When there is an Emergency

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When there is an Emergency

• Gregory A. Volturo MD FACEP
• Professor and Chairman
• Department of Emergency Medicine
• University of Massachusetts Medical School
• Umass Memorial Health Care

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Who Takes Care of you in an Emergency?

• Emergency physicians
• Emergency medicine is a medical specialty, and
  emergency physicians have developed specific
  lifesaving skills in adult and pediatric medicine
  that span multiple disciplines and specialties.
• One in three Americans visit emergency
  departments each year, for a total of more than
  130 million visits.
• Each with a unique set of circumstances and
  medical issues
• Emergency physicians often must use their
  judgment and expertise to quickly determine the
  best course of treatment in life and death
  situations.
• Emergency physicians treat the toughest cases
• Often must make decisions with limited medical
  information.
• Open 24 hours a day, seven days a week, 365 days
  a year

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10 Things Emergency Physicians Want You to Know

• Treatment is not first-come, first-served
• Wait times can be long
• You might need another specialist
• Plan ahead for an ER visit
• You might not be given a prescription
• Post-ER care matters
• Emergency physicians are specialists
• Only the tests you need will be ordered
• The ER is not for routine care
• Be specific about why youre at the ER

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Be Prepared

• Prevention
• "ICE" your cell phone address book.
• For example, "ICE1 - mom" and "ICE2 - husband."
• ICE stands for "In Case of Emergency,"
• If you arrive in the emergency department
  unconscious, emergency staff will check your cell
  phone for ICE contact information.

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What to do in an emergency

• Learn how to recognize emergency warning signs.
• Know where to get help.
• Learn what to do until help arrives.
• ABCs
• It's also important to know what not to do.
• Never move anyone who is unconscious or has
  struck his head or was injured in a car crash,
  unless he or she is in danger.
• When treating burns, don't use ice or butter or
  petroleum jelly.

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Facilitate Your Care

• Write down all the patients medications or put
  them in a re-sealable bag and bring them with
  you. And dont forget to include over-the-counter
  pills and any herbal medications.
• If a child swallows a substance that might be
  dangerous, bring the original container with you.
  
• If an event occurred bring in the person who saw
  exactly what happened.
• Dont leave the emergency department without
  written instructions.
• Dont be afraid to ask questions and have the
  doctor clarify all aspects of the patients
  condition and follow up care.
• Carefully follow the after care instructions,
  including any additional doctor or specialist
  appointments

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When should I go to the ED

• Difficulty breathing, shortness of breath
• Chest or upper abdominal pain or pressure
• Fainting, sudden dizziness, weakness
• Changes in vision
• Confusion or changes in mental status
• Any sudden or severe pain
• Uncontrolled bleeding
• Severe or persistent vomiting or diarrhea
• Coughing or vomiting blood
• Suicidal feelings
• Difficulty speaking
• Unusual abdominal pain

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What to Expect in the ED

• Triage
• Registration
• The waiting room
• Why am I waiting so long?
• Medial evaluation
• Hall beds
• Visitors

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What to Expect in the ED

• Triage
• Registration
• The waiting room
• Why am I waiting so long?
• Medical evaluation
• Hall beds
• Visitors

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Acute Coronary Syndromes
gt130 million ED visits
High Volume
10-13 million chest pain
High Liability
4-5 million discharged 1-5 unrecognized MIs
25 of these will die!
6-8 million admits 50 noncardiac 15-20
AMI 15-20 UA lt10 deaths
High Cost
High Risk
American Heart Association. Heart Disease and
Stroke Statistics2004 Update 2003 ACEP 2007.
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Atherosclerosis Timeline
Stary HC, et al. Circulation. 1995901355-1374.
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Heart Attacks

• Uncomfortable pressure, fullness, squeezing
  sensation or pain in the center of the chest,
  lasting more than a few minutes, or it goes away
  and comes back.
• Pain that spreads to the shoulders, neck, jaw,
  arms or back.
• Chest discomfort accompanied by lightheadedness,
  fainting, sweating, nausea or shortness of
  breath.
• Some less common warning signs of heart attack
  that should be taken seriously - especially if
  they accompany any of the above symptoms -
  include
• Shortness of breath and difficulty breathing.
• Abnormal chest pain (angina), stomach, or
  abdominal pain. (Symptoms may feel like
  indigestion or heartburn.)
• Nausea or dizziness.
• Unexplained anxiety, weakness, or fatigue.
• Palpitations, cold sweat or paleness.

