Perioperative Nursing Care of Patients with Craniofacial Injuries

SEPTEMBER 1996, VOL 64,NO 3

Home Study Program PERIOPERATIVE NURSING CARE OF PATIENTS WITH CRANIOFACIAL INJURIES

he article “Perioperative nursing care of patients with craniofacial injuries” is the basis for this AORN Journal independent study. The behavioral objectives and examination for this program were prepared by Janet S. West, RN, BSN, CNOR, clinical editor, with consultation from Susan Bakewell, RN, MS(N), professional education specialist, Center for Perioperative Education. A minimum score of 70% on the multiple-choice examination is necessary to earn three contact hours for this independent study. Participants receive feedback on incorrect answers. Each applicant who successfully completes this study will receive a certificate of completion. The deadline for submitting this study is Feb 28, 1997. Send the completed application form, multiple-choice examination, learner evaluation, and appropriate fee to AORN Customer Service c/o Home Study Program 2170 S Parker Rd, Suite 300 Denver. CO 8023 1-57 I 1

BEHAVIORAL OBJECTIVES

After reading and studying the article on penoperative nursing care of patients with craniofacial injuries, the nurse will be able to describe the major types of craniofacial injuries, discuss surgical setups for patients with craniofacial injuries, describe perioperative nursing care of patients with craniofacial injuries, and discuss perioperative nurses’ roles when caring for patients with craniofacial injuries.

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Perioperative Nursint Care of Patients with Craniofacial Injuries fl

raniofacial injuries (ie, fractures, soft tissue damage) usually are the result of motor vehicle collisions (MVCs), physical assaults, gunshot wounds, contact-sports mishaps, and occupational and home-related accidents. These injuries are caused by deceleration, blunt, or penetrating trauma. Depending on the mechanism of injury, the face can be fractured at any site. Craniofacial fractures from crushing forces are sustained in MVCs when individuals’ faces strike dashboards, windshields, or the ground. Craniofacial fractures from tapping forces occur when energy that has diminishing momentum is applied over a small surface area (eg, blows from kicks, baseball bats).I Penetrating trauma injuries often are caused by gunshot wounds from lowor high-velocity missiles or from metal projectiles (eg, caused by lawn mowers, farm equipment) that penetrate craniofacial soft tissues and bones. Craniofacial fractures can occur as incomplete, multiple, or comminuted fractures of different types. Incomplete fractures involve two bone segments and interrupt only the cortical or outer layers of bone. Multiple fractures possess a minimum of three bone segments, and comminuted fractures have many small broken bone fragments2 Craniofacial fractures require reconstructive materials of differing strengths;

therefore, the need for various intermaxillary fixation devices is imperative. Some reconstructive surgical procedures require several separate maneuvers and may last three to 16 hours or longer.3 EVOLUTION OF CRANIOFACIAL SURGERY

The development of reconstructive surgical procedures for craniofacial injuries began during World Wars I and 11. Surgeons’ experiences in these two wars resulted in the development of basic surgical techniques for the replacement of missing craniofacia1 bones, soft tissues, and skin. These early surgical techniques demonstrated that adequate corrections could be achieved by repositioning displaced parts of patients’ craniofacial skeletal frameworks. Increasingly complex craniofacial surgical procedures have been performed routinely since World War II.4 During the late 1940s and early 1950s, surgeons made their first attempts to ameliorate select congenital craniofacial deformities. A French surgeon, Dr Paul Tessier, demonstrated that large segments of craniofacial bones could be denuded completely of their blood supplies, be repositioned, and survive. He further demonstrated that the eyes could be translocated horizontally or vertically over considerable distances without impairing patients’ vision. Dr Tessier’s surgical approaches to craniofacial injuries led to surgical treatments A B S T R A C T Craniofacial injuries are the result of deceleration, blunt, or pen- for previously inaccessible anaetrating trauma. Depending on the mechanism of injury, craniofacial tomical areas of the face’ and fractures can be minor and go undetected, or they can produce dev- resulted in the development of astating facial deformities. With the advent of intermaxillary fixation today’s orbital-craniofacial surgidevices, surgeons can manipulate facial bone structures and repair cal subspecialty service. Modem soft tissue damage in the majority of patients with craniofacial trau- craniofacial surgical techniques ma injuries. Most patients experience optimal results from their have enabled surgeons to correct craniofacial surgical procedures and return to normal lives after severe deformities of the skull and face and associated soft tissue surgery. AORN J 64 (Sept 1996) 385-406. KETRA MARIE HAYES, RN; NANCY L. COMBS, RN

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Figure 1 Anterior view of cranium and craniofacial bones. (Illustrations by Mark Katnik Denver; original concepts for Figures 2, 3, and 4 by Ketra Marie Hayes, RN, Seattle.)

injuries.6 A multidisciplinary team approach often is required for the treatment of craniofacial injuries, with specialists in plastic and reconstructive surgery, neurosurgery, ophthalmology, oral maxillofacial surgery, and otorhinolaryngology participating in patient care a~tivities.~ CRANIOFACW BONE ANATOMY

The term cruniofuciul refers to the cranium (ie, the bony structures of the forehead; top, back, and upper sides of the skull) and the face (ie, cheeks, nose, lips, chin). The skeletal structure of the face (Figure 1) includes the frontal bone of the forehead and 14 craniofacial bones (ie, two each: nasal, maxillary, lacrimal, zygomatic, palatine, nasal concha1 bones; one each: vomer, mandible). As in the cranium, the craniofacial bones are fused into immovable joints, except for the mandible (ie, lower jaw).* The frontal bone forms the upper part of the eye orbits by articulating with the sphenoid, ethmoid, and paired nasal, lacrimal, maxillary, and zygomatic bones. The posterior eye orbits are formed by the sphenoid and palatine bones. The medial walls of the eye orbits are formed by the ethmoid, lacrimal, nasal, and maxillary bones. The lateral aspects of the eye orbits are formed by the zygomatic bones. The ethmoid bones form the roof and posterior lateral walls of both nasal cavities, and the nasal bones form the bridge of the nose between the two eye orbit^.^ Craniofacial bones are relatively thin and

unsupported. They protect organs, bones, and tissues that lie within and behind their structures (eg, eyes, lacrimal apparatus, pharynx, cervical spine, brain). They also provide an apparatus for mastication (ie, chewing) and a vestibule to the respiratory and vocal organs.I0 The maxillae (ie, upper jaw bones) hold the palate and join in the midline between the nose and oral cavity. The alveolar processes (ie, tooth-bearing bodies) of the maxillae hold the upper teeth. The mandible articulates with the temporal bones at the temporomandibular joints (TMJs), which are anterior to the ears, and meets midline in the mental region to form the chin. The alveolar processes of the mandible hold the lower teeth." N P E S OF CRANIOFACIAL FRACTURES

