Presentation on theme: "Victor Politi, M.D., FACP Medical Director, SVCMC Division of Allied Health, Physician Assistant Program."— Presentation transcript:
1Victor Politi, M.D., FACPMedical Director, SVCMC Division of Allied Health, Physician Assistant Program
2Specialty Selection Top Ten Leading Causes of Death in the U.S. Heart Disease: 726,974Cancer: 539,577Stroke: 159,791Chronic Obstructive Pulmonary Disease: 109,029Accidents: 95,644Pneumonia/Influenza: 86,449Diabetes: 62,636Suicide: 30,535Nephritis, Nephrotic Syndrome, and Nephrosis 25,331Chronic Liver Disease and Cirrhosis: 25,175Why 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.
3Appeal of Emergency Medicine Make an immediate differenceLife threatening injuries and illnessesUndifferentiated patient populationChallenge of “anything” coming inEmergency / invasive proceduresSafety net of healthcareThere 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.
4Appeal of Emergency Medicine Team approachPatient advocacyOpen job marketAcademic opportunitiesShift work / set hoursEvolving specialtyWithin 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.
6Downside to Emergency Medicine Interaction with difficult, intoxicated, or violent patientsFinding follow-up or care for uninsuredWork in a “fishbowl”without 20/20 hindsightWorking as a patientadvocateAt 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 problemMany 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.
7Subspecialties in Emergency Medicine Pediatric Emergency MedicineToxicologyEmergency Medical ServicesSports MedicineOne 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.
8Areas of Expertise Toxicology Emergency medical services Mass gatheringsDisaster managementWilderness medicineBeyond 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.
9Upcoming Areas of Emergency Medicine Hyperbaric medicineObservation unitsED ultrasoundInternational emergency medicineThe future of EM is limitless. We are branching out into various areas of medicine to include these.
11Trauma 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
12Trauma 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
13Trauma 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 year60 million injuries annually30 million need medical treatment3.6 million need hospitalization
14Trauma StatisticsImpact of trauma is greatest in children and young adultsTrauma cost the American public over $300 billion annually including lost wages, medical expenses, administrative costs, employer expenseApproximately 40% of health care monies are spent on trauma
15Trauma StatisticsTraumatic injuries, including unintentional injuries cause -43% of all deaths ages 1 to 449% of all deaths ages 5 to 1464% of all deaths ages 15 to 24
16Trauma StatisticsLeading cause of accidental death in US - motor vehicle accidentsdrinking is a factor in 49% of these cases
17Trauma 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
19Trauma StatisticsDrowning is the 4th most common cause of unintentional injury death for all agesIt ranks 1st for persons age 25 to 44It ranks 2nd for ages 5 to 44
20Designated Trauma Centers Immediate availability of necessary resourcesDesignated -RegionalAreaLevel ILevel II
21Tri-modal distribution of Trauma Death First peak: second - minutesbrain injury, high spinal cord, large vessels, cardiac arrestbest treated by preventionSecond peak: minutes - hourssub/epidurals, HTX/PTX, spleen, liver lacbest treated by applying principles of ATLSThird peak: days-weekssepsis, multi-organ failuredirectly correlated to earlier Rx
22Primary Evaluation Airway maintenance with c-spine control Breathing and ventilationCirculation with hemorrhage controlDisability or neurological statusExposure and environmental control
23Control the airway with basic maneuvers suctionadminister 100% oxygenhyperventilateprepare to intubateparalyze the patientuse appropriate Rx considering ?elevated ICPintubate, maintaining in-line traction
24Circulation Control exsanguinating hemorrhage control external bleeding promptlyestablish at least 2 R.L. wide-bore Ivslarge diameter/short length Ivsideally 14 ga. 1 1/4”add pressure bags
25Shock Classification Class III Class IV percentage loss 30-40% amount of loss mlClass IVpercentage loss more than 40%amount of loss >200mlClass Ipercentage loss up to 15%amount of loss up to 750mlClass IIpercentage loss 15-30%amount of loss ml
26Treatment of Hemorrhagic Shock due to trauma Defined as B/P less than 90 systolic in an adultThe treatment of shock should be directed not toward the class of shock but to the response to initial therapy
27Class III Blood Loss Respond to initial fluid bolus was initial bolus inadequate?is patient experiencing ongoing hemorrhage?As fluids are slowed, patient deteriorates
28Class III Blood Loss Usually indicates 20-40% blood loss Requires continued fluids, blood productsThe response to blood products dictates speed of surgical intervention
