Week 10 - Special Populations Flashcards
For the pediatric population, what is the Gold standard of care is based off of?
Gold standard of care is based off the color-coded length-based tape measure used throughout the world for pediatric emergencies.
What population has the highest multisystem organ injury? Why?
Peads population!!
Population with highest multisystem organ injury due to greater force distributed throughout the body because of the trauma due to the child’s lesser body mass.
Head > Body.
S
pinal column flexibility greater than spinal cord.
Smaller funnel shaped floppy airway with softer cartilage.
Short neck.
Thinner more compliant chest wall (decreased risk of rib fractures)
Heart more anterior and mediastinum mobile.
Lungs susceptible to barotrauma (physical tissue damage caused by a pressure difference between an unvented space inside the body and surrounding gas or fluid).
Smaller airways.
For geriatric patients what physiological differences exist in this population?
-Decreased pulmonary reserve,
-decreased muscle strength (inc. resp muscles),
-reduced cough reflex,
-reduced compensation,
-reduced compliance and vital capacity,
-lower cardiac output,
-atherosclerosis,
-less sympathetic nervous system response,
-decreased cerebral tissue volume and blood flow,
-dura adhered to the skull,
-slower nerve transmission,
-weaker swallow,
-lower thirst drive,
-slower gastric emptying and GI motility,
* fewer glomeruli and nephrons with less renal blood flow,
-less temp regulation,
-reduced body mass,
-reduced mobility,
-reduced sensation,
-thinner skin and less subq tissue,
Examples of Modifiable factors that impact geriatric trauma patients?
Modifiable factors – the older adult’s ability to respond to illness and injury are affected by lifestyle,
socioeconomic isolations,
poor diet
or failure to eat because of loss of appetite or financial restrictions.
For the peadatric population, What special equipment might be needed to properly care for this group? (6 things one big general theme tho!)
Pediatric-sized equipment: Pediatric patients require medical equipment that is sized appropriately for their smaller bodies: -This includes items such as hospital beds, examination tables, wheelchairs, and IV poles that are designed to fit children.
-Neonatal equipment: For newborns and premature infants, specialized equipment is needed, such as incubators, radiant warmers, and phototherapy lights.
-Child-friendly equipment: To make the hospital experience less scary for children, equipment can be designed to look less intimidating or even resemble toys. For example, blood pressure cuffs can be made to look like stuffed animals.
-Pediatric medication dosing tools: Children require different dosages of medications compared to adults, so healthcare facilities must have tools like pediatric dosing charts, syringe pumps, and liquid medication dispensers designed for children’s doses.
-Child life equipment: Hospitals and healthcare facilities for children may also have specialized equipment to help keep children entertained, such as toys, games, and movies.
-Monitoring and diagnostic equipment: To monitor vital signs, diagnose, and treat pediatric patients, specialized equipment such as pulse oximeters, ventilators, nebulizers, and infusion pumps are required
For the pregnant population what is the overall philosophy of care when there is both mother and fetus to care for?
Two patients instead of one! Save the mother to save the baby.
What has contributed to people living longer, and often with more active lifestyles?
Advances in management of chronic diseases, along with an emphasis on preventative medicine have contributed to people living longer, and often with more active lifestyles.
What influence has/does public health policy have on trauma rates with the peads population? (5)
Main takeaway: public policy greatly decreases pediatric trauma prevalence and fatality (Lewis et al., 2022). This article emphasizes the need for parental education for all preventable trauma related injuries.
Additional points:
-Trauma related injuries are still the leading cause of mortality in pediatric patients, many of which are preventable!!
-Car safety proper use of seatbelts, car, and booster seats decreases rates of fatality among pediatric population (Lewis et al., 2022)
-Parental education and national prevention strategies also helps to reduce prevalence and fatality
-Even though not all traumas are seen as ‘preventable’, there are safety mechanisms that can present further injury, for example restraining a child in a vehicle.
