HALO - Term Test 3 (Pediatric & Neonatal Resuscitation, Bariatric, Geriatric)

Question 1

Neonatal Resuscitation Medical Directive

Indications

Conditions

Contraindications

Answer 1

Indication: Neonatal patient

Conditions: Age <30 days of age

Contraindications: n/a

Question 2

Neonatal Resuscitation Medical Directive

Treatment

Clinical Considerations

Answer 2

Treatment: see screenshot

Clinical Considerations: if neonatal resuscitation is required, initiate cardiac monitoring and pulse oximetry monitoring

Question 3

Neonatal Resuscitation Medical Directive

Targeted Preductal SpO2

Answer 3

On the Right Hand/ R side - if baby is not crying, you can use this to determine if they’re doing okay

1 min: 60-65%

2 min: 65-70%

3 min: 70-75%

4 min: 75-80%

5 min: 80-85%

10 min: 85-95%

Question 4

What’s the difference between chronological age and corrected age?

Answer 4

Chronological Age: Your baby’s actual age

Corrected Age: You baby’s age starting from the expected due date (their age if they were expected to be born on their due date)

Question 5

A baby is born at 36 weeks. The expected due date was at 37 weeks. He is now 1 month old. What is the corrected age?

Answer 5

3 weeks (because 37 weeks is considered term and was the expected due date so the baby was one week preterm)

1 month/4 weeks old - 1 week preterm = 3 weeks old corrected age

Question 6

True or False. Any baby that is born pre-term, prepare for resus.

Answer 6

True

Question 7

During neonatal transition, there are 3 ducts that close once a baby is born and becomes oxygenated with air. What are these ducts called?

Answer 7

Ductus arteriosus

Ductus venosus

Foramen ovale

Question 8

What do the three ducts/shunts in the fetal circulation do (i.e. the ones that eventually close after birth)?

Answer 8

small passages that direct oxygenated blood to circulate locations by bypassing the lungs and liver

1) Ductus arteriosus: moves blood from pulmonary artery to the aorta

2) Ductus venosus: allows oxygenated blood in umbilical vein to bypass the liver

3) Foramen ovale: shunt moves blood from RA to LA, bypasses the lungs

Question 9

What purpose do the lungs serve in utero?

How does the fetal circulation transition from intrauterine to extrauterine?

Answer 9

No ventilatory purpose! There is diminished blood flow through the lungs as the baby does not rely on its lungs for gas exchange

Once the baby takes its first breaths of life, the lungs start to expand. As they expend, alveoli in the lungs are cleared of fluid. Increased the baby’s BP and major decrease in pulmonary pressures reduce need for ductus arteriosus to shunt blood so it closes. This also raises LA pressure and lowers RA pressure so foramen ovale also closes. For the ductus venosus, there is a great reduction of blood flow through here caused by clamping of the umbilical cord at birth.

Question 10

Why do babies not drown in waterbirths?

Answer 10

The baby is able to stay in the water as long as it’s still attached to the placenta and had that submerged transition (i.e. from womb to water, no contact with air at any point). The lungs are still collapsed and baby is still getting gas exchange through the cord.

HOWEVER, once you lift the baby out into the air, it will take its first breaths causing the lungs to expand and triggers the shunts closed. You are then unable to place the baby back in water

Question 11

In order to breathe in the extrauterine world, the infant must clear fluid in its lungs and establish regular respiratory pattern. Where does the fluid go and by what mechanisms?

What happens when the fluid in the neonate is unable to be cleared?

Answer 11

Fluid eliminating mechanisms:

• a considerable amount of pressure in the lungs are required to overcome fluid forces and open alveoli for the first time (and then once they’re open they will not close)
• 1/3 of fetal lung fluid is removed during vaginal delivery as the chest is squeezed through the birthing canal (after restitution, lungs are compressed so that when they come out they can inflate with the first breath)
• Remaining fluid passes through the alveoli into the lymphatic tissues

If fluid is not cleared:

• can experience apnea or weak respiratory effort
• prepare for resuscitation (compressions, suctioning, BVM w/ or w/o O2 to push air into the lungs and fluid out of body)

Question 12

How is asphyxia determined in a neonate snd what physiological mechanisms occur with asphyxia?

What potential obstetrical presentations may present with asphyxia?

Answer 12

• Determined via APGAR (no effectively breathing)
• Causes vasoconstriction in the lungs, bowels, kidneys, muscles and skin
• Prolonged asphyxia caused decrease in myocardial function and cardiac output and further reduced blood flow to vital organs leading to progressive organ damage
• Potential presentations: breech, preemies (22 wks is the earliest that could be resuscitated but will have lots of problems), shoulder dystocia, twins (or more, where one is bigger than the other and squishing them)
• C-sections need to be monitored for 1 hour post delivery for asphyxia

Question 13

Primary vs secondary apnea

Describe each and what treatment a PCP would provide.