34Minimal or No Response to Fluid Resuscitation Seen in small percentage of patientsusually dictates need for immediate surgical intervention to control exsanguinating hemorrhagePrepare the ORIf penetrating chest trauma consider cardiac injury
35gunshot wound left fronto-parietal region entrance wound (close-up)
36Golden HourThe hemodynamically unstable trauma patient needs only two things …hot lightscold steel
37Aggressive 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
38Decreasing BP increasing pulse Disorientation - confusionMechanism of injury
42Universal Donor Type O negative is available immediately used in exsanguinating hemorrhageused in patient with minimal or no response to initial crystalloid fluids bolusRemember -“Give Blood Save A Life”
43Radiologic 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
44Right pulmonary contusion, left chest wall defect with lung hernia
45C-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 clearedcontinue to protect c-spine during treatment
49Chest Radiograph Rule-out PTX/HTX - need immediate treatment Provides clues as to condition of -heart, lung, parenchyma, mediastinum, great vessels, bronchus, diaphragmAlmost unheard of to have significant chest injury w/o signs of same on CXRCXR are frequently misinterpreted and injuries are frequently overlooked
50Chest Radiograph Check position of tubes Locate foreign bodies (i.e. bullets)Free air under diaphragm or on lateral means perforated viscusCardiac tamponade
54Abdominal Trauma CAT scan with contrast utilizes PO and IV contrastMay require NGT for administration of contrastRisk of vomiting and aspirationRisk of allergic reaction to contrastIntubation to protect airway requiring sedationDifficult to obtain CT in unstable patient
56Pelvic Trauma Evaluate for pelvic, femoral neck, femur fractures Provides clues as to condition of -abdominal viscerabladderPatients can bleed out into thighMules and packers -products in distal colon
57Ultrasound Dynamic study performed in trauma room no need to move patient to x-ray or CTcan immediately visualize heart, pericardiumcan visualize liver, spleen, kidney lacscan visualize ~ 50 cc blood, fluid in abdomentakes approximately 5 minuteshighly operator dependent
59Trauma Code: ETA 5 minutes Stick with the basics - remember ABC’sConstantly re-evaluate patient not lab’sDon’t raise your voice - remain calmYou are not alone, consult the expertsdon’t get in over your headTake a step back -What are you missing ?What did you overlook ?
63Incidence of Chest Trauma Cause 1 of 4 American trauma deathsContributes to another 1 of 4Many die after reaching hospital - could be prevented if recognized<10% of blunt chest trauma needs surgery1/3 of penetrating trauma needs surgeryMost life-saving procedures do NOT require a thoracic surgeon
64Pathophysiology of Chest Trauma hypovolemiaventilation-perfusionmismatchInadequate oxygendelivery to tissueschanges inintrathoracicpressurerelationshipsTISSUEHYPOXIA
66Initial assessment and management Primary surveyResuscitation of vital functionsDetailed secondary surveyDefinitive care
67Initial assessment and management Hypoxia is most serious problem - early interventions aimed at reversingImmediate life-threatening injuries treated quickly and simply - usually with a tube or a needleSecondary survey guided by high suspicion for specific injuries
72A = AirwayAssess for airway patency and air exchange - listen at nose & mouthAssess for intercostal and supraclavicular muscle retractionsAssess oropharynx for foreign body obstruction
73B = BreathingAssess respiratory movements and quality of respirations look, listen, feelShallow respirations are early indicator of distress cyanosis is late
74C = Circulation Assess pulses for quality, rate, regularity Assess blood pressure and pulse pressureSkin - look and feel for color, temperature, capillary refillLook at neck veins - flat vs. distendedCardiac monitor
75ThoracotomyClosed heart massage is ineffective in a hypovolemic patientLeft anterior thoracotomy with cross-clamping of descending thoracic aorta and open-chest massage may be useful in pulseless victim of penetrating trauma
87Tension pneumothorax Air leaks through lung or chest wall “One-way” valve with lung collapseMediastinum shifts to opposite sideInferior vena cava “kinks” on diaphragm, leading to decreased venous return and cardiovascular collapse
89Tension pneumothoraxTension pneumothorax is not an x-ray diagnosis - it MUST be recognized clinicallyTreatment is decompression- needle into 2nd intercostalspace of mid-clavicular line -followed by thoracotomytube
91Open pneumothorax “Sucking Chest Wound” Normal ventilation requires negative intra-thoracic pressureLarge open chest-wall defect leads to immediate equilibration of intra-thoracic and atmospheric pressuresIf hole is >2/3 tracheal diameter, air prefers chest defect
92Open pneumothoraxInitial treatment - seal defect and secure on three sides (total occlusion may lead to tension pneumothoraxDefinitive repair of defect in O.R.
