External validation of the Norwegian survival prediction model in trauma after major trauma in Southern Finland.

BACKGROUND: The Norwegian Survival Prediction Model in Trauma (NORMIT) is a newly developed outcome prediction model for patients with trauma. We aimed to compare the novel NORMIT to the more commonly used Trauma and Injury Severity Score (TRISS) in Finnish trauma patients. METHODS: We performed a retrospective open-cohort study, using the trauma registry of Helsinki university hospital's trauma unit, including severely injured patients (new injury severity score > 15) admitted from 2007 to 2011. We used 30-day in-hospital mortality as the primary outcome, and discharge functional outcome as a secondary outcome of interest. Model performance was evaluated by comparing discrimination (by area under the receiver operating characteristic curve [AUC]), using a re-sample bootstrap technique, and by assessing calibration (GiViTI belt). RESULTS: We identified 1111 patients fulfilling the study inclusion criteria. Overall mortality was 13% (n = 147). NORMIT showed slightly better discrimination for mortality prediction (AUC = 0.83, 95% confidence interval [CI] = 0.80-0.86 vs. AUC = 0.79, 95% CI = 0.75-0.83, P = 0.004) and functional outcome prediction (AUC = 0.78, 95% CI = 0.76-0.82 vs. AUC = 0.75, 95% CI = 0.72-0.78, P < 0.001) than TRISS. Calibration testing revealed poor calibration for both NORMIT and TRISS (P < 0.001), by giving too pessimistic predictions (predicted survival significantly lower than actual survival). CONCLUSION: NORMIT and TRISS showed good discrimination, but poor calibration, in this mixed cohort of severely injured trauma patients from Southern Finland. We found NORMIT to be a feasible alternative to TRISS for trauma patient outcome prediction, but trauma prediction models with improved calibration are needed.

Trauma-registry survival outcome follow up: 30 days is mandatory and appears sufficient.

INTRODUCTION: Thirty-day in-hospital mortality is a common outcome measure in trauma-registry research and benchmarking. However, this does not include deaths after hospital discharge before 30 days or late deaths beyond 30 days since the injury. To evaluate the reliability of this outcome measure, we assessed the timing and causes of death during the first year after major blunt trauma in patients treated at a single tertiary trauma center. METHODS: We used the Helsinki Trauma Registry to identify severely injured (NISS ≥ 16) blunt trauma patients during 2006 to 2015. The Population Register center of Finland provided the mortality data for patients and Statistics Finland provided the cause of death information from death certificates. Disease, work-related disease, medical treatment, and unknown cause of death were considered as non-trauma related deaths. We divided the 1-year study period into the following three categories: in-hospital death before 30 days (Group 1), death after discharge but within 30 days (Group 2), and death 31 to 365 days since admission (Group 3). RESULTS: We included 3557 patients with a median NISS of 29. Altogether, 21.8% (776/3557) patients died during the first year since the injury. Of these non-survivors, 12.7% (450) were in Group 1, 4.0% (141) in Group 2, and 5.2% (185) in Group 3. Non-traumatic deaths not directly related to the injury increased substantially as the time from the injury increased and were 2.0% (9/450) in Group 1, 13.5% (19/141) in Group 2, and 35.7% (66/185) in Group 3. CONCLUSION: Thirty-day mortality is a proper outcome that measures survival after severe blunt trauma. However, applying only in-hospital mortality instead of actual 30-day mortality may exclude non-survivors who die at another facility before day 30. This could result in over-optimistic benchmarking results. On the other hand, extending the follow-up period beyond 30 days increases the rate of non-traumatic deaths. By combining data from different registries, it is possible to address this challenge in current trauma-registry research caused by lack of follow up.

How to Validate Data Quality in a Trauma Registry? The Helsinki Trauma Registry Internal Audit.