Craniofacial fractures may be minor and go undetected, or they may result in serious, disfiguring trauma injuries. Craniofacial fractures most often are described by the facial bones and regions involved (eg, mandibular, maxillary, zygomatic, nasal, midcraniofacial [ie, Le Fort]). General signs and symptoms of craniofacial fractures include pain, swelling, skin discoloration, facial deformity and malfunction, and cerebrospinal fluid (CSF) otorrhea or rhinorrhea.I2 Craniofacial fractures are diagnosed clinically by inspection, palpation, and radiographic studies. 386

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Mandibular fractures. Mandibular fractures occur most frequently in males 20 to 30 years of age.13 Injuries to the mandible may be related to physical assaults, MVCs, or contact-sports mishaps. Patients with mandibular fractures may manifest a combination of signs and symptoms, which include pain and swelling, skin discoloration, dental malocclusions, craniofacial distortions, bleeding around teeth, limited movement of the involved mandible, mandibular deviation toward the fracture, and preauricular edema of the fractured side.14 These patients also may exhibit ecchymosis, crepitus, craniofacial lengthening, and abnormal tooth mobility. Therapeutic interventions include application of local cold packs; open reduction and internal fixation (ORIF) of the fracture area with stainless-steel surgical wire, titanium plates, mesh, and screws; antibiotic administration; and tetanus prophylaxis. Maxillary fractures. Maxillary fractures may occur in combination with other craniofacial fractures or as isolated injuries from tapping forces. Signs and symptoms of maxillary fractures include ecchymosis, dental malocclusions, midfacial deformities (eg, flattening or smashedin appearance), and abnormal tooth mobility.I6 Therapeutic interventions include application of local cold packs and extensive ORIF repairs. Patient stabilization and subsequent reduction and fixation of maxillary and mandibular fractures should be completed as soon as possible depending on the presence and severity of the patient’s other trauma injuries. Endodontic consultation and intervention may be required to preserve teeth that are compromised by an inadequate blood supply. Zygomatic fractures. Zygomatic fractures are the result of blunt trauma (eg, physical assaults, MVCs) to the side of the face and upper cheek. Clinical findings with these types of fractures include crepitus, periorbital edema, craniofacial asymmetry, inability to open the mouth, lateral cheek flattening, subconjunctival ecchymosis, and paresthesia of the anterior cheek.”

The most common type of zygomatic fracture is a tripod fracture, in which there are fractures of the zygomatic arch, the infraorbital rim, and the frontal zygomatic suture line. Signs and symptoms of tripod fractures include diplopia (ie, double vision), decreased ocular movement, and a recessed globe that results in unequal pupil height.Is Zygomatic fractures are diagnosed clinically by looking down at the patient’s face from above and behind (ie, the fractured side will appear flat), palpating the infraorbital fracture, observing the patient demonstrate limited eye movement in the upward gaze, and noting swelling in the injured area.19 An ophthalmic examination may be required to rule out extensive intraocular trauma (eg, optic nerve injuries; eyelid, lacrimal, or global lacerations). Surgeons also examine the patient for evidence of a CSF leak caused by a fractured cribriform plate. Therapeutic interventions include application of local cold packs, administration of regional anesthesia for pain, and open or closed reduction of the fracture site.2o Nasalfractures. The most common craniofacial fracture is a nasal fracture, which usually occurs as a result of blunt trauma to the front or side of the nose.21Nasal fractures may involve fractures of the nasal bones, cartilage, and nasal septum. Clinical signs and symptoms include epistaxis; crepitus; periorbital ecchymosis; nasal airway obstruction; tenderness and swelling; and facial asymmetry, deformity, or angulation.22 It may be difficult to determine the presence or extent of nasal fractures when swelling is present; therefore, reductions of nasal fractures usually are delayed until the swelling subsides. Nasal fractures are reduced with nasal packs and external splints under topical and local anesthesia. Septa1 hematomas often are associated with nasal fractures. These hematomas need to be excised and packed promptly to prevent permanent “saddlenose” deformities caused by septa1 cartilage necrosis.23 Midfacial fractures. Midfacial fractures commonly result from deceleration trauma (eg, MVCs, airplane crashes) in which significant force is directed toward the middle one third of the face (ie, maxillary, zygomatic, nasal, lacrimal, ethmoid, sphenoid bones; nasal septum). Surgeons use the Le Fort classification 388

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Figure 2 Illustration of a Le Fort I (ie, transverse) midfacial fracture.

Figure 3 Illustration of a Le Fort II (ie, pyramidal) midfacial fracture.

of midfacial fractures to determine the most appropriate method of reduction and stabilization. Le Fort fractures are divided into three categories (ie, I, 11, 111), according to the number and location of the fracture lines. A Le Fort I fracture (Figure 2) traverses the maxillae and falls between the nose and the upper gum line. The fracture separates the hard palate from the rest of the maxillae. A Le Fort I1 fracture (Figure 3) is pyramidal in shape and extends from the extreme lateral edges of the maxillae upward under the eye orbits and across the nasal bone. A Le Fort 111fracture (Figure 4)is higher on the face and extends from the TMJs slightly upward and laterally through the eye orbits and above the nose. This fracture separates all the craniofacial bones from the frontal bone and the remainder of the cranium. An extensive Le Fort 111 fracture can cause a basilar skull fracture and CSF leakage.24 Le Fort fractures usually result in multiple midfacial fractures because of the severity of forces required to produce such trauma; therefore, a single Le Fort fracture is rare. Proper medical and surgical treatment is specific to each type of Le Fort fracture. Surgeons diagnose Le Fort fractures by correlating patients’ historical, clinical, and radiographic data. Clinical signs and symptoms of Le Fort fractures are similar to and consistent with other types of craniofacial fractures. Although all Le Fort fractures are serious injuries, Le Fort 111 fractures warrant special attention because of the pressing nature of other trauma injuries (eg, head, cervical spine, orbital damage) associated with these fractures. Clinical signs and symptoms of Le Fort 111fractures include a “midface mash” (ie, craniofacial structures are

