Alertness management in 24/7 settings: lessons from aviation.

Round-the-clock operational requirements pose physiological challenges for human operators. Fatigue due to sleep loss and circadian disruption can reduce safety, performance quality, and alertness. The authors describe the physiological factors underlying fatigue and provide examples from NASA research in aviation settings that demonstrate how fatigue affects real-world operations. A comprehensive alertness management approach to address fatigue effectively includes education, alertness strategies, scheduling, policy, and healthy sleep components. There is a need for cultural change that will encourage attitudes, behaviors, and practices that will reduce fatigue-related risks and improve safety, performance, and alertness in 24/7 operational settings.

What nursing has learned from famous traumas.

The deaths of three celebrities shed light on where trauma care needs to improve and remind us how far we have already come.

An objective analysis of process errors in trauma resuscitations.

OBJECTIVE: A computer-based system to apply trauma resuscitation protocols to patients with penetrating thoracoabdominal trauma was previously validated for 97 consecutive patients at a Level 1 trauma center by a panel of the trauma attendings and further refined by a panel of national trauma experts. The purpose of this article is to describe how this system is now used to objectively critique the actual care given to those patients for process errors in reasoning, independent of outcome. METHODS: A chronological narrative of the care of each patient was presented to the computer program. The actual care was compared with the validated computer protocols at each decision point and differences were classified by a predetermined scoring system from 0 to 100, based on the potential impact on outcome, as critical/noncritical/no errors of commission, omission, or procedure selection. RESULTS: Errors in reasoning occurred in 100% of the 97 cases studied, averaging 11.9/case. Errors of omission were more prevalent than errors of commission (2. 4 errors/case vs 1.2) and were of greater severity (19.4/error vs 5. 1). The largest number of errors involved the failure to record, and perhaps observe, beside information relevant to the reasoning process, an average of 7.4 missing items/patient. Only 2 of the 10 adverse outcomes were judged to be potentially related to errors of reasoning. CONCLUSIONS: Process errors in reasoning were ubiquitous, occurring in every case, although they were infrequently judged to be potentially related to an adverse outcome. Errors of omission were assessed to be more severe. The most common error was failure to consider, or document, available relevant information in the selection of appropriate care.

Atlanto-occipital dislocation: an unusual lethal airbag injury.

Airbag-induced injury fatality is increasing in frequency. We present the case of a 6-year-old passenger who sustained a fatal atlanto-occipital dislocation associated with airbag deployment in a low-speed motor vehicle crash. The current literature regarding airbag fatalities and methods to ameliorate airbag-induced injury are reviewed.

Penetrating trauma to the head.

Penetrating trauma to the brain is not as common as blunt trauma; however, the incidence is becoming a frequent occurrence in our society. Rapid transport to trauma centers where definitive care can be rendered is essential. Outcome depends on the site of the missile tract, the presenting neurologic status, and the extent of neurologic tissue destruction. Neurologic deterioration occurs rapidly, and outcome results seem to depend on the patient's neurologic status at the time of surgery. CT scanning is the diagnostic procedure of choice and should be performed if the patient's condition is stable (see Fig. 3). Aggressive removal of missile and bone fragments needs to be balanced by the knowledge that it is preferable to leave behind a few hard-to-reach fragments than to increase the patient's neurologic deficit. CT scanning in the postoperative period is very helpful in identifying abscess formation as well as new or recurrent hematomas, edema, and areas of tissue injury not evident at the time of initial scanning. Antibiotic therapy should be initiated preoperatively. Control of elevated ICP plays a significant role in decreasing mortality and morbidity. Judicious debridement of injured brain combined with medical management of increased ICP will maximize the quality of recovery and increase survivability. Although great strides have been made in reducing mortality and morbidity for trauma patients, the sad issue is that the majority of traumas are preventable. Until society is willing to understand that it needs to make firearm safety a priority, there will always be patients to care for who have sustained a penetrating injury.

Strangulation.

This final installment in our series focuses on survivors of hangings and other forms of strangulation. We'll cover neck anatomy, the four types of strangulation, and the interventions that can keep patients' injuries from turning deadly.

System improvements for the use of neuromuscular blocking agents.

Neuromuscular blocking agents (NMBA) are commonly used in the emergency department, operating room, and intensive care unit. After two separate incidents in which NMBA were not immediately available in an emergency, a quality assurance process was used to identify the method for controlling distribution and availability of NMBA use in the emergency department. The new system uses a pharmacy-stocked paralytic agent box and transport bag. The benefits of this system have included (1) 100% availability of NMBA when needed in the emergency department, (2) better availability of supplies and ease in transporting for times when a patient needs to be moved within the hospital, and (3) more efficient billing and tracking of controlled substances by the pharmacy department.

