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

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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 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 Trauma

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 ?


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

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

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