophy from prolonged immobility. Changes in the Musculoskeletal System  More susceptible to bone fractures from falls  Falls more likely to occur  Difficulty with tasks requiring fine motor coordination or hand and finger strength Primary Assessment  Use GEMS diamond to form a general impression.  G—Geriatric patient  E—Environmental assessment  M—Medical assessment  S—Social assessment Primary Assessment Primary Assessment  Airway and breathing  Geriatric patients are predisposed to airway problems.  Ensure airway is not obstructed.  Anatomic changes lessen effective breathing.  Treat with oxygen as soon as possible. Primary Assessment  Circulation  If circulation is compromised, the patient has fewer reserves in a circulatory crisis. Lower heart rate Radial pulse difficult to find Heart rhythm issues and irregular pulse  Treat with oxygen as soon as possible. Primary Assessment  Transport decision  Determine life-threatening conditions.  Treat to the best of your ability.  Provide transport to priority patients.  Older people will easily decompensate. History Taking  Use good communication skills.  Thoroughly take a history if possible.  Listen to the patient; wait for answers.  Explain the plan.  Preserve the patient’s dignity. History Taking  Comprehensive history includes:  Chief complaint  Present illness or injury  Pertinent medical history  Current health care status and needs History Taking  Pertinent medical history includes:  Current cardiovascular health  Exercise tolerance  Diet history  Medications  Smoking and drinking habits  Sleep patterns  Other intrinsic and extrinsic factors History Taking  Determining the chief complaint may be difficult because patients might:  Believe symptoms are just part of getting old  Ignore legitimate symptoms because they don’t want to be labeled a hypochondriac  Underreport symptoms or report vague symptoms History Taking  If the chief complaint seems trivial, use a standard list of screening questions to evaluate major organ systems functions.  The list should be designed to evaluate major organ systems functions.  Follow up on any positive answers. History Taking  After deducing the chief complaint, conduct a history of present illness.  May be difficult to separate from chronic problems How does this differ from last week? What happened today to make you call? History Taking  Obtain a detailed history of medications.  Have the patient list by name, dosing and frequency, and provider.  Obtain permission to bring medications to the hospital. Secondary Assessment  Adjust usual methods to fit older patients.  Limit physical manipulation.  Be aware of body temperature.  Only remove clothing as necessary for inspection and palpation, and re-cover immediately. Secondary Assessment  Postural BP changes vary with older people.  Marked BP changes and pulse rate—possible hypovolemia or overmedication  Normal BP tends to be higher. Secondary Assessment  Observe respiratory rate.  Tachypnea can indicate acute illness.  Take lung sounds in all fields.  Listen for carotid bruits and note JVD.  Note any dentures. Reassessment  Reassess often: conditions deteriorate quickly.  Repeat primary assessment.  Reassess vital signs.  Reassess the patient’s complaint.  Recheck interventions.  Treat changes. Polypharmacy and Medication Noncompliance  Polypharmacy becomes problematic when medications interact.  The chance of being hospitalized increases with the number of medications.  Medications may not be received because of caregiver theft. Polypharmacy and Medication Noncompliance  Noncompliance includes:  Failure to fill prescription  Administering medication improperly  Taking inappropriate medication Polypharmacy and Medication Noncompliance  Other issues:  Taking medication prescribed by different doctors who don’t know the full medication regimen  Taking medication prescribed for someone else  Difficulty understanding the drug regimen  Difficulty opening medication containers Pharmacokinetics  Toxic effects of drugs from aging-related alterations in pharmacokinetics  Predisposed to reactions by physiologic changes in body systems and composition  Medications affecting the CNS are the most common source of adverse reactions. Pharmacokinetics  Reduction in nervous system response increases risk of adverse anticholinergic effects.  Reduced beta-adrenergic receptor sensitivity causes most bronchodilators to be ineffective. Pharmacokinetics  Diuretics, antihypertensive  Cause hypotension and orthostatic changes from reduced cardiac output, total body water decrease  Decreased glucose tolerance  Hyperglycemic effects from diuretics and corticosteroids Pharmacokinetics  Pharmacokinetics can be influenced by:  Diet  Smoking  Alcohol consumption  Other drug use Pharmacokinetics  Dosage often needs to be reduced.  