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Heart Attacks

• Call 911
• Stay with the person until the ambulance
  arrives. Do not attempt to drive the person to
  the hospital if his or her condition should
  worsen, there is nothing you can do to help while
  driving.
• Administration of aspirin
• (not acetaminophen, ibuprofen or naproxen) and
  nitroglycerin (if prescribed) while
  emergency-response units are enroute to the scene

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Heart Attacks

• If the person is conscious, keep the person calm
  and help him or her into a comfortable position.
• The victim should stop all physical activity
• lie down, loosen clothing, and remain calm until
  the ambulance arrives.
• If the person becomes unconscious, make sure the
  person is lying on his or her back.
• Clear the airway
• Check for breathing and pulse if absent, and if
  trained to do so, begin cardiopulmonary
  resuscitation (CPR).

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Automated External Defibrillators (AEDs)

• (AEDs) used to apply electric shock to restart a
  heart that has developed a chaotic rhythm called
  ventricular fibrillation, the most common cause
  of sudden cardiac arrest.
• Survival is directly linked to the amount of time
  between the onset of sudden cardiac arrest and
  the treatment with an electric shock to stop the
  abnormal heart rhythm.

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Outside of the killings, Washington has one of
the lowest crime rates in the country. Mayor
Marion Barry, Washington DC
Math
You
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Stroke

• Sudden numbness, weakness or paralysis and
  drooping of the face, arm or leg, especially on
  one side of the body.
• Suddenly blurred or decreased vision in one or
  both eyes.
• Slurred speech, difficulty speaking or inability
  to understand or be understood.
• Loss of balance or coordination

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Stroke

• Some people may have additional, nontraditional
  (sometimes non-neurological) symptoms
• severe headache
• change in consciousness

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Stroke

• Stroke symptoms that last for only a few minutes
  and then subside may indicate a "mini-stroke," or
  a transient ischemic attack (TIA)..
• Stroke often goes unrecognized
• people often wait to see if their symptoms
  improve
• If stroke is suspected, it should be communicated
  directly immediately. Call 911

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Stroke

• WALK Is the persons balance off?TALK Is the
  speech slurred or the face droopy?REACH Is one
  side weak or numb?SEE Is vision all or
  partially lost?FEEL Is the headache severe?
• Just one of these symptoms could mean a potential
  problem. Dont hesitate Pick up the phone and
  call 911 immediately.

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Spider Bites and MRSA
Vetter RS. West J Med. 2000173357-358.
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Emergence of Acquired Antimicrobial Resistance in
S aureus
1980s Isolated reports of CA-MRSA
2000 CA-MRSA outbreaks
1961 First MRSA in UK
1944 Penicillin-resistant S aureus
1987 Mupirocin- resistant S aureus
2002 Vancomycin-resistant S aureus
1968 First MRSA in US
1960 Methicillin/ oxacillindeveloped
1996 Vancomycin-intermediate S aureus
1940 Penicillinmass- produced
1975 Multidrug- resistant
Deresinski S. Clin Infect Dis. 200540562-573.
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Types of CA-MRSA Infections

• Furuncles
• Impetigo
• Scalded skin syndrome
• Septic arthritis/osteomyelitis
• Pneumonia
• Endocarditis
• Toxic shock syndrome
• Necrotizing soft tissue infections

Kowalski TJ et al. Mayo Clin Proc.
2005801201-1208. Weber JT. Clin Infect Dis.
200541(Suppl 4)S269-S272.
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MRSA What to Tell Patients

• Can reduce risk by addressing the 4 Cs
• Contact
• Contaminated surfaces
• Crowding
• Cleanliness

Jernigan J. 44th ICAAC Oct 30-Nov 2, 2004
Washington, DC. Abstract 1463. Daum R. 44th
ICAAC Oct 30-Nov 2, 2004 Washington, DC.
Abstract 1464. www.cdc.gov/hcidod/hop/aresist/ca_m
rsa.public.htm.

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MRSA What to Tell Patients

• Advise to
• Keep hands clean by washing thoroughly with soap
  and water or using an alcohol-based hand
  sanitizer
• Keep cuts and scrapes clean and covered with a
  bandage until healed
• Avoid contact with other peoples wounds or
  bandages
• Avoid sharing personal items such as towels or
  razors

Jernigan J. 44th ICAAC Oct 30-Nov 2, 2004
Washington, DC. Abstract 1463. Daum R. 44th
ICAAC Oct 30-Nov 2, 2004 Washington, DC.
Abstract 1464. www.cdc.gov/hcidod/hop/aresist/ca_m
rsa.public.htm.

