Accidental

Abstract: We present the main findings of the 5th National Audit Project (NAP5) on accidental awareness during general anaesthesia (AAGA). Incidences were estimated using reports of accidental awareness as the numerator, and a parallel national anaesthetic activity survey to provide denominator data. The incidence of certain/probable and possible accidental awareness cases was ∼1:19 600 anaesthetics (95% confidence interval 1:16 700–23 450). However, there was considerable variation across subtypes of techniques or subspecialities. The incidence with neuromuscular block (NMB) was ∼1:8200 (1:7030–9700), and without, it was ∼1:135 900 (1:78 600–299 000). The cases of AAGA reported to NAP5 were overwhelmingly cases of unintended awareness during NMB. The incidence of accidental awareness during Caesarean section was ∼1:670 (1:380–1300). Two-thirds (82, 66%) of cases of accidental awareness experiences arose in the dynamic phases of anaesthesia, namely induction of and emergence from anaesthesia. During induction of anaesthesia, contributory factors included: use of thiopental, rapid sequence induction, obesity, difficult airway management, NMB, and interruptions of anaesthetic delivery during movement from anaesthetic room to theatre. During emergence from anaesthesia, residual paralysis was perceived by patients as accidental awareness, and commonly related to a failure to ensure full return of motor capacity. One-third (43, 33%) of accidental awareness events arose during the maintenance phase of anaesthesia, mostly due to problems at induction or towards the end of anaesthesia. Factors increasing the risk of accidental awareness included: female sex, age (younger adults, but not children), obesity, anaesthetist seniority (junior trainees), previous awareness, out-of-hours operating, emergencies, type of surgery (obstetric, cardiac, thoracic), and use of NMB. The following factors were not risk factors for accidental awareness: ASA physical status, race, and use or omission of nitrous oxide. We recommend that an anaesthetic checklist, to be an integral part of the World Health Organization Safer Surgery checklist, is introduced as an aid to preventing accidental awareness. This paper is a shortened version describing the main findings from NAP5—the full report can be found at http://www.nationalauditprojects.org.uk/NAP5_home.

Abstract: ACCIDENTAL death, characterized as the neglected disease of modern society,¹is the leading mortality cause for persons 1 through 39 years of age and the third for those of all ages.² Because of the medical, social, and economic implications of trauma, attention is increasingly focusing on a systems approach to reducing traumatic death and disability through prevention, treatment, and research.^3-5Regional trauma care systems have not been universally implemented, however, because of concerns about need, efficacy, and cost. This review traces the evolution of the preventable death concept, discusses its influence on trauma care systems development, and proposes future research directions.

HISTORICAL REVIEW

The American College of Surgeons first addressed trauma care in 1922 by forming the Committee on Treatment of Fractures, now the Committee on Trauma.⁶Excepting the military experience,⁷however, care quality for the multiply injured received relatively little attention during the next

Abstract: Objective : To dtermine what proportion of pre-hospital deaths from accidental injury - deaths at the scene of the accident and those that occur before the person has reached hospital - are preventable. Design : Retrospective study of all deaths from accidental injury that occurred between 1 January 1987 and 31 December 1990 and were reported to the 20 coroner. Setting : North Staffordshire. Main outcome measures : Injury severity score, probability of survival (probit analysis), and airway obstruction. Results : There were 152 pre-hospital deaths from accidental injury (110 males and 42 females). In the same period thee were 257 deaths in hospital from accidental injury (136 males and 121 females). The average age at death was 41.9 years forthose who died before reaching hospital, and thier average injury severity score was 29.3 In contrast, those who died in hospital were older and equally likely to be males or females. Important neurological injury occurred in 113 pre-hospital deaths, and evidence of airway obstruction in 59. Eighty six pre-hospital deaths were due to road traffic accidents, and 37 of these were occupants in cars. On the basis of the injury severity score and age, death was found to have been inevitable or highly likely in 92 cases. In the remaining 60 cases death had not been inevitable and airway obstruction was present in up to 5120patients with injuries that they might have survived. Conclusion : Death was potentially preventable in at least 39% of those who died from accidental injury before they reached hospital. Training in first aid20should be available more widely, and particularly to motorists as many pre-hospital deaths that could be20prevented are due to road accidents.