BACKGROUND AND AIMS: Trauma registry data are used for analyzing and improving patient care, comparison of different units, and for research and administrative purposes. Data should therefore be reliable. The aim of this study was to audit the quality of the Helsinki Trauma Registry internally. We describe how to conduct a validation of a regional or national trauma registry and how to report the results in a readily comprehensible form. MATERIALS AND METHODS: Trauma registry database of Helsinki Trauma Registry from year 2013 was re-evaluated. We assessed data quality in three different parts of the data input process: the process of including patients in the trauma registry (case completeness); the process of calculating Abbreviated Injury Scale (AIS) codes; and entering the patient variables in the trauma registry (data completeness, accuracy, and correctness). We calculated the case completeness results using raw agreement percentage and Cohen's κ value. Percentage and descriptive methods were used for the remaining calculations. RESULTS: In total, 862 patients were evaluated; 853 were rated the same in the audit process resulting in a raw agreement percentage of 99%. Nine cases were missing from the registry, yielding a case completeness of 97.1% for the Helsinki Trauma Registry. For AIS code data, we analyzed 107 patients with severe thorax injury with 941 AIS codes. Completeness of codes was 99.0% (932/941), accuracy was 90.0% (841/932), and correctness was 97.5% (909/932). The data completeness of patient variables was 93.4% (3899/4174). Data completeness was 100% for 16 of 32 categories. Data accuracy was 94.6% (3690/3899) and data correctness was 97.2% (3789/3899). CONCLUSION: The case completeness, data completeness, data accuracy, and data correctness of the Helsinki Trauma Registry are excellent. We recommend that these should be the variables included in a trauma registry validation process, and that the quality of trauma registry data should be systematically and regularly reviewed and reported.

Blunt Abdominal Trauma in a European Trauma Setting: Need for Complex or Non-Complex Skills in Emergency Laparotomy.

BACKGROUND AND AIMS: Blunt abdominal trauma can lead to substantial organ injury and hemorrhage necessitating open abdominal surgery. Currently, the trend in surgeon training is shifting away from general surgery and the surgical treatment of blunt abdominal trauma patients is often done by sub-specialized surgeons. The aim of this study was to identify what emergency procedures are needed after blunt abdominal trauma and whether they can be performed with the skill set of a general surgeon. MATERIALS AND METHODS: The records of blunt abdominal trauma patients requiring emergency laparotomy (n = 100) over the period 2006-2016 (Helsinki University Hospital Trauma Registry) were reviewed. The organ injuries and the complexity of the procedures were evaluated. RESULTS: A total of 89 patients (no need for complex skills, NCS) were treated with the skill set of general surgeons while 11 patients required complex skills. Complex skills patients were more severely injured (New Injury Severity Score 56.4 vs 35.9, p < 0.001) and had a lower systolic blood pressure (mean: 89 vs 112, p = 0.044) and higher mean shock index (heart rate/systolic blood pressure: 1.43 vs 0.95, p = 0.012) on admission compared with NCS patients. The top three NCS procedures were splenectomy (n = 33), bowel repair (n = 31), and urinary bladder repair (n = 16). In patients requiring a complex procedure (CS), the bleeding site was the liver (n = 7) or a major blood vessel (n = 4). CONCLUSION: The majority of patients requiring emergency laparotomy can be managed with the skills of a general surgeon. Non-responder blunt abdominal trauma patients with positive ultrasound are highly likely to require complex skills. The future training of surgeons should concentrate on NCS procedures while at the same time recognizing those injuries requiring complex skills.

Head Injuries in Urban Environment Skiing and Snowboarding: A Retrospective Study on Injury Severity and Injury Mechanisms.

BACKGROUND AND AIM: During the last decade urban skiing and snowboarding has gained a lot of popularity. In urban skiing/snowboarding riders try to balance on handrails and jump off buildings. Previous studies in skiing and snowboarding accidents have mostly been conducted at hospitals located close to alpine terrain with big ski resort areas. The aim of this study is to evaluate the types and severity of traumatic brain injuries occurring in small, suburban hills and in urban environment, and to characterize injury patterns to find out the specific mechanisms of injuries behind. MATERIALS AND METHODS: This study included all patients admitted to the Helsinki University Hospital Trauma Unit from 2006 to 2015 with a head injury (ICD 10 S06-S07) from skiing or snowboarding accidents in Helsinki capital area. Head injuries that did not require a CT-scan, and injuries older than 24 hours were excluded from this study. RESULTS: There were a total of 72 patients that met the inclusion criteria Mean length of stay in hospital was 2.95 days. According to the AIS classification, 30% had moderate, 14% had severe, and 10% had critical head injuries. Patients who got injured in terrain parks or on streets where more likely to be admitted to ICU than those injured on slopes. Based on GOS score at discharge, 78% were classified as having a good recovery from the injury, 13% had a moderate disability, 5% had a severe disability and 3% of the injuries were fatal. There were no statistically significant differences in decreased GOS between the accident sites. CONCLUSION: Head injuries occurring in small suburban hills and in urban environments can be serious and potentially fatal. The profile and severity of skiing injuries in urban environments and small, suburban hills is comparable to those on alpine terrain.

