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Post by Kirsty C on Aug 9, 2015 1:42:19 GMT
We know that adults and children have differences in their form and function (anatomy and physiology). What are these differences? What impact do these differences have on our management? Should we be managing them differently? When assessing a child we must be mindful that they are not small adults due to their differences in anatomy and physiology and that some children also differ from other children. Children differ from adults in that they have differently shaped heads and necks and their heads are proportionally larger to their bodies. Children also have proportionally larger tongues. These physical differences have implications for Airway management and mechanism of injury given their heads will move around a lot more during trauma. When gathering information and examining children we must take into account the child’s age and consequently their psychological perception of us. Keep children with their caregiver with familiar toys and be mindful that we will be seen as strangers. Obviously a history will come from the caregiver if the child is an infant but children over 4 years may be able to give a meaningful contribution to your history taking and examination. Older children such as teenagers may prefer more privacy to discuss their illness or injury. A great tool to use is the Paediatric Assessment Triangle. This consists of Appearance, Work of breathing and circulation to skin. Initially this can be done from across the room in a short time to allow you to get a general impression of the severity of the child’s condition before you approach and potentially change the child’s demeanour. A more detailed assessment of these parameters must follow incorporating pertinent questions to your findings such as is this the child’s normal cry, how many wet nappies have they had today etc. Parents may also be stressed so keeping calm, taking charge and coaxing small children through an examination will be beneficial to all involved.
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Post by Barry on Aug 11, 2015 22:17:52 GMT
Hi Kirsty, Great answer but I would like you to explore more around the airway, can you tell me what the physical difference's are in detail please Also you mentioned trauma why don't we look at that as well, what do we need to consider with children in trauma? this also happens when its a medical problem as well. Look forward to your answer Barry
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Post by Barry on Aug 11, 2015 22:20:58 GMT
Yay I am first ok, the most important thing to remember when dealing with children is "Children are not small adults". There are a number of factors you need to take into consideration in regards to this statement. Their A&P is different to an adult in that their head is proportionately bigger. This is relevant because it has issues in regard to airway management and also head movement. The head movement we need to consider in a trauma situation. The questioning has to be directed at the caregiver for the little ones that can't answer for themselves. Easy questioning that is age appropriate for the rest of the age group. For our older age group, the teenagers, questioning in the ambulance in a private setting maybe more effective in that you get more honest answers than questioning them in front of their friends and family. With children the importance of the appearance of the patient gives you a lot of information. The signs you see rather than the symptom, for example a child who is SOB, you would be looking for the work of breathing, blue colouring around the lips, level of activity, capillary refill, skin turgor. Questioning of importance as in, how many wet nappies?, is this normal for them?, is this their normal cry? I think that the biggest difference between children and adults is the ability to deteriorate very quickly as their ability to compensate is limited before going into decompensating then respiratory arrest then cardiac arrest. Hi Kat, Great answer but I would like you to explore more around the airway, can you tell me what the physical difference's are in detail please Also you mentioned trauma why don't we look at that as well, what do we need to consider with children in trauma? this also happens when its a medical problem as well. Look forward to your answer Barry
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kat
New Member
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Post by kat on Aug 15, 2015 22:07:26 GMT
Hi Team, Here is you next 2 weeks question, give me some great answers as I look forward to what you think; Older people often fall and injure, even fracture, their hip. In particular the area that may fracture in a fall is at the neck of the femur – where the femur meets the pelvis. Why is it so common for older people to fracture their hip? What can be done to prevent this type of injury?