93Massive hemothoraxRapid accumulation of >1500 cc blood in chest cavityHypovolemia & hypoxemiaNeck veins may be:flat - from hypovolemiadistended - intrathoracic bloodAbsent breath sounds, DULL to percussion
96Massive hemothorax - treatment Large-bore (32 to 36 F) tube to drain bloodIf moderate sized to 1500 ml - and stops bleeding, closed drainage usually sufficientIf initial drainage >1500 ml OR continuous bleeding >200 ml / hr, OPEN THORACOTOMY indicated
1076 Potential Life Threats Pulmonary contusionMyocardial contusionTraumatic aortic ruptureTraumatic diaphragmatic ruptureTracheobronchial tree injury - larynx, trachea, bronchusEsophageal trauma
108Pulmonary contusionPotentially life-threatening condition with insidious onsetParenchymal injury without lacerationMore than 50% will develop pneumonia, even with treatmentUp to 50% have only hemoptysis as presenting symptom
109Pulmonary contusionPatients with pre-existing conditions - emphysema, renal failure - need early intubationTreatment needs to occur over timeas symptoms develop
110Myocardial contusion Blunt precordial chest trauma Difficult to diagnoseRisk for dysrhythmias, sudden death,tamponade, pericarditis, ventricular aneurysm
111Myocardial contusion Also may see: myocardial concussion - “stunned” myocardium with no cell deathcoronary artery lacerationDiagnosis by:trans-esophageal echocardiogramserial cardiac enzymes
112Traumatic aortic rupture 90% or more dead at scene90% mortality each undiagnosed dayMust have high index of suspicionDisruption occurs at ligamentum arteriosum (ductus arteriosus)Contained hematoma of 500 to 1000 ml of blood
113Traumatic aortic rupture Radiographic signswide mediastinum1st & 2nd rib fxobliteration of aortic knobtracheal deviation to rightpleural capdepression left mainstem bronchuselevation and right shift mainstem bronchusobliteration “aortic window”deviation of esophagus to right
125Tracheobronchial tree injury Bronchusrare and lethalusually BLUNTtrauma withinone inch ofcarina
126Esophageal trauma Most commonly penetrating May be lethal if not recognizedHigh suspicion ifleft pneumothorax and hemothorax without rib fractureshock out of proportion to apparent blunt chest traumaparticulate matter in chest tube
127Esophageal traumaIf blunt trauma, linear tear in lower esophagus with leakage of stomach contents into mediastinum
1286 Other Frequent Injuries Subcutaneous emphysemaTraumatic asphyxiaSimple pneumothoraxHemothoraxScapula fractureRib fractures
131Traumatic asphyxia“Masque ecchymotique” - purple face from extravasation of bloodMajor damage is to underlying structuresPurple face fades over time insurvivors
132Simple pneumothoraxAir enters potential space between visceral and parietal pleuraBreath sounds down on affected sidePercussion shows hyper-resonanceTreatment: chest tube in 4th or 5th intercostal space anterior to mid-axillary line
133HemothoraxLung laceration OR disruption of intercostal artery or internal mammary arteryMost are self-limitingSurgical consultation forinitial flow of >20 cc/kg (~1500 cc)continued flow of >200 cc/hr
134Scapula fracturesFractures of scapula or 1st & 2nd ribs may indicate major mechanism ofinjury
135Rib fractures Ribs - most frequently injured part of thoracic cage Most commonly injured - 4th 9thIf 10th/11th/12th, be suspicious for liver or spleen injuriesIf 1st/2nd/3rd, worry about injury to head, neck, spinal cords, lungs, and great vessels
137In conclusion...Chest trauma is very common in the multi-injured patientAirway management and a judiciously placed needle can save many lives
138Trauma Code: ETA 5 minutes Stick with the basics - remember ABC’sConstantly re-evaluate patient not lab’sDon’t raise your voice - remain calmYou are not alone, consult the expertsdon’t get in over your headTake a step back -What are you missing ?What did you overlook ?