When there is an Emergency

Gregory A. Volturo MD FACEPP f d Ch iProfessor and Chairman

Department of Emergency MedicineUniversity of Massachusetts Medical School

Umass Memorial Health Care

Who Takes Care of you in an Emergency?

• Emergency physiciansEmergency medicine is a medical specialty and emergency– 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• 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 yand death situations.

• Emergency physicians treat the toughest cases – Often must make decisions with limited medical informationOften must make decisions with limited medical information.– Open 24 hours a day, seven days a week, 365 days a year

10 Things Emergency Physicians Want You to Know

T t t i t fi t fi t d• Treatment is not first-come, first-served• Wait times can be long

Y i ht d th i li t• You might need another specialist• Plan ahead for an ER visit

Yo might not be gi en a prescription• You might not be given a prescription• Post-ER care matters

Emergency physicians are specialists• Emergency physicians are specialists• Only the tests you need will be ordered

The ER is not for routine care• The ER is not for routine care• Be specific about why you’re at the ER

Be PreparedBe Prepared

• Prevention• "ICE" your cell phone address bookICE your cell phone address book.

– For example, "ICE1 - mom" and "ICE2 -husband "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.

What to do in an emergencyWhat to do in an emergencyL h t i i• Learn how to recognize emergency warning signs.K h t t h l• 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 dangershe is in danger.

– When treating burns, don't use ice or butter or petroleum jelly. p j y

Facilitate Your Care• Write down all the patient’s medications or put them

in a re-sealable bag and bring them with you Andin a re-sealable bag and bring them with you. And don’t 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• If an event occurred —bring in the person who saw exactly what happened.

• Don’t leave the emergency department withoutDon t leave the emergency department without written instructions.

• Don’t be afraid to ask questions and have the doctor f fclarify all aspects of the patient’s condition and

follow up care. • Carefully follow the after care instructions including• Carefully follow the after care instructions, including

any additional doctor or specialist appointments

When should I go to the EDWhen should I go to the EDDifficulty breathing shortness of breath• Difficulty breathing, shortness of breath

• Chest or upper abdominal pain or pressure • Fainting, sudden dizziness, weaknessFainting, 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• Severe or persistent vomiting or diarrhea • Coughing or vomiting blood • Suicidal feelingsSuicidal feelings • Difficulty speaking • Unusual abdominal pain

What to Expect in the EDWhat to Expect in the ED

• Triage• RegistrationRegistration• The waiting room

– Why am I waiting so long?• Medial evaluationMedial evaluation• Hall beds• Visitors

What to Expect in the EDWhat to Expect in the ED• Triage• RegistrationRegistration• The waiting room

– Why am I waiting so long?• Medical evaluationMedical evaluation• Hall beds• Visitors

Acute Coronary SyndromesAcute Coronary SyndromesAcute Coronary SyndromesAcute Coronary Syndromes

>130 million ED visits>130 million ED visits

1010--13 million “chest pain”13 million “chest pain” High Volume

44 5 illi di h d5 illi di h d 66 8 illi d it8 illi d it

High Liability

44--5 million discharged5 million discharged1%1%--5% unrecognized MIs5% unrecognized MIs

25% f th ill di !25% f th ill di !

66--8 million admits8 million admits50% + noncardiac50% + noncardiac1515--20% AMI20% AMI

High Cost25% of these will die!25% of these will die! 1515--20% AMI20% AMI

1515--20% UA20% UA<10% deaths<10% deathsHigh Risk

American Heart Association. Heart Disease and Stroke Statistics—2004 Update; 2003ACEP 2007.