Answer 13

Both can develop in utero

Primary apnea: pt is deprived of oxygen and HR falls, respiratory efforts cease

• Treatment: blow by oxygen - NC and blow it by their nose as O2 may induce respirations (infant is responsive to stimulation

Secondary apnea: if the asphyxia continues, the infant then begins irregular gasping respiratory efforts which then slowly decreases in frequency, HR continues to decline, BP falls, then respiratory weakens

• Infant is no longer responsive to stimulation
• Treatment: ventilation with oxygen must be initiated
• likely present with shoulder dystocia, labour dystocia, prolapse cord, breech

Question 14

Describe the general process/steps a PCP would take when completing a neonatal assessment and management (as per neonate standard):

Answer 14

1) Primary Survey

• Do they have good tone? - are they sick or not sick (children will 100% show good or bad tone to allow you to determine if they’re sick or not) - due to compensatory response
• Breathing - unlaboured?

2) History gathering

• Term gestation? Number of pregnancies and births
• Details of the labour (duration)
• details regarding delivery (precipitous, complications)
• Who delivered the neonatal patient
• Neonatal status since delivery (color, breathing, level of activity since delivery)
• Clinical care given to the neonate since delivery

3) If just delivered:

• reassess mother if required
• wipe mouth than nose if required
• clamp and cut cord
• “Sniffing position” - baby lying supine on firm surface with head/neck slightly extended (padding under neck)
• Record time of deivery
• Tag/tape neonate’s arm with time of dlivery and mom’s name if able
• If no neonate resus required, transport with skin-to-skin contact to facilitate temp regulation, advise mom to nurse if she wishes
• Swaddle neonate in blanket
• APGAR 1 and 5 minutes, and every 5 minutes thereafter

Question 15

Identify each component of APGAR.

Answer 15

• Additional notes:
  
  • sneezing is a great reflex (clearing airway - Good grimace)
  • blowing bubbles also very good (under grimace)

Question 16

Are babies mouth breathers or nasal breathers?

Answer 16

nasal breathers - forces baby to suckle which helps clear passage

Question 17

What is considered term (give a range)?

Answer 17

37-42 weeks - anytime between this period is considered term

Question 18

Approximately ____% newborns will need some assistance to begin breathing following delivery.

Approximately _____% require extensive resus.

Answer 18

Approximately 10% newborns will need some assistance to begin breathing following delivery.

Approximately <1% require extensive resus.

Question 19

When following the neonatal resuscitation medical directive, what is the definition between newly born and neonate?

Answer 19

Newly born: <24 hours old

Neonate: ≥24 hours old but <30 days (corrected age)

Question 20

When following the neonatal resuscitation directive, how do the steps differ between a newly born and a neonate for drying, positioning, and stimulating?

Answer 20

While drying, positioning and stimulating are intended for the newborn, this medical directive is applicable to all patients under 30 days of age. In the patient that is not newly born, begin by assessing respirations and heart rate; then proceed.

Question 21

If you assess a newborn and discover pt with a HR of 0, what are the appropriate steps as per your neonatal resuscitation medical directive?

Answer 21

• if HR 0 you MUST still start with effective PPV on room air prior to initiating chest compressions (do not skip any steps, following the medical directive as it is regardless of the newborn’s initial HR)
• In most cases, effective PPV/ventilation of the lungs will increase the newborn’s HR
  
  • Primary/secondary apnea is causing HR to fall so ventilations with correct HR as its an oxygenation issue
• A minimum of 30 sec of effective ventilation is required which may involve doing the following:
  
  • If ventilations are ineffective consider trying ‘MR SOPA’ - adjusting Mask to assure good seal, Reposition airway to “sniffing” position, Suction mouth and nose of secretions if necessary, Open mouth using manual manoeuvres, increase Pressure to achieve adequate chest rise, consider an Alternate Airway if available (ACP should consider ETT as an alternate airway

Question 22

If you assess a neonate (≥24h but <30 days) and discover pt with a HR of 0, what are the appropriate steps as per your neonatal resuscitation medical directive?

Does this change if their HR on initial assessment was 60?

Answer 22

• Chest compressions are indicated immediately and would not be delayed to warm, dry, stimulate or provide only ventilations
• If pt HR <60bpm but >0, you still must start with effective PPV on room air prior to initiating PPV with 100 O₂ and chest compressions
• If ventilations are ineffective consider trying ‘MR SOPA’ - adjusting Mask to assure good seal, Reposition airway to “sniffing” position, Suction mouth and nose of secretions if necessary, Open mouth using manual manoeuvres, increase Pressure to achieve adequate chest rise, consider an Alternate Airway if available (ACP should consider ETT as an alternate airway).

Question 23

Why are BVM ventilations to be performed with room air only first and not attached to an oxygen source?

Answer 23

Neonate is more susceptible to harm from increased oxygen concentrations (hyperoxemia)

increased risk of burning of sclera and causing blindness

Question 24

Meconium with poor muscle tone and breathing/crying needs to be addressed. How would you go about this?