The use of aortic balloon occlusion in traumatic shock: first report from the ABO trauma registry.

PURPOSE: Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a technique for temporary stabilization of patients with non-compressible torso hemorrhage. This technique has been increasingly used worldwide during the past decade. Despite the good outcomes of translational studies, clinical studies are divided. The aim of this multicenter-international study was to capture REBOA-specific data and outcomes. METHODS: REBOA practicing centers were invited to join this online register, which was established in September 2014. REBOA cases were reported, both retrospective and prospective. Demographics, injury patterns, hemodynamic variables, REBOA-specific data, complications and 30-days mortality were reported. RESULTS: Ninety-six cases from 6 different countries were reported between 2011 and 2016. Mean age was 52 ± 22 years and 88% of the cases were blunt trauma with a median injury severity score (ISS) of 41 (IQR 29-50). In the majority of the cases, Zone I REBOA was used. Median systolic blood pressure before balloon inflation was 60 mmHg (IQR 40-80), which increased to 100 mmHg (IQR 80-128) after inflation. Continuous occlusion was applied in 52% of the patients, and 48% received non-continuous occlusion. Occlusion time longer than 60 min was reported as 38 and 14% in the non-continuous and continuous groups, respectively. Complications, such as extremity compartment syndrome (n = 3), were only noted in the continuous occlusion group. The 30-day mortality for non-continuous REBOA was 48%, and 64% for continuous occlusion. CONCLUSIONS: This observational multicenter study presents results regarding continuous and non-continuous REBOA with favorable outcomes. However, further prospective studies are needed to be able to draw conclusions on morbidity and mortality.

Radiological evaluation of tube depth and complications of prehospital endotracheal intubation in pediatric trauma: a descriptive study.

PURPOSE: Pediatric prehospital endotracheal intubation (PHETI) is a difficult and rarely performed procedure that remains the gold standard for prehospital airway management when ventilation and/or anesthesia is required, but high complications rates, including malposition continue to concern. We reviewed the experience in our institution of pediatric intubations with particular emphasis on the position of the endotracheal tube (ETT) tip within the trachea and related complications. METHOD: Intubated pediatric patients presenting directly from the scene to our level 1 trauma center, between 2006 and 2014, were included in our study. Patient records and radiographs were retrospectively reviewed to identify the ETT tip-to-carina distance and possible intubation-related complications. ETT tips identified beyond the carina on radiographs or by clinical diagnosis were defined as misplaced. Because head movement causes a significant ETT movement within the trachea, which is age related, we also defined ETT tip placement (1) less than 2 cm above the carina in children younger than 8 and (2) less than 3 cm above the carina in children 8 years or older as "near miss" intubations. RESULTS: From a total of 34 cases, ETT misplacement was identified in seven cases. Diagnosis was made radiologically in five cases and clinically in two cases. Four of these patients had left lung atelectasis due to tube misplacement. Tube thoracotomy was performed in two of these patients without concurrent evidence of chest injury. "Near miss" intubations accounted for 7/9 and 9/25 in children <8 years and ≥8 years old, respectively, totaling 16/34, with two of these leading to late displacements. CONCLUSIONS: Pediatric endotracheal tube intubation carries a high rate of tube malposition and left lung atelectasis in our experience of pediatric trauma patients, with less than a third of ETTs placed in a safe position.

Bleeding Pelvic Fracture Patients: Evolution of Resuscitation Protocols.

