09 Special Populations

Shared emergency priorities

Emergency care for special populations keeps the same immediate priorities used for every patient: identify immediate threats, support airway, breathing, and circulation, and reassess. Adapt assessment and treatment to age, physiology, communication needs, and likely causes of deterioration. Use current local protocols, medical direction, and age-appropriate equipment and medication references.

Obstetric assessment

Pregnancy can change how illness or injury presents and what consequences it may have. Ask about gestational age or estimated due date, prenatal complications, pregnancy-related medications, contractions, fluid leakage, vaginal bleeding, fetal movement, and prior pregnancies. For a postpartum patient, ask how long ago delivery occurred because serious pregnancy-related complications can also occur after birth.

Assess the pregnant patient as you would any adult, prioritizing maternal oxygenation, ventilation, and perfusion. Obtain vital signs, assess mental status and skin signs, and look for shock. Do not let an apparently reassuring blood pressure delay care when bleeding, pain, weakness, syncope, or altered mental status suggests hemorrhage.

In later pregnancy, the enlarged uterus can compress major vessels when the patient lies flat. If tolerated and not contraindicated, use left lateral positioning or manually displace the uterus to the left, especially during resuscitation. For trauma, manage the mother’s life threats first and transport promptly.

Time-critical obstetric problems

Consider Ectopic pregnancy in anyone who could be pregnant and has abdominal or pelvic pain, vaginal bleeding, syncope, or shock, even if pregnancy has not been confirmed. Rupture can cause life-threatening internal bleeding.

Bleeding later in pregnancy may reflect placental complications. Avoid unnecessary vaginal examination in the field; treat shock, provide supportive care, and transport urgently. Suspect Preeclampsia/eclampsia when pregnancy or recent delivery is accompanied by severe headache, visual changes, upper abdominal pain, altered mental status, or seizure. Protect the patient from injury, support airway and ventilation, manage seizures according to protocol, and expedite transport.

Postpartum hemorrhage requires rapid hemorrhage and shock management when heavy bleeding after delivery is accompanied by pallor, weakness, tachycardia, or poor perfusion. Follow local guidance for uterine massage, uterotonic medication, and transport; do not delay transport to complete field interventions.

Imminent or ongoing delivery

When birth is imminent, prepare a warm, clean area and delivery supplies. Support the mother and allow birth to proceed without pulling on the infant, and note the time of birth. After delivery, assess the newborn’s breathing, tone, and heart rate; dry, warm, and stimulate as indicated.

If the newborn is not breathing effectively or has a low heart rate, follow the neonatal resuscitation algorithm; effective ventilation is the key initial intervention. If the head delivers but the shoulders do not, recognize Shoulder dystocia, call for help, and use protocol-approved positioning and maneuvers. Never apply fundal pressure. For a visible Prolapsed cord, relieve pressure on the cord with a gloved hand as trained, position the patient to reduce compression, and transport immediately.

Neonatal transition and resuscitation

A newborn is transitioning from placental support to breathing with the lungs. Temperature loss, airway obstruction, and inadequate ventilation can rapidly worsen the newborn’s condition. Keep the newborn warm and dry, position the airway to remain open, and repeatedly assess breathing and heart rate. A vigorous newborn may remain skin-to-skin with the parent when safe and feasible.

If resuscitation is needed, follow the Neonatal algorithm and prioritize effective ventilation. Use pulse oximetry and oxygen according to the algorithm and local protocol. Do not confuse this immediate newborn transition with resuscitation of an older infant or child: the neonatal algorithm is intended for birth and the early postnatal transition.

Pediatric assessment and respiratory care

Infants and children have smaller airways, higher oxygen consumption, and less reserve than adults. Respiratory failure is a common pathway to pediatric cardiac arrest. Children may show Compensation for shock through tachycardia and vasoconstriction, so hypotension is often a late, ominous sign. Emphasize work of breathing, mental status, skin perfusion, and trends in vital signs rather than interpreting a single measurement in isolation.

Begin with an overall visual impression, then conduct a structured primary assessment of airway, breathing, circulation, disability or mental status, and exposure. The Pediatric Assessment Triangle uses appearance, work of breathing, and circulation to the skin to rapidly identify a child who needs immediate intervention while a fuller assessment continues.

Look for respiratory distress or failure signs such as retractions, nasal flaring, abnormal positioning, grunting, poor air movement, fatigue, or declining responsiveness. Provide oxygen and ventilatory support as indicated. Do not mistake diminishing effort in an exhausted child for improvement.

Pediatric shock and cardiac arrest

Look for shock signs including altered mental status, tachycardia, weak peripheral pulses, cool or mottled skin, and delayed capillary refill. Hypotension signals decompensation. Treat the likely cause, establish appropriate access, and administer fluids or other therapies in protocol-directed, weight-based increments; reassess frequently for response and fluid overload.

For cardiac arrest, use pediatric resuscitation guidance for infants and children, with age- and size-appropriate equipment and weight-based therapy. Because pediatric arrest often follows respiratory or circulatory deterioration, effective ventilation and treatment of the underlying cause are essential.

Pediatric communication and safeguarding

Use a calm, developmentally appropriate approach. Whenever possible, keep the child with a caregiver, obtain history from both caregiver and child, and use an interpreter when needed. Establish baseline behavior, medical conditions, medications, allergies, and the circumstances and timeline of illness or injury.

Measure weight in kilograms when possible; use a validated length-based tool if weight is unavailable. Confirm every medication dose and equipment size against a reliable reference and local protocol. Consider Nonaccidental injury when the history, developmental ability, and findings do not fit together. Maintain a neutral, objective approach, protect the child, document observations and statements accurately, and follow mandatory reporting and agency procedures.

Geriatric assessment

Do not attribute a new symptom or decline to normal aging. Older adults may have serious illness or injury without classic symptoms; confusion, weakness, a fall, reduced function, fatigue, or loss of appetite may be the first clue. Fever may be absent in infection, and significant injury can follow a seemingly minor fall.

Establish Baseline mental status, mobility, and daily function, then identify what has changed and when. Use glasses, hearing aids, dentures, interpreters, and caregiver or facility-staff information when available. Ask about medications, including recent changes, over-the-counter products, anticoagulants, and medication adherence, along with allergies, medical conditions, advance-care documents, and the patient’s goals. A medication list or medication containers can help when the history is limited.

Geriatric clinical judgment and care

Assess for time-sensitive causes such as stroke, acute coronary syndrome, infection, hypoglycemia, medication effects, dehydration, and Occult trauma. A fall may result from syncope, arrhythmia, orthostatic symptoms, medication effects, or acute illness; assess the cause, not only visible injuries. Evaluate for head injury and anticoagulant use, and maintain a low threshold to suspect serious injury when the mechanism or examination warrants it.

Frailty, reduced physiologic reserve, and comorbid disease can make deterioration rapid and recovery more difficult. Titrate interventions to clinical response and monitor closely for adverse effects. Communicate respectfully with the patient directly, preserve warmth and privacy, handle fragile skin and painful joints gently, and avoid assumptions about cognition or treatment preferences based on age alone.