Presentation is loading. Please wait.

Presentation is loading. Please wait.

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

Similar presentations

Presentation on theme: "Victor Politi, M.D., FACP Medical Director, SVCMC Division of Allied Health, Physician Assistant Program."— Presentation transcript:

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

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

4 Appeal of Emergency Medicine Team approach Patient advocacy Open job market Academic opportunities Shift work / set hours Evolving specialty


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

7 Subspecialties in Emergency Medicine Pediatric Emergency Medicine Toxicology Emergency Medical Services Sports Medicine

8 Areas of Expertise Toxicology Emergency medical services Mass gatherings Disaster management Wilderness medicine

9 Upcoming Areas of Emergency Medicine Hyperbaric medicine Observation units ED ultrasound International emergency medicine

10 Introduction to Trauma

11 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 –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 Battles 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 Pulmonary Contusion Right pulmonary contusion, left chest wall defect with lung hernia

43 C-Spine Dont become distracted by trying to clear the c- spine A properly applied cervical collar never killed anyone! Dont 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 Dont 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 ABCs Constantly re-evaluate patient not labs Dont raise your voice - remain calm You are not alone, consult the experts –dont get in over your head Take a step back - –What are you missing ? –What did you overlook ?

58 Questions ???

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

Similar presentations

Ads by Google