Figure 4 IllustrationOf a Le Fort 111 (ie, craniofacial dysjunction) fracture.

forced inward, creating a “dish-face’’deformity), hemorrhage, craniofacial lengthening, dental malocclusion, significant edema and soft tissue injury, mobile fractured bone segments, and possible airway compromise from posterior dislocation of fracture segments.2s Cervical spine and soft tissue injuries often are present because of the magnitude of force required to create Le Fort I11 fractures. Immobilization of patients’ heads and cervical spines is imperative if cervical spine injuries are suspected. Substantial soft tissue injuries also may require hemorrhage management with nasal catheters and packing.26 SOFT T#S8UE INJURIES

Craniofacial soft tissue injuries include abrasions, lacerations, and contusions. Abrasions. Small craniofacial abrasions require only cleansing and minor skin debridement to prevent infection and to remove embedded foreign bodies. A sterile scrub brush is adequate for minor skin debridement procedures, which are performed under local anesthesia (eg, 1% lidocaine hydrochloride with a 1:100,OOO concentration of epinephrine hydrochloride). Large craniofacial abrasions are treated like burns and require skin grafting procedures under general anesthesia. Lacerations. Craniofacial lacerations are common soft tissue injuries, and immediate repair of craniofacial lacerations is important to obtain good scar formation and reduce the incidence of infection. Most lacerations can be repaired by primary closure after all devitalized tissue is thoroughly debrided.

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Craniofacial lacerations should be sutured within the first eight hours after injury; however, lacerations that are eight to 24 hours old may be sutured if systemic antibiotics are admini~tered.~~ When surgeons evaluate craniofacial lacerations, they consider the possibility of associated injuries to underlying deep facial regions (eg, craniofacial nerves, skeletal and vascular structures). Physicians specifically evaluate cheek lacerations for possible injuries to craniofacial nerve branches and muscles and the parotid glands. Ophthalmologists physically examine the eyes for ocular damage, visual acuity, loss of vision, and diplopia and funduscopically examine the eyes for possible hyphema or detached retina.2nBlood loss from craniofacial lacerations may appear massive, but most bleeding can be controlled with direct pressure or pressure dressings. Pressure dressings also may be used to support soft tissues and eliminate dead space, which reduces the potential for hematoma formation.29 Contusions. Blunt trauma injuries to the face often produce contusions that do not cause patient problems unless underlying hematomas are present. Physicians evacuate hematomas to prevent fibrous scar formation and encapsulation that may produce craniofacial disfigurement. Surgical treatment of craniofacial fractures also requires topical hemostasis to prevent postoperative hematoma formation. Postoperative hematomas often require additional surgical procedures for evacuation, and untreated hematomas may become infected.’O PATIENT ASSESSMENT

Patients with craniofacial trauma injuries usually enter the health care system through emergency departments (EDs). Their craniofacial injuries often are associated with other multisystem trauma injuries; therefore, ED physicians and nurses treat patients concurrently with surgeons from various surgical subspecialties. The most life-threatening injuries (eg, chest, cranial, abdominal) are treated first. Craniofacial injuries rarely threaten patients’ lives except in conjunction with airway damage and obstruction. All patients with craniofacial injuries are assumed to have additional head and neck injuries until proven otherwise. Prophylactic treatment measures (eg, fluid resuscitation) are initiated on all patients with craniofacial injuries to prevent shock from de~eloping.~’ Initial emergency care. When confronted with a patient who has possible craniofacial fractures, ED

physicians’ and nurses’ principal concerns include airway maintenance, control of bleeding, and cervical spine support. Airway maintenance. The state of the patient’s airway is of primary concern because airway obstruction may be caused by bone fragments, blood clots, broken teeth, or a separated palate lodged in the back of the throat. For example, if the patient has a Le Fort I fracture, the hard palate may fall back over the nasopharynx and obstruct the airway.32 If the patient’s teeth are broken, the ED physicians and nurses save the loose teeth in the event reimplantation is possible. They place the patient on supplemental oxygen or mechanical ventilatory support as needed to aid breathing and maintain airway patency. Control of bleeding. Most craniofacial injuries involve profuse external bleeding because of the multitude of vascular structures in the face. Direct pressure and bulky dressings are used to control bleeding; however, ED physicians and nurses apply pressure at the wound edges, not over probable craniofacial fracture sites. They do not attempt to stop blood or C S F drainage from the patient’s ears because doing so could increase the patient’s intracranial pressure and risk of infection if a skull fracture is present.33 Cervical spine support. A cervical spine injury is suspected in the presence of all craniofacial trauma. The ED physicians and nurses assess the patient’s neck for any obvious injuries (eg, bleeding, bruising, swelling) and, if they suspect a spinal injury, the patient’s cervical spine is protected through the continuous use of a rigid or extrication collar, cervical traction, or a halo brace. Preoperative assessment of craniofacial injuries. After the patient’s condition is stable, the surgical specialists (eg, otorhinolaryngology, plastic and reconstructive, oral maxillofacial surgeons) further assess the patient’s craniofacial injuries. Assessment measures include obtaining an accurate patient history, including the mechanism of injury; performing a physical examination; observing the patient; performing neurologic evaluations; and obtaining radiologic studies (eg, x-rays, computed tomography [CT] scans). Physical examination. The surgeons examine the patient’s craniofacial soft tissues for signs of abrasions, lacerations, or contusions. They also evaluate the patient’s face for the presence of puncture wounds or embedded foreign bodies. The surgeons palpate all bony prominences and note any tenderness

