Lesson 9
Special Considerations
Overview (1 of 2)
• Pediatrics
• Geriatrics
• Multiple patient
situations
• Trauma
resuscitation issues
Overview (2 of 2)
• In the United States, trauma is the most
common cause of death in children
• The elderly are the fastest growing subset
in our population
Our Bodies Change Over Time
• There are anatomic
differences between
infants, children, and
adults
• Body systems continue
to develop and mature
in the young
• Aging body systems
show signs of
dysfunction
ABCs
• Airway
– Anatomic differences
• Age and size of the patient affects equipment
choice
• Breathing
– Respiratory complications
• Circulation
– Pediatric patients compensate well but
deteriorate quickly
– Geriatric patients compensate poorly and may
be on medications that affect pulse and blood
pressure
Anatomy and Physiology:
Pediatric (1 of 5)
• Less body fat, increased elasticity of
connective tissue, and close proximity of
organs to the body surface impair
dissipation of energy applied
• Incomplete calcification of bones and
active growth centers limit absorption of
energy and can increase potential for
injury
Anatomy and Physiology:
Pediatric (2 of 5)
• Larger head and tongue
– Special attention to positioning
– Potential for airway obstruction
• Conical-shaped trachea
– Uncuffed versus endotracheal tubes
• Shorter trachea
– Danger of main stem intubation
Anatomy and Physiology:
Pediatric (3 of 5)
Anatomy and Physiology:
Pediatric (4 of 5)
• Respiratory concerns
– Hypoventilation and hypoxia are more likely
than hypovolemia and hypotension
– Injured children can rapidly deteriorate from
labored breathing to tachypnea and progress
to apnea from exhaustion
Anatomy and Physiology:
Pediatric (5 of 5)
• Shock
– Most pediatric injuries
do not cause
immediate
exsanguination
– Blood pressure is a
poor indicator of blood
loss and peripheral
perfusion
– Children remain in
compensated shock
longer than adults, but
decline very rapidly
Managing Pediatric Patients
(1 of 5)
• Airway and breathing
– Ensure airway patency
– Provide supplemental oxygen
– Assist ventilations when indicated
• A bag-mask device may be adequate
• Intubate only if bag-mask device is not effective
– Tachypnea and increased effort to breathe
can indicate shock
– Monitor for signs of respiratory fatigue
Managing Pediatric Patients
(2 of 5)
• Circulation
– Evaluate skin color, temperature, and
peripheral perfusion
– Pediatric patients may not show signs of
hypotension until 30% of volume is lost
– Decreasing pulse rate in the face of shock is
an ominous sign
– Fluid replacement
• 20 ml/kg bolus
• May repeat based on clinical response
Managing Pediatric Patients
(3 of 5)
• Disability
– Glasgow Coma Scale (GCS)
• Use the pediatric GCS for preverbal children
– Level of consciousness (LOC) is most
important factor
• A child who is lethargic or asleep rather than upset
may indicate hypoperfusion or traumatic brain
injury (TBI)
Managing Pediatric Patients
(4 of 5)
Managing Pediatric Patients
(5 of 5)
•
•
•
•
Use appropriately sized equipment
Preserve body heat
Frequently reassess patients
Transport:
– In an age-appropriate device
– To an appropriate facility
Anatomy and Physiology:
Geriatric (1 of 4)
• Overview
– The body gradually loses its ability to maintain
homeostasis
– Pre-existing conditions can increase mortality
from less severe injuries
– Malnourishment is common
– Geriatric patients may have:
• Slower cognitive responses
• Degenerative diseases
• Decline in sensory acuity
Anatomy and Physiology:
Geriatric (2 of 4)
• Airway and breathing
– Ventilatory function declines
• Increased stiffness in chest wall
• Alveolar surface decreases
• Decreased ability to saturate hemoglobin with
oxygen
• Circulation
– Pre-existing diseases may compromise
compensatory mechanisms
Anatomy and Physiology:
Geriatric (3 of 4)
• Disability
– Slower response to stimuli
– Declining mental and psychomotor activity
– Sensory changes
•
•
•
•
Hearing
Vision
Pain
Temperature regulation
Anatomy and Physiology:
Geriatric (4 of 4)
• Musculoskeletal
– Loss of height due to
dehydration of vertebral
discs
– Compressed spinal cord due
to narrowing of spinal canal
– Kyphosis
– Porous and brittle bones
– Loss of muscle mass
– Loss of range of motion
© Dr. P. Marazzi / Science Source
Management of Geriatric
Patients
• Airway and breathing
– Loss of soft tissue and teeth may make face
mask seal difficult
• Circulation
– Administer fluid
with caution
• Possibility of
fluid overload
© Medicimage/Visuals Unlimited, Inc.