Toxic effects present with:  Psychiatric symptoms  Cognitive impairment © Jones & Bartlett Learning. Geriatric Trauma Emergencies  Factors that place an older person at higher risk of trauma:  Slower reflexes and reduction in agility  Visual and hearing deficits  Equilibrium disorders  Reduction in agility Geriatric Trauma Emergencies  Less favorable outcomes in trauma due to:  Changes in homeostatic compensatory mechanisms  Aging effects on body systems  Preexisting conditions Geriatric Trauma Emergencies  Successful treatment when trauma-related blood loss is compensated enough for:  Increased pulse rate  Increased respirations  Adequate vasoconstriction Geriatric Trauma Emergencies  Unsuccessful recovery likely if:  Decreased respiratory function  Impaired renal activity  Ineffective vasoconstriction  More likely to sustain serious injury due to:  Stiffened blood vessels  Fragile tissue  Demineralized bones Geriatric Trauma Emergencies  Most cases involve falls or motor vehicles  Falls are associated with:  Higher incidence of anxiety and depression  Loss of confidence  Postfall syndrome Geriatric Trauma Emergencies  Falls are divided into two categories:  Extrinsic causes  Intrinsic causes  Risk increases with preexisting gait abnormalities and cognitive impairment. Geriatric Trauma Emergencies Geriatric Trauma Emergencies  Home safety assessment by EMS  Check for: Clear pathway to and from bathroom Handrails in bathtubs and on steps Loose rugs or other objects on floor Wheelchair ramps with grip tape Geriatric Trauma Emergencies  Older adults are far more likely to be fatally injured in a motor vehicle crash.  At higher risk for crashes due to: Vision impairment Errors in judgment Underlying medical conditions Geriatric Trauma Emergencies  Conditions that can influence outcomes:  Cirrhosis  Congenital coagulopathy  COPD  Ischemic heart disease  Diabetes mellitus Pathophysiology  Head trauma: increased fragility of cerebral blood vessels, enlarged subdural space  Hematoma often develops over days or weeks.  As intracranial pressure increases: The patient’s state of consciousness becomes depressed. The patient becomes drowsy. Pathophysiology  Spinal cord injury and compression  Degenerative spinal changes cause arthritic spurs and vertebral canal narrowing.  Even a sudden movement of the neck may cause spinal cord injury. Pathophysiology  Chest injuries are exacerbated by rib brittleness and stiffening of the chest wall.  Abdominal trauma often causes liver injury.  Orthopaedic injuries are common results of falls. Pathophysiology  Burns have significant risk of morbidity and mortality, especially if:  Preexisting medication conditions are present  Defense mechanism against infection are weakened.  Fluid replacement is complicated by renal compromise.  Monitor hydration status. Pathophysiology  Heat gain/loss slowed by:  Internal temperature  Atherosclerotic vessels regulation slows.  Slowed circulation  Delayed ability to recognize temperature fluctuations  Decreased sweat production Pathophysiology  Thermoregulation affected  Half of hypothermia deaths by: are in older people.  Chronic disease  Hyperthermia death rates  Medications more than double in older  Alcohol use adults. Pathophysiology  Check for environmental emergencies in extreme hot and cold.  You may need to keep the patient compartment at higher-than-normal temperature. Assessment and Management of Trauma  Check mechanism of injury.  Check for possible medical problem before the trauma.  Initial management follows ABCDEs first. Assessment and Management of Trauma  Check for rib fracture when assessing breathing.  Obtain baseline BP.  Normal blood pressure may be hypotension in an older person. Assessment and Management of Trauma  Do neurologic status assessment using AVPU scale.  Try to obtain complete history of the event from the patient and bystanders. © Jones & Bartlett Learning. Courtesy of MIEMSS. Assessment and Management of Trauma  Obtain a list of regular medications, especially those that may affect treatment.  Beta blockers  Antihypertensives  Diabetes medications Assessment and Management of Trauma  Conduct secondary assessment, watching for signs of injury to the:  Head  Cervical spine  Ribs and abdomen  Long bones  Remember the patient’s pain perception may be decreased. Assessment and Management of Trauma  Additional treatment based on injuries  Be cautious about isotonic solutions.  Monitor cardiac rhythm throughout.  Preserve temperature.  Consider pain medication.  Immobilize the cervical spine before transporting.