-Suicide in youth: Gun laws - “Minors’ legal access to firearms varies state by state as gun registration is state-dependent.” - 75% of youth suicides committed with gun owned by parents
For bariatric patients, what are medications that are hydrophilic (dissolve in water) are dosed based on?
Medications that are hydrophilic (dissolve in water) are dosed based on ideal body weight and not actual body weight and an obese person has leaner muscle mass which holds water.
What makes make children a unique population to assess and treat?
Growth and development patterns make children a unique population to assess and treat so trauma teams must have good understanding of children’s developmental stages
What is key when working with bariatric patients?
Patient dignity is key – this population experience more discrimination and bias than any other demographic in healthcare settings
When working with bariatric patients what makes it challenging to follow safety practices?
Improper fitting safety equipment or the inability to use it at all make it challenging to follow safety practices
S+S of resp distress in babies/toddlers? What will Colour change indicate for peads pop?
Head bobbing, nasal flaring, retractions, grunting are signs of resp distress in babies/toddlers.
Colour change will indicate shock much faster than BP changes. Immunization status/birth history important in young children—CIAMPEDS mnemonic from assessment class.
What do geriatric patients suffer from? what kind of phrases do they prefer?
This population also suffers healthcare provider bias and phrases such as “older adult” are preferable over “geriatric”.
What are pregnant patients at risk for after the reach 20 weeks? Why?
3.) Supine hypotension risk after 20 weeks as the aorta and inferior vena cava are compressed by the uterus and its contents when the patient is supine.
What syndrome are geriatric patients at risk for? Why?
Endocrine decrease with decrease thyroid and parathyroid
Risk of metabolic syndrome and aldosterone production drop (essential for sodium conservation in the kidney, salivary and sweat glands, and the colon).
How is a geriatric patient classified?
Classified as a patient over 60 years of age.
What Further complicates trauma injuries in/with the pregnant population?
Further complexity to this trauma population is you now have two patients: Mother and baby.
What is the biggest factor in injuries that result in fetal death for the pregnant population?
Biggest factor in injuries resulting in fetal death are from maternal pelvic fractures.
What are the most common causes of fatal and nonfatal injury in adults > 65 years of age?
Falls, motor vehicle collisions, burns, and penetrating injuries are the most common causes of fatal and nonfatal injury in adults > 65 years of age.
What is the leading cause of death for women of reproductive age and the leading cause of nonobstetrical related death in pregnant women across the globe?
Trauma is a leading cause of death for women of reproductive age and the leading cause of nonobstetrical related death in pregnant women across the globe
For geriatric patients what differences in assessment techniques or findings should we expect?
-Atypical symptoms!
-Anterioposterior chest diameter increased,
-kyphosis more likely,
-diminished breath sounds, slower resp rate,
-lower baseline PaO2,
-more pronounced pulses except pedal absent,
-murmurs from stiff heart valves,
-ECG waveforms smaller,
-longer PR/QRS/QT,
-heart rate affected by beta blockers or CCBs,
-less colour to extremities,
-more variation in normal neuro findings due to comorbidities,
-slower GI motility,
-decreased bone and muscle mass,
-unsteady gait/balance or inability to walk,
-abdominal protrusion,
-reduced urinary output
What are 12 Pregnant Patients - Anatomical and Physiological Changes?
1.) Hypervolemia increasing resting heart rate.
2.) Increased hormonal levels causing vasodilation with corresponding systemic vascular resistance (force exerted on circulating blood by the vasculature of the body), and peripheral vascular resistance (resistance in the circulatory system that is used to create blood pressure, the flow of blood, and is also a component of cardiac function).
3.) Supine hypotension risk after 20 weeks as the aorta and inferior vena cava are compressed by the uterus and its contents when the patient is supine.
4.) Venous return decreases and cardiac output (volume of blood being pumped by a single ventricle of the heart per unit time) falls by 30-40%.
5.) Engorged pelvic vessels.