Answer 24

suctioning the mouth and pharynx before the nose while ensuring oxygenation is maintained. Routine meconium suctioning is not required

Question 25

As per additional considerations for the neonatal resuscitation medical directive, if central cyanosis is present in a neonate but respirations appear adequate and HR>100 BPM, do you need to administer oxygen?

Answer 25

No, O₂ administration is not required

Question 26

As per additional considerations for neonatal resuscitation medical directive, if respiratory distress is present (i.e. sternal retractions, nasal flaring, grunting), what are appropriate next steps a PCP should take?

Answer 26

administer oxygen by mask at 5- 6 L/min or by cupping a hand around the oxygen tubing and holding the tubing 1-2 cm from the patient’s face; slowly withdraw as the patient’s colour improves.

Question 27

Anatomical/physiological differences in pediatrics?

Answer 27

• Vitals: higher HR & RR, lower BP (because they’re smaller), different GCS scale
• Physical:
  
  • ​Tongue - larger (for suckling reflex)
  • Trachea - more pliable, smaller diameter and more cone-shaped, immature tracheal rings
  • Epiglottis - large, more U-shaped/oblong
  • Larynx - sits at 1st or 2nd cervical vertebrae
  • Mainstem bronchi - less angled
  • Patella - not formed (until 5 years)
  • Skin - thinner, and larger BSA
• Physiological:
  
  • ​enhanced CNS receptivity: unable to response to painful stimuli compared to past experiences
  • higher metabolic rate
  • immature immune system

Question 28

Vitals for (HR, RR, BP):

0-1 mos

1-3 mos

3-6 mos

6-12 mos

Answer 28

0-1 mos: HR 93 - 182, RR 26-65, BP 45-80/33-52

1-3 mos: HR 120 - 176, RR 28 - 55, BP 65-85//35-55

3-6 mos: HR 107-197, RR 22-52, BP 70-90/35-65

6-12 mos: HR 108-178, RR 22-52, BP 80-100/40-65

Question 29

Vitals for (HR, RR, BP):

1-2 yrs

2-3 yrs

3-5 yrs

5-7 yrs

Answer 29

1-2 yrs: HR 90-152, RR 20-50, BP 80-100/40-70

2-3 yrs: HR 90-152, RR 20-40, BP 80-110/40-80

3-5 yrs: HR 74-138, RR 20-30, BP 80-115/40-80

5-7 yrs: HR 65-138, RR 20-26, BP 80-115/40-80

Question 30

Vitals for (HR, RR, BP):

8-10 yrs

11-13 yrs

14-18 yrs

Answer 30

8-10 yrs: HR 62-130, RR 14-26, BP 85-125/45-85

11-13 yrs: HR 62-130, RR 14-22, BP 95-135/45-85

14-18 yrs: HR 62-120, RR 12-22, BP 100-145/50-90

Question 31

Psychological differences in pediatrics (compared to adults)

Answer 31

• they are learning social skills through caregiveres and by participating in the world, and developing their ability to recognize and manage emotions
• Social relationships heavily impact emotional development (secure/attachment)
• Lack of stable social relationships can be reflected in coping skills and behaviour
• Cognitive development is still ongoing (ensure clear communication) - growth of thought occurring
• A kid who is talked to will be able to have better engagement and autonomy when compared to a kis being talked at

Question 32

Describe Piaget’s Stages of Cognitive Development

Answer 32

Sensorimotor (0-2 years): infant explores the world through direct sensory and motor contact. Object permanence and separation anxiety develop during this stage.

• They want to grab and touch things at this age
• Objective permanence: the ability to know that something still exists even though they are no longer seen/heard
• Talk to these bbs with grand gestures, blankets, toys, suckies, and talk at their eye level

Preoperational (2-6 yrs): Child uses symbols (words and images) to represent objects but does not reason logically (i.e. it they open an oven they won’t really know that it’s hot and shouldn’t be touched.

• They also have the ability to pretend - they will give you animated answers
• At this stage, the child is egocentric (word revolves around them)

Concrete operational (6-12 yrs):

• Child can think logically about concrete objects and can add and subtract (not math. i.e. if we take the child into the ambulance, they know they are leaving their home)
• They can understand conversation

Formal operational (12 yrs - adult): The adolescent can reason abstractly and thinks in hypothetical terms. They also want to make their own decisions.

Question 33

Age of consent for sex, medical care, and being an adult.

Answer 33

Sex: 16 y.o.

A 14 or 15 year old can consent to sexual activity as long as the partner is less than five years older and there is no relationship of trust, authority or dependency or any other exploitation of the young person

Medical care: 16 y.o

Being an adult: 18 y.o.

Question 34

What special considerations are there for responding to calls for adolescents?

