1. Victor Politi, M.D., FACP
Medical Director, SVCMC Division of Allied Health, Physician Assistant Program

2. Specialty Selection Top Ten Leading Causes of Death in the U.S.
Heart Disease: 726,974
Cancer: 539,577
Stroke: 159,791
Chronic Obstructive Pulmonary Disease: 109,029
Accidents: 95,644
Pneumonia/Influenza: 86,449
Diabetes: 62,636
Suicide: 30,535
Nephritis, Nephrotic Syndrome, and Nephrosis 25,331
Chronic Liver Disease and Cirrhosis: 25,175
Why would one choose emergency medicine?
Here are the Top Ten leading causes of death in the United States.
As you can see from the table, Heart Disease, Cancer, Stroke, Pulmonary Disease and Trauma make up the top 5 causes. The patients that we evaluate in the emergency department, typically have these types of disease processes.

3. Appeal of Emergency Medicine
Make an immediate difference
Life threatening injuries and illnesses
Undifferentiated patient population
Challenge of “anything” coming in
Emergency / invasive procedures
Safety net of healthcare
There is no better job than emergency medicine. We work as the detective to determine the cause of the patients complaints. Patients are not admitted to us with pyelonephritis. They present with an undifferentiated complaint such as back pain and fever. We have to investigate the complaint through history and physical exam, as well as labs and radiographs. We have to work through a very large differential.
We see anybody and everybody. We have the chance to make the difference in somebody’s health almost every day. We must be prepared to take care of any emergency that arrives at the ED.

4. Appeal of Emergency Medicine
Team approach
Patient advocacy
Open job market
Academic opportunities
Shift work / set hours
Evolving specialty
Within EM, we work through a team approach with other specialties to arrive at an appropriate diagnosis and treatment plan for the patient. We must stand firm on what is best for the patient even if our consultants would rather not admit them.
We work set hours which allows us to better plan our lives. It allows us more time for our families or interests. We know where our work day ends and our private lives begin.
The opportunities within academics are huge. You can work in any setting from a community hospital to a level 1 intercity trauma center.
Emergency medicine will continue to grow in the future. There are many avenues that we can improve upon and develop.

6. Downside to Emergency Medicine
Interaction with difficult, intoxicated, or violent patients
Finding follow-up or care for uninsured
Work in a “fishbowl”
without 20/20 hindsight
Working as a patient
advocate
At times, dealing with consultants can be difficult. This is due to the personality of that particular consultant, not the specific specialty.
Some patients are under the influence of drugs that cause them to be violent or inappropriate. This should be looked upon as a challenge, not a problem
Many patients arrive at the ED without any emergency. Instead they arrive because of convenience for either them or their physician. Although frustrating, it still allows you to practice medicine.
There will be times when other specialists look back at your care and determine that it was inappropriate now that they have much more information. Always do the right thing based on what information you have available.

7. Subspecialties in Emergency Medicine
Pediatric Emergency Medicine
Toxicology
Emergency Medical Services
Sports Medicine
One can move onto various areas of sub-specialty from the specialty of Emergency Medicine. These are the four areas in which we can become board certified through fellowship training.

8. Areas of Expertise Toxicology Emergency medical services
Mass gatherings
Disaster management
Wilderness medicine
Beyond the areas of fellowships, there are several areas of expertise within the field of emergency medicine. Many other specialties may consult you about these areas to help manage patients.
This can include the care of patients on a helicopter, or at a large gathering such as the Olympics. It might also include the management of multiple injuries at the site of a disaster such as a building collapse.
Poisonings and environmental injuries are often managed emergently in the ED. However, the continued resuscitation within the hospital is often better known to us than the physician taking care of the patient.

9. Upcoming Areas of Emergency Medicine
Hyperbaric medicine
Observation units
ED ultrasound
International emergency medicine
The future of EM is limitless. We are branching out into various areas of medicine to include these.