6.) Oxygen consumption increase - resp alkalosis more likely due to faster/more shallow respirations (uterus/baby puts pressure on diaphragm)
7.) Displaced organs to the upper abdomen mask typical findings of guarding and rigidity.
8.) Prolonged gastric emptying.
9.) Increased risk of urinary tract infection.
10.) Bladder displaced into abdomen.
11.) Softening and relaxation of sacral ligaments and pubic symphysis makes the pelvis more flexible.
12.) ECG changes due to heart muscle shift in anatomy.
What are some nonmodifiable factors that contribute to geriatric patients? (6)
Nonmodifiable factors – aging affects response to stress,
illness,
temperature,
medications,
trauma
and blood loss
What conditions are bariatric patients at a higher risk of?
Higher risk of:
-Hypertension
-Renal insufficiency
-Diabetes
-Cardiovascular disease
-Deep vein thrombosis
-Pulmonary embolism
-Decreased mobility
-Decreased blood circulation in lower extremities
What are the 5 main Trauma risks for bariatric patients?
Trauma risks in this population include:
1.) Infectious complications
2.) Acute respiratory distress syndrome (ARDS – life-threatening lung injury that allows fluid to leak into the lungs)
3.) Hematologic complications like anemia, polycythemia (increase in blood cells – red >white), iron deficiency and chronic inflammation
4.) Pressure ulcers
5.) Multiorgan failure with increased mortality after severe blunt trauma complicated by higher risk of diabetes
For the pregnant population what risks or complications exist for this group?
-Nosebleeds and airway obstruction,
-hypotension from occlusion of inferior vena cava by fetus,
-DVT/PE/DIC,
- acid reflux,
- hypoxia,
-risk of fetal injury or demise with maternal pelvic or abdominal injuries
For bariatric patients what differences in assessment techniques or findings should we expect?
-Harder to hear breath sounds/more faint (more adipose tissue), -harder to hear heart sounds/more faint (more adipose tissue), -ECG waveforms smaller,
-may need different size cuff for accurate BP,
-normal redness to face more common,
-cyanosis also more common,
-edema/ulcers to lower legs more common,
-pressure sores more common
What kind of injuries/hospital and survival rates do bariatric patients have?
Fewer injuries but more severe with longer hospital and ICU lengths of stay and lower survival rates.
What are some common injuries for the pregnant population? (5 of them)
Common injuries in this population are:
-Abdominal and pelvic injury
-Preterm labor
-Abruptio placentae
-Uterine rupture
-Cardiac arrest caused by hemorrhage or hypoxia
For bariatric patients what special equipment might be needed to properly care for this group?
-Bariatric hospital beds/ OR tables/ wheelchairs
-Bariatric Lifts
-Additional staff may be require to log roll patient/move patient
-Large blood pressure cuffs/ arterial line
-Bag Mask ventilation can be difficult to achieve, and while there are factors contributing to difficulties with intubation, this is often the only viable option.
-Recommendations include use of a short handle for direct laryngoscopy, or where available, video-laryngoscope.
A high-flow nasal cannula can be used for pre‐ oxygenation of obese patients
-Similarly, obtaining intravenous access, including central venous as well as peripheral options, may not be achievable
-Moving directly to intraosseous (IO) access has been suggested
-Sandbags and towel rolls can be utilized to properly stabilize the cervical and thoracic spine when backboards cannot be used
For geriatric patients how will our nursing and medical interventions be different with this group? (4 things)
-Give o2 early to prevent hypoxia,
-veins more easily burst during IV insertion,
-loss of teeth or facial mass makes effective BVM (baged valve mask) use harder,
-*Increased need for blood products and IV fluids but give carefully
What are pediatric lungs more susceptible to?
Lungs susceptible to barotrauma (physical tissue damage caused by a pressure difference between an unvented space inside the body and surrounding gas or fluid).
What is the BMI that is classified as obese/bariatirc?
BMI >= 30 kg/m2 or greater is classed as obese.
For geriatric patients how are injury patterns and outcomes different in this group? (refer to journal article) (5 things)
-Older adults (>65 y/o) are hospitalized for injury more often than younger despite lower injury severity.