Answer 34

• More able to participate in decision-making about their own care - can have opinions and view that challenges those of their family’s or HCPs
• Ensure their safety but also allow them some responsibility in care
• More inclined to be experimental, high-risk behaviour which may impact health and response to intervention
• History gathering and accurate physical exam:
  
  • avoiding leading questions (open vs closed ended questions)
  • must be capable of identifying any immediate/potential life threats
  • know your peds vital signs
  • have caregivers present for assessment unless they are interfering with care (consider need for PD is necessary)

Question 35

What is the one telltale sign for a pediatric that would indicate whether this patient is sick or not?

Answer 35

TONE

Question 36

Are children considered little adults? Explain your rationale.

Answer 36

Children are NOT little adults - many differences between adults and peds that impact the way illness and disease present

differences in anatomical and physiology, cognitive, social, and emotional aspects

Question 37

What is the Broselow tape and what is it used for?

Answer 37

• Head to toe colour-coded tape measure which lands them in a colour which will tell us what to do for resuscitation (at the toe is where you look and see)
• Helps to measure height and weight
• Calculates medications
• Helps airways sizes
• Used in the hospital setting
• Fast and reliable for quick responses esp. with trauma

Question 38

What is the pediatric assessment triangle (PAT)?

Answer 38

• a method of quickly determining the acuity of the child (the type and urgency of intervention)
• integral part of your general assessment of a sick child
• Done by visualization and auditory clues (forming your general impression)
• replaces the primary survey for adults and answers the big question: “sick or not sick?”
• has 3 arm, any abnoormalities in the arms of the PAT denotes an unstable child - immediate clinical intervention is required

Question 39

Components of the PAT

Answer 39

1) Appearance:

• abnormal tone
• ↓ interactiveness
• ↓ consolability
• abnormal look/gaze
• abnormal speech/cry

2) Work of Breathing

• abnormal sounds
• abnormal position
• retractions
• flaring
• apnea/gasping

3) Circulation to Skin

• pallor
• mottling
• cyanosis

Question 40

When assessing a pediatric patient, what are additional considerations that are not part of the PAT?

Answer 40

• Changes in appetite, changes in behavior, irritability, inconsolable, lethargy, excessive drooling, # wet diapers, patient positioning (i.e. tripoding), work of breathing
• Head to toe
• Fontanelles (if they have sunken fontanelles it is a sign of dehydration)

Question 41

What does it mean when it’s said that pediatric’s clinical status is similar to the cliff?

Answer 41

• Pediatrics compensate MUCH longer than an adult (they will not decline/continue to compensate until right before they die) - so they may look fine and clinically stable and then drop dead
• Adults will decline and start to decompensate before they die so it’s a lot easier to catach compared to peds

Question 42

What is ARM 1 of the PAT and what does it represents (i.e. what are its components)?

Describe each characteristic and what would be normal/abnormal.

Answer 42

Arm 1: Appearance - can also be associated with airway

• Reflects the child’s age, stage of development (i.e. sensorimotor, preoperational, etc.) and ability to interact with environment

TICLS Mnemonic

• Tone: moves spontaneously, resists examination, sits or stands (age-appropriate)
  
  • Abnormal: floppy/rigid muscle tone or not moving
• Interactiveness: alert/engaged with caregiver, interacts well with people/environment, reaches for objects
  
  • Abnormal: decreased LOA/reponse to parents or environment
• Consolability: stops crying when held/comforted by caregiver
  
  • Abnormal: difficult to console
• Look/Gaze: makes eye contact with clinician, eye tracking
  
  • Abnormal: decreased eye tracking/abnormal look
• Speech/Cry: uses age-appropiate speech
  
  • Abnormal: no or abnormal cry/muffled sounds

Question 43

What is ARM 2 of the PAT and what does it represents (i.e. what are its components)?

Describe each characteristic and what would be normal/abnormal.

Answer 43

Arm 2: Work of breathing - describes respiratory status (degree to which the child must work in order to oxygenate and ventilate)

Normal: regular breathing without excessive respiratory muscle effort or audible respiratory sounds

Abnormal:

• Abnormal airway sounds (grunting, wheezing, muffled/hoarse speech, snoring, stridor)
• Abnormal positioning - tripoding, prefers seating posture, potentially sniffling position
• Retractions - supraclavicular, intercostal, substernal, head bobbing (in infants)
• Flaring (of nares)
• Apnea/Gasping

Question 44

Ventilation vs oxygenation

Answer 44

Ventilation: taking air in physically (lungs moving in and out)

Oxygenation: the amount of oxygen rich molecules in the blood

Question 45

What is ARM 3 of the PAT and what does it represents (i.e. what are its components)?

Describe each characteristic and what would be normal/abnormal.