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as a possible fracture site. Severe pain is common with craniofacial fractures, and muscular contractions in the mandibular region may cause further fracture displacement and pain. Patient observation. The surgeons observe the patient’s face for significant structural deformities, abnormal extraocular movements (EOMs), trismus (ie, tonic contraction of the muscles of mastication), loss of mandibular function, and difficulty with speech. They also look for the presence of tooth mobility; craniofacial lengthening; paresthesia; subconjunctival ecchymosis; recessed globes; and abnormal pupil shape, size, or response to light. Neurologic evaluation. The surgeons always perform neurologic examinations on any patient with suspected craniofacial injuries. A baseline neurologic evaluation includes gathering information on the patient’s level of consciousness and neurologic and visual signs. An ear examination also is conducted to check for a possible hearing deficit caused by a hemotympanum and to check for Battle’s sign (ie, bruising, swelling behind the ear).34Neurologic signs and symptoms of craniofacial injuries include decreased consciousness or disequilibrium, sensory deficits (eg, loss of smell, loss of taste), inability to speak, skull deformity, unequal pupil size, presence of Battle’s sign, recessed eye (ie, one eye appears to more inwardly depressed than the other eye), raccoon’s eyes (ie, black or discolored skin under each eye), and blood or CSF flowing from the ears or nose.35 The surgeons also check the patency of the four cranial nerves that traverse the face. Injuries to the face may involve the third, fourth, fifth, and seventh cranial nerves. The third cranial nerve (ie, oculomotor) innervates the majority of the ocular muscles to provide eye movement. Elevation of the upper eyelid and constriction of the pupil also are controlled by the third cranial nerve. The fourth cranial nerve (ie, trochlear) provides for downward and inward movement of the eye. The surgeons evaluate the normal functioning of the third and fourth cranial nerves by testing the pupillary shape, size, and response to light and EOMs in all four quadrants of the patient’s eyes. The fifth cranial nerve (ie, trigeminal) elicits craniofacial sensation and jaw movement. The surgeons evaluate its functioning by testing the patient’s ability to feel pain and objects touched to the face,

inquiring about the presence of numbness or tingling, and assessing the patient’s reaction to hot and cold stimuli. The seventh cranial nerve (ie, facial) divides into branches (ie, temporal, zygomatic, buccal, marginal mandibular). To check for damage to the temporal branch of the seventh craniofacial nerve, the surgeons ask the patient to raise his or her eyebrows and wrinkle the forehead. The surgeons test the zygomatic branch by having the patient manipulate the orbicularis oris muscle and squeeze both eyes until they are tightly shut. To evaluate the integrity of the buccal branch, the surgeons ask the patient to elevate his or her upper lip and wrinkle the nose. To test the marginal mandibular branch, the surgeons observe the patient for loosening and depression of the lower lip.36 Radiologic studies. The surgeons confirm the patient’s diagnosis by x-ray films or CT scans that identify the specific fractured craniofacial bones. Diagnostic x-ray films may include a Caldwell and Waters view; anteroposterior, lateral, and submentovertex views; or a basilar view. The surgeons analyze three-dimensional CT scans and cephalometric tracings superimposed on the patient’s transparent photographs to determine the extent of the craniofacia1 fractures and to plan for skeletal rearrangement of the patient’s craniofacial features.3’ After the surgeons assess the patient’s craniofacial injuries, they communicate the nature and extent of the patient’s trauma injuries to other surgical team members. PREOPERATIVE NURSING INTERVENTIONS

The preoperative patient interview provides perioperative nurses with necessary information to initiate a plan of care before the surgical procedure begins. Nursing assessment. When the patient enters the perioperative receiving area, the preoperative nurse notes the patient’s overall appearance. For example, the patient with multisystem trauma injuries may have a distorted facial appearance from craniofacial fractures and lacerations and head injuries. The preoperative nurse checks the patient’s identification band, notes any allergies, and asks the patient when he or she last ate or drank. Ideally, the patient should be NPO six to eight hours before surgery; however, this is not always possible if the patient needs emergent surgical intervention. The preoperative nurse checks the patient’s most recent laboratory tests results, especially the hematocrit level. because coronal incisions and

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Figure 5 Lateral view of a computed tomography scan of a trauma patienf‘s craniofacial injuries.

Figure 6 Anterior view of a computed tomography scan of a trauma patient‘s craniofacial injuries.

manipulation of craniofacial fractures create substantial blood loss. The nurse then telephones blood bank personnel to determine the quantity of blood products available for the patient. If blood products have not been ordered in the ED, the preoperative nurse asks the anesthesia care provider or the surgeons if the patient needs blood drawn for blood type and cross-matching tests. If the patient has a suspected cervical spine injury, the preoperative nurse tries to determine whether x-ray films have ruled out a cervical spine injury before the patient is transferred to the OR and intubated under general anesthesia. Whenever possible, the preoperative nurse verifies the presence of a signed surgical consent form in the patient’s medical chart. He or she reassures the patient and provides a positive attitude about the potential outcome of the impending surgical procedure. The patient’s fear of facial disfigurement can have a great psychological impact on his or her preoperative anxiety level. The preoperative nurse asks a family member to bring in a photograph of the patient to help the surgeons plan for reconstruction of the patient’s face. If the surgical procedure involves simultaneous correction of a mandibular malocclusion and orbitocranial skeletal reconstruction, the oral maxillary surgeon will cut and mount dental models on an articulator for reference during the surgical procedure.-’x OR preparation. A successful surgical procedure begins with accurate and expedient OR preparation. Preparation time can be five to 30 minutes

depending on the severity of the patient’s condition and the urgency of the impending surgical procedure. The circulating nurse prepares the OR by stocking linen and other necessary surgical supplies. He or she performs a preoperative check of all electrical equipment (eg, electrosurgical unit [ESU], temperature regulating unit, power console for surgical drills and saws) to ensure their safe working order. The circulating nurse also ensures that necessary patient positioning devices (eg, full-length patient roller, gel mattress overlay, egg crate foam pads, pillows, arm sleds, donut headrests) are available for immediate use. He or she places all equipment around the OR bed so that surgical team members’ movements are unhindered and so that the scrub person can maintain the integrity of the sterile field. The circulating nurse ensures that the patient’s x-ray films and CT scans (Figures 5 and 6) are in the OR before the surgeons arrive. The surgeons are responsible for placing the x-ray films and CT scans on the viewing board in the anticipated order of use. INTRAOPERAllVE PATIENT CARE

The following is a description of the surgical management of a patient undergoing maxillomandibular fixation (MMF) and intermaxillary fixation procedures for repair of craniofacial fractures. The preoperative nurse and the anesthesia care provider transfer the patient to the OR. The circulating nurse checks the patient’s identification band and surgical consent form, when appropriate, for

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Figure 7 Arm sleds position the patient‘s arms to the side of the OR bed during a craniofacial surgical procedure.