10. Introduction to Trauma1

11. Trauma is a major cause of death in young people
Trauma is a major cause of death in young people. The cost in human lives and economic terms is tremendous

12. Trauma is the leading cause of death for all age groups under the age of 44
In the US - it is the leading cause of death in children

13. Trauma Statistics 4th leading cause of death of Americans of all ages
Nearly 150,000 people of all ages in the US die from trauma each year
60 million injuries annually
30 million need medical treatment
3.6 million need hospitalization

14. Trauma Statistics
Impact of trauma is greatest in children and young adults
Trauma cost the American public over $300 billion annually including lost wages, medical expenses, administrative costs, employer expense
Approximately 40% of health care monies are spent on trauma

15. Trauma Statistics
Traumatic injuries, including unintentional injuries cause -
43% of all deaths ages 1 to 4
49% of all deaths ages 5 to 14
64% of all deaths ages 15 to 24

16. Trauma Statistics
Leading cause of accidental death in US - motor vehicle accidents
drinking is a factor in 49% of these cases

17. Trauma Statistics Falls -
2nd leading cause of accidental death for ages 45 to 75 years and
#1 cause of unintentional death for persons age 75 and older

18. Seatbelt Injury

19. Trauma Statistics
Drowning is the 4th most common cause of unintentional injury death for all ages
It ranks 1st for persons age 25 to 44
It ranks 2nd for ages 5 to 44

20. Designated Trauma Centers
Immediate availability of necessary resources
Designated -
Regional
Area
Level I
Level II

21. Tri-modal distribution of Trauma Death
First peak: second - minutes
brain injury, high spinal cord, large vessels, cardiac arrest
best treated by prevention
Second peak: minutes - hours
sub/epidurals, HTX/PTX, spleen, liver lac
best treated by applying principles of ATLS
Third peak: days-weeks
sepsis, multi-organ failure
directly correlated to earlier Rx

22. Primary Evaluation Airway maintenance with c-spine control
Breathing and ventilation
Circulation with hemorrhage control
Disability or neurological status
Exposure and environmental control

23. Control the airway with basic maneuvers
suction
administer 100% oxygen
hyperventilate
prepare to intubate
paralyze the patient
use appropriate Rx considering ?elevated ICP
intubate, maintaining in-line traction

24. Circulation Control exsanguinating hemorrhage
control external bleeding promptly
establish at least 2 R.L. wide-bore Ivs
large diameter/short length Ivs
ideally 14 ga. 1 1/4”
add pressure bags

25. Shock Classification Class III Class IV percentage loss 30-40%
amount of loss ml
Class IV
percentage loss more than 40%
amount of loss >200ml
Class I
percentage loss up to 15%
amount of loss up to 750ml
Class II
percentage loss 15-30%
amount of loss ml

26. Treatment of Hemorrhagic Shock due to trauma
Defined as B/P less than 90 systolic in an adult
The treatment of shock should be directed not toward the class of shock but to the response to initial therapy

27. Class III Blood Loss Respond to initial fluid bolus
was initial bolus inadequate?
is patient experiencing ongoing hemorrhage?
As fluids are slowed, patient deteriorates

28. Class III Blood Loss Usually indicates 20-40% blood loss
Requires continued fluids, blood products
The response to blood products dictates speed of surgical intervention

29. Fingertip amputation

30. Identify the Site Most obvious source is external hemorrhage
Next consider hemothorax
Consider abdominal source
spleen laceration
hemoperitoneum
renal hematoma
liver laceration
injury to a great vessel

31. Identify the Site Consider mechanism of injury
Every trauma victim should have a finger or tube in every hole

32. Battle’s sign - base of skull injury

33. 'Racoon Eyes' sign of base of skull fracture

34. Minimal or No Response to Fluid Resuscitation
Seen in small percentage of patients
usually dictates need for immediate surgical intervention to control exsanguinating hemorrhage
Prepare the OR
If penetrating chest trauma consider cardiac injury

35. gunshot wound left fronto-parietal region
entrance wound (close-up)

36. Golden Hour
The hemodynamically unstable trauma patient needs only two things …
hot lights
cold steel

37. Aggressive fluid resuscitation must be initiated not when blood pressure is falling/absent but as soon as the early signs/symptoms of blood loss are suspected

38. Decreasing BP increasing pulse
Disorientation - confusion
Mechanism of injury

39. High voltage wiring injury

40. Blood Transfusion No substitute for the real thing
cross match if time permits
compatible with ABO and Rh blood types
minor antibody incompatibilities may occur

41. cutting two fingers off in a meat slicer

42. Universal Donor Type O negative is available immediately
used in exsanguinating hemorrhage
used in patient with minimal or no response to initial crystalloid fluids bolus
Remember -
“Give Blood Save A Life”

