March 2, 2026

This month, we'll be discussing Children and Youth with Special Healthcare Needs (CYSHCN). Although 13 – 18% of children are considered to have special needs, there is a consistent discrepancy in terms of medical complexity, functional limitations, and resource needs among CYSHCN. These patients are commonly identified as children who require health services above the average and are expected to be required for more than 12 months, sometimes dependent on assistive devices for daily living. The group of CYSHCN patients is extremely wide and includes several conditions, such as syndromic patients, patients affected by metabolic diseases, patients with neurological problems (i.e., severe seizure or malformations of the central nervous system), patients with congenital skeletal conditions, and users of medical devices. The Centers for Disease Control (CDC) estimates that 11.2 million children (representing roughly 15.1 % of children in the United States) are CYSHCN. Greater than 11% utilize durable medical equipment, and approximately 25 – 30% of children treated in the ED have special needs. Nearly 1 out of every 5 children in the United States has a physical, intellectual, and developmental disability, as well as long-standing medical conditions. This is four times the number of hospitalizations, twice as many physician visits, and 1.5 times as many ED visits. As EMS providers, it is important to know which children in your geographic area have special needs.

Parents of these children are forced to provide managed care. Most are knowledgeable about their child’s medical history and conditions; you should use them as a resource. They live with these patients, work with the portable equipment, know how to troubleshoot, and know the treatments very well. Fortunately, we have seen many medical advancements with portable technology as well as improved and efficacious medications. When evaluating these patients, please remember to assess and manage Airway, Breathing, and Circulation (ABCs) first, as you would with any other child. Treat the child, not the equipment. If the emergency is due to the child’s equipment, use your own equipment. It is important to note that (1) physical handicaps do not necessarily imply mental deficits and (2) assess and communicate with the child on his/her developmental age, not chronological age.

• Challenges to caring for these children include: 

• Language barriers  

• Developmental delay  

• Visual/auditory deficits 

• The scene and the child’s response to that environment can be a great source of tension and anxiety 

• Multiple providers can create fear  

• Multiple voices can cause confusion 

• Anxiety in a child 

• The child may resist being restrained 

Use a soothing voice to provide comfort. Please try to explain each movement to them. Remember to ask the caregiver for a medical summary card. Sometimes, caregivers may be too stressed to remember vital information. During transport, allow the child to lie in a comfortable position and use padding around buckles and contractures. Do not use excessive force to straighten or manipulate contracted extremities. The patient may have osteopenia or osteogenic imperfecta and be prone to fractures. Brittle bones and muscle contractures can easily lead to injuries during transport; do not pull on extremities. In addition, some CYSHCN are unable to straighten extremities beyond a nominal degree. A slow, careful transfer with two or more people is preferable. Ask for the “go bag,” which usually has the child’s spare equipment and supplies. Bring the bag with you during transport. Transfer the patient, if possible, to their medical “home” hospital.  

 Next week, we will discuss specific medical illnesses/ailments that affect CYSHSN. Have a great week.

Stay warm, and thank you so much for all that you do,

Regina Yaskey, MD

March 9, 2026

Hello everyone. This week, we will continue discussing Children and Youth with Special Health Care Needs (CYSHCN).  

Pulmonary Disorders and Airway Defects 

• Apnea is defined when respirations cease for > 20 seconds or when respirations cease for < 20 seconds with cyanosis or bradycardia. It can be obstructive, central, or mixed. It affects both premature and full-term infants. If there is ever a chief complaint of apnea, then these patients should be transported to the hospital for evaluation.

• Cystic Fibrosis is an autosomal recessive disorder. It affects 30,000 Americans. It causes mucus builds up in lungs thereby causing breathing difficulty and lung infections in patients. Signs and symptoms include increased respiratory rate, increased oxygen requirement, paleness or cyanosis. Managing these patients involves giving oxygen, chest therapy with bronchial or postural draining, antibiotics, and bronchodilators (e.g. albuterol). 

Cardiovascular Heart Defects 

Congenital Heart Defects (CHDs) occur approximately in 1 in 1,000 live births. There are 2 types: Acyanotic and Cyanotic.

• Acyanotic Heart Defects account for the majority of CHD in children. It is caused by mixing of desaturated blood in the systemic arterial circulation. Oxygen saturation for these patients is in the normal range. Causes include septal defects, obstructions to the flow of blood, and incomplete heart development.