Burns
Burns: Overview
• All burns are serious, regardless of size
• Burns are not just a skin injury
– Large burns involve multiple organ systems
• Smoke inhalation can be life-threatening
– It is often more dangerous than the burn itself
• Children account for 20% of all burn
victims
– Consider the possibility of intentional injury
(abuse)
Burn Assessment
(1 of 4)
• Depth of injury
– Superficial (first-degree)
– Partial-thickness (second-degree)
• Superficial
• Deep
– Full-thickness (third- and fourth-degree)
– Burn depth may evolve over time
Burn Assessment
(2 of 4)
Courtesy of Dr. Jeffrey Guy
Burn Assessment
(3 of 4)
Courtesy of Dr. Jeffrey Guy.
Burn Assessment
(4 of 4)
• Extent of burn
(burn size
estimation)
– Percent of
body surface
area (BSA)
involved
• Rule of nines
Burn Management:
Primary Assessment (1 of 3)
• Conduct the primary assessment
— Airway occlusion may occur as swelling
progresses
•
Consider early airway intervention
— Breathing may become compromised from
chest wall eschar or toxic pulmonary injury
•
Monitor ventilatory rate, SpO2, and ETCO2
Burn Management:
Primary Assessment (2 of 3)
• Circulatory status may be compromised
as fluid leaks into damaged tissue
causing swelling and hypotension
– Ensure IV access and fluid replacement
Burn Management:
Primary Assessment (3 of 3)
• Disability
—
Altered mentation suggests hypotension or
hypoxia
• Expose
—
—
Allows for complete assessment but may
lead to loss of body temperature
Cover patient upon completion of
assessment
Burn Management
(1 of 3)
• Specific burn therapy
– Stop any ongoing burning
– Cover with dry, sterile nonadherent dressing
(sheet)
• Do not use any ointments or other topical
antibiotic
Burn Management
(2 of 3)
• Specific burn therapy:
– Initiate fluid administration
• Parkland formula: total fluid in first 24 hours 
(2–4 ml)(body weight in kg)(% BSA burned)
– Half of total fluid should be given in the first 8 hours after
burn
– Second half of total fluid should be given in the next 16
hours after burn
– Adults receive lactated Ringer’s
– Pediatric patients receive 5% dextrose in lactated
Ringer’s
Burn Management
(3 of 3)
• Analgesia
– Adequate pain relief is critical
– Narcotic analgesics are indicated for
significant burns
– Ice is not a proper analgesic
• Leads to hypothermia
• May increase the overall size and depth of burn
• Transport to burn center as indicated
Extended or Delayed Transport
• Need to provide care for extended time
period
• Continue to provide same type and level of
care
• Be cautious of and monitor for:
– Hyperventilation
– Fluid overload
– Body heat loss
• Continually reassess the patient
Multiple Patient Situations
Multiple Patient Situations
(1 of 2)
• A multiple patient scenario occurs each
time there is more than one patient
• Are there sufficient resources available on
scene to manage all patients?
– Triage is used primarily when the number of
patients exceeds the immediate treatment
and/or transport capacity
Multiple Patient Situations
(2 of 2)
• Transport only one critical patient per
ambulance (ideally)
• When possible, distribute patients to all
available hospitals
– Avoid overloading the closest hospital when
possible
Trauma Resuscitation Issues
Trauma Resuscitation Issues
(1 of 3)
• It may be allowable to withhold or
terminate resuscitation efforts in:
– Injuries not compatible
with life
– Pulseless and nonbreathing
blunt trauma victims
– Trauma patients with
witnessed cardiopulmonary
arrest and 15 minutes of
unsuccessful resuscitation and CPR
Courtesy Norman McSwain, MD, FACS, NREMT-P
Trauma Resuscitation Issues
(2 of 3)
• Special consideration in trauma
resuscitation must be given to victims who
have greater likelihood of survival,
including:
– Hypothermia
– Immersion incidents
– Lightning strike
– Other situations as defined by local protocol
Trauma Resuscitation Issues
(3 of 3)
• In many EMS systems, online medical control
is necessary to confirm the decision to
terminate resuscitation efforts
• Policies and protocols for termination of
resuscitation efforts:
– Should be developed and implemented under the
guidance of the EMS system’s medical director
– Should include notification of the appropriate law
enforcement agencies and medical examiner
• EMS providers should have access to
resources for debriefing and counseling as
needed
Summary
• EMS providers will
often encounter
special patient
populations and
situations
• Awareness of the
unique aspects of
each will optimize
patient management
and outcome
© EML/ShutterStock, Inc.
© Photodisc
© Roger Nomer/AP Images
Questions?