Answer 45

Arm 3: Circulation to skin - reflects general perfusion throughout body

• note colour and colour pattern of skin and mucous membranes
• in the context of blood/fluid loss, changes in venous tone occur which cause compensatory mechanisms to shunt blood to vital organs and away from periphery

Components:

• Pallor: cold, pale, blanched mucous membranes
• Mottling: patchy skin discolouraiton due to variable vasoconstriction, can show with significant dyspnea and apnea
• Cyanosis: blueish discolouration, mostly in lips and nail beds

Normal: Colour normal for child, no significant bleeding

Abnormal: Cyanosis, mottling, pallor, obvious significant bleeding

Question 46

Patients presents with

Appearance: Normal
Work of Breathing: Normal
Circulation to Skin: Normal

What would this be categorized as?

Answer 46

Stable

Question 47

Patients presents with

Appearance: Normal
Work of Breathing: Abnormal
Circulation to Skin: Normal

What would this be categorized as?

Answer 47

Respiratory distress

Question 48

Patients presents with

Appearance: Abnormal
Work of Breathing: Abnormal
Circulation to Skin: Normal

What would this be categorized as?

Answer 48

Respiratory Failure

Question 49

Patients presents with

Appearance: Normal/Abnormal
Work of Breathing: Normal
Circulation to Skin: Abnormal

What would this be categorized as?

Answer 49

Shock

Question 50

Patients presents with

Appearance: Abnormal
Work of Breathing: Normal
Circulation to Skin: Normal

What would this be categorized as?

Answer 50

CNS/metabolic disturbance

Question 51

Patients presents with

Appearance: Abnormal
Work of Breathing: Abnormal
Circulation to Skin: Abnormal

What would this be categorized as?

Answer 51

Cardiopulmonary Failure

Question 52

Pediatric GCS

Eye Opening Response

Answer 52

>1 year: everything is the same as adult (spontaneous, to verbal command, to pain, no response)

<1 year:

• 4: Spontaneous
• 3: to shout (the only difference)
• 2: to pain
• 1: no response

Question 53

Pediatric GCS

Motor Response

Answer 53

>1 year: same as adult (obeys, localizes pain, withdrawal, decorticate, decerebrate, no response)

<1 year:

• 6: spontaneous (instead of obeys command - the only difference)
• everything else after this is the same

Question 54

Pediatric GCS

Verbal Response

Answer 54

0-23 months:

• 5: smiles/coos appropriately
• 4: cries and is consolable
• 3: persistent inappropriate crying and/or screaming
• 2: grunts, agitated, and restless
• 1: no response

2-5 years:

• 5: appropriate words/phrases
• 4: inappropriate words
• 3: persistent cries and screams
• 2: grunts
• 1: no response

>5 years: the same as adult

• 5: oriented
• 4: disoriented/confused
• 3: inappropriate words
• 2: incomprehensible sounds
• 1: no response

Question 55

What is the definition of a child in need of protection, as per BLS?

Answer 55

means a child who is or who appears to be suffering from abuse and/or neglect (i.e. physical, sexual, or emotional abuse, neglect, or risk of harm).

Question 56

What is the definition of duty to report, as per Child in Need of Protection Standard in the BLS?

Answer 56

means the requirement to promptly report any reasonable suspicion that a child is or may be in need of protection directly to a Children’s Aid Society (CAS).

duty to report overrides PHIPA

Question 57

What is the definition of reasonable grounds, as per Child in Need of Protection Standard in the BLS?

Answer 57

refers to the information that an average person, using normal and honest judgement, would need in order to decide to report.

Question 58

In situations where the paramedic has reasonable grounds to believe that the patient is a child who is or may be in need of protection, the paramedic shall:

Answer 58

1. ensure the patient is not left alone;
2. request police assistance at the scene when it is believed that the patient is at risk of imminent harm;
3. obtain as clear a history of the inciden as possible, with no display of personal curiosity
4. make no accusations or comments about your suspicions in front of the parents or bystanders
5. transport child in all cases
6. report suspicions to the receiving hospital and complete the duty to report to the CAS

Question 59

The following types of pediatric problems are noteworthy for specific attention when a paramedic is determining if the patient may be a child in need of protection:

Answer 59

• submersion injury
• all burns
• accidental ingestions/poisoning
• other types of in-home injuries (eg. falls)

Question 60

Scene observations which may prompt consideration that the patient is a child in need of protection include:

Answer 60

• Household/siblings dirty, unkempt, and/or in disarray
• Evidence of violence, e.g. overturned or broken furniture
• Animal/pet abuse
• Evidence of substance abuse, e.g. empty liquor bottles, drug paraphernalia

Question 61

Physical signs which may prompt consideration that the patient is a child in need of protection include:

Answer 61

• Gross/multiple deformities which are incompatible with the incident history, especially in a child under 2 y.o. who is developmentally incapable of sustaining this type of injury
• Multiple new and/or old bruises which have not been reported, or which have been reported as all being new
• Distinctive marks or burns, e.g. belt, hand imprint, cigarette burns;
• Bruises in unusual areas: chest, abdomen, genitals, buttocks
• Burns in unusual areas: buttocks, genitals, soles of feet
• Signs of long-standing physical neglect, e.g. dirty, malodourous skin, hair and clothing, severe diaper rash, uncut/dirty fingernails
• Signs of malnutrition - slack skin folds, extreme pallor, dull/thin hair, dehydration Signs of “shaking” syndrome - hemorrhages over the whites of the eyes; hand or fingerprints on the neck, upper arms or shoulders; signs of head injury unrelated to the incident history.