High Risk

Atherosclerosis TimelineAtherosclerosis Timeline

Foam cellsFoam cells Fatty streakFatty streakIntermediate Intermediate

lesionlesion AtheromaAtheromaFibrous Fibrous plaqueplaque

Complicated Complicated lesion/rupturelesion/rupture

Endothelial DysfunctionEndothelial DysfunctionEndothelial DysfunctionEndothelial Dysfunction

From first decadeFrom first decade

Growth mainly by lipid accumulationGrowth mainly by lipid accumulation

From third decadeFrom third decade From fourth decadeFrom fourth decade

Smooth muscle Smooth muscle d lld ll

Thrombolysis, Thrombolysis, h th ty y py y p

Stary HC, et al. Circulation. 1995;90:1355-1374.

and collagenand collagen hematomahematoma

“Heart Attacks”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• 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:include:

• Shortness of breath and difficulty breathing. • Abnormal chest pain (angina), stomach, or abdominal pain.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.

“Heart Attacks”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 d t h l hil d i ido to help while driving.

• Administration of aspirin– (not acetaminophen, ibuprofen or naproxen) and

nitroglycerin (if prescribed) while emergency-i hresponse units are enroute to the scene

“Heart Attacks”Heart Attacks

• If the person is conscious, keep the person calm and help him or her into a comfortable positionand help him or her into a comfortable position.– The victim should stop all physical activity– lie down, loosen clothing, and remain calm until the , g,

ambulance arrives. • If the person becomes unconscious, make sure

the person is lying on his or her backthe person is lying on his or her back. – Clear the airway – Check for breathing and pulse; if absent and if– Check for breathing and pulse; if absent, and if

trained to do so, begin cardiopulmonary resuscitation (CPR).

Automated External Defibrillators (AEDs)Defibrillators (AEDs)

(AED ) d t l l t i h k t• (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 Su a s d ect y ed to t e a ou t otime between the onset of sudden cardiac arrest and the treatment with an electricarrest and the treatment with an electric shock to stop the abnormal heart rhythm.

“O t id f th killiMath You“Outside of the killings, Washington has one of theWashington has one of the lowest crime rates in the

country.”

Mayor Marion Barry Washington DCMayor Marion Barry, Washington DC

StrokeStroke

• Sudden numbness, weakness or paralysis and drooping of the face, arm or leg, p g , g,especially on one side of the body.

• Suddenly blurred or decreased vision in• Suddenly blurred or decreased vision in one or both eyes.

• Slurred speech, difficulty speaking or inability to understand or be understood.inability to understand or be understood.

• Loss of balance or coordination

StrokeStroke

• Some people may have additional, nontraditional (sometimes non-(neurological) symptoms

severe headache– severe headache – change in consciousness

StrokeStroke

• Stroke symptoms that last for only a few minutes and then subside may indicate a y"mini-stroke," or a transient ischemic attack (TIA)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 911y y

StrokeStrokeWALK: Is the person’s balance off?• WALK: Is the person’s balance off?

TALK: Is the speech slurred or the face droopy?

REACH: Is one side weak or numb?

SEE I i i ll ti ll l t?SEE: Is vision all or partially lost?

FEEL: Is the headache severe?

• Just one of these symptoms could mean a potential problem Don’t hesitate: Pick up the phone and callproblem. Don t hesitate: Pick up the phone and call 911 immediately.

“Spider Bites” and MRSAp

Vetter RS. West J Med. 2000;173:357-358.

Emergence of Acquired Antimicrobial Resistance in SAntimicrobial Resistance in S

aureus1961:

First MRSA in UK

1980s:Isolated

reports of CA-MRSA

2000:CA-MRSA outbreaks

1987: Mupirocin-resistant

1968: First MRSA

1944: Penicillin-resistant S aureus

2002: Vancomycin-

resistant

in UK

1996: Vancomycin

S aureus

1975:

in US S aureus

1940: Penicillin

1960: Methicillin/ Vancomycin-

intermediateS aureus

1975:Multidrug-resistant

Penicillinmass-

produced

Methicillin/ oxacillin

developed

1940 1960 1970 1980 1990 2000Year

Deresinski S. Clin Infect Dis. 2005;40:562-573.

Types of CA MRSA InfectionsTypes of CA-MRSA InfectionsFuruncles• Furuncles

• Impetigop g• Scalded skin syndrome

S ti th iti / t liti• Septic arthritis/osteomyelitis• Pneumonia• Endocarditis• Toxic shock syndrome• Necrotizing soft tissue infectionsNecrotizing soft tissue infections

Kowalski TJ et al. Mayo Clin Proc. 2005;80:1201-1208.Weber JT. Clin Infect Dis. 2005;41(Suppl 4):S269-S272.