BACKGROUND AND AIMS: Massive transfusion protocol seems to improve outcome in massively bleeding trauma patients, but not pelvic fracture patients. The aim of this study was to evaluate the effect of massive transfusion protocol on the mortality and fluid resuscitation of shocked pelvic fracture patients. MATERIAL AND METHODS: This is a trauma register study from a single hospital. From the trauma registry patients with pelvic fracture, injury severity score >15, admission base excess below -5, age >15 years, blunt trauma, and primary admission from the scene were identified. Patients were divided into two groups: Group 1-pre-massive transfusion protocol (2006-2009) and Group 2-post-massive transfusion protocol (2010-2013). Basic characteristics and intensive care unit length of stay, mortality, and fluid resuscitation data were retrieved from the registry. Standardized mortality ratio was assessed using revised injury severity classification, version II methodology. RESULTS: Altogether, 102 patients were identified. Group 1 ( n = 56) and Group 2 ( n = 46) were comparable in their basic characteristics. The observed mortality was 35.7% and 26.1% in Groups 1 and 2, respectively. The standardized mortality ratio failed to reveal any difference between observed and expected mortality in either group. In the emergency room, the use of crystalloids decreased from 5.3 ± 3.4 to 3.3 ± 1.8 L ( p = 0.002) with increased use of fresh frozen plasma (2.9 ± 4.4 vs 5.1 ± 5.3, p = 0.007). CONCLUSION: No improvement in the adjusted survival of shocked pelvic fracture patients is apparent after implementation of massive transfusion protocol. Implementation of massive transfusion protocol is associated with a higher use of fresh frozen plasma and improved ratio of fresh frozen plasma:red blood cell toward the targeted 1:1 and decreased use of crystalloids.

Severe intimate partner violence affecting both young and elderly patients of both sexes.

BACKGROUND: Intimate partner violence (IPV) affects 25-35 % of women and men in Western countries. Despite the high prevalence of IPV among trauma patients, very little is known about the associated injuries. Most previous studies excluded male victims and IPV is often limited to violence against women. Few reports on IPV among elderly patients exist. METHODS: We examined self-reports of IPV among patients at two major trauma centers of the Helsinki Central Hospital in Finland. Based on previous studies, we hypothesized that we would find the most severe injuries among young and middle-aged women. RESULTS: We identified 29 patients with a total of 105 injuries; patients typically presented with multiple injuries. Half of all patients required hospitalization or surgery. Contrary to previous studies, 17 % of our cohort were male, while 17 % of patients were 65 years or older. We found that 40 % of male victims presented with a New Injury Severity Score (NISS) over 15, indicating severe trauma. Two elderly patients presented with an NISS of 27, the highest in our study. CONCLUSIONS: IPV leads to severe injury across all age groups among both male and female patients. The injury mechanism should be clearly defined for all trauma patients, keeping IPV in mind as a potential cause despite patient age or gender.

Accuracy and Coverage of Diagnosis and Procedural Coding of Severely Injured Patients in the Finnish Hospital Discharge Register: Comparison to Patient Files and the Helsinki Trauma Registry.

BACKGROUND AND AIMS: The Finnish Hospital Discharge Register data are frequently used for research purposes. The Finnish Hospital Discharge Register has shown excellent validity in single injuries or disease groups, but no studies have assessed patients with multiple trauma diagnoses. We aimed to evaluate the accuracy and coverage of the Finnish Hospital Discharge Register but at the same time validate the data of the trauma registry of the Helsinki University Hospital's Trauma Unit. MATERIALS AND METHODS: We assessed the accuracy and coverage of the Finnish Hospital Discharge Register data by comparing them to the original patient files and trauma registry files from the trauma registry of the Helsinki University Hospital's Trauma Unit. We identified a baseline cohort of patients with severe thorax injury from the trauma registry of the Helsinki University Hospital's Trauma Unit of 2013 (sample of 107 patients). We hypothesized that the Finnish Hospital Discharge Register would lack valuable information about these patients. RESULTS: Using patient files, we identified 965 trauma diagnoses in these 107 patients. From the Finnish Hospital Discharge Register, we identified 632 (65.5%) diagnoses and from the trauma registry of the Helsinki University Hospital's Trauma Unit, 924 (95.8%) diagnoses. A total of 170 (17.6%) trauma diagnoses were missing from the Finnish Hospital Discharge Register data and 41 (4.2%) from the trauma registry of the Helsinki University Hospital's Trauma Unit data. The coverage and accuracy of diagnoses in the Finnish Hospital Discharge Register were 65.5% (95% confidence interval: 62.5%-68.5%) and 73.8% (95% confidence interval: 70.4%-77.2%), respectively, and for the trauma registry of the Helsinki University Hospital's Trauma Unit, 95.8% (95% confidence interval: 94.5%-97.0%) and 97.6% (95% confidence interval: 96.7%-98.6%), respectively. According to patient records, these patients were subjects in 249 operations. We identified 40 (16.1%) missing operation codes from the Finnish Hospital Discharge Register and 19 (7.6%) from the trauma registry of the Helsinki University Hospital's Trauma Unit. CONCLUSION: The validity of the Finnish Hospital Discharge Register data is unsatisfactory in terms of the accuracy and coverage of diagnoses in patients with multiple trauma diagnoses. Procedural codes provide greater accuracy. We found the coverage and accuracy of the trauma registry of the Helsinki University Hospital's Trauma Unit to be excellent. Therefore, a special trauma registry, such as the trauma registry of the Helsinki University Hospital's Trauma Unit, provides much more accurate data and should be the preferred registry when extracting data for research or for administrative use, such as resource prioritizing.

