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Red Blood Cell Transfusion: Experience in a Rural Aeromedical Transport Service
- George L. Higgins III, Michael R. Baumann, Kevin M. Kendall, Michael A. Watts, Tania D. Strout
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- Journal:
- Prehospital and Disaster Medicine / Volume 27 / Issue 3 / June 2012
- Published online by Cambridge University Press:
- 12 June 2012, pp. 231-234
- Print publication:
- June 2012
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Introduction
The administration of blood products to critically ill patients can be life-saving, but is not without risk. During helicopter transport, confined work space, communication challenges, distractions of multi-tasking, and patient clinical challenges increase the potential for error. This paper describes the in-flight red blood cell transfusion practice of a rural aeromedical transport service (AMTS) with respect to whether (1) transfusion following an established protocol can be safely and effectively performed, and (2) patients who receive transfusions demonstrate evidence of improvement in condition.
MethodsA two-year retrospective review of the in-flight transfusion experience of a single-system AMTS servicing a rural state was conducted. Data elements recorded contemporaneously for each transfusion were analyzed, and included hematocrit and hemodynamic status before and after transfusion. Compliance with an established transfusion protocol was determined through structured review by a multidisciplinary quality review committee.
ResultsDuring the study, 2,566 missions were flown with 45 subjects (1.7%) receiving in-flight transfusion. Seventeen (38%) of these transports were scene-to-facility and 28 (62%) were inter-facility. Mean bedside and in-flight times were 22 minutes (range 3-109 minutes) and 24 minutes (range 8-76 minutes), respectively. The most common conditions requiring transfusion were trauma (71%), cardiovascular (13%) and gastrointestinal (11%). An average of 2.4 liters (L) of crystalloid was administered pre-transfusion. The mean transfusion was 1.4 units of packed red blood cells. The percentages of subjects with pre- and post-transfusion systolic blood pressures of <90 mmHg were 71% and 29%, respectively. The pre- and post-transfusion mean arterial pressures were 62 mmHg and 82 mmHg, respectively. The pre- and post- transfusion mean hematocrit levels were 17.8% and 30.4%, respectively. At the receiving institution, 9% of subjects died in the Emergency Department, 18% received additional transfusion within 30 minutes of arrival, 36% went directly to the operating room, and 36% were directly admitted to intensive care. Thirty-one percent of subjects died prior to hospital discharge. There were no protocol violations or reported high-risk provider blood exposure incidents or transfusion complications. All transfusions were categorized as appropriate.
ConclusionsIn this rural AMTS, transfusion was an infrequent, likely life-saving, and potentially high-risk emergent therapy. Strict compliance with an established transfusion protocol resulted in appropriate and effective decisions, and transfusion proved to be a safe in-flight procedure for both patients and providers.
Higgins GL 3rd, Baumann MR, Kendall KM, Watts MA, Strout TD. Red blood cell transfusion: experience in a rural aeromedical transport service. Prehosp Disaster Med. 2012;27(3):1-4.
7 - Nursing Considerations in Emergency Department Procedural Sedation and Analgesia
- from SECTION ONE - OVERVIEW AND PRINCIPLES IN EMERGENCY ANALGESIA AND PROCEDURAL SEDATION
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- By Tania D. Strout, Maine Medical Center, Department of Emergency Medicine, Research Nurse, 321 Brackett Street, Portland, ME 04102, Email: strout@mmc.org, Dawn B. Kendrick, Division of Emergency Medicine, Department of Pediatrics, University of Alabama at Birmingham, MTC 205, 1600 7th Avenue South, Birmingham, AL 35233–1711, Email: dkendrick@peds.uab.edu
- John H. Burton, Albany Medical College, New York, James Miner, University of Minnesota
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- Book:
- Emergency Sedation and Pain Management
- Published online:
- 03 December 2009
- Print publication:
- 14 January 2008, pp 38-42
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Summary
SCOPE OF THE PROBLEM
Procedural sedation and analgesia (PSA) is a standard component of emergency medicine practice. Emergency nurses are frequently called upon to assist in the assessment of and provision of care to this patient population. Although the administration of PSA medications by the registered nurse is regulated by institutional policy and state law, compliance with regulatory requirements and professional practice standards is also essential to ensure patient safety and quality care.
Both the Emergency Nurses Association (ENA) and the American College of Emergency Physicians (ACEP) support the delivery of medications used for PSA by credentialed emergency nurses who are working under the direct supervision of an emergency physician. These professional organizations state that PSA agents potentially administered by the emergency nurse include, but are not limited to, etomidate, propofol, ketamine, fentanyl, and midazolam.
In addition to ENA and ACEP, several other professional organizations have developed clinical policies and guidelines surrounding emergency department (ED) PSA. Important aspects of these guidelines recommend formal institutional-based programs of education and credentialing for nurses who administer PSA, programs to evaluate and document competency, continuing education, staffing adequate to ensure that nurses caring for PSA patients have no other responsibilities that might interfere with the care of the PSA patient, and guidelines and protocols for aspects of PSA, including drug administration, monitoring, discharge criteria, and complication management.
9 - Patient Assessment: Pain Scales and Observation in Clinical Practice
- from SECTION TWO - ANALGESIA FOR THE EMERGENCY PATIENT
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- By Tania D. Strout, Maine Medical Center, Department of Emergency Medicine, Portland, ME, Dawn B. Kendrick, Division of Emergency Medicine, Department of Pediatrics, University of Alabama, Birmingham, AL
- John H. Burton, Albany Medical College, New York, James Miner, University of Minnesota
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- Book:
- Emergency Sedation and Pain Management
- Published online:
- 03 December 2009
- Print publication:
- 14 January 2008, pp 55-66
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- Chapter
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Summary
SCOPE OF THE PROBLEM
The measurement of a patient's pain intensity is inherently complex. The pain experience is unique to each individual, influenced by many factors such as medical condition, developmental level, emotional and cognitive state, culture, the hospital environment, family issues and attitudes, language barriers, and levels of fear and anxiety. The often chaotic, loud, and hurried emergency department (ED) environment only serves to compound these difficulties. It is well documented in scientific literature that oligoanalgesia is a significant issue within emergency medicine. In order to appropriately manage patients' pain, we must attempt to accurately assess their pain.
CLINICAL ASSESSMENT
There are multiple barriers to the clinical assessment of pain, including, but not limited to, provider biases, patient anxiety, family attitudes, cultural beliefs, and provider suspicion of “drug-seeking” behavior. The National Institutes of Health has stated that patient self-report is the most reliable indicator of the existence and intensity of pain. Barriers to pain assessment are greatest for those patient populations who cannot self-report their pain experience.
Pediatric patients and those with impaired cognition communicate and display pain in very different ways. Infants and young children often cry or whimper when they are in pain. They often cannot localize or describe their pain and, therefore, it may be difficult to assess and quantify. This may be similar in the elderly patient with dementia or other cognitive and communicative impairments.