Figure 8 The circulating nurse places a pillow under the patient‘s knees for a craniofacial surgical procedure.

accuracy. He or she provides reassurance and verbal comfort to the patient during the transfer to the OR bed. The patient may be able to move onto the OR bed without much assistance: however, if the patient has a suspected cervical spine injury, an adequate number of surgical team members must log roll the patient as a single unit onto the OR bed. The circulating nurse places a towel over the patient’s thighs and secures the safety strap on top of the towel. The towel prevents the rubber or plastic safety strap from rubbing against the patient’s skin and causing skin breakdown. The circulating nurse places warm blankets over the patient to provide comfort and to prevent hypothermia. He or she ensures that the blankets are not tucked so tightly that they pull the patient’s toes downward during the surgical procedure. Anesthesia preparations. The patient may be intubated before he or she arrives in the OR. If the patient has been intubated in the ED, the anesthesia care provider connects the patient to the ventilator and begins to administer general anesthesia. If the patient has not been intubated in the ED, the anesthesia care provider induces general anesthesia and intubates the patient with an endotracheal (ET) or a nasotracheal (NT) tube. The circulating nurse applies cricoid pressure to the patient’s throat to prevent possible reflux of stomach contents. If an ET or NT tube is contraindicated because of upper craniofacial fractures, the surgeon may elect to perform a preoperative tracheotomy to maintain an adequate airway during and after the surgical procedure. The anesthesia care provider also may elect to use a hypotensive anesthesia technique to reduce blood loss during an extensive surgical procedure.-79The circulating nurse ensures that the anesthesia care provider has all the necessary supplies to place arterial or central venous access lines after the patient is intubated. The anesthesia care provider inserts arterial and central

venous access lines into the patient if the surgical procedure is expected to last several hours. Patient positioning. The circulating nurse consults with the surgeons to determine the ideal patient positioning before the start of surgery. To allow optimal access to the surgical site, the patient usually is positioned supine with the arms tucked at the sides and slightly flexed to prevent hyperextension of the arms. The OR bed is turned at least 90 degrees away from the anesthesia care provider to ensure the integrity of the sterile field. If the MMF and intermaxillary fixation procedures are scheduled to last more than six hours, the nurse ensures that a full-length, gel-type mattress overlay has been placed on the OR bed before the patient’s arrival. The gel-type mattress overlay disperses the patient’s weight and reduces pressure on the upper back, sacrum, elbows, calves, and heels. Patient positioning varies according to the presence of other patient care devices (eg, casts, splints, cervical collars, external fixation devices). The circulating nurse ensures that the patient’s neck, spine, and pelvis are in a straight line and that the patient’s legs are parallel to the OR bed. Correct body alignment decreases the incidence of postoperative nerve injuries and muscle tension. If the patient has a cervical spine injury, the surgeons determine whether removal of the cervical collar is necessary for the surgical procedure. If the patient’s cervical collar is removed, the surgeons physically perform that task. After removal of the cervical collar, the surgeons and the circulating nurse secure the head by placing sandbags on either side of the patient’s head and neck. If a coronal incision is not required, the circulating nurse places a strip of wide adhesive tape across the patient’s forehead and secures the tape on either side of the OR bed. He or she takes care not to shear the patient’s skin when removing the tape. If the patient does not have a cervical spine injury, sandbags and adhesive tape are not used. Instead, the anesthesia care 396

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Figure 9 The surgeon shaves a one-inch strip of hair behind the patient‘s hairline for a coronal incision.

Figure 10 The surgeon injects local anesthesia into the incision site to control bleeding during surgery.

provider places the patient’s head on donut headrests. The circulating nurse ensures that the patient’s shoulders are in a relaxed, neutral position. If the patient’s shoulders slump back, he or she may develop a permanent postoperative brachial plexus injury and muscle and joint pain.40 The circulating nurse also ensures that the patient’s fingers are relaxed and that the thumbs point toward the ceiling to prevent ulnar nerve compression.?’ He or she notes the location of the patient’s fingers in relationship to the OR bed to ensure they will not be injured if any of the bed joints are flexed. The circulating nurse places egg crate foam pads under the patient’s arms and wraps a drawsheet around the patient’s torso. He or she secures the drawsheet with a clamp to hold the patient’s arms in an anatomically correct position. If the patient is large and a drawsheet is not adequate, the circulating nurse uses arm sleds (Figure 7) to position the patient’s arms to the side of the OR bed. He or she pads the arm sleds so that the edges do not dig into the patient’s arms. The use of arm sleds decreases the amount of material under the patient, reduces shearing forces, minimizes pressure on the patient’s skin, and increases surgical team members’ access to the surgical site. It is difficult to slide the arm sleds under the OR bed’s mattress, so the circulating nurse places a drawsheet under the mattress to allow surgical team members to lift the patient and the mattress at the same time. The use of a drawsheet also allows the circulating nurse to slide the arm sleds easily under the patient and avoid damage to the mattress. Other circulating nurse duties. If the surgical procedure is scheduled to last more than two hours, the circulating nurse places antiembolism stockings and pneumatic compression sleeves on the patient’s lower extremities unless contraindicated because of other limb injuries. The circulating nurse also inserts a Foley catheter if the surgical procedure is scheduled

to last three or more hours. After inserting the Foley catheter, he or she secures the catheter tubing to the patient’s thigh and places the measured urine collection bag on the anesthesia care provider’s side of the OR bed for patient monitoring. The circulating nurse places the ESU dispersive pad on a large muscle area of the patient’s body (eg, anterior, lateral thigh). He or she avoids placing the ESU dispersive pad over hollow body cavities and bony prominences to prevent possible organ damage. The circulating nurse places a soft pillow under the patient’s knees (Figure 8) to reduce back strain, increase venous return, and relieve pressure on the calves and heels. A firm pillow is not used because it places undue pressure on the patient’s popliteal and tibia1 nerves. The circulating nurse places a temperature regulating blanket (eg, forced-air warming device) over the patient to warm the patient as necessary. The temperature regulating blanket is placed over the safety strap to permit complete circulation of air in the blanket. Direct warming of the patient allows the circulating nurse to lower the room temperature and provide for the comfort of surgical staff members during a long surgical procedure. The scrub person and circulating nurse also perform the initial sponge and needle counts before the surgeons make their first incision. Surgical site preparation. If the patient has long hair, the circulating nurse braids the hair into sections and holds it in place with rubber bands to prevent the hair from falling into the surgical site. The surgeons may not shave the patient’s entire head, depending on their preferences and location of the injuries. If the surgeons use a coronal incision, they usually shave a one-inch strip of hair behind the patient’s hairline from ear to ear and across the top of the head (Figure 9). This modified shave prep helps preserve the patient’s self-esteem after the surgical procedure. The surgeons apply antibiotic ointment to the edges of the shaved area to keep fine,

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Figure 11 After the skin prep, the patient‘s eyes are rinsed with balanced salt solution to prevent burns.

