# Rescuscitating little people



## citizensoldierny (May 30, 2010)

This might sound like it's coming from left field but I don't think it has been done before. One of my fellow firefighters who is also a special ed. teacher asked me which pads should be used on a little person aka midget/dwarf. I'm pretty sure it is adult pads as an  8 y.o. developmentally normal child isn't all that big. On the other hand what if the little person is of extremely small stature would you use the child paddles?. Also would one treat them as adults when it comes to meds or if I encounter an extremely small statured little person should I be using a broselow tape?


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## got_shoes (May 30, 2010)

I would like to know this as well, I would say do they fit on the broselow tape? if so then I would think that they would need to be treated as a pedi of the same size. But at the same time Most midgets/dwarfs weigh a bit more which might cause some problems with weight based medications.


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## Fox (May 30, 2010)

citizensoldierny said:


> This might sound like it's coming from left field but I don't think it has been done before. One of my fellow firefighters who is also a special ed. teacher asked me which pads should be used on a little person aka midget/dwarf. I'm pretty sure it is adult pads as an  8 y.o. developmentally normal child isn't all that big. On the other hand what if the little person is of extremely small stature would you use the child paddles?. Also would one treat them as adults when it comes to meds or if I encounter an extremely small statured little person should I be using a broselow tape?



I was told only adult pads for adults, child for children, despite age and height, but I have no sources and would like to see the answer from someone who might know more about it.


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## rescue99 (May 30, 2010)

citizensoldierny said:


> This might sound like it's coming from left field but I don't think it has been done before. One of my fellow firefighters who is also a special ed. teacher asked me which pads should be used on a little person aka midget/dwarf. I'm pretty sure it is adult pads as an  8 y.o. developmentally normal child isn't all that big. On the other hand what if the little person is of extremely small stature would you use the child paddles?. Also would one treat them as adults when it comes to meds or if I encounter an extremely small statured little person should I be using a broselow tape?



 There are many types of dwarfism. The most common type has a normal torso and developement with shortened limbs. Size usually is not a consideration when it comes to joules. Age and development is. Treat them as you would anyone of average size under most conditions, locating patches where needed. Weight based drugs are weight based. Adults are adults. Kids are kids. Treat each accordingly unless told otherwise.


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## dmiracco (May 30, 2010)

I would look at the weight of the patient more than the size. Typically ped pads are for 10kg and less and alot of services only have adult and ped pads so there could be some of a gray area so to speak. So Adult pads A/P is what I would do for the instance.


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## got_shoes (May 30, 2010)

"A dwarf is a person of short stature - under 4’ 10” as an adult. More than 200 different conditions can cause dwarfism. A single type, called achondroplasia, causes about 70 percent of all dwarfism. Achondroplasia is a genetic condition that affects about 1 in 25,000 people. It makes your arms and legs short in comparison to your head and trunk. Other genetic conditions, kidney disease and problems with metabolism or hormones can also cause short stature.
Dwarfism itself is not a disease. However, there is a greater risk of some health problems With proper medical care, most people with dwarfism have active lives and live as long as other people." source http://www.nlm.nih.gov/medlineplus/dwarfism.html

Also something else to think about, what other meds are they on due to mitigating psychosocial stresses that dwarfs tend to face as compared to other persons of similar age. I would also say that for the forms of dwarfism associated with the endocrine system may be treated using hormonal therapy. I seem to think that might be important in considering the effects of some effects of medications. also I believe that some dwarfs have issues with kidney function.


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## fma08 (May 30, 2010)

Treat the drugs by their weight based dosages? For example, Lidocaine 1-1.5mg/kg, q 3-5min up to a total of 3mg/kg. I'm not sure though. An interesting question to say the least. Check with your medical director?


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## got_shoes (May 30, 2010)

I did check with my med director, today. he said that he wasnt sure how it would be any different then treating an elderly person on similar meds, or an overly obese person, his idea was to try and fix under lying condition. he also said that he would look into it. and he would try and provide some extra information.


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## citizensoldierny (May 30, 2010)

Got shoes,
Thanks for all the leg work. So it seems the consensus is to treat them like adults. Works for me, as I've never been instructed differently but then again I've never bee instructed to deal with little people at all as far as I can remember. They might have  touched on how to address them in nursing school but that is as far as my training goes specifically in re: little people.:wacko:


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## arealdwarf (May 30, 2010)