Missed Injuries in Polytrauma Patients after Trauma Tertiary Survey in Trauma Intensive Care Unit.

BACKGROUND AND AIMS: Injuries are often missed during the primary and secondary surveys in trauma patients. Studies have suggested that a formal tertiary survey protocol lowers the number of missed injuries. Our aim was to determine the number, severity, and consequences of injuries missed by a non-formalized trauma tertiary survey, but detected within 3 months from the date of injury in trauma patients admitted to a trauma intensive care unit. MATERIAL AND METHODS: We conducted a cohort study of trauma patients admitted to a trauma intensive care unit between 1 January and 17 October 2013. We reviewed the electronic medical records of patients admitted to the trauma intensive care unit in order to register any missed injuries, their delay, and possible consequences. We classified injuries into four types: Type 0, injury detected prior to trauma tertiary survey; Type I, injury detected by trauma tertiary survey; Type II, injury missed by trauma tertiary survey but detected prior to discharge; and Type III, injury missed by trauma tertiary survey and detected after discharge. RESULTS: During the study period, we identified a total of 841 injuries in 115 patients. Of these injuries, 93% were Type 0 injuries, 3.9% were Type I injuries, 2.6% were Type II injuries, and 0,1% were Type III injuries. Although most of the missed injuries in trauma tertiary survey (Type II) were fractures (50%), only 2 of the 22 Type II injuries required surgical intervention. Type II injuries presumably did not cause extended length of stay in the intensive care unit or in hospital and/or morbidity. CONCLUSION: In conclusion, the missed injury rate in trauma patients admitted to trauma intensive care unit after trauma tertiary survey was very low in our system without formal trauma tertiary survey protocol. These missed injuries did not lead to prolonged hospital or trauma intensive care unit stay and did not contribute to mortality. Most of the missed injuries received non-surgical treatment.

The Effect of Evolving Fluid Resuscitation on the Outcome of Severely Injured Patients: An 8-year Experience at a Tertiary Trauma Center.

BACKGROUND AND AIMS: Fluid resuscitation of severely injured patients has shifted over the last decade toward less crystalloids and more blood products. Helsinki University trauma center implemented the massive transfusion protocol in the end of 2009. The aim of the study was to review the changes in fluid resuscitation and its influence on outcome of severely injured patients with hemodynamic compromise treated at the single tertiary trauma center. MATERIAL AND METHODS: Data on severely injured patients (New Injury Severity Score > 15) from Helsinki University Hospital trauma center's trauma registry was reviewed over 2006-2013. The isolated head-injury patients, patients without hemodynamic compromise on admission (systolic blood pressure > 90 or base excess > -5.0), and those transferred in from another hospital were excluded. The primary outcome measure was 30-day in-hospital mortality. The study period was divided into three phases: 2006-2008 (pre-protocol, 146 patients), 2009-2010 (the implementation of massive transfusion protocol, 85 patients), and 2011-2013 (post massive transfusion protocol, 121 patients). Expected mortality was calculated using the Revised Injury Severity Classification score II. The Standardized Mortality Ratio, as well as the amounts of crystalloids, colloids, and blood products (red blood cells, fresh frozen plasma, platelets) administered prehospital and in the emergency room were compared. RESULTS: Of the 354 patients that were included, Standardized Mortality Ratio values decreased (indicating better survival) during the study period from 0.97 (pre-protocol), 0.87 (the implementation of massive transfusion protocol), to 0.79 (post massive transfusion protocol). The amount of crystalloids used in the emergency room decreased from 3870 mL (pre-protocol), 2390 mL (the implementation of massive transfusion protocol), to 2340 mL (post massive transfusion protocol). In these patients, the blood products' (red blood cells, fresh frozen plasma, and platelets together) relation to crystalloids increased from 0.36, 0.70, to 0.74, respectively, in three phases. CONCLUSION: During the study period, no other major changes in the protocols on treatment of severely injured patients were implemented. The overall awareness of damage control fluid resuscitation and introduction of massive transfusion protocol in a trauma center has a significant positive effect on the outcome of severely injured patients.

