PATIENTS WITH SPECIAL NEEDS

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1 PATIENTS WITH SPECIAL NEEDS This prtcl includes: Patient with trachestmies Patient n ventilatrs Patients with indwelling catheters Patients with gastrstmy tubes Bariatric patients GENERAL CONSIDERATIONS A. Treat the ABC s first. Treat the patient, nt the equipment. If the emergency is due t an equipment malfunctin, manage the patient using yur wn equipment. B. Parents and caretakers are usually trained in emergency management and can be f assistance t EMS persnnel. Listen carefully t the caregiver and fllw his/her guidance. C. When mving a special needs patient, a slw, careful transfer with tw r mre peple is preferable. (The bariatric ppulatin will require as many peple as pssible t safely mve the patient.) D nt try t straighten r unnecessarily manipulate cntracted extremities as it may cause injury r pain t the patient. D. Caregivers may als carry a brief medical infrmatin card r frm. The patient may be enrlled in a medical alert prgram where medical persnnel can get quick access t the patient s medical histry. E. Knwing which patients in yur respnse area have special needs and keeping a lg bk is encuraged. F. Children with chrnic illnesses ften have different physical develpment frm well children. Therefre, their baseline vitals may differ frm nrmal standards. The size and develpmental level may be different frm age-based nrms and length-based tapes used t calculate drug dsages. Ask the caregiver if the child typically has abnrmal vital signs (i.e., tachycardia, lw pulse ximeter reading, etc.) TRACHEOSTOMIES and VENTILATORS Basic EMT A. The patient shuld be examined fr ther pssible prblems. D nt assume the prblem is with the trachestmy tube and/r the ventilatr. B. Examine the patient quickly fr pssible causes f distress which may be easily crrectable, such as a detached xygen surce. C. Patients n mechanical ventilatin may exhibit sudden r gradual deteriratin, cardiac arrest, increased xygen demand, increased respiratry rate, retractins, and changes in mental status. D. Try t establish the patient s baseline respiratry status. Effective 7/1/11 Special Needs Patients Page 1 f 4

2 E. If n a ventilatr, remve the patient frm the ventilatr and ventilate with BVM and a secure xygen surce; there may be a prblem with the ventilatr r xygen surce. F. Accumulatin f debris may cause an bstructin. Suctin the trachestmy tube with a flexible suctin catheter. G. If still n imprvements, transprt immediately t the clsest, mst apprpriate facility. Initiate resuscitatin as needed. Advanced EMT / Paramedic A. If the trachestmy tube has an inner cannula, remve it; if the cannula is the cause f bstructin, there shuld be immediate imprvement. B. If there is n imprvement and the patient is in severe distress, the tube shuld be remved and attempt BVM ventilatin. If anther tube is available, insert int the stma and resume ventilatin. A standard endtracheal tube may be used r the used trachestmy tube that was remved may be reinserted after being cleaned. C. Refer t Respiratry Emergency Prtcl as needed. INDWELLING VENOUS ACCESS CATHETERS GENERAL CONSIDERATIONS A. Patients may have indwelling venus access catheters (central lines) in several lcatins. Sme f the devices are lcated under the skin and can be felt but nt seen. B. Cmmn emergencies invlving these catheters include: blckage f the line, cmplete r partial accidental remval, cmplete r partial laceratin f the line. Basic and Advanced EMT A. Always evaluate the patient fr cardivascular stability as sme cmplicatins may be lifethreatening. B. Patients may be experiencing cmplicatins fr their underlying medical cnditin; ask caregivers abut the patient s cnditin. If the line is blcked, d nt attempt t frce the catheter pen. C. Fr partial r cmplete remval, d nt attempt t reinsert. Apply dressing t the site and maintain pressure until bleeding has stpped. If the catheter was cmpletely remved, bring it with the patient t the hspital. D. Fr partial r cmplete laceratin f the line, clamp prximally t the laceratin with a padded clamp. Effective 7/1/11 Special Needs Patients Page 2 f 4