• Signs and Symptoms of Acyanotic Heart Disease

• Increased respiratory rate (tachypnea)

• Increased heart rate (tachycardia)

• Heart murmur

• Signs of heart failure include auscultation rales on lung exam, palpating a liver edge on exam, and edema noted on extremities.  

• Types of Acyanotic Heart Defects  

• Ventral Septal Defect (most common)

• Defect in wall that separates ventricles  

• Atrial Septal Defect

• Patent ductus arteriosus

• Fetal blood passage doesn’t close after birth 

• Obstructive lesions

• Narrows the aorta or valves 

• Cyanotic Heart Defects result in blood from arteries and veins that mix in the heart. It is important to note that typical oxygen saturation for these patients usually ranges from 70% - 90% on room air. Palliative procedures are often performed at birth in order to save the lives of these children. Caregivers/medical control may advise that you avoid administration of oxygen unless O2 saturation is below usual. Otherwise, never withhold oxygen (low flow). 

• Signs and Symptoms of Cyanotic Heart Disease

• Cyanosis

• Increased respiratory rate

• Retractions

• Increased heart rate

• Poor perfusion

• Diminished peripheral pulses

• Poor feeding and sweats with feeds

• Remember that low oxygen level in the blood can cause the lips, toes and fingers to look blue (cyanotic).  

• Types of Cyanotic Heart Defects 

• Hypoplastic Left Heart Syndrome 

• Transposition of the great arteries 

• Tetralogy of Fallot  

• Tricuspid Atresia  

• Pulmonary Atresia  

• Truncus Arteriosus  

• Cardiac Arrhythmias 

Down Syndrome (Trisomy 21) is the most common chromosomal abnormality. It affects 1 in 800 births. The highest risk is seen in women who are older than 35 years of age. Although super cute, these children are at risk for medical complications of multiple systems, including a large tongue, hypotonia, short neck, obesity, short stature, and loose ligaments. This can lead to difficulty when trying to provide an advanced airway in these patients.  

Conditions Associated with Down Syndrome: 

• Congenital heart disease  

• VSD, ASD, AV canal  

• Orthopedic conditions  

• Atlantoaxial subluxation  

• Neurologic Conditions  

• Epilepsy  

• Airway and Respiratory problems (large tongue, hypotonia, short neck) 

• Dental and speech abnormalities 

Traumatically Disabled Children 

Unintentional injuries are the leading cause of morbidity and mortality in these children. Examples include traumatic brain injuries and spinal cord injuries. They are at increased risk for seizures and are at high risk of abuse. EMS Providers are mandatory reporters for suspected cases of child abuse. These children may also have difficulty regulating body temperature and may need CSF shunts, feeding tubes, or wheelchairs. Pressure sores are serious concerns in these patients. If there are any concerns from the family, it is important that the child be transported to the ED for an evaluation and management. 

Thank you for all that you do. Stay safe and warm,

Regina Yaskey, MD

March 16, 2026

Hello everyone. This week, we will discuss airway interventions using special technology and neurologic conditions.  

Airway and Ventilator Management

Children with special health care needs frequently rely on advanced airway support, including tracheostomies and chronic mechanical ventilation. Respiratory distress may result from airway obstruction, mucus plugging, equipment malfunction, or underlying pulmonary disease rather than acute infection alone. Assessment should focus on airway patency, adequacy of ventilation, and oxygenation, while recognizing that baseline respiratory findings may differ from those of typical children. Caregivers are often the best source of information regarding normal ventilator settings and respiratory status. 

Tracheostomy Emergencies

Tracheostomy-related emergencies commonly involve displacement, obstruction, or equipment failure. Initial evaluation should confirm that the tracheostomy tube is properly positioned, the obturator has been removed, and any speaking valves or caps are off. Suctioning should be performed using appropriately sized catheters, preferably those supplied by the family. If respiratory distress persists, oxygen administration, manual ventilation, or emergent tracheostomy tube replacement may be required. 