Question 62

When obtaining as clear a history of the incident as possible for the child, you must attempt to determine the validity of the history provided. Consider if the patient may be a child in need of protection in what situations?

Answer 62

• the story changes frequently or parents’ stories differ,
• the parents are vague about what happened or blame each other,
• the nature of the injury appears to be inconsistent or improbable with the explanation provided,
• the MOI is obviously beyond the developmental capabilities of the child,
• there has been prolonged, unexplained delay in seeking treatment, or
• there is a history of recurrent injuries;

Question 63

When you’re determining whether a child is in need of protection or not, what are you trying to observe from the child’s interaction with the parents/caretakers?

Answer 63

• potential lack of interaction between parents/caretakers, and between parents and child
  
  • parents openly hostile
  • child is inappropriately fearful
  • child avoiding parents or clinign to one parent and avoiding the other
  • or paradoxically protecting the abusive party (either out of fear or losing a parent or due to verbal threats to keep quiet)
• appropriateness of parental/caretaker response to the child’s injury and/or emotional distress - e.g. lack of concern, lack of physical comforting, anger inappropriately directed towards the child
• appropriateness of child’s behaviour relevant to the situation/injury, e.g. inappropriate fear, indifference, lack of emotion;

Question 64

The failure to report a suspicion of the child in need of protection is an offence under which Act?

Answer 64

Child and Family Services Act

Question 65

True or False. Paramedics have a duty to report a child in need of protection even if it’s not the patient.

Answer 65

True

the duty to report under the Child and Family Services Act (Ontario) extends to any child he/she encounters in his/her professional duties and is not limited to the person(s) requesting 911 services.

Question 66

What are the top 4 pediatric emergencies?

Answer 66

1) Fever - the most common prehospital call in childnre
2) Resp difficulty
3) Injuries
4) Vomiting/diarrhea (dehydration)

Question 67

What is a fever?

Answer 67

• elevation of temperature past 38 degrees
• A symptom NOT a condition (not a sickness, it’s a coping mechanism to the condition)
• Universal component of acute phase response to illness

Question 68

What is the concern regarding fevers in children?

Answer 68

• can lead to febrile seizures
• results from any process associated with inflammation/cytokine release (i.e. malignancy, immunological reactions, trauma, infections)
• PAT assessment will give you guesses to possible presence of serious bacterial infection

Question 69

S/S of meningitis

Answer 69

headache

stiff neck

altered mental status

petechiae

Question 70

What are some important questions to ask as a paramedic relating to a fever?

Answer 70

• Sick contacts
• travel
• antibiotic use
• Immunization status
• Duration and timing of the fever
• Meningitis concerns: stiff neck, altered LOA, petechiae

Question 71

What are some common conditions that manifest as respiratory difficulties in children?

What types of questions are pertinent to these calls?

Answer 71

Common conditions: asthma & croup (both of these are most common for SOB in kids), epiglottitis (excessive drooling noted)

Hx questions:

• fever?
• URI Sx?
• Cough?
• Sick contacts?
• travel?
• puffer use?
• wheezing?
• work of breathing?
• drooling? epiglottitis

Question 72

What is the leading cause of death and disability in pediatrics?

Answer 72

injury

MVCs (teenagers)

Drowning (at crawling age)

Injury related to respiratory distress (ex. pneumothorax) - older children

Question 73

What is the leading cause of hospitalization in pediatrics (for any child that is of moving age)?

Answer 73

falls

Question 74

What is the trimodal death distribution?

Answer 74

Describes three distinct peaks of mortality secondary to trauma

First peak: seconds to minutes after injury - only prevention can affect mortality

Second peak: minutes to hours - rapid assessment, tx can improve mortality (ex. Drowning, head injury, accidental suffocations)

Third peak: days to weeks - Multi organ system failure - requires definitive care at specialized ped center

Question 75

Factors in pediatric trauma

Answer 75

• Smaller size = greater risk of bigger injuries
• Higher metabolic rate and larger BSA = increased heat loss
• Absolute blood volume is less so they can bleed out faster (++% of total blood volume)
• Head injuries – manage airway, avoid hypoxia and hypotension

Question 76

What is dehydration and why is it a concern?

Answer 76

Dehydration: significant depletion of body water & electrolytes; a common complication of illness

• 2 bouts of diarrhea increases risk of dehydration
• early recognition and intervention is important to reduce tisk of progression to hypovolemic shock, organ failure

Question 77

Volume depletion in pediatrics is typically due to:

Answer 77

vomiting diarrhea

less commonly: DKA, burns, third space losses (where fluid does not normally collect)

Question 78

What questions are pertinent to pediatric calls re: dehydration?