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Post by janell on Aug 23, 2015 2:37:31 GMT
Hi team! Hope all is well x. Anyway....Sorry for the delay Barry and sorry for the loooong reply haha but here goes my story lol... Firstly great answers Kat and Brendon! You've pretty much covered all but I just thought I could add a few things extra. As we know there are many differences and that children are NOT small adults. Children are going to be frightened just by seeing an ambulance with lights on etc! They will probably have reduced interaction and activity if they are really unwell or are badly injured. Children can only communicate to their vocabulary so gaining a good rapport and trust with child is a biggy. When questioning the patients guardian or parent it is also important to involve the child i.e allowing child to touch, play with tools and equipment. This might help them chill out abit. So before touching child I would be looking for signs of distress, colour,sweaty looking at activity of child as stated by Brendon. Asking guardians if this is their normal cry/behavior. When a child is unconscious the child's upper airway tends to get obstructed by their rather large, limp tongue or kinked because of head flexion caused by the prominent occiput. Children have narrower airways which could make inserting a OPA & LMA more difficult. Because a child's head and neck is slightly larger in comparison to their body this makes it difficult to manage their airway if need to. The adults palate is hard as in a child it is soft and hasn't quite developed so when inserting an OPA we would insert it by going straight in with out twisting like we would with an adult. Children have a faster respiratory rate and can only compensate through an increased heart rate. They rely on their rate of respiration to help get them through respiratory distress. This is because they can't inhale deeply as the diaphragm cannot move further downwards because there's no room. The tool we use to assess young kids especially those under 5 is the Paediatric Assessment Triangle (PAT). This involves an assessment of ACTIVITY (What is the child's movement, interaction and tone like?) BREATHING (What is the child's respiratory rate and work of breathing like?) and CIRCULATION (What is the child's HR and perfusion status?). IF the PAT is normal, children are unlikely to have an illness or injury. The more abnormal segments, the more severe of the child's illness or injury.
Why is it so common for older people to fracture their hip? What can be done to prevent this type of injury? Most hip fractures happen to the older people and they are usually caused by falls. As we age the Skeletal system can be effected by the thinning of bones (particularly in women but men can get it to) Also, our bones naturally loose their strength causing them more likely to break. Older people may also experience a loss of balance making falls more likely. So with inadequate balance, causing falls and a loss of strength and thinning of the bones, this is the possible cause of why it is common for older people to fracture their hips. Another thing I thought of was when a young/middle aged person falls we intend to use our quick reactions by putting our arms out to soften the landing. With older people there quick reactions can be delayed due to age or illnesses causing them to land on their hips and upper limbs. (Dunno if that's written anywhere but it was just a thought lol) Hip fractures could be reduced by making sure their home is safe. i.e removing clutter of grounds, ensuring adequate lighting, becoming aware of any slippery when wet surfaces and maybe installing grab bars in and around the house. My own honest opinion is whanau tautoko (Family support) can also be a huge help to ensuring the home is safe. Another thing could be exercise. Moderate exercise will maintain muscle strength and can also improve balance and coordination. Tai Chi is balance training and has been shown to improve body balance, Decrease falls and therefor reduce the risk of hip fractures.
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Post by Brendoon on Aug 23, 2015 22:18:52 GMT
Hiya, so older folk and hip fractures are common for a whole lot of reasons. Firstly I guess the bone density decreases as we get older so if we fall the chances of breaking a bone is greater. And as we get older our reflexes slow, eyesight, coordination and balance go, our muscles don't hold us up as well as they use to and we just get weaker. Could be impacted by poor nutrition, just not eating properly. Women in particular lose bone density earlier due to estrogen levels after menopause begins. It could be hereditary, bone disease, smoking and drinking and also the medications they are taking or changes in medication could increase the chances of a fall or bone density. Also if someone fractures their hip once then they are more susceptible to doing it again. Neck of femur fracture in particular happens when the foot gets planted and the rest of the body turns. And if you're not as nimble as you once were unplanting that foot even just turning round in the kitchen or garden may be difficult. Prevention for this type of injury would mean fall proofing Nan and Pops house and keeping them as healthy as possible. Older people in general seem to like having a lot of stuff around them, so just making sure rugs are down at the corners, leads tucked away, handrails installed? And this is my picture
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Post by Kirsty C on Aug 24, 2015 23:35:47 GMT
Hi Kirsty, Great answer but I would like you to explore more around the airway, can you tell me what the physical difference's are in detail please Also you mentioned trauma why don't we look at that as well, what do we need to consider with children in trauma? this also happens when its a medical problem as well. Look forward to your answer Barry The physical differences between children and adults in regard to the airway are that firstly children have a narrower airway so even small amounts of swelling have a relatively greater reduction in airway diameter, than in an adult. The tongue in children is relatively larger and in their smaller oral cavity it is more likely to obstruct the airway than in an adult. Positioning the head in an unconscious child leaves little room for error also. The back of the head is relatively larger so flexes the head forward which has implications for the airway. A Neutral position can be achieved by lifting the chin or putting a towel or something similar under their body. Care must be taken not to hyper extend the neck as this to can cause airway obstruction. Children also have a proportionally larger head to body ratio, weaker necks, thinner skulls and a larger subarachnoid space in which the brain can move around in more freely, than adults. This has implications for trauma as they are at a much greater risk of sustaining a serious head injury, even from a small fall or a minor accident, than adults.