Tibial Fractures in Alpine Skiing and Snowboarding in Finland: A Retrospective Study on Fracture Types and Injury Mechanisms in 363 Patients.

BACKGROUND AND AIM: Alpine skiing and snowboarding share the hazards of accidents accounting for tibial fractures. The aim of this study was to evaluate the fracture patterns and mechanisms of injury of tibial fractures taking place in downhill skiing and snowboarding. MATERIALS AND METHODS: All patients with tibial fracture due to alpine skiing or snowboarding accident treated in four trauma centers next to the largest ski resorts in Finland were analyzed between 2006 and 2012. The hospital records were retrospectively reviewed for data collection: equipment used (skis or snowboard), age, gender, and mechanism of injury. Fractures were classified according to AO-classification. RESULTS: There were 342 skiing and 30 snowboarding related tibial fractures in 363 patients. Tibial shaft fracture was the most common fracture among skiers (n = 215, 63%), followed by proximal tibial fractures (n = 92, 27%). Snowboarders were most likely to suffer from proximal tibial fracture (13, 43%) or tibial shaft fracture (11, 37%). Snowboarders were also more likely than skiers to suffer complex AO type C fractures (23% vs 9%, p < 0.05). Adult skiers had both wider variety of fractures and higher prevalence of proximal tibial fractures compared to children (49% vs 16%, p < 0.05). Skiers typically got injured due to falling down on the same level (70%) and snowboarders due to loss of control while jumping (46%). CONCLUSION: The most important finding was the relatively high number of the tibial plateau fractures among adult skiers. The fracture patterns between snowboarding and skiing were different; the most common fracture type in skiers was spiral tibial shaft fracture compared to proximal tibial fractures in snowboarders. Children had more simple fractures than adults.

Unconscious trauma patients: outcome differences between southern Finland and Germany-lesson learned from trauma-registry comparisons.

PURPOSE: International trauma registry comparisons are scarce and lack standardised methodology. Recently, we performed a 6-year comparison between southern Finland and Germany. Because an outcome difference emerged in the subgroup of unconscious trauma patients, we aimed to identify factors associated with such difference and to further explore the role of trauma registries for evaluating trauma-care quality. METHODS: Unconscious patients [Glasgow Coma Scale (GCS) 3-8] with severe blunt trauma [Injury Severity Score (ISS) ≥16] from Helsinki University Hospital's trauma registry (TR-THEL) and the German Trauma Registry (TR-DGU) were compared from 2006 to 2011. The primary outcome measure was 30-day in-hospital mortality. Expected mortality was calculated by Revised Injury Severity Classification (RISC) score. Patients were separated into clinically relevant subgroups, for which the standardised mortality ratios (SMR) were calculated and compared between the two trauma registries in order to identify patient groups explaining outcome differences. RESULTS: Of the 5243 patients from the TR-DGU and 398 from the TR-THEL included, nine subgroups were identified and analyzed separately. Poorer outcome appeared in the Finnish patients with penetrating head injury, and in Finnish patients under 60 years with isolated head injury [TR-DGU SMR = 1.06 (95 % CI = 0.94-1.18) vs. TR-THEL SMR = 2.35 (95 % CI = 1.20-3.50), p = 0.001 and TR-DGU SMR = 1.01 (95 % CI = 0.87-1.16) vs. TR-THEL SMR = 1.40 (95 % CI = 0.99-1.81), p = 0.030]. A closer analysis of these subgroups in the TR-THEL revealed early treatment limitations due to their very poor prognosis, which was not accounted for by the RISC. CONCLUSION: Trauma registry comparison has several pitfalls needing acknowledgement: the explanation for outcome differences between trauma systems can be a coincidence, a weakness in the scoring system, true variation in the standard of care, or hospitals' reluctance to include patients with hopeless prognosis in registry. We believe, however, that such comparisons are a feasible method for quality control.