43. Radiologic Studies C-spine, chest and pelvis x-rays
CAT scan or specific x-rays that are indicated based on mechanism of injury and primary exam

44. Right pulmonary contusion, left chest wall defect with lung hernia

45. C-Spine Don’t become distracted by trying to clear the c-spine
A properly applied cervical collar never killed anyone!
Don’t remove cervical collar until c-spine is cleared
continue to protect c-spine during treatment

47. Fracture-dislocation C7-T1

49. Chest Radiograph Rule-out PTX/HTX - need immediate treatment
Provides clues as to condition of -
heart, lung, parenchyma, mediastinum, great vessels, bronchus, diaphragm
Almost unheard of to have significant chest injury w/o signs of same on CXR
CXR are frequently misinterpreted and injuries are frequently overlooked

50. Chest Radiograph Check position of tubes
Locate foreign bodies (i.e. bullets)
Free air under diaphragm or on lateral means perforated viscus
Cardiac tamponade

51. Right diaphragm laceration on chest x-ray

52. Abdominal Trauma Remove all clothing including undergarments
Perform adequate visual exam for injuries
Don’t forget the rectal exam

53. Spleen Laceration on CT - Grade III

54. Abdominal Trauma CAT scan with contrast
utilizes PO and IV contrast
May require NGT for administration of contrast
Risk of vomiting and aspiration
Risk of allergic reaction to contrast
Intubation to protect airway requiring sedation
Difficult to obtain CT in unstable patient

55. Renal retroperitoneal hematoma Grade IV

56. Pelvic Trauma Evaluate for pelvic, femoral neck, femur fractures
Provides clues as to condition of -
abdominal viscera
bladder
Patients can bleed out into thigh
Mules and packers -
products in distal colon

57. Ultrasound Dynamic study performed in trauma room
no need to move patient to x-ray or CT
can immediately visualize heart, pericardium
can visualize liver, spleen, kidney lacs
can visualize ~ 50 cc blood, fluid in abdomen
takes approximately 5 minutes
highly operator dependent

59. Trauma Code: ETA 5 minutes
Stick with the basics - remember ABC’s
Constantly re-evaluate patient not lab’s
Don’t raise your voice - remain calm
You are not alone, consult the experts
don’t get in over your head
Take a step back -
What are you missing ?
What did you overlook ?

60. CHEST TRAUMA

61. splinter

63. Incidence of Chest Trauma
Cause 1 of 4 American trauma deaths
Contributes to another 1 of 4
Many die after reaching hospital - could be prevented if recognized
<10% of blunt chest trauma needs surgery
1/3 of penetrating trauma needs surgery
Most life-saving procedures do NOT require a thoracic surgeon

64. Pathophysiology of Chest Trauma
hypovolemia
ventilation-
perfusion
mismatch
Inadequate oxygen
delivery to tissues
changes in
intrathoracic
pressure
relationships
TISSUE
HYPOXIA

65. Pathophysiology of Chest Trauma
Tissue hypoxia
Hypercarbia
Respiratory acidosis - inadequate ventilation
Metabolic acidosis - tissue hypoperfusion (e.g., shock)

66. Initial assessment and management
Primary survey
Resuscitation of vital functions
Detailed secondary survey
Definitive care

67. Initial assessment and management
Hypoxia is most serious problem - early interventions aimed at reversing
Immediate life-threatening injuries treated quickly and simply - usually with a tube or a needle
Secondary survey guided by high suspicion for specific injuries

68. 6 Immediate Life Threats
Airway obstruction
Tension pneumothorax
Open pneumothorax
“sucking chest wound”
Massive hemothorax
Flail chest
Cardiac tamponade

69. 6 Potential Life Threats
Pulmonary contusion
Myocardial contusion
Traumatic aortic rupture
Traumatic diaphragmatic
rupture
Tracheobronchial tree
injury - larynx, trachea,
bronchus
Esophageal trauma

70. 6 Other Frequent Injuries
Subcutaneous emphysema
Traumatic asphyxia
Simple pneumothorax
Hemothorax
Scapula fracture
Rib fractures

71. Primary Survey
Airway
Breathing
Circulation

72. A = Airway
Assess for airway patency and air exchange - listen at nose & mouth
Assess for intercostal and supraclavicular muscle retractions
Assess oropharynx for foreign body obstruction

73. B = Breathing
Assess respiratory movements and quality of respirations look, listen, feel
Shallow respirations are early indicator of distress cyanosis is late

