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

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

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 • 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. 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 III percentage loss 30-40% amount of loss 1500-2000ml Class IV percentage loss more than 40% amount of loss >200ml Shock Classification

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 Pulmonary Contusion

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