Ventilator Emergencies

Children on ventilators may deteriorate rapidly due to circuit disconnection, power failure, high airway pressures, or worsening pulmonary disease. When alarms sound or respiratory distress is noted, the priority is to assess the child rather than troubleshoot the machine. If necessary, the child should be disconnected from the ventilator and manually ventilated with a bag-valve device and oxygen while evaluating for airway obstruction or equipment failure. Transport should not be delayed by prolonged ventilator assessment. 

Neurologic Conditions

Neurologic disorders are common among children with special health care needs and include seizure disorders, hydrocephalus, cerebral palsy, spina bifida, and developmental disabilities. These conditions may affect airway control, respiratory drive, and baseline mental status, complicating assessment during emergencies. A clear understanding of the child’s usual neurologic function is essential. 

Seizure Disorders

Seizures may be febrile or non-febrile and can present in several forms, including generalized tonic-clonic, absence, and partial seizures. Many children have home rescue medications or implanted devices such as vagal nerve stimulators. Management focuses on airway protection, oxygenation, and administration of antiepileptic medications per protocol, while avoiding unnecessary interventions once the seizure has resolved. 

Hydrocephalus and CSF Shunts

Children with hydrocephalus often have cerebrospinal fluid (CSF) shunts, most commonly ventriculoperitoneal shunts. Shunt malfunction or infection can lead to increased intracranial pressure and present with headache, vomiting, altered mental status, bradycardia, hypertension, or abnormal eye findings. Fever or redness along the shunt tract should raise concern for infection. These findings warrant urgent medical evaluation and transport. 

Cerebral Palsy and Developmental Disorders

Cerebral palsy and other developmental disorders may be associated with muscle contractures, impaired communication, seizure disorders, and difficulty managing secretions. During care and transport, providers should avoid forceful manipulation of extremities, support the child in a position of comfort, and work closely with caregivers to minimize anxiety and injury. 

Key Points

Airway and neurologic emergencies in children with special health care needs require rapid assessment, respect for baseline differences, and close collaboration with caregivers. Treating the child rather than the equipment and recognizing when manual airway support or urgent transport is needed are critical to safe outcomes. 

EMS PEARLS / HIGH-RISK RED FLAGS: Airway / Tracheostomy 

• Inability to pass a suction catheter suggests tube obstruction or displacement 

• Sudden respiratory distress is airway until proven otherwise 

• Always remove caps, speaking valves, or decannulation plugs during distress 

• Never force suction catheters 

EMS PEARLS / HIGH-RISK RED FLAGS: Ventilator Emergencies

• Do not delay care to troubleshoot ventilator alarms 

• Disconnect and bag if the child looks sick 

• Remember DOPE: Displacement, Obstruction, Pulmonary issue, Equipment failure 

• Transport with the child’s ventilator and backup supplies, if possible 

EMS PEARLS / HIGH-RISK RED FLAGS: Seizures 

• Airway compromise is the most immediate threat 

• Many seizures stop before EMS arrival — avoid unnecessary medications 

• Ask about baseline seizure frequency and home rescue plans 

• Postictal states may mimic altered mental status from other causes  

EMS PEARLS / HIGH-RISK RED FLAGS: CSF Shunt Malfunction / Infection 

• Headache, vomiting, altered mental status = shunt problem until proven otherwise 

• Bradycardia with hypertension is a late, ominous sign 

• Fever or redness along the shunt tract suggests infection 

• Urgent transport is required — do not delay on scene 

EMS PEARLS / HIGH-RISK RED FLAGS: Cerebral Palsy / Developmental Disorders 

• Do not force contracted extremities — high fracture risk 

• Position of comfort is preferred over standard immobilization when safe 

• Physical handicap does not necessarily imply mental deficits  

Thank you so much, everyone. Have a great week and be safe,

Regina Yaskey, MD

March 23, 2026

Hello everyone. This week, we will be discussing behavioral and emotional emergencies in children.  

Overview of Behavioral and Emotional Emergencies 

Children with special behavioral and emotional needs represent a high-risk population during prehospital encounters. Behavioral emergencies may present as agitation, aggression, or emotional dysregulation and should be understood as potential manifestations of underlying developmental, psychiatric, or neurologic disorders rather than willful misconduct. Families frequently experience social isolation and caregiver fatigue and may delay activating emergency services due to concerns about stigma, misinterpretation, or escalation of the situation. 