74. C = Circulation Assess pulses for quality, rate, regularity
Assess blood pressure and pulse pressure
Skin - look and feel for color, temperature, capillary refill
Look at neck veins - flat vs. distended
Cardiac monitor

75. Thoracotomy
Closed heart massage is ineffective in a hypovolemic patient
Left anterior thoracotomy with cross-clamping of descending thoracic aorta and open-chest massage may be useful in pulseless victim of penetrating trauma

76. Thoracotomy
Nipple

77. 6 Immediate Life Threats
Airway obstruction
Tension pneumothorax
Open pneumothorax
“sucking chest wound”
Massive hemothorax
Flail chest
Cardiac tamponade

78. Airway Obstruction
Chin-lift - fingers under mandible, lift forward so chin is anterior

79. Airway Obstruction

80. Airway Obstruction
Jaw thrust - grasp angles of mandible and bring the jaw forward

81. Airway Obstruction Oropharyngeal airway inserted in
mouth behind tongue.
DO NOT push
tongue further back.

82. Airway Obstruction Nasopharyngeal airway - well lubricated “trumpet”
gently
inserted
through
nostril

83. Airway Obstruction Definitive management - tube in trachea
through vocal cords
with balloon
inflated.

84. Airway Obstruction Orotracheal intubation
Nasotracheal intubation - in breathing patient without major facial trauma
surgical airways
jet insufflation
cricothyrotomy
tracheostomy

85. Jet insufflation adapters
Airway Obstruction
Jet insufflation adapters

86. Airway Obstruction
Tracheotomy tubes

87. Tension pneumothorax Air leaks through lung or chest wall
“One-way” valve with lung collapse
Mediastinum shifts to opposite side
Inferior vena cava “kinks” on diaphragm, leading to decreased venous return and cardiovascular collapse

88. Inferior vena cava

89. Tension pneumothorax
Tension pneumothorax is not an x-ray diagnosis - it MUST be recognized clinically
Treatment is decompression
- needle into 2nd intercostal
space of mid-clavicular line -
followed by thoracotomy
tube

91. Open pneumothorax “Sucking Chest Wound”
Normal ventilation requires negative intra-thoracic pressure
Large open chest-wall defect leads to immediate equilibration of intra-thoracic and atmospheric pressures
If hole is >2/3 tracheal diameter, air prefers chest defect

92. Open pneumothorax
Initial treatment - seal defect and secure on three sides (total occlusion may lead to tension pneumothorax
Definitive repair of defect in O.R.

93. Massive hemothorax
Rapid accumulation of >1500 cc blood in chest cavity
Hypovolemia & hypoxemia
Neck veins may be:
flat - from hypovolemia
distended - intrathoracic blood
Absent breath sounds, DULL to percussion

96. Massive hemothorax - treatment
Large-bore (32 to 36 F) tube to drain blood
If moderate sized to 1500 ml - and stops bleeding, closed drainage usually sufficient
If initial drainage >1500 ml OR continuous bleeding >200 ml / hr, OPEN THORACOTOMY indicated

98. Flail chest
“Free-floating” chest segment, usually from multiple ribs fractures
Pain and restricted
movement
“Paradoxical
movement” of
chest wall with
respiration

100. Flail chest - treatment
Adequate ventilation
Humidified oxygen
Fluid resuscitation
PAIN MANAGEMENT
Stabilize the chest
internal - ventilator
external - sand bags

101. Cardiac tamponade Usually from penetrating injuries
Classic “Beck’s triad”
elevated venous pressure - neck veins
decreased arterial pressure - BP
muffled heart sounds
Blood in sac
prevents cardiac
activity

102. Cardiac tamponade
May find “pulsus paradoxus” - a decrease of 10 mm Hg or greater in systolic BP during inspiration
Systolic to diastolic gradient of less than 30 mm Hg also suggestive

103. Cardiac tamponade
Treatment is removal of small amount of blood - 15 to 20 ml may be sufficient - from pericardial sac

105. Stab wound to
right ventricle

106. pericardium
epicardial fat

107. 6 Potential Life Threats
Pulmonary contusion
Myocardial contusion
Traumatic aortic rupture
Traumatic diaphragmatic rupture
Tracheobronchial tree injury - larynx, trachea, bronchus
Esophageal trauma