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Post by Barry on Aug 26, 2015 0:35:52 GMT
Great answer however if we have a little one to deal with, what is the most important thing we have to deal with?
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Post by Ian Tanner on Aug 26, 2015 21:15:32 GMT
Hey guys-sorry been really slack on these.......no excuses.......Barry, in my opinion with little ones it is very important to deal with the adult caregiver as well-if they feel secure in the knowledge that the ambulance crew know what they are dealing with and are confidently managing the little patient and their equipment it will make them more relaxed, feel better about sharing vital information and will help convince the child/paed that the ambulance crew are the good guys and are there to help. If the caregiver is angry, scared, uninformed etc then it will make it very difficult to get useful information about the patient and having an upset caregiver will almost definitely result in an upset patient-quite possibly causing an increase in the patients condition-ie a child that is having an asthma attack will undoubtedly get more short of breath and more anxious seeing their caregiver upset, thus making a bad situation even worse. Having a calm crew will almost always result in a calm caregiver and hopefully this will result in a calmer or more manageable patient. In my recent experience, having a parent to cuddle their young baby on the way to hospital enabled me to administer my salbutamol/ipratropium (YES!!), listen to lung sounds, assess skin condition and breathing and get a comprehensive history from the parent-whilst the patient was getting more comfortable it was obvious that my charm.....and the treatment plan was working well as the patient had definite improvements during transport-it also allowed discussion between myself and the paramedic as to what the plan was and how we would manage down the track. I fully informed the parent during treatment and kept them up to date with what is and would happen. If the parent had been upset and it had affected the patient, it is almost certain that the patient would have dropped rapidly to status 1-was only just status 2 on arrival-and been a much different outcome. I do think that this is really no different from how we treat every other patient we treat, keeping them informed and being confident and relaxed is always going to be the best way to get the best result for the patient.
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Post by Barry on Aug 26, 2015 23:54:40 GMT
HI Ian, Well done ...yes you are right having the caregiver/parent calm is the most important thing as this relaxes the child generally so we can as A/O's do our job more effectively. Also getting the confidence of the child also is important and I have been known to be playing with their toys for 5 minutes so that I can get a connection to be able to treat them.
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Post by Ian Tanner on Aug 27, 2015 10:50:56 GMT
Hey team.....the elderly....have had the last few weeks full of elderly patients-growing old sucks!!
But I have also learnt some very valuable lessons and been taught some very cool tricks by the crews at Wanganui-the problem is interpreting the signals that are given. One lovely older lady was very receptive when I spoke to her like the adult she was, answering questions, allowing baseline vitals to be taken and allowing a thorough secondary survey to be carried out due to her slipping down some steps and getting a hurt, not dislocated hip. The very next patient would only talk to me and virtually ignored the female paramedic I was crewing with-even though she had all the good drugs-the roles then reversed with another elderly patient the following week, very hard to get information from, very uncooperative and very little history-but once he sees the lovely nurse at the hospital he starts singing like a bird about this condition and that medication.....frustrating. But to be honest, talking to the patient like they are a fully functioning adult, being a sympathetic ear to all sorts of problems aside from the one called to, doing the simple things like locking the door, putting the dog out, getting the suitcase and backpack of medicine to take to the hospital is always so effective in reassuring these patients who are almost always (in my limited experience) scared, frustrated, or just plain fed up with their conditions-especially when you listen to their fantastic stories of things they got up to when they were younger-dignity, respect, explaining everything before doing it, speaking to them and not at them, specific questioning and actually not only listening to their answers but looking at what they are saying-I have found elderly patients to be so tough and not wanting to worry anyone that they call 9 out of 10 pain a 3 or a 4 because its easier-all of these things I have found over the past few weeks to be especially crucial to get some great answers and treatment plans underway. Yes they are more frail, their bone density is not as good as youger patients, they have more medical conditions to document and treat-thats what we are there for-great to hear different lung sounds especially this time of year to be honest-but if we manage these patients well and use the new skills we are acquiring, we can make very big differences to a bit of a rough day-today was a good lesson day-we were called to a retirement village, to breathing difficulties, it came in as a red, then downgraded to an orange, then a grey and finally a green-sciatic pain was in the notes on the MDT-so from getting quite keen to be able to possibly give some ipratropium and salbutamol, or put in an LMA, or any of the other skills we might be able to do, it was a bit of a letdown when it went to a green for pain-not professional I know (but i'm being honest)-when we got there I was thinking entonox for the pain she must be in. Walking in the door with a very experienced paramedic (and a second paramedic who was Barrys education offsider from Palmy) we were confronted with an elderly patient in obvoius pain and distress-I sorted out the entonox and got ready to ask her about her recent scuba diving habits, when the paramedic said to hold on a second and he just started talking to her, slowing down her breathing and sorting out her anxiety.....we stayed there coaching her breathing for the next 30 minutes, gave her the meds she hadnt taken and eventually dceided to transport for her own good-it was fantastic watching how effective talking and listening was-and reading the signs I had totally missed. We gave no drugs, did nothing more invasive than a BGL and helped a scared elderly lady have a better day. That was a big lesson about not just the elderly but every patient-it might be okay to have a bit of a plan in your head before you arrive, but it may not always go to that plan....and dont get forget to look at the whole picture. Hope I've answered the question.....what was it again?