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Colds

• The signs and symptoms of colds include
• An initial tickle in the throat
• A runny or stuffy nose and sneezing
• Cough
• Sore throat
• Headache
• Mild fever
• Mild fatigue
• Mild muscle aches
• Loss of appetite
• A change in nasal discharge from watery to thick
  yellow or green.
• Colds may be treated with over-the-counter
  decongestants and cough medicines. Follow the
  instructions on the label carefully. Note that,
  as of January 2008, the Food and Drug
  Administration (FDA) has stated that cough and
  cold medications not be given to children under
  age 2 (and they are considering expanding this
  restriction to children up to age 6).  
• Prolonged colds (lasting longer than one week)
  and those associated with a high fever or a cough
  that produces yellow mucus or phlegm may need
  evaluation by a physician.

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Current Issues
Flu
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Influenza Viruses

• Influenza A
• Found in many animals
• Wild birds are natural hosts
• domestic fowl (chickens, turkeys) most
  susceptible
• ducks, wild birds relatively resistant
• mild infection to rapidly fatal disease
  (mortality 100)
• The cause of all pandemics
• Influenza B
• Circulates widely only in humans, not animals
• Influenza C
• Causes mild infection in humans

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Influenza the Burden of Disease

• 50 million (1 in 6) infected per year
• 500 million affected annually worldwide
• 2 to 5 fold increase in hospitalization rates
• mediumlevel pandemic
• 89,000 to 207,000 deaths
• 314,000 to 734,000 hospitalizations
• 18 to 42 million outpatient visits
• 20 to 47 million people sick
• 15 - 35 of the U.S. population affected
• economic impact 71.3 to 166.5 billion

www.cdc.gov/flu/pandemic/keyfacts
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Pandemic Influenza
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Influenza

• Influenza, commonly known as "the flu," is caused
  by a virus, which infects the respiratory tract.
  The flu is spread from person to person by direct
  contact or through virus-infected droplets
  coughed or sneezed in the air. Most people who
  get the flu recover completely in one to two
  weeks, but some develop serious and potentially
  life-threatening illnesses, such as pneumonia,
  especially elderly people.
• The flu sometimes develops into bacterial
  pneumonia, ear infection, sinus infection,
  dehydration and worsening of chronic medical
  conditions. Very young children and the elderly
  are more susceptible to complications of the flu
  than the general population. About 36,000 people
  die each year from the flu.

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Influenza

• Signs and symptoms of the flu may include
• High fever (usually 100 degrees F to 103 degrees
  F in adults and often higher in children)
• Chills
• Headache
• Fatigue
• Muscle aches
• Dizziness
• Loss of appetite
• Dry cough
• Sore throat
• Runny or stuffy nose
• Weakness
• Ear infection
• Diarrhea

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Influenza

• Call your doctor if there are signs of
  dehydration, seizures, earache, a cough that
  produces discolored mucus or difficulty
  breathing. Children with chronic conditions, such
  as severe asthma or cystic fibrosis, may require
  hospitalization.
• In the case of children who have the flu, call
  the doctor if the child
• Has symptoms that are serious or get worse  - or
  starts to get better and suddenly gets worse.
• Has a temperature greater than 102 degrees F for
  more than a few days.
• Keep in mind the flu usually lasts no more than a
  week or two and is best cured by getting rest,
  good nutrition and plenty of fluids.

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Flu Vaccination

• The best way to protect against the flu is to get
  vaccinated every year.
• The ideal time to get vaccinated is usually
  October or November, before flu season begins
• Getting a flu shot later may still provide
  protection since flu season typically peaks in
  January and last through about March.
• Persons who are at high risk of having serious
  flu complications and people who live with or
  care for high flu-risk individuals (including
  home caregivers and health care workers) get
  vaccinated each year.
• Persons in high-risk groups include
• Children six months old through age five.
• Pregnant women.
• Persons age 50 and older.
• Persons with chronic medical conditions.
• Persons in nursing homes and long-term care
  facilities.

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Additional Resources

• The American College of Emergency Physicians
• ACEP.org

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Baby Boomers 60s vs. 00s

• THEN
• Long hair
• KEG
• Acid Rock
• Hoping for a BMW
• Rolling Stones
• Peace sign

• NOW
• Longing for hair
• EKG
• Acid Reflux
• Hoping for a BM
• Kidney stones
• Mercedes logo

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