-Emphasis on lower extremity fractures (including hip fractures)
-Discharges to home settings are less common than other populations
-An understanding of frailty (syndrome of vulnerability), advanced care planning, and end-of-life care are important considerations because injury is often a tipping point leading to functional decline and poor outcomes.
-Injury prevention efforts in older adults focus on fall prevention and driver safety programs.
What are some difficulties that healthcare providers have found with treating a bariatric trauma patient?
Health care providers have identified the following difficulties in treating the bariatric trauma patient:
-Assessments (faint heart/lung sounds 2nd to increased adipose tissue)
-Measuring vital signs
-Diagnostic testing
-Venipuncture
-Intravenous cannulations
-Patient positioning and mobilization
-Urinary catheterization
-Airway management
-Resuscitative measures
-Difficulty finding appropriately sized equipment
-Delayed healing due to inadequate nutrition
What are different Geriatric (Older Adult) – Anatomical and Physiological Changes that make them unique trauma patients to deal with?
Changes in postural stability, balance, motor strength and coordination.
Slower reaction times.
Poor visual acuity.
Reduction of proprioceptive (sense of position and movement of limbs and trunk, sense of effort, the sense of force, and the sense of heaviness) sensation and vibratory sensation.
Hearing impairments.
Increased sway.
Atrophy of oral mucosa – loose or poor fitting dentures can obstruct airway lead to difficulty bagging
Relaxed musculature.
Decreased gag and cough reflexes
Osteoporosis.
Spinal stenosis most common at C4-C5 so lever action causes fractures above and below these points.
Rigidity.
Decreased range of motion.
Increased respiratory rate.
Reduced tidal volume due to calcification of costal cartilage.
Respiratory fatigue.
Limited ability to increase heart rate and cardiac output.
Hypoperfusion is poorly tolerated because of declining cardiac reserve.
With pregnant patients, why do Health care providers deviate from standard trauma principles?
Health care providers deviate from standard trauma principles due to distraction of the pregnancy.
For the pregnant population what physiological differences exist in this population?
-enlarged uterus puts pressure on diaphragm/chest,
-rib cage flares out to compensate,
-decreased pulmonary reserve but higher minute ventilation,
-higher circulating blood volume,
-capillary engorgement,
-hypercoagulation,
-increased oxygen consumption,
-delayed gastric emptying,
-widened symphysis pubis in third trimester,
-increased renal blood flow
For pediatric population what do trauma outcomes fluctuate between?
Trauma outcomes fluctuate between rural and urban centers.
What are Pregnant women twice as likely to experience compared to nonpregnant women?
Pregnant women are twice as likely to experience violent trauma as nonpregnant women.
For bariatric patients what risks or complications exist for this group? (think of conditions) What king od injury are they less likey to have? Why?
-Higher risk of obstructive sleep apnea, more likely to have HTN, CAD, CHF, more likely to get DVT/PE/stroke, more at risk of increased ICP from positioning or head injury, risk of dermatitis and other infections from skin folds and reduced ability to cleanse skin,
-Less risk of some fractures and internal injuries due to more soft tissue to cushion
What may be more common during pregnancy than conditions women are routinely screened for such as gestational diabetes and preeclampsia?
Intimate partner violence may be more common during pregnancy than conditions women are routinely screened for such as gestational diabetes and preeclampsia.
What differences in assessment techniques or findings should we expect? (peads population)
-Harder to assess-rely on parents for a lot of information.
Start with peds assessment triangle from 370 (appearance, work of breathing, colour).
-Normal vitals differ by age.
-Compensate very well—normal vitals not always reassuring.
-Airways easily occluded and kids put everything in their mouths!
-Breath sounds easily transmitted to other side.
-Head bobbing, nasal flaring, retractions, grunting are signs of resp distress in babies/toddlers.
-Colour change will indicate shock much faster than BP changes. Immunization status/birth history important in young children—CIAMPEDS mnemonic from assessment class.
