Exacerbating Matters: Iatrogenic Injuries

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Specialists ARE THE THIRD LEADING CAUSE OF DEATH IN THE U.S., CAUSING 250,000 DEATHS EVERY YEAR. Passings every year 12,000 - Unnecessary surgery 7,000-Medication mistakes 20,000-Other blunders 80,000-Nosocomial infections106,000-Negative ADE\'sAfter heart/cardiovascular ailment, tumor; Higher than injury!!.

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Aggravating Matters: Iatrogenic Injuries/Complications During Resuscitation Scott R. Petersen, MD, FACS St. Joseph's Hospital and Medical Center Phoenix, Arizona

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DOCTORS ARE THE THIRD LEADING CAUSE OF DEATH IN THE U.S., CAUSING 250,000 DEATHS EVERY YEAR Deaths every year 12,000 - Unnecessary surgery 7,000-Medication mistakes 20,000-Other blunders 80,000-Nosocomial contaminations 106,000-Negative ADE's After heart/cardiovascular malady, growth; Higher than injury!! Starfield B: JAMA 2000; 284: 483-5

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Principle of Medicine: PRIMUM NON NOCERE "First do no mischief" Hippocrates

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Hippocrates Injunction: "First do no damage" Neither Hippocrates or Galen Middle Ages – transmitted orally Thomas Sydenham (1624-1689), English Physician Common use in U.S. since 1880 Potent update that each restorative choice can hurt the patient

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Iatrogenesis: Unfavorable reaction to medicinal treatment that is actuated by the remedial exertion itself. 4-9% of hospitalized patients Dubois RW, Brooks RH: Preventable passings: Who, how regularly and why? Ann Int Med 1988; 109: 582-589.

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Pandora's Box – "Mistakes in Medicine" 20% iatrogenic harm 1964 Schimmel 4% iatrogenic damage 1991 Brennan Harvard restorative practice study – 14% casualty rate Estimates – 180,000 passings/year ~ 3 kind sized fly accidents q 2 days Leape LL, JAMA 1994

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ICU Errors Each patient encounters 178 occasions/day (staff, methodology, therapeutic collaborations 1.7 blunders/day (1% disappointment rate) Perspective: 2 hazardous arrivals at O'Hare/day US mail – 16,000 lost pieces/hour Banking – 32,000 checks deducted from wrong record/hour

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Iatrogenesis Acts of Commission versus Demonstrations of Omission Study: Described blunders (acts or oversights in which the doctors felt dependable 53 mistakes 4 (7.5%) negligence suits 30 missed analyses 8 malignancies, 5 injury, 5 AMI, 4 SBO, 3 meningitis, 4 others 11 surgical accidents (9 OB) 8 restorative treatment (tranquilize organization) Patient wellbeing ought to stay concentrated on potential reasons for iatrogenic wounds and their prevention

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Public Suggestions on Iatrogenesis Survey – 1,207 grown-ups (phone) Reducing preventable therapeutic blunders that outcome in damage Giving specialists more opportunity to go through with patients – 78% extremely powerful Requiring clinics to create frameworks to evade medicinal mistakes – 74% Better preparing social insurance experts – 73% Using just specialists prepared in ICU medication – 73% Requiring healing centers to report all genuine therapeutic mistakes 71% Increasing the quantity of attendants – 69% Reducing work-hours of specialists in preparing – 66% Encouraging intentional doctor's facility detailing of blunders – 62%

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Iatrogenesis We have to essentially change the way we consider blunders and why they happen Leape LL, JAMA 1994

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Preventable Deaths 1991-2004 Total patients – 35,482 Total passings – 2,216 (6.2%) Possibly Preventable/Preventable – 73 3.3% of all passings St. Joseph's Hospital and Medical Center, Phoenix, AZ

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Causes of Preventable Deaths n = 73/2,216 (3.3%) Preventable Deaths 1991-2004 Number of Deaths Other Delay to OR Prehospital Quality issues Technical blunders Delay/Missed Dx Errors in Judgment Inadequate revival/observing St. Joseph's Hospital and Medical Center, Phoenix, AZ

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Iatrogenic Complications in Trauma 8.2% overall Failure to intubate Esophageal intubation Technical blunders/cricothyroidotomy Inability to intubate RSI Aspiration with LMA, oral aviation routes Preventable passings Prehospital Errors: Universally because of inability to suitably deal with the aviation route!

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Causes of Preventable Deaths n = 73/2,216 (3.3%) Preventable Deaths 1991-2004 Number of Deaths Other Delay to OR Prehospital Quality issues Technical blunders Delay/Missed Dx Errors in Judgment Inadequate revival/checking St. Joseph's Hospital and Medical Center, Phoenix, AZ

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Preventable Deaths San Diego Trauma System n=76/1295 passings (5.9%) Resuscitation Phase Operative Phase Critical Care Phase Davis JW, et al: J Trauma 1992; 32: 660-666.

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Errors in Trauma System San Diego Trauma System n=1032 mistakes/22,577 patients – 4.5% general Resuscitation Phase Operative Phase Critical Care Phase Davis JW, et al: J Trauma 1992; 32: 660-666.