108. Pulmonary contusion
Potentially life-threatening condition with insidious onset
Parenchymal injury without laceration
More than 50% will develop pneumonia, even with treatment
Up to 50% have only hemoptysis as presenting symptom

109. Pulmonary contusion
Patients with pre-existing conditions - emphysema, renal failure - need early intubation
Treatment needs to occur over time
as symptoms develop

110. Myocardial contusion Blunt precordial chest trauma
Difficult to diagnose
Risk for dysrhythmias, sudden death,
tamponade, pericarditis, ventricular aneurysm

111. Myocardial contusion Also may see:
myocardial concussion - “stunned” myocardium with no cell death
coronary artery laceration
Diagnosis by:
trans-esophageal echocardiogram
serial cardiac enzymes

112. Traumatic aortic rupture
90% or more dead at scene
90% mortality each undiagnosed day
Must have high index of suspicion
Disruption occurs at ligamentum arteriosum (ductus arteriosus)
Contained hematoma of 500 to 1000 ml of blood

113. Traumatic aortic rupture
Radiographic signs
wide mediastinum
1st & 2nd rib fx
obliteration of aortic knob
tracheal deviation to right
pleural cap
depression left mainstem bronchus
elevation and right shift mainstem bronchus
obliteration “aortic window”
deviation of esophagus to right

117. Traumatic aortic rupture
Treatment -
SURGICAL REPAIR

118. Traumatic diaphragmatic rupture
Blunt trauma - tears leading to immediate herniation
Penetrating trauma - small tears which may take years to develop herniation
Usually on left side

121. Traumatic diaphragmatic rupture
Treatment - surgical repair

122. Tracheobronchial tree injury
Larynx - rare
hoarseness
subcutaneous
emphysema
palpable crepitus
Intubation may be difficult
tracheostomy (not cricothyroidotomy) is treatment of choice

123. Tracheobronchial tree injury
Trachea
blunt or penetrating
esophagus, carotid
artery and jugular
vein may be involved
noisy breathing 
partial airway
obstruction

125. Tracheobronchial tree injury
Bronchus
rare and lethal
usually BLUNT
trauma within
one inch of
carina

126. Esophageal trauma Most commonly penetrating
May be lethal if not recognized
High suspicion if
left pneumothorax and hemothorax without rib fracture
shock out of proportion to apparent blunt chest trauma
particulate matter in chest tube

127. Esophageal trauma
If blunt trauma, linear tear in lower esophagus with leakage of stomach contents into mediastinum

128. 6 Other Frequent Injuries
Subcutaneous emphysema
Traumatic asphyxia
Simple pneumothorax
Hemothorax
Scapula fracture
Rib fractures

129. Subcutaneous emphysema
“Rice Krispies”
May result from
airway injury
lung injury
blast injury
No treatment
required - address underlying
problem

131. Traumatic asphyxia
“Masque ecchymotique” - purple face from extravasation of blood
Major damage is to underlying structures
Purple face fades over time in
survivors

132. Simple pneumothorax
Air enters potential space between visceral and parietal pleura
Breath sounds down on affected side
Percussion shows hyper-resonance
Treatment: chest tube in 4th or 5th intercostal space anterior to mid-axillary line

133. Hemothorax
Lung laceration OR disruption of intercostal artery or internal mammary artery
Most are self-limiting
Surgical consultation for
initial flow of >20 cc/kg (~1500 cc)
continued flow of >200 cc/hr

134. Scapula fractures
Fractures of scapula or 1st & 2nd ribs may indicate major mechanism of
injury

135. Rib fractures Ribs - most frequently injured part of thoracic cage
Most commonly injured - 4th  9th
If 10th/11th/12th, be suspicious for liver or spleen injuries
If 1st/2nd/3rd, worry about injury to head, neck, spinal cords, lungs, and great vessels

136. Rib frac tures Treatment consists of… Contraindications include…
intercostal blocks
epidural anesthesia
systemic analgesics
Contraindications include…
taping
rib belts
external splints

137. In conclusion...
Chest trauma is very common in the multi-injured patient
Airway management and a judiciously placed needle can save many lives

138. Trauma Code: ETA 5 minutes
Stick with the basics - remember ABC’s
Constantly re-evaluate patient not lab’s
Don’t raise your voice - remain calm
You are not alone, consult the experts
don’t get in over your head
Take a step back -
What are you missing ?
What did you overlook ?

139. Questions