Abstracts of the Literature
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JULY-SEPTEMBER 2000 INTERNATIONAL JOURNAL OF TRAUMA NURSING/Abstracts of the Literature 109 ABSTRACTS OF THE LITERATURE Therefore less stringent retrospective experimental designs are more often employed in outcomes research. (Jacobs LM, Gabram S, Sztajnkrycer M, Robinson K, Libby M. Helicopter air medical transport: ten-year out- comes for trauma patients in a New England program. Connecticut Medicine 1999;63:677-82.) Reviewer: KO DURATION OF PATIENT IMMOBILIZATION IN THE EMERGENCY DEPARTMENT A prospective, observational study was conducted over a 10-week period to evaluate iatrogenic pain in trauma patients who are immobilized for spine precautions. Patients in the study were brought to the emergency department (ED) from the scene by ambulance and were immobilized for spine pre- cautions. Multiple trauma patients and those transferred from another hospital were excluded. A total of 102 patients were included in the study, of which only 2 patients were found to have spine fractures. Both patients with spine fractures were stable and did not require surgery. The authors found that patients spent an average of 53.9 minutes immobilized on backboards; however, the time could be decreased if the board was removed before radi- ographs are completed. Other studies have found that healthy volunteers undergoing spine immobilization have iatrogenic pain after 30 minutes. The authors concluded that pain devel- oped in patients in the ED as a result of being immobilized. Iatrogenic pain could result in increased length of stay and cost if radiographs were required to assess the source of pain. The authors suggest 3 interventions to reduce pain result- ing from universal spine immobilization. First, physicians should clinically assess patients on arrival in the ED. If the spine cannot be cleared with the examination, the patient would benefit by shortening the delay time before radi- ographs are completed. Second, boards should be padded and should provide support for natural contours of the spine. Finally, criteria could be developed that permit clinical eval- uation in the prehospital setting, thereby reducing the num- ber of patients who are immobilized. (Lerner E, Moscati R. Duration of patient immobilization in the ED. Am J Emerg Med 2000;8:28-30.) Reviewer: JMW MANAGEMENT OF LOWER EXTREMITY RIDING LAWN MOWER INJURIES IN CHILDREN It is estimated that 8 children are injured by riding lawn mowers every day in the United States, and approximately 25,300 injuries occur every year. Injuries are worse from riding lawn mowers because of their design. A typical riding lawn mower has a 26-in blade that rotates at 3000 revolutions per minute and has the ability to thrust 2100 ft/lb of energy. This gives an appreciation for the amount of trauma a child’s lower limb will sustain. Int J Trauma Nurs 2000;6:109-10. Copyright © 2000 by the Emergency Nurses Association. 1075-4210/2000/$12.00 + 0 65/3/108367 doi:10.1067/mtn.2000.108367 United States HELICOPTER AIR MEDICAL TRANSPORT: TEN-YEAR OUTCOMES FOR TRAUMA PATIENTS IN A NEW ENGLAND PROGRAM The philosophy behind air medical transport of trauma patients is that rapid transport combined with the highest level of prehospital care will optimize outcome. A retrospec- tive database review was conducted to obtain program demo- graphics and outcome data from a 10-year period. The out- comes of trauma patients were compared with mortality derived from a national database that used physiologic indices of severity. The authors found that trauma patients accounted for 59.8% of all flight requests. The mean age was 31 ± 18 years, and 71.8% were men. Motor vehicle crashes accounted for 68.5% of all trauma patients; 7.5% involved pedestrians or bicyclists struck by a motor vehicle. Of injuries occurring on roadways, 46.7% occurred on undivid- ed state roadways and 8.8% occurred on interstate highways, which highlights the use of the helicopter in rural areas. Trauma patients who survived accounted for 77.4%. To determine whether transportation by helicopter with an advanced life support crew affected trauma patient outcome, observed percent survival for a given Trauma Score was plot- ted against the national norm of predicted survival. The results indicated an overall 13% reduction in mortality for patients transported via air who were picked up at the scene. For patients with a trauma score between 4 and 13, there was a 35% reduction in predicted mortality, illustrating the impact of air medical transport and lifesaving scene inter- ventions (such as airway management) on this subset of trau- ma patients. The majority of patients transported with trauma scores of 14 or greater were triaged on the basis of mecha- nism of injury, and the data show no difference in survival in this group of patients when compared with the control group. Mortality, not morbidity, was examined in this study. The authors point out that the air medical industry needs to redefine appropriate triage criteria because current triage criteria, based on American College of Surgeons Trauma Center guidelines, yield an over-triage rate of 35% to 40% to minimize morbidity and mortality from occult injury. In addition, trauma center utilization guidelines were not designed specifically for air medical transport. The authors note that it is ethically and logistically implausible to ran- domize potentially critically ill and injured patients to con- form to controlled, prospective experimental designs.