*Resuscitating a dwarf*

I'm not an EMT, but I am a real dwarf.  Some general answers:  medicate based on weight, not size.  Like most people, our weight varies (sometimes it's good and sometimes it ain't so good).  I don't think you'll find us as a group more likely to be on "psychosocial drugs" than any other group of people - we have been dwarfs all our lives and we're quite used to it.    Note:  there are over 200 types of dwarfism, so it's important to not generalize . . . however . . . some dwarfism types involve problems with the C1/C2 vetebrae, in which case that person should not be intubated by someone who does not know exactly what they're doing.  If the patient is an adult (or old enough to communicate) and conscious, she/he can probably tell you what you need to know - just listen!    I once spent a very long night in an ER in a cervical collar because x-rays showed a pattern common to my type of dwarfism.  I understand the caution, but the collar was apparently made for a giraffe - very painful - and I could not get anyone to hear me tell them that what they were seeing was quite normal for me.  Again, I understand the caution, it's just very frustrating to be ignored.  Dwarfism can also be part of osteogenesis imperfecta (brittle bone), in which case of course you should use great care.  Dwarfism can be caused by many things.  We're generally aware of the peculiarities of our particular condition.  btw - the word "midget" is generally disapproved of (I will personally forgive it once or twice if used in ignorance) because it is the word of choice when someone WANTS to be rude or hurtful.  Dwarf, little person, short-statured person, etc. are cool to most people.  www.lpaonline.org has tons of links to good info.
Thank you all for the great work you do!
ARD


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## LucidResq (May 30, 2010)

ARD - thank you so much for your extremely insightful post. 

I contacted the Chair of the Medical Advisory Board of LPA quite a long time ago to see if they could direct me to any information specific to emergency medical treatment, resuscitation and such of people with dwarfism but didn't hear back from them.  

Your post is a good start... think I might spend some time digging around for more info tonight since it seems we all have a lot of questions.


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## LucidResq (May 30, 2010)

This is interesting. 

It's from the LPA written for laypeople, but near the end it sounds like she's mentioning a link between osteogenesis imperfecta and malignant hyperthermia. Not relevant to all us, I know... but those of us who are permitted RSI perhaps... I'm digging.


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## citizensoldierny (May 30, 2010)

Arealdwarf,
Thanks for info I definitely appreciate it as I didn't even consider the airway just figured I'd use a smaller ET and all would be good. As for the meds I might have been unclear as I'm running on big sleep deficit lately but I meant to say should I use adult standing order protocols i.e. epi 1mg,atropinge 1mg to a max of 3 mg etc. or would I have to go the weight/based route which is why I mentioned broselow tape.  Thanks for the insight into dwarfism. No harm was intended when I said midget, I honestly  thought it was a name for a certain type of little person, I chose to use little people in the title as I am aware that it is the term of choice these days, just used the other terms for clarity of communication as they are still in the common vernacular . Obviously my knowledge doesn't go much farther, though with your help I wont step in it the future and needlessly insult someone again. Apologies and once again thanks.


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## LucidResq (May 30, 2010)

Hooray!!! From this article:

Dvorak, D. M., Rusnak, R. A., and Morcos, J. J. 1993. Multiple trauma in the achondroplastic dwarf: An emergency medicine physician perspective case report and literature review. The American Journal of Emergency Medicine 11:390-395.

...

-Orotracheal or endotracheal intubation usually are not too big of a hassle. 

-Cervical spine abnormalities + narrow foramen magnum make hyperextending the neck dangerous. It can cause apnea, quadriplegia, etc... 

-Vascular access, especially in the extremities, can be difficult due to increased subq fat, also common anatomical landmarks may be hard to find. 

-Decreased vital capacity... but pulmonary function is generally normal. 



> Based on our experience in a critical resuscitation situation, we would recommend placement of CVP catheters via the internal jugular route using the posterior approach to the internal jugular vein, as recommended by others...





> One investigator found a significant venous gradient across the thoracic inlet in two of live ADS and ascribed it to narrowing of the thoracic inlet. This resulted in an increase in intracranial pressure with inspiration. In such instances, hyperventilation of the head-injured patient may paradoxically elevate the intracranial pressure (ICP).





> This abnormal geometric configuration simulates hyperextension in the neutral neck position and creates the potential for high-cervical cord injury with even minor head or neck trauma or during extension of the neck for intubation.


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## Epi-do (May 31, 2010)

About a year ago, I had this exact conversation at my firehouse, with the other medics.  We arrived at the general consensus that if we were talking about achondroplasia, that they would be treated like any other adult of normal stature.  We didn't have anything to back this up, just the knowledge that the torso & head are of "normal" size, and that it is the extremities are shortened.

The thing that we couldn't figure out though, was if you had a primordial dwarf, since they tend to be proportionally "normal", but with a much smaller stature & weight than a person of "normal" size.  At that point, would you dose according to weight?


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## LucidResq (May 31, 2010)

Epi... you did read above right? I had no idea either til I did some research tonight but apparently some of their skull and spinal anatomy is pretty different and may hold quite a bit of significance for EMS. Of course, you don't want to mess with anyone's neck especially in possible SCI.... but it really could be a matter of life-or-death for this population...


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## Epi-do (May 31, 2010)

LucidResq said:


> Epi... you did read above right? I had no idea either til I did some research tonight but apparently some of their skull and spinal anatomy is pretty different and may hold quite a bit of significance for EMS. Of course, you don't want to mess with anyone's neck especially in possible SCI.... but it really could be a matter of life-or-death for this population...



