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
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

17. Seatbelt injury

18. 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

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

20. 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

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

22. 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

23. 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

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

25. 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

26. Class III Blood Loss Respond to initial fluid bolus
was initial bolus inadequate?
is patient experiencing ongoing hemorrhage?
As fluids are slowed, patient deteriorates
Usually indicates 20-40% blood loss
Requires continued fluids, blood products
The response to blood products dictates speed of surgical intervention

27. Fingertip amputation

28. 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

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

30. Battle’s sign - base of skull injury

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

32. 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

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

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

35. 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

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

37. High voltage wiring injury

38. 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

39. cutting two fingers off in a meat slicer

40. 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”

41. 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

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

43. 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

45. Fracture-dislocation C7-T1

47. 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

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

49. Right diaphragm laceration on chest x-ray

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

51. Spleen Laceration on CT - Grade III

52. 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

53. Renal retroperitoneal hematoma Grade IV

54. 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

55. 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

57. 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 ?

58. Questions ???