Transcript of Abstracts of the Literature
JULY-SEPTEMBER 2000 INTERNATIONAL JOURNAL OF TRAUMA NURSING/Abstracts of the Literature 109
ABSTRACTS OF THE LITERATURE
Therefore less stringent retrospective experimental designsare more often employed in outcomes research.
(Jacobs LM, Gabram S, Sztajnkrycer M, Robinson K,Libby M. Helicopter air medical transport: ten-year out-comes for trauma patients in a New England program.Connecticut Medicine 1999;63:677-82.)
Reviewer: KO
DURATION OF PATIENT IMMOBILIZATION INTHE EMERGENCY DEPARTMENT
A prospective, observational study was conducted over a10-week period to evaluate iatrogenic pain in trauma patientswho are immobilized for spine precautions. Patients in thestudy were brought to the emergency department (ED) fromthe scene by ambulance and were immobilized for spine pre-cautions. Multiple trauma patients and those transferred fromanother hospital were excluded. A total of 102 patients wereincluded in the study, of which only 2 patients were found tohave spine fractures. Both patients with spine fractures werestable and did not require surgery.
The authors found that patients spent an average of 53.9minutes immobilized on backboards; however, the timecould be decreased if the board was removed before radi-ographs are completed. Other studies have found that healthyvolunteers undergoing spine immobilization have iatrogenicpain after 30 minutes. The authors concluded that pain devel-oped in patients in the ED as a result of being immobilized.Iatrogenic pain could result in increased length of stay andcost if radiographs were required to assess the source of pain.The authors suggest 3 interventions to reduce pain result-ing from universal spine immobilization. First, physiciansshould clinically assess patients on arrival in the ED. If thespine cannot be cleared with the examination, the patientwould benefit by shortening the delay time before radi-ographs are completed. Second, boards should be padded andshould provide support for natural contours of the spine.Finally, criteria could be developed that permit clinical eval-uation in the prehospital setting, thereby reducing the num-ber of patients who are immobilized.
(Lerner E, Moscati R. Duration of patient immobilizationin the ED. Am J Emerg Med 2000;8:28-30.)
Reviewer: JMW
MANAGEMENT OF LOWER EXTREMITYRIDING LAWN MOWER INJURIES INCHILDREN
It is estimated that 8 children are injured by riding lawnmowers every day in the United States, and approximately25,300 injuries occur every year. Injuries are worse fromriding lawn mowers because of their design. A typical ridinglawn mower has a 26-in blade that rotates at 3000 revolutionsper minute and has the ability to thrust 2100 ft/lb of energy.This gives an appreciation for the amount of trauma a child’slower limb will sustain.
Int J Trauma Nurs 2000;6:109-10.Copyright © 2000 by the Emergency Nurses Association.
1075-4210/2000/$12.00 + 0 65/3/108367
doi:10.1067/mtn.2000.108367
United States
HELICOPTER AIR MEDICAL TRANSPORT:TEN-YEAR OUTCOMES FOR TRAUMAPATIENTS IN A NEW ENGLAND PROGRAM
The philosophy behind air medical transport of traumapatients is that rapid transport combined with the highestlevel of prehospital care will optimize outcome. A retrospec-tive database review was conducted to obtain program demo-graphics and outcome data from a 10-year period. The out-comes of trauma patients were compared with mortalityderived from a national database that used physiologicindices of severity. The authors found that trauma patientsaccounted for 59.8% of all flight requests. The mean age was31 ± 18 years, and 71.8% were men. Motor vehicle crashesaccounted for 68.5% of all trauma patients; 7.5% involvedpedestrians or bicyclists struck by a motor vehicle. Ofinjuries occurring on roadways, 46.7% occurred on undivid-ed state roadways and 8.8% occurred on interstate highways,which highlights the use of the helicopter in rural areas.Trauma patients who survived accounted for 77.4%.
To determine whether transportation by helicopter with anadvanced life support crew affected trauma patient outcome,observed percent survival for a given Trauma Score was plot-ted against the national norm of predicted survival. Theresults indicated an overall 13% reduction in mortality forpatients transported via air who were picked up at the scene.For patients with a trauma score between 4 and 13, there wasa 35% reduction in predicted mortality, illustrating theimpact of air medical transport and lifesaving scene inter-ventions (such as airway management) on this subset of trau-ma patients. The majority of patients transported with traumascores of 14 or greater were triaged on the basis of mecha-nism of injury, and the data show no difference in survival inthis group of patients when compared with the control group.Mortality, not morbidity, was examined in this study.
The authors point out that the air medical industry needsto redefine appropriate triage criteria because current triagecriteria, based on American College of Surgeons TraumaCenter guidelines, yield an over-triage rate of 35% to 40% tominimize morbidity and mortality from occult injury. Inaddition, trauma center utilization guidelines were notdesigned specifically for air medical transport. The authorsnote that it is ethically and logistically implausible to ran-domize potentially critically ill and injured patients to con-form to controlled, prospective experimental designs.