Answer 78

• fluid intake
• wet diapers (how many) - should usually go through 8-10/day
• urine output
• fever
• infectious symptoms
• assess for sunken fontanelles

Question 79

Emergency Childbirth Medical Directive

Indications

Conditions

Contraindications

Answer 79

Indications: pregnant patient experiencing labour OR post-partum patient immediately following delivery

Conditions:

• Delivery:
  
  • Age: Childbearing years
  • Other: second stage labour and/or imminent birth
• Umbilical Cord Management:
  
  • Age: Childbearing years
  • Other: Cord complications OR if neonatal or maternal resuscitation is required OR due to transport considerations
• External Uterine Massage:
  
  • Age: Childbearing years
  • Other: Post-placenal delivery

Contraindications: N/A

Question 80

Emergency Childbirth Medical Directive

Treatment

Answer 80

Treatment:

1) Consider delivery - see screenshot

2) Consider umbilical cord management

• If prolapsed cord: fetal part should be elevated to relieve pressure on the cord. Assist the patient into a knee-chest position or exaggerated Sims position, and insert gloved fingers/hand into the vagina to apply manual digital pressure to the presenting part which is maintained until transfer of care in hospital.
• If a nuchal cord is present and loose, slip cord over the neonate’s head. Only if a nuchal cord is tight and cannot be slipped over the neonate’s head, clamp and cut the cord, encourage rapid delivery.
• Following delivery of the neonate, the cord should be clamped and cut immediately if neonatal or maternal resuscitation is required. Otherwise, after pulsations have ceased (approximately 2-3 minutes), clamp the cord in two places and cut the cord.

3) Consider external uterine massage

Question 81

Bariatric is often defined as a pt weighing over ______ lbs.

Answer 81

350

Question 82

All patients ≥ _____ lbs would be considered as potentially requiring special equipment and extra attention.

Answer 82

250

Question 83

The word “obesity” comes from Latin term ________

Answer 83

fattened by eating

Question 84

Bariatrics refers to

Answer 84

the practice of healthcare relating to treatment of obesity and associated conditions

Question 85

RESPECT acronym when considering bariatric calls

Answer 85

R: Respect

E: Environment/equipment (appropriate for the call)

S: Safety - focusing attention on their safety considerations

P: Privacy

E: Encouragement

C: Caring/Compassion

T: Tact - being wise with your words

Question 86

Obesity is a risk factor for what diseases?

Answer 86

• CAD, T2DM, cancer, HTN, stroke, liver and gallbladder disease, sleep apnea
• OA, GYN problems
• Kidney disease
• Psychological issues (depression, low self-esteem, impaired self image)

Question 87

Pulmonary Health in obese patients

Answer 87

• All tissue (include adipose tissue) requires oxygen so body’s oxygen demand rises exponentially with obesity
• Heart then needs to circulate blood faster to accommodate increased distribution and the individual to breath more rapidly to increase rate of gas exchange
• Physiological changes - often present with tachypnea and become SOB easily
• Sleep apnea (interruptions to breathing while asleep) and other respiratory problems such as asthma
• Even in the absence of pulmondary diseases, obesity causes a decrease in pulmonary residual volume and total lung capacity

Question 88

Cardiovascular Health in obesity

Answer 88

• 75% of the incidence of HTN is related to obesity
• HTN risk factor for CAD, CVA, and renal failure
• For every 10 kg increased in body weight, there is a 3 mmHg increase in SBP and 2.3mmHg in DBP
• For every 10kg increase in body weight, risk of CAD rises 12% and CVA 24%
• Fatty deposits can actually infiltrate heart muscle itself and adipose tissue strands can begin to separate myocardial cells → reuslts in obesity cardiomyopathy
• DVT and PE

Question 89

Changes to skin in obesity

Answer 89

• correlation between obesity and skin disorders
• Loss of skin integrity - risk of infection, pain, increased odor, loss of independence or self-esteem
• Skin injuries among larger, heavier individuals typically manifest as intertrigonous (skin folds) dermatitis, pressure ulcers, candidiasis, incontinence-associated dermatitis, lower leg ulcers, skin tags, striae distensae, plantar hyperkeratosis
• Most problematic and COMMON area: abdominal pannus

Question 90

What is the abdominal pannus?

What is the grading for this?

Answer 90

Excess fold or “apron” of skin that hangs dependently. These are two different places of skin that shouldn’t be touching normally so will increase risk of ulcers, candida, dermatitis. Scale grades the extent of redundant skin fold

Pannus Grading:

I: apron covers pubic hairline

II: apron covers genitals at the level of the upper thigh crease

III: covers upper thigh

IV: covers mid-thigh

V: covers knees

Question 91

What is the issue with skin folds?