Figure 12 The surgeon makes a coronal incision in a zigzag fashion across the top of the patient‘s scalp.

loose hairs from contaminating the surgical site. Injection of local anesthesia. The surgeons then inject the incision sites with a mixture of 1% lidocaine hydrochloride with epinephrine hydrochloride 1:100,000 (Figure 10). The use of 1% lidocaine hydrochloride decreases surgical stimulation of the incision sites by preventing the generation and conduction of nerve impulses. The use of 1: 100,OOO epinephrine hydrochloride reduces blood loss by causing vasoconstriction at the incision sites.42 If an extraoral approach is necessary to treat a mandibular fracture, the surgeons inject only 1 :100,000 epinephrine hydrochloride solution to establish vasoconstriction. They do not inject 1% lidocaine hydrochloride because the facial nerve needs to remain responsive to electrical stimulation so that its branches can be identified. The use of 1: 100,000 epinephrine hydrochloride and the reversal of any paralytic agents used by the anesthesia care provider allows the surgeons to use a nerve stimulator to assess the facial nerve’s motor functions. Eye prep. After the surgeons complete the injection of local anesthesia, they may perform a tarsorrhaphy (ie, sewing the upper and lower eyelids together) with a 6-0 silk suture. Suturing the patient’s upper and lower eyelids together helps prevent corneal abrasions and inadvertent eye injuries during surgery. If a subciliary incision is needed for exposure of an orbital floor fracture, the surgeons usually perform a tarsorrhaphy. If the surgeons use a transconjunctival incision, a tarsorrhaphy is not necessary. The anesthesia care provider applies ophthalmic ointment to the patient’s eyes to maintain moisture and prevent corneal abrasions. He or she ensures that there is not excessive pressure against the eyes to cause thrombosis of the central retinal artery, which can result in blindness if the problem is not c0rrected.~3 Skin p r e p . The circulating nurse preps the

patient’s face with povidone-iodine solution if the patient is not allergic to iodine. The patient is prepped from the clavicles up to the posterior portion of the head, which includes the patient’s mouth and eyes, the ET or NT tube, the balloon used to inflate the ET or NT tube’s cuff, the shaved area of scalp, and the patient’s hair. The balloon is prepped to allow the anesthesia care provider quick access to the ET or NT tube in case of an emergency. The circulating nurse thoroughly saturates all portions of the patient’s hair with povidone-iodine solution. After the skin prep is completed, he or she rinses the patient’s eyes with balanced salt solution to prevent injury from povidone-iodine solution inadvertently entering the eyes (Figure 11). Before the sterile drapes are placed, the anesthesia care provider rechecks the patient’s arterial and central venous access lines, and the circulating nurse reassesses the patient’s position. Draping. The circulating nurse uses aseptic technique to lift the patient’s head while supporting the neck so the surgeons can place a sterile towel under the patient’s head and establish a base for the sterile field. The surgeons square off the patient’s head with sterile towels and secure the towels to the skin with skin staples. The scrub person places one 3/4-length drape sheet from the patient’s clavicles to the toes. He or she then drapes an adhesive split sheet over the 3/4-length drape sheet and wraps the adhesive end of the drape around the patient’s head. The surgeons finish draping the patient by placing a drain pouch slightly under the patient’s head so that it is positioned at the head of the OR bed. This drain pouch helps reduce the amount of blood and imgation fluid that falls to the floor and keeps surgical team members’ feet dry. Equipment setup. The scrub person passes all cords and tubing (eg, electrosurgical, suction, bipolar, powered drills) off the foot of the OR bed to keep the surgical field free of clutter and to allow 398

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Figure 13 Craniofacial instruments and screws that are used during intermaxillary fixation procedures.

Figure 14 Craniofacial instruments and plates that are used during intermaxillary fixation procedures.

ease of movement around the OR bed. The circulating nurse ensures that all equipment power settings are at appropriate levels before he or she activates the equipment to prevent inadverent soft tissue injury during surgery. Maxillomandibular fixation. To restore the patient’s preinjury dental occlusion, the surgeons immobilize the mandibular and maxillary fractures by interdental wiring if the patient has upper and lower teeth. The surgeons shape upper and lower arch bars to the patient’s maxillary and mandibular teeth and pass 24- or 25-gauge stainless steel surgical wire between the teeth to secure the connecting arch bars. Each arch-bar strand contains a series of small lugs, which the surgeons use to place wire loops and small rubber bands around to hold the patient’s teeth in a normal occlusion. If the patient does not have teeth, the surgeons perform an ORIF by circumferentially wiring over an intraoral splint or screws and using connecting bars.44 The MMF procedure provides the surgeons with a stable base that they can use to reduce and stabilize the patient’s intermaxillary fractures. Intermaxillary fixation. The surgeons often use multiple surgical approaches (eg, intraoral, extraoral, subciliary, transconjunctival, lateral brow, coronal, hemicoronal) to repair intermaxillary fractures. They use coronal or hemicoronal incisions depending on the amount of exposure needed. The amount of cranial bone graft material needed for the repair of intermaxillary fractures also may determine the type of incision the surgeons perform. The surgeons make a coronal incision in a zigzag fashion across the top of the patient’s scalp (Figure 12). They make a hemicoronal incision from above the patient’s ear to the top of the head. The zigzag method allows the patient’s new hair to fall randomly over the incision site and to cover it completely after surgery. A straight incision across the

patient’s scalp causes the hair to part along the scar from the incision site; therefore, the surgeons make the incisions behind the frontal hairline for cosmetic purposes. This can be challenging if the patient has a receding hairline. The surgeons obtain adequate exposure of the fracture sites by using different bone and soft tissue instruments from the craniofacial instrument set. One surgeon holds the soft tissue retractors to maintain exposure, and another surgeon uses small, modified periosteal elevators, Kocher clamps, and Dingman bone-holding forceps to reduce the intermaxillary fractures. The key to successful plating of these fractures is an accurate and complete reduction of each fracture site before it is plated for rigid fixation. Depending on the nature of the patient’s maxillary fractures, the surgeons may perform various osteotomies to advance, align, and reposition the craniofacial bones. After the surgeons reduce all the intermaxillary fractures, they use appropriate-sizedtitanium plates and screws (eg, 1.0, 1.3, 1.5, 2.0, or 2.4 mm) (Figures 13 and 14) for rigid fixation of the fracture sites. The location and severity of the intermaxillary fractures dictate the size of plate that is used. The surgeons usually use titanium plates and screws because of their strength and tissue compatibility. The surgeons use cranial bone graft material to bridge any gaps left from the intermaxillary fracture sites. They cut strips of bone from the patient’s calvarium (ie, upper domelike portion of the skull) by using a round cutting burr, an oscillating saw with straight and custom-bent blades, narrow osteotomes, and a mallet (Figure 15). The surgeons first outline the desired bone strips by using an oscillating saw and straight blade to cut into the diploetic space (ie, cancellous bone layer of the skull). They use a large, round burr to grate through the bone anterior to the bone graft material. They then place the oscillating saw and a custom-bent blade against the patient’s

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Figure 15 The surgeon takes strips of bone from the patient‘s calvarium to use as grafting material.