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Phases of Care Primary Survey Resuscitation Secondary overview Diagnostic imaging/tests Medications/drugs Interventions Errors Airway, C-spine Inadequate volume/liquid over-burden Hypothermia Failure to support; control discharge; delays; missed wounds Delays/blunders in translation ADE's Lines, tubes, channels (LTD's) Iatrogenic Injuries and Resuscitation

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Iatrogenic Injuries and Resuscitation Primary Survey Failure to perceive: Upper aviation route obstacle Tension pneumothorax Massive hemothorax Open pneumothorax Cardiac tamponade Flail Chest All can prompt to cardiopulmonary capture in the injury room

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Value of Intubating Patients with Suspected Head Injury AVOID HYPOXIA! RSI – Succinylcholine (1 mg/kg) Obtunded Head damage (GCS < 10) Shock Drugs, ETOH, Pitfalls: Perform a fast neurologic examination before loss of motion Redan JA, et al J Trauma 1991; 31: 371.

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The Agitated, Combative Patient … . Peril to themselves Prevent wounds to faculty Two "F-word" Rule Pitfalls: Allow these patients to battle, harm themselves or others, meddle with demonstrative imaging (development) Occasionally intubate a tanked, yet … .. In any event not a hypoxic plastered !!

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AGITATION = HYPOXIA Intubation NOT Medication

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Circulation Controlling Hemorrhage Best technique: Direct weight Avoid improper cinches/tourniquets Five regions for mysterious draining Chest - CXR Abdomen - FAST, DPL Pelvis - Pelvic x-beams Thighs - Femur Fxs "Road" DO NOT disregard scalping cut Hemorrhage under massive dressings Pitfalls: Delay in getting a draining patient to the working space for authoritative control

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Iatrogenic Complications During Resuscitation Fluid/volume over-burden ACS, Secondary ACS Secondary furthest point compartment disorder Avoid unreasonable crystalloid imbuement Hypothermia Cold condition, liquids, blood Coagulopathy Prevention is central Damage control Metabolic acidosis Excessive utilization of saline for revival can add to acidosis J Trauma 53: 833-837, 2002 J Trauma 51: 173-177, 2001

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Secondary Survey Head-to-Toe Examination "Tube and Fingers in each opening (ATLS ® ) Usually hazard free EXCEPT: Probing neck wounds that enter the platysma Examination of cervical spine

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Penetrating neck wounds Iatrogenic blunders Probing injury may unstick clusters and disturb hematomas Result in exsanguinating discharge Compromise the aviation route. Critical circumstance NOW gets to be and EMERGENCY!! Counteract: Explore these injuries in the operating room/Zone II Alternatively: CT angiography, endoscopy in stable patients

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Evaluation of the Cervical Spine Principles: Rarely clear C-spine in the injury room (Leave in C-neckline) C-spine radiographs must be "immaculate" (through C 7 - T 1 ) with NO midline spine delicacy LIBERAL utilization of CT (whole cervical spine) Clinical freedom just with "Minor Mechanisms" ~15% frequency of extra Fxs in either cervical, thoracic or lumbar spine.

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"Clinical Clearance" - Cervical Spine Blunt Trauma Patient ready and situated NO diverting wounds NO ETOH, drugs, medicines NO spinal/neurological shortfalls NO neck torment NO midline neck delicacy "Paltry Mechanism" *Modified after: Hoffman, et al: N Engl J Med 2000; 343: 94-97.

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Bypassing C-Spine Radiographs in Acutely Injured Patients CSR will miss ~ 15% of C-spine Fx CT a great deal more touchy (1-0.4%) CSR must be "flawless" if got May miss clear harm if "skipped" Sanchez, et al J Trauma 2005; 59: 197-183.

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Cervical Spine Clearance Protocol Compliance (%)

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Iatrogenic Complications: Diagnosis Abdominal Trauma DPL - 0.5% wounds; 6-8% negative laparotomies US (FAST) – 8% false negative CT – "La promenade de mort" Charles Wolferth, MD, FACS 1994

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Iatrogenesis Diagnostic Imaging Inadequate movies Inordinate postpones Oral Contrast Gastrograffin – danger of desire; poor detail Barium – adjuvant to sore development Iodinated Intravenous Contrast Nephrotoxicity – dosage related, hypovolemia, sepsis, diabetes, anti-infection agents; Prevent with IV hydration, NaHCO 3 , acetylcysteine; Visipaque®; Gadolinium (NSF) Allergy – rash, shellfish sensitivity; genuine response 0.22% (hypotension, dyspnea, heart failure Local Extravasation – compartment disorder Air Embolism – control injectors, CTA

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"Filmless" Radiology Potential Problems/Misinterpretations Inadequate, "reasonable" screens High encompassing light in injury room Image distortion/unpretentious discoveries Communication amongst radiologists and specialists

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Drug Tetanus toxoid Antibiotics Corticosteroids Vasopressors Osmotic operators (mannitol) Colloid expanders Local soporifics Etomidate Adverse occasion "Unpardonable" sickness Reactions, superinfections < 8 hrs SCI, adrenal deficiency Contraindicated in hypo. stun Hypovolemia CHF, coagulopathy Allergy, seizures, resp. capture Adrenal deficiency Adverse Drug Events (ADE) Resuscitation

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Vasopressors During Resuscitation Contraindicated in the treatment of hypovolemia Maybe? w/neurogenic stun Neurogenic stun Rx Initial Rx – volume extension Bradycardia – Rx atropine Monitoring –CVP, PA catheter Vasopressors – dopamine, neo Keep MAP > 80

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"Lines, Tubes, Drains" (LTD) Common wellspring of iatrogenic intricacies 60% are pre

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