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

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.

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.

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.

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.

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.

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.

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.

Introduction to Trauma 1

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

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

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

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

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

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

Seatbelt injury

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

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

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

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

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

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

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 750-1500ml Class III percentage loss 30-40% amount of loss 1500-2000ml Class IV percentage loss more than 40% amount of loss >200ml

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

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

Fingertip amputation

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

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

Battle’s sign - base of skull injury

'Racoon Eyes' sign of base of skull fracture

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

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

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

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

Decreasing BP increasing pulse Disorientation - confusion Mechanism of injury

High voltage wiring injury

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

cutting two fingers off in a meat slicer

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”

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

Right pulmonary contusion, left chest wall defect with lung hernia

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

Fracture-dislocation C7-T1

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

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

Right diaphragm laceration on chest x-ray

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

Spleen Laceration on CT - Grade III

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

Renal retroperitoneal hematoma Grade IV

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

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

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 ?

Questions ???