Figure 16 The surgeon uses titanium plates and screws to repair the intermaxillary fracture sites.

skull with the blade pointed at the diploetic space to cut the bone strips. They remove the strips of bone graft material with a curved osteotome and mallet. If the bone strips cannot be removed easily, they use osteotomes and a mallet to tap out the bone graft material. They use titanium plates and screws to maintain the stability of the bone graft material in the defect After all fracture sites are reduced and plated (Figure 16), the surgeons use copious amounts of sterile normal saline to irrigate the incision sites; therefore, it is important that all surgical staff members wear protective eyewear to prevent splash injuries. The surgeons place self-regulating suction drainage devices and anchor the drains at the exit sites through the patient’s skin or scalp with suture. The scrub person attaches the drains to suction as the surgeons complete the subcutaneous closure with absorbable suture. The surgeons carefully close the incision sites to avoid nerve injuries and to obtain good cosmetic results. The circulating nurse and the scrub person use the time during wound closure to record the medical implant devices used. The circulating nurse ensures that all medical implant devices are documented accurately on the patient’s medical record and on the OR’S implant log. Documentation on the patient’s medical record includes location, type, size, and quantity of medical implant devices used during surgery. The circulating nurse ensures that the documentation is complete and accurate before he or she gives the information to the patient care coordinator. The scrub person and circulating nurse then perform final sponge and needle counts. After the scrub person ensures that all surgical instruments are off the sterile field, the surgeon removes the surgical drapes from the patient. Surgical team members clean the patient’s incision sites, hair, and face to promote comfort after the

surgical procedure. The circulating nurse sets up a prep stand with warm, sterile water; a comb; and towels. He or she unbraids the patient’s hair, if applicable, and rinses the patient’s hair with the warm, sterile water. The circulating nurse combs blood and bone debris out of the patient’s hair. The scrub person washes the patient’s face and applies antibiotic ointment to the incision sites while the circulating nurse places warm blankets over the patient. The circulating nurse notifies the appropriate postoperative care unit (eg, intensive care unit [ICU], postanesthesia care unit [PACU]) when the surgical procedure is completed. If the patient is to remain intubated, the circulating nurse notifies the ICU nurses as soon as possible so that a ventilator is available when the patient arrives in the ICU. The circulating nurse ensures that the patient’s bed is ready (ie. clean linen on bed, oxygen tank and portable hemodynamic monitor at foot of bed, wire cutters taped to head of bed) before bringing it into the OR. Wire cutters are used to cut the stainless steel surgical wires connecting the arch bars if the patient experiences respiratory difficulty or to prevent aspiration if the patient experiences vomiting. Before surgical team members move the patient to a bed, the circulating nurse checks the ESU dispersive pad site for skin redness or swelling. He or she notes any changes in the patient’s skin integrity on the back, buttocks, posterior thighs, heels, occiput, shoulders, and arms in the patient’s medical record. Any changes in the patient’s skin integrity are monitored by ICU or PACU nurses during the patient’s postoperative recovery period. Surgical team members transfer the patient as a single unit to the patient bed. The anesthesia care provider secures all IV tubing and catheters and makes the patient as comfortable as possible before he or she is transported to the ICU or PACU. The surgeons and the anesthesia care provider transport 402

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the patient to the appropriate postoperative care unit. Ketra Marie Hayes, RN, is an assistant nurse manager and the OR charge nurse of the otolaryngologyloral maxillocraniofaciallophthalmology services at Harborview Medical Center, Seattle.

SUMMARY

Craniofacial injuries involve the craniofacial bones (eg, mandible; maxillary, zyogmatic, nasal, lacrimal bones) and soft tissue trauma frequently associated with MVCs, physical assaults, gunshot wounds, contact-sports mishaps, and occupational and home-related accidents. Craniofacial fractures may be minor, or they may result in serious, disfiguring injuries. Craniofacial injuries usually d o not threaten patients’ lives; however, they frequently are associated with other multisystem trauma injuries that may be life threatening (eg, head injuries, cervical spine fractures). Preoperative planning and OR preparation and the total cooperation of all surgical team members are essential for successful treatment results. Perioperative nurses’ knowledge of craniofacial anatomy, mechanisms of injuries, intermaxillary fixation procedures, craniofacial reconstruction devices, and patient positioning and preparation helps ensure optimal patient outcomes. A NOTES 1. R Haug, A Greenberg, “Etiolcgy, distribution, and classification of fractures,” in Craniofacial Fractures: Principals of Internal Fixation Using the AOIASIF Technique, ed A M Greenburg (New York: SpringerVerlag New York, Inc, 1993) 6. 2. N G Elliott, “Maxillocraniofacial, anterior neck, and eye trauma,” in Flight Nursing Principals and Practice. ed G Lee (St Louis: MosbyYear Book, Inc, 1991) 203-204. 3. L J Atkinson, N H Fortunato, Berry & Kohn’s Operating Room Technique, eighth ed (St Louis: Mosby-Year Book, Inc, 1996) 745. 4. Ibid. 5. Ibid. 6. I Munro, “Head & Neck,” in Craniofacial Surgery, ed E P Caronni (New York: Little, Brown, and Co, 1985) 131. 7. Atkinson, Fortunato, Berry & Kohn’s Operating Room Technique, eighth ed, 745. 8. H Gray, Anatomy: Descriptive and Surgical, 15th ed (New York: Barnes & Noble Books, 1995) 50. 9. Atkinson, Fortunato, Berty &

Nancy L. Combs, RN, was an RN II in the OR at Harborview Medical Center, Seattle, at the time this article was written. She now is enrolled in an RNfirst assistant education program in Columbus, Ohio. The authors wish to acknowledge Robert B. Stanley, MD. DDS, professor at the University of Washington Medical Center and chief of otolaryngologylhead and neck surgery at Harborview Medical Center, Seattle; and Elizabeth Visco, CRNA, a teaching associate at Harborview Medical Center, Seattle,for their assistance.