-Cannot always assess orientation/obeying commands–modified GCS or use AVPU. Spinal fractures that don’t show up on xray/CT are more common in peds
What are 5 pediatric Anatomical and Physiological Changes that makes them unique?
Large organs and thin muscle walls.
Less abdominal fat and elastic ligamentous attachments.
Incomplete calcification and open epiphyseal plates.
Greater body surface area.
Thinner skin and less subcutaneous fat.
How is BMI calculated?
BMI is calculated by dividing a person’s weight in kilograms by the individual’s height in meters squared.
For bariatric patients what physiological differences exist in this population?
-Larger,
-less mobile neck,
-resp muscles must work harder,
-higher resting resp rate,
-higher blood volume,
-higher resting heart rate,
- more tissue to perfuse,
-idiopathic intracranial hypertension,
-chronic venous insufficiency to lower legs
For the pregnant population how will our nursing and medical interventions be different with this group?
-Place wedge under pelvis when lying flat to tilt left (place under spine board if present to tilt entire patient to the left),
-intubation more difficult from airway capillary engorgement,
-give O2 to prevent maternal and fetal hypoxia,
-give fluids to maintain hypervolemic state even if vitals normal,
-insert NG early (assume stomach is full and at risk for aspiration),
- proceed with xrays/CTs if necessary—maternal life outweighs fetal risk
What are the risks + complications that exist in the pediatric population?
Less frequent but more severe heart and great vessel injuries.
Rib fractures rare, pulm contusions more common.
Mobile mediastinum=massive hemo or tension pneumo.
Prone to hypothermia and hypoglycemia without intervention.
Small volume changes=big risks to cardiovascular hemostasis.
Higher c-spine injuries from large head/floppy neck.
Can become hypovolemic from scalp wounds.
Liver/spleen damage more common
For the pregnant population what differences in assessment techniques or findings should we expect?
-Resp alkalosis with hypocapnia,
-resps faster and more shallow because uterus/baby puts pressure on diaphram,
-heart rate 10-20 bpm faster,
-slightly lower BP in 2nd trimester,
-any change in LOC is abnormal,
-lordosis more common,
-include fetal heart rate and fundal height,
-check for amniotic fluid or bleeding during GU exam,
-increased urine output and glucose in urine,
-increased RBC/WBC/clotting factors/GFR and decreased Hb/HCT/BUN/crea in labs, can lose 1200-1500mL before hypovolemia becomes apparent—fetus will be in distress.
-Include obstetric history with health history
What are the main physiological differences that exist with the peadartirc population?
Smaller airways, larger tongue, softer cartilage in larynx,
larger/flopper epiglottis, shorter funnel shaped trachea, larger head proportion
Nose breathers <3-6 months, less elasticity in lungs, smaller lungs with fewer alveoli
Higher metabolism=higher cardiac output, tachycardia to maintain BP (hypotension and especially bradycardia are late signs), no ability to contract harder/change stroke volume—just faster
Not always verbal, thinner skull, smaller brains with less myelinization, fontanelles in young children, smaller subarachnoid space
More susceptible to heat loss
More flexible bones
For geriatric patients what risks or complications exist for this group?
-Loose dentures obstructing airway,
-dysrhythmias more common,
-preexisting hypertension more common preexisting neurological impairment more common,
-polypharmacy,
-pressure sores,
-prone to hypothermia,
-risk of cerebral bleed higher, fractures more common due to OP/OA,
-higher risk of pneumonia/aspiration/infection/sepsis,
-risk of electrolyte imbalance and fluid overload,
For bariatric patients how will our nursing and medical interventions be different with this group?
-More difficult to ventilate and intubate - reverse Trendelenburg or side lying may improve respirations,
With the pregnant population, what does the increase in O2 consumption make them more likely to experience? Why?
Oxygen consumption increase - resp alkalosis more likely due to faster/more shallow respirations (uterus/baby puts pressure on diaphragm)