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Post by Kirsty C on Aug 30, 2015 1:52:29 GMT
It is common for older people to fracture their hips when they fall due to Osteoporosis which causes bones to become brittle and fragile due to loss of bone tissue typically from a deficiency of calcium or vitamin D or as a result in hormonal changes. Approximately 90% of all hip fractures are in people over 60 years of age and due to the fact the women are more susceptible to Osteoporosis then men, hip fractures are more prevalent in older women. To decrease the chance of falls elderly people and their families can implement many ideas. Removing hazards such as floor rugs, unstable furniture and electrical cords etc can reduce the chance of tripping. Keeping as active as possible helps with balance. Many medical conditions such as Parkinsons disease, Multiple Sclerosis, Rheumatoid conditions and diabetes can affect balance and increase the chance of tripping. Regular visits to the GP are advisable. Devices such as hand rails are helpful throughout the house especially for stairs and bathrooms. The importance of good lighting should not be underestimated and neither should sensible shoes for walking. Small house dogs like Chew Hua’s should be avoided at all cost!!
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Post by Barry on Oct 6, 2015 19:38:01 GMT
Hi Team here is your first Trauma question; The idea that patients with major trauma will have the best chance of survival if they get to definitive care (e.g. a tertiary hospital with surgeons) within an hour of their accident has been coined “The Golden Hour”. What are your thoughts on this theory?
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Post by Ian TanMan on Oct 7, 2015 6:49:07 GMT
The Golden Hour as I understand it is defined as the time from when the incident occurs, through until the patient is in the hands of a trauma care (to use an american term) hospital. It includes the time taken to get the call details and proceed to the incident-hence an accident occuring in a rural environment with little or no cellphone coverage could possibly significantly increase the time it takes the call information to get to the call center and the emergency vehicles to get to the incident location. Time taken to stabilise and extricate the patient is also a big issue-heavy entrapment may require specialist teams and equipment, it certainly takes alot more time to do a full entrapment extrication than it does to pop a door and drag a patient out....alright....carefully remove....not drag out. Access to that trauma care facility might then be the next issue-certainly the use of helicopters is a valuable tool-and if it is an accident then ACC pay.....So I guess if the accident occurs, the crews arive, stabilise and extricate and the patient is on the operating table being seen to within an hour....their chance of survival/recovery is greatly enhanced. Obviously major injuries and multi system trauma will make the situation even more urgent-but even a relatively minor injury, if not operated on or handled well could prove fatal, ie a relatively slow internal bleed could become a slow and fatal internal bleed if it could not be operated on in a timely manner-fractures to legs and the pelvis also have significant blood loss associated with them-all progressively putting our patients further into shock the longer they are away from specialist care.
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Post by B on Oct 11, 2015 23:11:09 GMT
It seems to me that obviously if someone is suffering from major trauma. Then the faster they get the care needed the greater their chance of survival. So it is our job to stabilise and manage pain as quickly and efficiently as possible enabling the the safe transport of the patient to the definitive care needed. As for the 'golden hour' I am not sure. I think that every second after sustaining significant injuries counts. So yes, after an hour chances of survival decrease but I think someone said the golden hour a long time ago and it stuck. If someone is dying, and we cannot do anything for them we have to get them to someone who can help as quickly as possible.
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