Necrotizing fasciitis: an uncommon consequence of pressure ulceration.

Pressure ulcers may occur in patients with chronic illnesses, especially in those who are bed-bound or chair-bound. Local measures usually suffice to allow primary ulcer healing and support skin grafting or tissue transfer reconstruction. On rare occasions, however, pressure ulcers may progress to invasive infection and necrosis of adjacent soft tissues, possibly leading to necrotizing fasciitis. Early recognition and aggressive medical and surgical therapy are required to halt disease progression and prevent patient mortality. Two cases are presented to describe the severity of this soft-tissue infection.

Improved emergency department efficiency with a three-tier trauma triage system.

This pilot study was carried out to determine whether converting from a two-tier to a three-tier in-hospital trauma triage system improves the efficiency of emergency department (ED) care and minimizes inappropriate triage. Patients at an urban, Level 1 trauma centre were triaged using either a two-tier (months 1-3; n = 197) or three-tier (months 4-6; n = 240) trauma response system. Patients were assessed for triage type, age, sex, injury severity score, Glasgow coma score, post-ED disposition, total ED time, survival, complication rate, probability of survival and unexpected death. Comparisons were made by ANOVA table analysis; significance was assumed for p < 0.05. Two-tier (n = 197) and three-tier patients (n = 240) were matched with respect to mean age, sex, mean injury severity score, mean Glasgow coma score, post-ED disposition, survival and probability of survival. Two-tier patients were triaged to give 20% alerts [criteria = physiological derangement (PD) and/or injury mechanism (MOI)] and 80% consults; three-tier patients were triaged as 20% category I (criteria = PD), 18% category II (criteria = MOI) and 62% consults. Total ED time decreased from two-tier (3.98 +/- 2.81 h) to three-tier triage (3.53 +/- 2.14 h, p = 0.001). There was no difference between two-tier alert and three-tier category I times (2.09 +/- 1.64 vs. 1.95 +/- 1.75 h; p = 0.72). Category II patients (3.28 +/- 1.98 h; p = 0.009) spent less time in the ED than did two-tier consults (4.36 +/- 2.65 h). The mean ED three-tier consult time significantly decreased as well (3.95 +/- 2.42 h, p = 0.008 vs. two-tier consult). Complications per patient were unchanged from two-tier to three-tier triage (0.17 +/- 0.52 vs. 0.12 +/- 0.48; p = 0.15). Under-triage (5%) and over-triage (7.5%) were minimal under three-tier triage. It is concluded that using a three-tier triage system results in an increase in the early involvement of the trauma service while decreasing emergency department time and minimizing over-triage.

A system for working with unidentified trauma patients.

Problems can occur when trauma centers receive severely injured unidentified patients who require immediate interventions. Most health care facilities rely on computerized databases to keep patient records and to requisition care. Although computerization of records increases accuracy and efficiency, it is a disadvantage in an emergency setting if the database requires complete identification to issue a chart and medical record number. A method that allows for unique identification of unknown patients is presented along with how it is implemented and changed once the patient's identity is found.

Sudden severe barotrauma from self-inflating bag-valve devices.

Self-inflating bag-valve devices are commonly used for the ventilation of intubated patients, especially during resuscitation and transport. These devices are generally safe, but minor deviations in their recommended use can expose patients to airway pressures greater than 135 cm H2O. We present a patient in whom a sudden tension pneumothorax developed during ventilation with a bag-valve device. We believe that this complication resulted from high airway pressures generated in the bag-valve device. The ability of the device in question to cause barotrauma was confirmed by bench-top measurements of the peak airway pressures generated by minor deviations from proper use of the device.

How to have a stroke at an early age: the effects of crack, cocaine and other illicit drugs.

Illicit drugs have rapidly become one of the most frequent causes of stroke in the under 45 years of age group. Stroke and death can occur for either the first time or long-term user due to the pharmacologic actions of the drugs. The neuroscience nurse needs to be aware of the potential for stroke that can occur with illicit drugs and be prepared to intervene appropriately.

Video recording trauma resuscitations: a guide to system set-up, personnel concerns, and legal issues.

Video recording trauma resuscitations has great merit with respect to healthcare-provider education, clinical research, and quality improvement. This paper addresses systems equipment problems, provider concerns, and legal issues that surround the implementation of a video recording system in the resuscitation suite.