Are you referring to the links that have been posted, or the rest of the thread, in general?  I haven't read the links yet, but have looked at everything else that has been posted so far.  

I realize these people can have a whole host of other issues that can make things difficult for us, and the majority of us (myself included) wouldn't even have a clue if the patient or some other family member cannot fill us in on it.

I just went back and looked at my other post.  I totally left out that I was referring to drug dosages, and nothing else.  (And I even read over it before posting it...)  I can see where you would think I haven't read anything else that has been posted, based upon what was there.  I really need to get some sleep!  And on that note, I am headed off to bed.


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## firetender (May 31, 2010)

*Just Gotta Say: This Is GREAT Stuff!*

I said it.


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## got_shoes (May 31, 2010)

arealdwarf: thanks so much for the information, I am sorry for saying the word 

midget. no harm by it. The comment on psycosocial issues I believe was for, 

more for those dwarfs that are having a hard time dealing with living in a world 

that isn't designed for them and due to reasons that deal with people being 

ignorant of dwarfs. I was thinking a lot about this subject last night and came 

to the idea that dwarfs more then likely know about their medical conditions, 

as such means that we as EMS providers should talk to them about 

treatment, and any and all questions should go back to online med control. 

over the last day or so I have learned a lot from this post just from doing a lot 

of research. Another great thing happened as well. my med director is going 

to help set up a program dealing with the special population. if that offends anyone, sorry


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## medicRob (May 31, 2010)

got_shoes said:


> arealdwarf: thanks so much for the information, I am sorry for saying the word
> 
> midget. no harm by it. The comment on psycosocial issues I believe was for,
> 
> ...



I am an American Heart Association Instructor, and your post has encouraged me to seek to set about the same type of program and to provide information in my service's protocols with regard to how to handle individuals faced with dwarfism as it relates to our patient care interventions, where necessary. Now, it's time for me to get back to watching doogie howser and being lazy before my shift. 

Btw, Hulu.com's desktop player + Downtime = A Great Time Killer


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## LucidResq (May 31, 2010)

medicRob said:


> Btw, Hulu.com's desktop player + Downtime = A Great Time Killer



I agree, for some reason I've become obsessed with Parks and Recreation. 

Back to topic though 

I had a really hard time finding any information on AEDs or resuscitation. If you or anyone else can find anything please share.


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## got_shoes (May 31, 2010)

Although uncommon, the achondroplastic dwarf (AD) may become the victim of multiple trauma, presenting special challenges for the emergency department (ED) physician. Traditional management of airway, breathing, circulation, and neurological disability is altered by the unique anatomic features of achondroplasia. Despite facial abnormalities observed in the AD, orotracheal and nasotracheal intubation are usually accomplished without particular difficulty; however, abnormalities of the base of the skull and cervical spine make hyperextension of the neck especially hazardous in these patients. The lungs are functionally normal, although vital capacity is decreased and thoracic case abnormalities and abdominal obesity impair lung expansion. Vascular access in the AD is difficult. Peripheral access is difficult because of excessive subcutaneous fat, whereas central venous access is complicated by neck, chest wall, and spinal abnormalities that obscure commonly used anatomic landmarks. Major neurological syndromes observed in ADs are hydrocephalus, cervical medullary compression, and thoracolumbar stenosis. The ED physician should recognize these syndromes, their potential to produce neurological disability, and their unique implications for trauma. source pubmed.gov


If left untreated, growth hormone deficiency will lead to short stature and delayed puberty.

Growth hormone deficiency may occur with deficiencies of other hormones, including the following:

Thyrotropins (control production of thyroid hormones)
Vasopressin (controls water balance in the body)
Gonadotropins (control production of male and female sex hormones)
Adrenocorticotrophic hormone or ACTH (controls the adrenal gland and its production of cortisol, DHEA, and other hormones)
source: http://www.nlm.nih.gov/medlineplus/ency/article/001176.htm:

An abnormally short height in childhood (called short stature) may occur if there is not enough growth hormone produced. Growth hormone is produced in the pituitary gland, which is located at the base of the brain.

Most of the time, no cause is found.

Growth hormone deficiency may be present at birth (congenital) or acquired as the result of an injury or medical condition.

*Children with physical defects of the face and skull, such as cleft lip or cleft palate*, can also have decreased growth hormone levels.

Growth hormone deficiency also can be caused by severe brain injury.

Growth retardation may first be noticed in infancy and continue throughout childhood. The pediatrician will usually plot the child's "growth curve" on a standardized growth chart. The child's growth may range from flat (no growth) to very shallow (minimal growth). Normal puberty may or may not occur, depending on how well the pituitary gland can produce hormones other than growth hormone.

Although it is uncommon, growth hormone deficiency may also be diagnosed in adults. Possible causes include:

Hormonal problems involving the pituitary gland or hypothalamus
Brain radiation treatments for cancer
Severe head injury
source:http://www.nlm.nih.gov/medlineplus/ency/article/001176.htm


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