No long-term effects of ultrasound therapy on bioabsorbable screw-fixed lateral malleolar fracture.

BACKGROUND AND AIMS: The present study was initiated to evaluate the long-term effects of low-intensity ultrasound therapy on bioabsorbable screw-fixed lateral malleolar fractures, which has not been studied earlier. PATIENTS AND METHODS: The study design was prospective, randomized, double-blinded, and placebo-controlled. Sixteen dislocated lateral malleolar fractures were fixed with one bioabsorbable self-reinforced poly-L-lactide screw. The patients used an ultrasound device 20 minutes daily for six weeks without knowing it was active (eight patients) or inactive (eight patients). The follow-up time was 18 months. The radiological bone morphology was assessed by multidetector computed tomography (MDCT) scans, the bone mineral density by dual-energy X-ray absorptiometry scans, and the clinical outcome by Olerud-Molander scoring and clinical examination of the ankle. RESULTS: The MDCT scans revealed that all fractures were fully healed, and no differences were observed in radiological bone morphology at the fracture site. The bone mineral density of the fractured lateral malleolus tended to increase slightly during the 18-month follow-up, the increase being symmetrical in both groups. No differences were observed in the clinical outcome or Olerud-Molander scores. CONCLUSIONS: The six-week low-intensity ultrasound therapy had no effect on radiological bone morphology, bone mineral density or clinical outcome in bioabsorbable screw-fixed lateral malleolar fractures 18 months after the injury.

Incidence of Recreational Alpine Skiing and Snowboarding Injuries: Six Years Experience in the Largest Ski Resort in Finland.

BACKGROUND AND AIMS: The aim of this study was to provide information on incidences and severity of recreational alpine skiing and snowboarding injuries in Northern Finland and to discuss possible preventive measures to reduce the number and severity of injuries in the future. MATERIALS AND METHODS: This retrospective study consists of all injured skiers and snowboarders in the Levi Ski Resort during the 2006-2012 winter seasons. The Levi Ski Resort has a SKIDATA® system which records automatically every ski-lift run taking place. The emergency system of the resort registers the data (conditions during the injury, patient characteristics, and observed and/or suspected injuries) of all injured persons they meet. The severity of injury is defined by the needed level of care: Grade 1 (treated by the emergency system with no need for further referral), Grade 2 (referral to the local primacy care clinic), Grade 3 (transfer to hospital by ambulance), and Grade 4 (transfer to tertiary care by helicopter). RESULTS: During the 6-year study period, there were 29,576.132 lift runs and 2911 injuries were met by the emergency system, resulting in the average injury incidence of 0.98 injuries per 10,000 lift runs. Vice versa, the average number of the ski-lift rides needed to generate one injury was 10,160. The knee injuries of the skiers constituted almost one-third of all cases, whereas snowboarders sustained more injuries to the upper limb and axial areas. CONCLUSION: Skiing and snowboarding are related to a relatively high risk of injury. The most common injuries affect the knee in skiers and the upper extremity, especially the wrist, in snowboarders. A continuous and systematic review of injuries is needed to monitor the effects of changes made in terms of the safety.

Factors associated with in-hospital outcomes in 594 consecutive patients suffering from severe blunt chest trauma.

