HAN 416 Final Exam

Head size in pediatric patients

- proportionately larger in infants

increases risk of blunt head trauma

Airway positioning for children <3 years old

Place padding under the back for neutral position

Airway positioning for children 3 years and older

Place padding under the occipital for sniffing position

Airway characteristics in pediatric patients

- narrower airways

- obligate nose breathers

- tongue is proportionally larger

- trachea is softer and more flexible

- larynx is higher and the cricoid ring is the narrowest part

- epiglottis is omega-shaped in infants

avoid neck hyper extension

What is the Cole formula?

endotracheal tube ETT sizing

Age/4 + 4

consider cuffed tubes; select 1/2 size smaller

Depth estimation for ETT sizing

Age/2 + 12 or 3x the ETT size

True or false- lung tissue in pediatrics is more fragile than that of adults.

True

True or false- infants/children are diaphragmatic breathers.

True

True or false- pediatric patients are prone to gastric distention.

True

True or false- pediatric patients are at greater risk for temperature extremes; increased risk of dehydration and hypothermia.

True

Oxygen needs in pediatric patients

Double the metabolic oxygen requirement compared to adults

oxygen reserves are proportionately smaller

Blood volume in pediatric patients

Smaller absolute volume; smaller loss needed for shock.

Blood pressure in pediatric patients

Pediatric can maintain BP longer than adults, but shock risk is high.

hypotension is a LATE and ominous sign

- minimum SBP estimate: 70 + (age in years X2)

True or false- pediatrics are prone to hypothermia due to larger BSA-to-weight ratio.

True

newborns/neonates cannot shiver

AED use on pediatric patients

- use pediatric pads/attenuator for children <8 years old if available.

- use adult pads if pediatric pads are unavailable; ensure pads DO NOT TOUCH.

- follow manufacturer instructions for placement; turn on AED first.

Pediatric assessment triangle (PAT)

rapid assessment tool for overall physiological status

- appearance

- work of breathing

- circulation to skin

Respiratory distress

Increase work of breathing with adequate gas exchange.

Signs: nasal flaring, retractions, abnormal airway sounds, tachyons, tachycardia, pallor, and anxiety

Respiratory failure

Compensatory mechanisms fail; hypoxia/hypercarbia occur. Requires urgent intervention.

Signs: altered mental status, decreased/absent retractions (fatigue), an abnormal rate (bradypnea)

Respiratory arrest

Absence of spontaneous breathing; requires BVM.

Progression of respiratory emergencies

Distress ——-> Failure ——-> Arrest

Croup (larygnotracheobronchitis)

Viral upper airway infection

- Barky cough, stridor, worse at night.

- treatment: position of comfort, avoid agitation, dexamethasone

Pertussis (whooping cough)

Highly contagious bacterial infection. Starts like a cold, progresses to severe cough.

maintain airway, O2 and transport

What is shock syndrome?

Inadequate oxygen/nutrient delivery to tissues

Hypovolemic shock

Decreased circulating volume (fluid loss)

- can be hemorrhagic or non-hemorrhagic

Distributive shock

Impaired vascular tone, decreased SVR and increased permeability.

Ex: septic, anaphylactic, and neurogenic

Cardiogenic shock

Myocardial dysfunction (inadequate cardiac output)

Ex: arrhythmias, ductal-dependent lesion, etc.

Obstructive shock

Physical obstruction of great vessels/heart.

Ex: tension pneumothorax, cardiac tamponade, pulmonary embolism, etc.

Female reproductive organs

1. Ovaries (2)

2. Fallopian tubes (2); oviducts

3. Uterus

4. Cervix

5. Vagina

6. Mammary glands

7. Fimbriae

8. Endometrium

Cervix

Connects the uterus to the vagina

Ovaries and follicles

- each ovary contains approximately 200,000 follicles

- each follicle contains an egg (ovum)

- monthly, several follicles mature but usually only one releases an ovum

Hormonal regulation in female reproductive system

- anterior pituitary gland releases follicle-stimulating hormone (FSH) to mature the oocyte.

- anterior pituitary gland releases luteinzing hormone, estrogen, and progesterone.

- prostaglandins and oxytocin trigger uterine contractions and labor

Ovum transport

- ovum travels from ovaries to uterus via fallopian tubes

- ciliary motion and smooth muscle contractions aid in ovum movement.

