victor politi, m.d., facp medical director, svcmc division of allied health, physician assistant...

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Introduction to Emergency Medicine

American College of EmergencyPhysicians

Victor Politi, M.D., FACPMedical 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

Appeal of Emergency Medicine

Make an immediate differenceLife threatening injuries and

illnessesUndifferentiated patient populationChallenge of “anything” coming inEmergency / invasive proceduresSafety net of healthcare

Appeal of Emergency Medicine

Team approachPatient advocacyOpen job marketAcademic opportunities Shift work / set hoursEvolving specialty

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

Subspecialties in Emergency Medicine

Pediatric Emergency MedicineToxicologyEmergency Medical ServicesSports Medicine

Areas of Expertise

ToxicologyEmergency medical servicesMass gatheringsDisaster management Wilderness medicine

Upcoming Areas of Emergency Medicine

Hyperbaric medicineObservation unitsED ultrasoundInternational emergency medicine

Introduction to Trauma

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 449% of all deaths ages 5 to 1464% of all deaths ages 15 to 24

Trauma Statistics

Leading cause of accidental death in US - motor vehicle accidentsdrinking 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

Trauma Statistics

Seatbelt Injury

Trauma Statistics

Drowning 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

Designated Trauma Centers

Designated Trauma CentersImmediate availability of necessary

resourcesDesignated -

• Regional• Area• Level I• Level II

Tri-modal distribution of Trauma Death

First peak: second - minutesbrain injury, high spinal cord, large vessels,

cardiac arrestbest treated by prevention

Second peak: minutes - hourssub/epidurals, HTX/PTX, spleen, liver lacbest treated by applying principles of ATLS

Third peak: days-weekssepsis, multi-organ failuredirectly correlated to earlier Rx

Primary Evaluation

Airway maintenance with c-spine control

Breathing and ventilationCirculation with hemorrhage controlDisability or neurological statusExposure and environmental control

Control the airway with basic maneuverssuctionadminister 100% oxygenhyperventilateprepare to intubateparalyze the patientuse appropriate Rx considering ?elevated

ICPintubate, maintaining in-line traction

Circulation

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

Shock Classification

Class I percentage loss up to

15% amount of loss up to

750ml Class II

percentage loss 15-30% amount of loss 750-

1500ml

Class IIIpercentage loss

30-40%amount of loss

1500-2000mlClass 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 boluswas 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

Class III Blood Loss

Fingertip amputation

Identify the Site

Most obvious source is external hemorrhage

Next consider hemothoraxConsider abdominal source

spleen lacerationhemoperitoneumrenal hematomaliver lacerationinjury 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 patientsusually dictates need for immediate

surgical intervention to control exsanguinating hemorrhage

Prepare the ORIf 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 lightscold 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 thingcross match if time permitscompatible with ABO and Rh blood

typesminor antibody incompatibilities may

occur

cutting two fingers off in a meat slicer

Universal Donor

Type O negative is available immediately

used in exsanguinating hemorrhageused 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-raysCAT scan or specific x-rays that are

indicated based on mechanism of injury and primary exam

Pulmonary Contusion

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 clearedcontinue 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, diaphragmAlmost unheard of to have significant

chest injury w/o signs of same on CXRCXR are frequently misinterpreted and

injuries are frequently overlooked

Chest Radiograph

Check position of tubesLocate 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 viscerabladder

Patients can bleed out into thighMules and packers -

products in distal colon

Ultrasound

Dynamic study performed in trauma roomno 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

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 ?

CHEST TRAUMACHEST TRAUMA

splinter

Incidence 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

Pathophysiology of Chest Trauma

hypovolemia

ventilation-perfusionmismatch

changes in intrathoracic

pressure relationships

Inadequate oxygendelivery to tissues

TISSUE HYPOXIA

Pathophysiology of Chest Trauma

Tissue hypoxiaHypercarbiaRespiratory acidosis - inadequate

ventilationMetabolic acidosis - tissue

hypoperfusion (e.g., shock)

Initial assessment and management

Primary surveyResuscitation of vital functionsDetailed secondary surveyDefinitive care

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

6 Immediate Life Threats

Airway obstructionTension pneumothoraxOpen pneumothorax “sucking chest wound”Massive hemothoraxFlail chestCardiac tamponade

6 Potential Life Threats

Pulmonary contusionMyocardial contusionTraumatic aortic ruptureTraumatic diaphragmatic ruptureTracheobronchial tree

injury - larynx, trachea, bronchus

Esophageal trauma

6 Other Frequent Injuries

Subcutaneous emphysemaTraumatic asphyxiaSimple pneumothoraxHemothoraxScapula fractureRib fractures

Primary Survey

Airway

Breathing

Circulation

Assess for airway patency and air exchange - listen at nose & mouth

Assess for intercostal and supraclavicular muscle retractions

Assess oropharynx for foreign body obstruction

A = Airway

Assess respiratory movements and quality of respirations - look, listen, feel

Shallow respirations are early indicator of distress - cyanosis is late

B = Breathing

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. distendedCardiac monitor

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

Thoracotomy

6 Immediate Life Threats

Airway obstructionTension pneumothoraxOpen pneumothorax “sucking chest wound”Massive hemothoraxFlail chestCardiac tamponade

Airway Obstruction

Chin-lift - fingers under mandible, lift forward so chin is anterior

Airway Obstruction

Airway Obstruction

Jaw thrust - grasp angles of mandible and bring the jaw forward

Airway Obstruction

Oropharyngeal airway inserted in mouth behind tongue. DO NOT push tongue further back.