Kohn’s Operating Room Technique, eighth ed, 744. 10. Gray, Anatomy: Descriptive and Surgical, 15th ed, 50. 11. Atkinson, Fortunato, Berry & Kohn’s Operating Room Technique, eighth ed, 744. 12. S A Budassi, R Kotler, N Smith, “Eye, ear, nose, throat, maxillocraniofacial, and dental emergencies,” in Emergency Nursing, third ed, S A Budassi, J M Barber, eds (St Louis: Mosby-Year Book, Inc, 1992) 344.

13. Haug, Greenberg, “Etiology, distribution, and classification of fractures,” 10. 14. H D Grant, R H Murray, J D Bergeron, Brady Emergency Care, sixth ed (Englewood Cliffs, NJ: Prentice Hall, 1994) 337. 15. Budassi, Kotler, Smith, “Eye, ear, nose, throat, maxillocraniofacial, and dental emergencies,” 344. 16. K J Donahoe, “Plastic and reconstructive surgery,” in Alexander’s Care of the Patient in Surgery, 10th ed, M H Meeker, J C Rothrock, eds (St Louis: Mosby-Year Book, Inc, 1995) 971. 405 AORN JOURNAL

17. Budassi, Kotler, Smith, “Eye, ear, nose, throat, maxillocraniofacial, and dental emergencies,” 343. 18. Ibid, 343-344. 19. Ibid. 20. Ibid. 2 1. Ibid. 22. Ibid. 23. Ibid. 24. Grant, Murray, Bergeron, Brady Emergency Care, sixth ed,336. 25. J Luckmann, K C Sorensen, Medical-Surgical Nursing: A PsychophysiologicApproach, fourth ed (Philadelphia: W B Saunders Co, 1993) 2210. 26. Elliott, “Maxillocraniofacial, anterior neck, and eye trauma,” 203204. 27. Haug, Greenberg, “Etiology, distribution, and classification of fractures,” 12. 28. Budassi, Kotler, Smith, “Eye, ear, nose, throat, maxillocraniofacial, and dental emergencies,” 341. 29. Ibid. 30. Ibid. 31. Grant, Murray, Bergeron, Brady Emergency Care, sixth ed, 335-337; Budassi, Kotler, Smith,

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“Eye, ear, nose, throat, maxillocraniofacial, and dental emergencies,” 340. 32. Grant, Murray, Bergeron, Brady Emergency Care, sixth ed, 336-337. 33. /hid, 335; Budassi, Kotler, Smith, “Eye, ear, nose, throat, maxillocraniofacial, and dental emergencies,” 340. 34. Budassi, Kotler, Smith, “Eye, ear, nose, throat, maxillocraniofacial, and dental emergencies,” 34 1. 35. Grant, Murray, Bergeron, Brady Emergency Care, sixth ed, 331-332. 36. Elliott, “Maxillocraniofacial,

anterior neck, and eye trauma,” 203204. 37. Budassi, Kotler, Smith, “Eye, ear, nose, throat, maxillocraniofacial, and dental emergencies,” 344, Atkinson, Fortunato, Berry & Kohn’s Operating Room Technique, eighth ed, 745. 38. Atkinson, Fortunato, Berry & Kohn’s Operating Room Technique, eighth ed, 745. 39. Ihid. 40. F McAlpine, B Sechel, “Complications of positioning: The peripheral nervous system,” in Positioning in Anesthesia and Surgery, second ed, J T Martin, ed (Philadelphia: W B

AORN is accredited as a provider of continuing education in nursing by the American Nurses Credentialing Center‘s Cammission an Accreditation. AORN recognizes this activity as cantinuing education for registered nurses. This recognition does not imply that AORN or the American Nurses Credentialing Center‘s Commission on Accreditation approves or endorses any product included in the activiv. AORN maintains the following provider numbers: Alabama ABNP0075, California BRNO0667, Florida 27FO 177, Iowa 103. AORN is approved as a provider of continuing nursing

Saunders Co, 1987)303-327. 41. B L Smith, “The traditional supine position,” in Positioning in Anesthesia and Surgery, second ed, J T Martin, ed (Philadelphia: W B Saunders Co, 1987)33-35. 42. Drug Facts and Comparisons, 50th ed (Philadelphia: J B Lippincott Co, 1996) 2417 and 2982. 43. S S Fairchild, Perioperative Nursing: Principles and Practice, second ed (Boston: Little, Brown and Co, 1996) 326. 44.Atkinson, Fortunato, Berry & Kohn’s Operating Room Technique, eighth ed, 747. 45. Ihid, 748.

education by the Kansas State Board of Nursing. This course offering is approved for three contact hours. The Kansas State Board of Nursing approved provider number is LTO 1 14-03 16. Professional nurses are invited to submit manuscripts far the Home Study Program. Manuscripts or queries should be sent to the €ditar, AORN Journal, 2 I 7 0 S Parker Rd, Suite 300, Denver, CO 80231-571 1. As with all manuscripts sent to the Journal, papers submitted far Home Study Programs should not have been previously published or submitted simultaneously to any other publication.

Drowsy Drivers Endanger Public Health Speakers at the National Sleep Foundation’s first International Forum on Sleeplessness and Crashes reported that at least 1,500 Americans die every year because sleepy drivers insist on staying on the road. The forum was part of a campaign called “Drive Alert, Arrive Alive,” started by the foundation in 1993. According to a physician from the Center for Sleep and Respiratory Neurology at the University of Pennsylvania Medical Center, Philadelphia, police accident-report data indicate that falling asleep while driving leads to about 1.4% of all vehicular accidents and about 4% of all fatal crashes. These figures may underestimate the magnitude of the problem because police officers often do not receive training that would enable them to recognize drowsy driving. The

same physician reports that drivers most at risk for a crash due to sleepiness are those who: are sleep deprived or who have worked all day before driving; drive long distances without taking rest breaks; drive through the night or at other times when they would normally be asleep; take medication that makes them sleepy; drive after drinking alcohol; drive alone; drive on long, boring, rural roads; or are frequent travelers. ‘Drowsy drivers endanger public health, forum says, ’ Medical Tribune 37 (June 20, 1996) 1, 6.

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