Uterus

- located between the urinary bladder and the rectum.

- functions: fertilized ovum implantation, fetal development, and labor.

Placenta

Provides blood supply from the mother to the fetus.

Umbilical cord

Provides blood supply to the fetus and connects the fetus to the placenta.

there is ONE umbilical vein and TWO umbilical arteries

Functions of the vagina

- receives penis during intercourse

- passage for menstrual flow

- passage for childbirth

Mammary glands

- primary purpose; lactation

- signs that a woman is most likely pregnant: breast enlargement, tenderness, and milk excretion.

Early fetal development

- two weeks post-conception; blastocysts evolves into embryonic disc

- embryo begins to draw on maternal circulation at 2 weeks

- three weeks post conception; blastocyst becomes an embryo

- body systems form, heart beats and blood cells circulate by week 3.

Placental development

- develops in the fourth week

- functions: early liver function, antibody production, fetal lung function, nutrient transport and waste excretion, heat transfer from mother to fetus, and barrier against harmful substances.

Human Chorionic Gonadotropin (HCG)

Maintains pregnancy and stimulates maternal changes.

Umbilical vein

Carries oxygenated blood from the placenta to the fetus.

Umbilical arteries

Carry deoxygenated blood from the fetus to the placenta.

Amniotic sac and gestation

- encloses the fetus in amniotic fluid

- major organs and body systems form between the 4th and 8th week

What is the normal gestational period?

38 weeks

calculated from the first day of the pregnant woman's last menstrual period

Uterus changes during pregnancy

- pre-pregnancy: weighs about 2.5 oz with a fluid capacity of 10 mL

- end of pregnancy: weighs 2.24-2.6 pounds with a fluid capacity of 5 L

Fundus growth during pregnancy

Can indicate growth problems, breech position, or twins

Gastrointestinal changes during pregnancy

- pressure on intestines and rectum leads to constipation

- smooth muscle relaxation in the GI tract due to progesterone which causes heartburn and burping.

- delayed stomach emptying increases the risk of vomiting

Renal changes during pregnancy

- kidneys increase in size and volume; uterus increases in diameter

- increased urinary frequency and urinary tract infections

Other changes during pregnancy include...

1. Integumentary changes

2. Hemodynamic changes

3. Airway changes

4. Breathing changes

5. Circulatory changes

Positional considerations for pregnant patients

- sensitivity to body position increases with gestation

- supine position can compress the inferior vena cava or common iliac vein.

- compression can decrease cardiac output

- venous pressure increases progressively in the lower extremities late in pregnancy.

Factors to consider when transporting a pregnant patient

1. Appropriate hospital selection

2. Transport time

3. Access to the patient

4. Weather conditions

5. Patient stability

6. Fetal status

7. Crew configuration

8. Available resources

general treatment guidelines

Gravidity

Number of times pregnant

Parity

Delivery of an infant who is alive

Primigravida

Woman with only one pregnant

Primipara

Woman with only one delivery

Multigravida

Two or more pregnancies

Multipara

Woman who has had two or more delivers

Grand multipara

Woman with more than five delivers

Nullipara

Woman who has never delivered

GTPAL system

G: # of times pregnant

T: term births (after 37 weeks)

P: preterm births

A: abortions

L: living children

Dilation

Extent of cervical dilation is measured by palpation.

full dilation is 10 cm

Effacement

- thickness of the cervix, expressed as a percentage

- Normal cervix is 2 cm thick and thins during labor

- 50% effaced means the cervix is thinned to 1 cm

Station

- refers to the fetal head's position relative to the mother's ischial spines, measured in cm and expressed as a - or +.

- station 0 s when the fetal vertex is at the level of ischial spines

Stage 1 of labor consists of...

Early labor and active labor

Early labor

Cervix dilates and effaces; mild, irregular contractions, water breaks

Active labor

Cervix dilates from 6 cm-10 cm; contractions become stronger, closer and regular

What is stage 2 of labor?

Birth

Stage 3 of labor

delivery of the placenta

- placenta is delivered

- typically delivered in 30 minutes but can last as long as an hour.

True or false- high-risk OB patients are increasingly common due to women having children later in life.

True

3 step approach to resuscitate a high-risk OB patient

1. Resuscitate the mom

2. Resuscitate the fetus

3. Treat underlying causes

True or false- maternal hypotension and hypoxia are significant concerns for fetal well-being.

