Corresponding author's email: Paul.Boesch@cchmc.orgPressure ulcers are commonly acquired in pediatric institutions and are a key indicator of standard and effectiveness of care. Rationale:Pressure ulcers are associated with pain, infection, and length of hospitalization. Tracheostomy tubes cause pressure ulcers by creating a constant pressure interface with further disruption of skin integrity due to wetness from sweat and respiratory secretions. We recognized a high rate of tracheostomy-related pressure ulcers (TRPU) in our ventilator unit and instituted a quality improvement program to develop and test potential interventions for TRPU prevention. We condensed them into a clinical bundle, and then implemented it into standard clinical practice.The setting was an 18-bed multidisciplinary unit within an academic children's hospital, whose primary mission is transition of Methods: children requiring invasive mechanical ventilation to home. All tracheostomy-dependent patients from July 2008-August 2010 were included. TRPU stage, description, number of days each TRPU persisted, and bundle compliance were recorded in real time. All TRPU were staged by a wound-care expert within 24 hours. The intervention model utilized a rapid-cycle, Plan-Do-Study-Act (PDSA), framework for improvement research. The interventions identified for incorporation into the TRPU-prevention bundle included the following: Skin Braden Q risk assessment and full body skin assessments daily, and device assessments every 8 hour shift, assessment:Moisture-free Hydrophilic polyurethane foam under tracheostomy to wick moisture from the skin surface, device interface:Pressure-free device "extended" style tracheostomy tubes in children with anatomy in which the neck was not clearly exposed in the neutral position interface: (figure 1). Figure 1 Fit of standard vs. extended-style tracheostomy tube in ventilated infant. Note the crowding of the ventilator circuit in the neck with focal pressure of the adapter edge against the sternum. This is the site of 72% of the TRPU that developed during the study period.Over the study period there were 717 patients and 8770 trach days evaluated; 22 TRPU were identified. There was a significant Results: decrease in the rate of patients who developed a TRPU from 8.1% during the baseline period, to 2.6% during bundle development, and 0.5% after the bundle was implemented (figure 2). The percentage of trach days affected by a TRPU decreased from 12.5% to 0.4% between baseline and implementation periods. There was a marked difference between standard and extended tracheostomy tubes in TRPU occurrence (3.7% vs 0%, P=0.035) and days affected by a TRPU (6% vs 0.2%, P<0.0001). Figure 2

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Objective: To describe the clinical features of crush syndrome, the inter-relationship between rhabdomyolysis, compartment syndrome and crush syndrome, and to make recommendations on the pre-hospital and emergency department management of the condition. Clinical features: Three case reports are described of patients presenting with crush syndrome following dmg induced coma, including one patient in cardiac arrest. Raised compartment pressures were confirmed by manometry, and extensive rhabdomyolysis by myoglobinuria and raised creatine kinase. Intervention and outcome: Vigorous medical management was undertaken including infusion of laige volumes of intravenous fluid, and therapy with bicarbonate, mannitol, frusemide and dopamine. Surgical fasciotomy was not performed and a good outcome resulted in each case. Conclusion: Drug induced coma is now the commonest cause of the crush syndrome. Effective medical management may obviate the need for surgical fasciotomy in cases with raised compartment pressures.