Answer 91

One layer of skin is resting on/against another layer of skin hat creates a warm, moist, and dark environment that can be a potential area for skin breakdown, skin to skin friction, and

• shear
• maceration (waste away)
• irritation
• skin tears
• rashes
• candidiasis
• viral or bacterial infectoin
• potential pressure ulcers

Question 92

Concerns regarding genital care and obese patients.

Answer 92

• both sexes experience challenges with genital and perineal care
• women face challenges in general and also when menstruating
• men may be at risk for Fournier’s gangrene - caused by yeast and skin bacteria
• Other problems: moisture and toileting
• Presence of large pannus/skin folds also aggravate problems

Question 93

Odor may be caused by what?

Answer 93

particularly skin-on-skin cotnact

direct skin surface contact locks in moisture which increases bacterial or yeast growth and reuslts in odor due to high bacterial/fungal load

Question 94

Assessment of the batriatic patient should have what sorts of considerations?

Answer 94

• Keep them on their side or upright as much as possible
• Listen to lung sounds on the back just medial to scapula (decreased adipose tissue in this area)
• Apply pulse ox on 5th digit (meter’s light waveform is less likely to be dampened by adipose tissue)
• Assess cyanosis inside lips and eyelids
• Use proper BP cuff (can use thigh cuff on arm or large cuff on foraem)
  
  • Too small = increased BP
• Avoid ECG electrodes on abdomen bc signals don’t transmit through adipose tissue well. Place leg leads on lateral aspect of lower abdomen

Question 95

What are some pathophysiological differences in obese patients that may affect your assessment findings?

Answer 95

ECG findings: their chest wall size will likely cause:

• lower voltages on their ECG - important to r/o pericardial effusion each time before saying it’s because of adipose tissue
• longer QT intervals at baseline
• signs of LVH over time

Respiratory: decreased respiratory reserve 2’ to decreased TLC and FRC; this compromises their ability to toleate respiratory insuls like pneumonia

• increased airway pressures due to more resistance (heavier chest walls, icnreased abdominal girth, atelectatic lung bases) which leads to
  
  • higher incidence of hypoxemia and hypercapnia at baseline
  • higher risk of aspiration pneumonia
  • more difficult to ventilation via BVM

Question 96

Average maximum human life span?

Answer 96

100 years

Question 97

Reasons for increased life expectancy presently compared to the past?

Answer 97

• better medical and prenatal care
• better delivery techniques
• better nutrition
• more leisure time
• better preventative measures
• general higher standard of living

Question 98

What are the key factors involved with how an aging patient will live?

Answer 98

External Factors: caregivers, home environment

Physical Exam: Vision & hearing; swallowing, nutrition, and hydration; bladder and bowel; injury; skin

History: Gait and falls; continence; sensory; medications

Psychiatric Exam: cognitive screen, delirium, mood, pre-existing problems

Functional Assessment: gait and balance; ADLs

Question 99

What is the highest/primary reason for geriatric hospitalization and death? What %?

Answer 99

falls; 70%

Question 100

____ per 1000 elderly patients are abused by their environments.

There is a _______ (male/female/no) definite sex predomination.

Answer 100

32

no definite sex predomination (however statistically the abuser tends to be adult male children that are the primary care givers)

Question 101

True or False. Caregivers are not financially dependent on the elderly patient therefore do not typically suffer a loss of income if the patient is not home with them.

Answer 101

False. They broke and need monies

Question 102

What is elder abuse?

Answer 102

single or repeated act or lack of action occuring in a relationship where there is an expectation of trust which causes harm or distress to another person

Question 103

What is elder neglect?

Answer 103

depriving a person of proper medical treatment, food, heat, clothing or comfort or essential medications and depriving a person of needed services to force certain kinds of actions, financial or otherwise.

Passive vs active neglect (i.e. intentional vs not)

Question 104

What are some special considerations when assessing geriatric patients?

Answer 104

• S/S of chronic illness can overlap with acute illness
• Aging can affect their response to illness/injury
• Pain may be diminished or absent
• social and emotional factors have a greater influence on health
• Pt may fear losing autonomy
• May have concerns re: cost of care

Question 105

What does GEMS stand for? (hint: it’s in relation to assessing geriatric patients)

Answer 105

An approach to your assessment to ensure it is comprehensive and views the patient as a whole

Geriatric patient

Environment ax (i.e. failure to thrive?)

Medical ax

Social ax

Question 106

When concerning geriatric patients, what are the 3 Ds?

What disease process will these 3 Ds contribute to?

Answer 106

depression, delirium, dementia

makes up Lewy-body dementia disease process

Question 107

When conducting a psychological assessment in a geriatric patient, what are you looking for?

Answer 107

• Mental Health changes: insomnia, sleep pattern changes, cognitive dysfunction
• anorexia, weight loss, constipation, fatigue
• Preoccupation with bodily functions, increasd alcohol or caffeine intake
• Delusions, hallucinations, past MH issues, psychoactive drugs, and recent medication changes
• Mood changes, cognitive changes that worsen daily function