True

Treatment for high-risk OB patients

- positioning of the patient on her left side

- administering high-flow oxygen

- starting a second IV line

- administering a fluid bolus

- initiating a vasopressor; epinephrine/norepinephrine

Fetal resuscitation involves...

Addressing maternal hypotension and hypoxia and reducing contractions with medications like magnesium sulfate and terbutaline

True or false- regular assessment of the mother and the fetus is essential.

True

Early fetal heart rate decelerations

Head compression

Variable fetal heart rate decelerations

Cord compression

Late fetal heart rate decelerations

Fetal hypoxia or placental insufficiency

What is the normal fetal heart rate baseline?

110-160 bpm

accelerations and moderate variability are positive signs

What are the vasopressors used during pregnancy?

Norepinephrine (levophed) and epinephrine

What is a perimortem cesarean delivery?

An emergency procedure conducted when a pregnant woman experiences cardiac arrest, usually during resuscitation efforts, to relieve aortocava compression and facilitate both maternal and fetal survival.

should occur within 4 minutes of the start of arrest

Patient with special challenges may need modified:

1. Communications

2. Assessments

3. Treatment

4. Transport

Invaluable resources include:

- online medical control

- electronic medical reference materials

- coworkers' experience

True or false- poverty and lack of health insurance affect a person's health habits.

True

How many people in the U.S. live in poverty as of 2015?

43.1 million people

Homeless people are prone to:

- numerous chronic medical conditions

- mental illness

- substance abuse

Medical care of homeless people is difficult because of:

- environmental exposure

- crime/violence

- malnutrition

- lack of hygiene

Hospitals are frequently able to provide:

- financial assistance

- payment plans

- low-cost health care services

- help enrolling in insurance programs

Care of patients with terminal illness

- the focus changes to improving the quality of time left

- medical care continues, but aggressive interventions cease.

- the patient and caregiver often know the best way to manage sudden discomfort.

- assess for pain using techniques based on the patient's- age, ability to communicate and cognitive function.

Assessment of patients with terminal illness include:

1. Level of consciousness

2. Vital signs

3. Medical history

4. Pain medication history

follow standing protocols for medications and contact hospice care

Advance directives

- signed by the patient or surrogate decision maker

- instruct health care providers on medical decisions for when the patient is incapacitated

- can be revoked if the patient has decision-making capacity.

DNR orders

do not resuscitate

- physician orders to withhold resuscitation efforts in case of respirator or cardiovascular collapse

- may be generic or specifically discuss what methods are indicated or withheld.

What does MOLST stand for?

Medical orders for life-sustaining treatment

MOLST

- serves as a single document that contains a patient's goals and preferences regarding them

- instructions for intubation, mechanical ventilation, and resuscitation instructions.

- general treatment buildings

- future hospitalization and transfer

- artificially administered fluids and nutrition, antibiotics

- dialysis and other instructions about treatments not listed

True or false- under state law, the MOLST form is the only authorized form in the NYS for documenting both nonhospital DNR and DNI orders.

True

MOLST form

- May also be used for individuals who wish to avoid and/or receive specific life-sustaining treatments.

- generally for patients with advanced illness who require long-term care services and/or who might die within 1-2 years.

MOLST form page 1

- brief description of MOLST

- patient information (section A)

- urgent orders (Section B-C)

- consent (Section D)

- signatures of the authorized provider (section E)

- medical orders include resuscitation instructions, respiratory support, and transport orders.

MOLST form page 2

- provides additional orders regarding patient preferences for life-sustaining treatment

- primarily geared towards hospital or long-term phase of care

- useful guidance to EMS clinicians

MOLST form page 3

- a physician, NP, or PA should review the MOLST form at least 90 days or if the patient or other decisions maker changes their mind about treatment.

- should also be reviewed if the patient moves from one location to another for care or if there are major changes in the patient's health

- MOLST remains valid even if not reviewed in the 90 day period.

Healthcare proxy (agent)

A legal form that designates a health care agent. When the patient lacks capacity to make decisions, a health care agent has the authority to make all health care decisions, including the decision to remove life-sustaining treatment.

Living will

An advance directive that states an individual's wishes about medical care in the event an irreversible conditions prevents an individual from making their own medical decisions.