3 E. Fr patients with a sudden deteriratin begin basic resuscitatin and transprt (the patient may have a pneumthrax r internal bleeding). F. If there are fluids infusing thrugh the central line, determine the nature f the fluid and the time that the fluid was started. EMTs are nt t initiate, adjust, r discntinue the infusin. Per the State f Ohi EMS Bard s Psitin Paper in January 2004, EMTs are allwed t transprt a patient with a pre-existing medical device r drug administratin (MDDA) nt cvered in the EMT s scpe f practice. Cntact Medical Cntrl fr any cncerns r questins. Paramedic A. If the indwelling catheter is functinal and nt the cause f the emergency AND if unable t establish peripheral IV access fr emergent medicatin / fluid administratin, the paramedic wh has been trained t use central lines and has the apprpriate equipment may cntact Medical Cntrl and ask fr permissin t use the catheter. GASTROSTOMY TUBES GENERAL CONSIDERATIONS A. Patients with gastrstmy tubes may have cmplicatins f bstructin r disldgment. While these cmplicatins are nt life-threatening, the patient may require nn-emergency transprt t the hspital. A disldged tube needs t be replaced as sn as pssible. B. Patients with gastrstmy tubes frequently have prblems with regurgitatin and/r aspiratin. Transprt patient with head elevated when pssible. Be prepared t suctin as necessary. Basic / Advanced EMT / Paramedic A. Be aware f and address any ther pssible prblems frm their underlying medical cnditin. B. Cver the site with a sterile dressing and cntrl any bleeding with direct pressure. Effective 7/1/11 Special Needs Patients Page 3 f 4

4 BARIATRIC PATIENTS GENERAL CONSIDERATIONS A. Patients wh weigh greater than 300 punds are frequently classified as high risk because if the increased medical cmplicatins assciated with their excess weight. B. In EMS systems, they present the additinal prblem f mvement and transprtatin. C. These individuals have the right t expect prmpt and expert emergency medical care. Therefre, in rder t facilitate the care f these individuals withut risking the health f EMS wrkers, the fllwing prtcl is established. Basic / Advanced EMT / Paramedic A. In managing a patient with a weight ver 300 lbs., at n time shuld the patient be mved withut adequate assistance. EMS persnnel may be supplemented by law enfrcement r ther safety persnnel as apprpriate. B. Cnsider utilizatin f specialized bariatric transfer services in yur area. C. It may be necessary t remve drs, walls, r windws. The situatin is n different than extricatin frm a vehicle, althugh prperty damage may be higher. At all times the scene safety and the patient s life must be the pririties. D. The patient is t be placed n an adequate transfer device designed fr this ppulatin. E. It is recmmended that the patient be laded nt a ct that is in the lwest psitin and keep the ct in the lw psitin. F. It is necessary t ntify the hspital well in advance f yur arrival s that preparatins can be made in a timely fashin. G. If individuals in the cmmunity are knwn t fall within this special categry it is apprpriate t infrm them in advance f the type f assistance they can expect frm the EMS system, and help them make plans well in advance t assist yu. Ask the individual t identify themselves and their special needs when calling fr EMS assistance. Effective 7/1/11 Special Needs Patients Page 4 f 4