MRSA – What to Tell Patients• Can reduce risk by addressing

th “4 C ”the “4 Cs”:Contact–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_mrsa.public.htm.

MRSA – What to Tell Patients

• Advise to:• Advise to:– Keep hands clean by washing thoroughly with

soap and water or using an alcohol-based handsoap and water or using an alcohol-based hand sanitizer

– Keep cuts and scrapes clean and covered with aKeep cuts and scrapes clean and covered with a bandage until healed

– Avoid contact with other people’s wounds or p pbandages

– 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_mrsa.public.htm.

ColdsColds• 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.

C• 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 g g g(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 phlegmwith a high fever or a cough that produces yellow mucus or phlegm may need evaluation by a physician.

Current IssuesCurrent Issues

Flu

Influenza VirusesInfluenza Viruses

Influenza A:Found in many animals– 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 pandemicsThe cause of all pandemicsInfluenza B:

Circulates widely only in humans, not animalsy y ,Influenza C:

Causes mild infection in humans

Influenza: the Burden of Disease

• 50 million (1 in 6) infected per year50 million (1 in 6) infected per year – ~500 million affected annually worldwide

• 2 to 5 fold increase in hospitalization rates• 2 to 5 fold increase in hospitalization rates• “medium–level” pandemic

89 000 to 207 000 deaths– 89,000 to 207,000 deaths– 314,000 to 734,000 hospitalizations

18 42 illi i i i– 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 billioneconomic impact $71.3 to $166.5 billion

www.cdc.gov/flu/pandemic/keyfacts

Pandemic InfluenzaYear Name Subtype Deaths

Pandemic InfluenzaYear Name Subtype Deaths

1918 S i h Fl H1N1 20 50M1918 Spanish Flu H1N1 20-50M

1957 Asian Flu H2N2 >3M

1968 Hong Kong Flu

H3N2 >1MFlu

InfluenzaInfluenzaInfluenza commonly known as "the flu " is caused• 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 th h i i f t d d l t h d dthrough 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

i d t ti ll lif th t i illserious 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 medicaldehydration 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 eachgeneral population. About 36,000 people die each year from the flu.

InfluenzaInfluenza• Signs and symptoms of the flu may include:• 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• Chills • Headache • Fatigue

M l h• Muscle aches • Dizziness • Loss of appetite • Dry cough • Sore throat • Runny or stuffy nose y y• Weakness • Ear infection • DiarrheaDiarrhea

InfluenzaInfluenzaCall your doctor if there are signs of dehydration• Call your doctor if there are signs of dehydration, seizures, earache, a cough that produces discolored mucus or difficulty breathing. Children with chronic

diti h th ti fib iconditions, 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 worsestarts 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.p y

Flu Vaccination• The best way to protect against the flu is to get

vaccinated every year. y y– 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– Getting a flu shot later may still provide protection since flu season typically peaks in January and last through about March.

P h t hi h i k f h i i fl• 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 g ( g gand health care workers) get vaccinated each year.

• Persons in high-risk groups include:C f• 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.

Additional ResourcesAdditional Resources

• The American College of Emergency PhysiciansEmergency Physicians– ACEP.org

Baby Boomers 60s vs. 00s

•• THENTHENLong hairLong hair

•• NOWNOW–– Longing for hairLonging for hair–– Long hairLong hair

–– KEGKEGLonging for hairLonging for hair

–– EKGEKG–– Acid RockAcid Rock

Hoping for aHoping for a–– Acid RefluxAcid Reflux

H i f BMH i f BM–– Hoping for a Hoping for a BMWBMW

–– Hoping for a BMHoping for a BM

Kidney stonesKidney stones–– Rolling StonesRolling Stones–– Peace signPeace sign

–– Kidney stonesKidney stones

–– Mercedes logoMercedes logo–– Peace signPeace sign Mercedes logoMercedes logo