110 INTERNATIONAL JOURNAL OF TRAUMA NURSING/Abstracts of the Literature VOLUME 6, NUMBER 3
Case studies are presented that discuss soft tissue andbony injuries, the fixation or repair, as well as common com-plications or problems. The psychosocial impact of injuries isa major factor because most of the operators are familymembers and the guilt or blame is extremely stressful tofamilies. A child’s coping mechanism can be challenged bythe reaction to the disfigurement and pain-related procedures.Children may act out and have behavioral, eating, and social-ization changes during hospitalization. The authors recom-mend that medical and nursing personnel use behavior mod-ification rather than pharmacologic interventions.
The multiple aspects of care are presented, including pho-tographs and radiographs of before, during, and after treat-ment for lawn mower injuries, as well as prosthesis care,wound care, flaps, grafts, scars, moisture content, and familycounseling regarding the future procedures and possibleproblems. Preventing injuries should start with manufacturerwarnings and safety standards.
(Kroening L, Davids J. Management of lower extremityriding lawn mower injuries in children. Orthopedic Nurs J2000;19:29-37.)
Reviewer: MP
COMPLICATIONS OF PRONE VENTILATION INPATIENTS WITH MULTISYSTEM TRAUMAWITH FULMINANT ACUTE RESPIRATORYDISTRESS SYNDROME
Prone positioning has been used to improve the ventila-tion and oxygenation of critically ill patients with acuterespiratory distress syndrome (ARDS). Trauma patients maybe more difficult to treat in a prone position because of thenumerous tubes, catheters, and external stabilization devices.To investigate the use of prone position in severely injuredand critically ill postoperative trauma patients with ARDS, aprospective study was conducted.
All patients who developed postinjury ARDS duringAugust 1997 to September 1998 were identified and fol-lowed. ARDS was defined by use of standard criteria, and allpatients received mechanical ventilatory support. Prone ven-tilation was considered for patients with refractory hypox-emia despite standardized treatment. Physiologic data werecollected before and after prone positioning was used.
A total of 9 patients with postinjury ARDS were treatedwith prone ventilation during the study period. Four of the 9patients experienced major complications that included thefollowing: l patient with a midline abdominal incision forexploratory laparotomy had wound dehiscence; severe facialand upper chest wall pressure necrosis developed in 2patients despite extensive padding and careful attention; 1patient had immediate cardiac arrest with turning.
The authors recommend that prone position can resultin improved oxygenation in patients with severe postinjuryARDS, and the risk of complications can be minimized withanticipation and attention to detail; a standardized turning
process; anticipation of problems with invasive devices;reassessment of the patient and ventilator after turning thepatient; elevation of the head of the bed to decrease facialedema; careful positioning of the neck and extremities toavoid compression neuropathy.
(Offner PJ, Haenel JB, Moore EE, Biffl WL, Francoise RJ,Burch JM. Complications of prone ventilation in patientswith multisystem trauma with fulminant acute respiratorydistress syndrome. J Trauma 2000;48:224-8.)
Reviewer: JSH
INSTILLATION OF NORMAL SALINE DURINGENDOTRACHEAL SUCTIONING: EFFECTS ONMIXED VENOUS OXYGEN SATURATION
It is a common practice to instill a bolus of normal salineinto a patient’s endotracheal tube before suctioning. Thispractice is believed to help liquify and remove secretions,thereby improving airway clearance and ventilation. Thispractice does not appear to have research data verifying whateffects instilling normal saline has on oxygenation.
A descriptive, observational study was conducted toinvestigate what effect normal saline instillation would haveon mixed venous oxygen saturation. A total of 35 patientswho had undergone coronary artery bypass graft surgery inthe cardiovascular intensive care unit of one hospital wereassigned to groups. The first group contained 15 subjectstreated with normal saline instillation before suctioning; thesecond group included 20 patients who did not receive nor-mal saline before suctioning. Both groups underwent suc-tioning according to an established study protocol. Data wererecorded at timed intervals: baseline, during the procedure,and until the mixed venous oxygen saturation returnedto baseline levels. Patients who were treated with normalsaline instillation before suctioning required an averageof 3.78 minutes longer to return to their baseline value formixed venous oxygen saturation.
The authors concluded that instillation of normal salinebefore endotracheal suctioning had an adverse effect on oxy-genation as indicated by mixed venous oxygen saturation andbelieved this study did not support the practice.
(Kinloch D. Instillation of normal saline during endotra-cheal suctioning: effects on mixed venous oxygen saturation.Am J Crit Care 1999;8:231-40.)
Reviewer: JSH
Reviewers:JMW — Jane M. Wick, RN, BSN, Operating Room
Trauma Nurse, Legacy Emanuel Hospital and Health Center,Portland, Ore.
JSH — Judith Stoner Halpern, RN, MS, CEN, EditorKO — Kristin Oberg, RN, MSN, EMT-P, Flight Nurse,
Life Star, Hartford Hospital, Hartford, Conn.MP — Miki Patterson, MS, RNCS, NP, ONC, Orthopedic
Trauma Coordinator, University of Massachusetts MedicalCenter, Worcester, Mass.