Implications for EMS Systems and Response 

Traditional EMS response models may be insufficient for pediatric behavioral emergencies. These calls often require adaptive decision-making, interdisciplinary collaboration, and de-escalation strategies rather than rapid transport alone. Requests for assistance may originate from caregivers, educators, or school personnel seeking urgent intervention for a child who is “out of control.” Early coordination with pediatric specialists or mental health professionals has the potential to reduce escalation and improve continuity of care; however, many EMS agencies lack formal policies, training, or access pathways to support these interventions.

Underlying Conditions Associated with Behavioral Emergencies 

Several psychiatric and developmental conditions are commonly associated with behavioral emergencies in children. These include mood disorders such as depression and bipolar disorder; thought disorders such as schizophrenia; developmental disorders including autism spectrum disorder; anxiety-related conditions such as posttraumatic stress disorder; and attention deficit hyperactivity disorder. Recognition of these conditions is crucial for accurate assessment, effective communication, and appropriate management in the prehospital setting. 

Family Dynamics and Ethical Considerations 

Families of children with psychiatric and behavioral disorders often face complex and competing fears, including concern for the child’s safety, fear of violent behavior toward family members, and anxiety regarding potential harm if restraints or law enforcement involvement becomes necessary. EMS providers serve a critical advocacy role by balancing patient and provider safety with the principles of least restrictive intervention, dignity, and trauma-informed care. Awareness of caregiver exhaustion and chronic stress is essential to effective and compassionate prehospital management. 

Pharmacologic Management in Behavioral Emergencies 

When non-pharmacologic de-escalation strategies are insufficient, medication administration may be required in accordance with local protocols. Routes of administration may include oral, intranasal (IN), intramuscular (IM), or intravenous (IV) delivery. Common medication classes used in pediatric behavioral emergencies include benzodiazepines (e.g., midazolam, lorazepam), antipsychotics (e.g., haloperidol, olanzapine, ziprasidone), dissociative agents (e.g., ketamine), and antihistamines (e.g., diphenhydramine). Medication selection should prioritize patient safety, ongoing reassessment, and adherence to established EMS guidelines. Please refer to your protocols and dosages for patients with behavioral concerns. Per the UH protocol, patients who are agitated, but not combative, can receive Benadryl as a slow push IV/IM/OI; combative – not violent patients under 16 years with risk to self and others (can receive midazolam or lorazepam); and combative, violent patients (can receive ketamine, lorazepam, and midazolam). Capnography is required for ALL patients who receive chemical restraint.

That’s all for this week. Have a great week, everyone. Stay safe out there,

Regina Yaskey, MD

March 30, 2026

Good morning. This week’s message addresses important considerations for managing children and youth with special healthcare needs (CYSHCN). Always remember to treat the airway, breathing, and circulation first with any child with a special healthcare need. Treat the child, not the equipment. This means that if you cannot get the equipment to work, you should remove the child from the ventilator, ventilate the child with a bag-valve-mask, and take the ventilator with you to the hospital so troubleshooting can happen there. It is the same with a tracheostomy tube; if unable to replace the trach, please use a bag-valve-mask. When bagging the patient, remember to cover the stoma site to prevent significant leakage. If the emergency is due to the child’s equipment, use your own equipment. Remember to always speak with family since they are experts on their child. Ask for help from parents and home health staff, as they can share critical information regarding the child’s baseline, communication style, and specific needs, allowing for a calmer, less stressful emergency scene.   

Physical handicaps do not necessarily imply mental deficits. Remember to assess and communicate with the child on his/her developmental age, not chronological age. 

Ask for the “go bag,” which usually has the child’s spare equipment and supplies, and bring it with you during transport. Do not use excessive force to straighten or manipulate contracted extremities. Remember that some CYSHCN are unable to straighten extremities beyond a nominal degree; therefore, a slow, careful transfer with two or more people is preferable.  

It is important to know which children in your geographic area have special needs. Proactive knowledge improves care coordination during emergencies and helps identify necessary equipment needed (ventilators, catheters, trachs), therefore reducing complications and ensuring better, faster patient care. Ask if they have a brief emergency medical information form, card, or summary. Look for MedicAlert jewelry. If possible, transfer the child to their medical “home” hospital. If unsure, follow protocol or call medical command.  

This is it for the month of March. Thank you for all the hard, caring work that you do. Stay safe,

Regina Yaskey, MD