Airway Obstruction

Nasopharyngeal airway - welllubricated“trumpet”gently insertedthroughnostril

Airway Obstruction

Definitive management - tube in trachea through vocal cords with balloon inflated.

Airway Obstruction

Orotracheal intubationNasotracheal intubation - in

breathing patient without major facial trauma

surgical airwaysjet insufflationcricothyrotomytracheostomy

Airway Obstruction

Jet insufflation adapters

Airway Obstruction

Tracheotomy tubes

Tension pneumothorax

Air leaks through lung or chest wall“One-way” valve with lung collapse Mediastinum shifts to opposite sideInferior vena cava “kinks” on

diaphragm, leading to decreased venous return and cardiovascular collapse

Inferior vena cava

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

Open pneumothorax

“Sucking Chest Wound”Normal ventilation requires negative

intra-thoracic pressureLarge 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

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.

Massive hemothorax

Rapid accumulation of >1500 cc blood in chest cavity

Hypovolemia & hypoxemiaNeck veins may be:

flat - from hypovolemiadistended - intrathoracic blood

Absent breath sounds, DULL to percussion

Massive hemothorax - treatment

Large-bore (32 to 36 F) tube to drain blood

If moderate sized - 500 to 1500 ml - and stops bleeding, closed drainage usually sufficient

If initial drainage >1500 ml OR continuous bleeding >200 ml / hr, OPEN THORACOTOMY indicated

Flail chest

“Free-floating” chest segment, usually from multiple ribs fractures

Pain and restricted movement “Paradoxical movement” of chest wall with respiration

Flail chest - treatment

Adequate ventilationHumidified oxygenFluid resuscitationPAIN MANAGEMENTStabilize the chest

internal - ventilatorexternal - sand bags

Cardiac tamponade

Usually from penetrating injuriesClassic “Beck’s triad”

elevated venous pressure - neck veinsdecreased arterial pressure - BPmuffled heart sounds

Blood in sac prevents cardiac activity

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

Cardiac tamponade

Treatment is removal of small amount of blood - 15 to 20 ml may be sufficient - from pericardial sac

Stab wound toright ventricle

pericardium

epicardial fat

6 Potential Life Threats

Pulmonary contusionMyocardial contusionTraumatic aortic ruptureTraumatic diaphragmatic ruptureTracheobronchial tree injury -

larynx, trachea, bronchusEsophageal trauma

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

Pulmonary contusion

Patients with pre-existing conditions - emphysema, renal failure - need early intubation

Treatment needs to occur over time

as symptoms develop

Myocardial contusion

Blunt precordial chest traumaDifficult to diagnoseRisk for dysrhythmias, sudden

death,tamponade, pericarditis, ventricular aneurysm

Myocardial contusion

Also may see:myocardial concussion - “stunned”

myocardium with no cell deathcoronary artery lacerationDiagnosis by:trans-esophageal echocardiogramserial cardiac enzymes

Traumatic aortic rupture

90% or more dead at scene90% mortality each undiagnosed

day Must have high index of suspicionDisruption occurs at ligamentum

arteriosum (ductus arteriosus)Contained hematoma of 500 to

1000 ml of blood

Traumatic aortic rupture

Radiographic signs wide mediastinum1st & 2nd rib fxobliteration of aortic

knob tracheal deviation to

rightpleural capdepression left

mainstem bronchus

elevation and right shift mainstem bronchus

obliteration “aortic window”

deviation of esophagus to right

Traumatic aortic rupture

Treatment - SURGICAL REPAIR

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

Traumatic diaphragmatic rupture

Treatment - surgical repair

Tracheobronchial tree injury

Larynx - rarehoarsenesssubcutaneous emphysemapalpable crepitus

Intubation may be difficulttracheostomy (not cricothyroidotomy)

is treatment of choice

Tracheobronchial tree injury

Tracheablunt or penetratingesophagus, carotid artery and jugular vein may be involvednoisy breathing partial airway obstruction

Tracheobronchial tree injury

Bronchusrare and lethalusually BLUNT trauma within one inch of carina

Esophageal trauma

Most commonly penetratingMay be lethal if not recognizedHigh suspicion if

left pneumothorax and hemothorax without rib fracture

shock out of proportion to apparent blunt chest trauma

particulate matter in chest tube

Esophageal trauma

If blunt trauma, linear tear in lower esophagus with leakage of stomach contents into mediastinum

6 Other Frequent Injuries

Subcutaneous emphysemaTraumatic asphyxiaSimple pneumothoraxHemothoraxScapula fractureRib fractures

Subcutaneous emphysema

“Rice Krispies”May result from

airway injurylung injuryblast injury

No treatment required - address underlying problem

Traumatic asphyxia

“Masque ecchymotique” - purple face from extravasation of blood

Major damage is to underlying structures

Purple face fades over time in survivors

Simple pneumothorax

Air enters potential space between visceral and parietal pleura

Breath sounds down on affected side

Percussion shows hyper-resonanceTreatment: chest tube in 4th or 5th

intercostal space anterior to mid-axillary line

Hemothorax

Lung laceration OR disruption of intercostal artery or internal mammary artery

Most are self-limitingSurgical consultation for

initial flow of >20 cc/kg (~1500 cc)continued flow of >200 cc/hr

Scapula fractures

Fractures of scapula or 1st & 2nd ribs may indicate major mechanism of

injury

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

Rib frac tures

Treatment consists of…intercostal blocksepidural anesthesiasystemic analgesics

Contraindications include…tapingrib beltsexternal splints

In conclusion...

Chest trauma is very common in the multi-injured patient

Airway management and a judiciously placed needle can save many lives

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