5 ABDOMINAL SPECIAL PAIN SITUATIONS / NAUSEA VOMITING TRACHEOSTOMIES BASIC AND VENTILATORS KEY BASIC EMT ADVANCED EMT PARAMEDIC MED CONTROL ASSESS OPEN AND AND MANAGE AIRWAY AIRWAY MAINTAIN CHECK O2 FOR SATS DETACHED >95% OXYGEN SOURCE, IF EVALUATE ON VENTILATOR PATIENT REMOVE CONDITION AND MANUALLY MONITOR VENTILATE VITAL PATIENT SIGNS SUCTION HYPOPERFUSION PATIENT (BP IF INDICATED < 100 SYSTOLIC) OBTAIN REMOVE MEDICAL CANNULA HISTORY IF IT IS CAUSE OF OBSTRUCTION NAUSEA/VOMITING MAINTAIN SURGERY O2 SATS >95% EVALUATE TRAUMA PATIENT CONDITION MONITOR REASSURE VITAL PATIENT SIGNS REASSURE GIVE NOTHING PATIENT BY MOUTH TRANSPORT IN POSTIION OF COMFORT REMOVE IV NS (RUN TUBE TO IF MAINTAIN PATIENT PERFUSION) REMAINS IN DISTRESS AND MONITOR REPLACE ECG WITH NEW TRACH TUBE OR ET TUBE CONSIDER PAIN MANAGEMENT PROTOCOL IF NO IMPROVEMENT SEE RESPIRATORY DISTRESS PROTOCOLS

6 ABDOMINAL SPECIAL SITUATIONS PAIN / NAUSEA INDWELLING VOMITING CATHETERS KEY BASIC EMT ADVANCED EMT PARAMEDIC MED CONTROL ASSESS OPEN AND AND MANAGE MANAGE AIRWAY AIRWAY MAINTAIN O2 O2 SATS SATS >95% >95% EVALUATE PATIENT CONDITION MONITOR IDENTIFY VITAL ALL SIGNS LOCATIONS OF CENTRAL LINES HYPOPERFUSION (BP < 100 SYSTOLIC) OBTAIN CHECK MEDICAL LINES FOR HISTORY BLOCKAGES, LACERATIONS, NAUSEA/VOMITING OR ACCIDENTAL REMOVAL. SURGERY IF LINE IS BLOCKED DO NOT ATTEMPT TO TRAUMA FORCE OPEN IF LINE IS LACERATED CLAMP LINE REASSURE PATIENT CLOSE TO LACERATION GIVE NOTHING BY MOUTH CHECK LINE AT INSERTION SITE TRANSPORT IF PARTIALLY IN POSTIION REMOVED OF COMFORT DO NOT ATTEMPT TO PUSH THE LINE BACK IN IF COMPLETE REMOVED MAINTAIN PRESSURE TO STOP BLEEDING MONITOR VITAL SIGNS REASSURE PATIENT TRANSPORT MAY USE IF CENTRAL NAUSEA AND LINE VOMITING FOR IV ACCESS PRESENT WITH CLEARANCE FROM MEDICAL CONTROL IF PROPERLY TRAINED ADMINISTER AND ONDANSETRON HAVE APPROPRIATE (ZOFRAN) EQUIPMENT 4MG SLOW IV PUSH OR IM

7 ABDOMINAL SPECIAL SITUATIONS PAIN / NAUSEA GASTROSTOMY VOMITINGTUBES KEY BASIC EMT ADVANCED EMT PARAMEDIC MED CONTROL ASSESS OPEN AND AND MANAGE MANAGE AIRWAY AIRWAY MAINTAIN PROBLEM O2 SATS WITH >95% TUBE MAY BE RESULT OF EVALUATE REGURGITATION PATIENT CONDITION OR ASPIRATION MAINTAIN MONITOR O2 VITAL SATS SIGNS >95% EVALUATE HYPOPERFUSION PATIENT CONDITION (BP < 100 SYSTOLIC) CHECK OBTAIN TUBE MEDICAL FOR HISTORY DISLODGEMENT IF NAUSEA/VOMITING TUBE IS REMOVED DO NOT ATTEMPT TO REPLACE SURGERY THE TUBE COVER TRAUMA SITE WITH STERILE DRESSING AND REASSURE CONTROL PATIENT BLEEDING WITH DIRECT PRESSURE MONITOR GIVE NOTHING VITAL BY SIGNS MOUTH REASSURE TRANSPORT PATIENT IN POSTIION OF COMFORT TRANSPORT

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