BACKGROUND AND AIMS: Blunt thoracic injury is a common cause for hospital admission after trauma. The effect of the number of rib fractures on the outcome is controversial. In this study, our hypothesis was that an increasing number of rib fractures correlates with mortality and hospital resource utilization. In addition to mortality, our focus was on the length of stay at hospital and in the intensive care unit, ventilator days, and the days in continuous positive airway pressure. MATERIAL AND METHODS: The present investigation is a retrospective study from a single trauma center. The study includes patients with severe thoracic injury (thoracic Abbreviated Injury Scale (AIS) > 2) admitted to hospital after blunt trauma. Patients with isolated thoracic spine injuries and patients who were dead on arrival were excluded. Vital signs, laboratory results on admission, given care, intensive care unit and hospital length of stay, injuries, and in-hospital mortality were collected for the study. RESULTS: A total of 594 patients from a 5-year period (2003-2007) were included in the study. The mean age of the patients was 45 years, and 76.9% of the patients were males. The average Injury Severity Score was 22, and the patients had on average 5.5 injuries. Overall mortality was 6.4%. In the multivariate analysis, the mortality was associated with base excess and tromboplastin time in admission. The number of rib fractures did not correlate with the outcome measures, but the presence of bilateral rib fractures correlated with the outcome measures other than mortality. CONCLUSIONS: The number of rib fractures does not correlate with mortality or the length of stay in the intensive care unit in blunt trauma patients with severe thoracic injury. Mortality in these patients correlated with the degree of hypoperfusion (base excess) and coagulation abnormalities (tromboplastin time) on admission.

Trauma registry comparison: six-year results in trauma care in Southern Finland and Germany.

PURPOSE: To compare the treatment and survival of trauma patients in Germany and Southern Finland. METHODS: Data from Helsinki University Hospital trauma registry (TR-THEL) and TraumaRegister DGU(®) (TR-DGU) were compared in a period from 2006 until 2011. From TR-DGU level-one trauma centers treating annually >50 injury severity score (ISS) >15 patients were included. The inclusion criterion was ISS >15. Patients under 16 years with penetrating trauma without head injury and transferred in with isolated head injury were excluded. The compared parameters were age, sex, pre-injury ASA, injury scoring, injury pattern, mechanism of injury, injury distribution, pre-hospital timings, transportation method, pre-hospital intubation, treatment at hospital, discharge destination, and 30-day hospital mortality. Expected mortality was defined with the Revised Injury Severity Classification score (RISC). RESULTS: Eighty-five German level-one trauma centers were included. A total of 15,306 and 1,274 patients were included in the outcome analysis from TR-DGU and TR-THEL, respectively. The difference between the observed and expected mortality of all patients was -4.1% (standardized mortality ratio [SMR] 0.82) at German hospitals and -4.0% (SMR 0.79) in Helsinki. Differences in the pre- and in-hospital treatment between the two countries were noted (transportation method, intubation rate, intensive care unit treatment, ventilation time, length of stay). CONCLUSION: The overall outcome results of the Helsinki University Hospital trauma unit were similar to those of the German level-one trauma centers. Registry comparison is a feasible method of quality control in a trauma centre.

Traumatic deaths at hospital: analysis of preventability and lessons learned.

PURPOSE: The aim of the present study was to characterize traumatic deaths of major trauma patients occurring in a university trauma centre and to assess retrospectively the quality of given care by evaluating whether any of the deaths could be identified as potentially preventable. METHODS: All consecutive deaths of trauma patients between January 1, 2004 and December 31, 2008 in the Töölö Hospital Trauma Centre were retrospectively reviewed. The inclusion criterion was death of a trauma patient occurring during stay at hospital. Patients aged >65 years with an isolated proximal femoral fracture, burn patients, patients with isolated limb fracture other than femoral or tibial shaft fracture, and patients with isolated traumatic brain injuries were excluded as well as patients admitted more than 24 h after injury. RESULT: A total of 130 patients fulfilled the inclusion criteria. The autopsy reports were obtained for 103 of the cases (80.4 %). The majority of the patients were male, and the median age was 58 years (range 1-95 years). Blunt trauma was the most common type of injury. The most common injury mechanisms were fall from a higher level (31 %), fall from the level of the patient (21 %), and motor vehicle accident (17 %). Of the injuries not diagnosed before autopsy, the most common were liver lacerations, rib fractures, pulmonary contusions, sternum fractures, and blunt cardiac injuries. In our study population 12.5 % of the cases were considered potentially preventable. The reasons for preventability were inadequate treatment of coagulopathy, overuse of opioid medication, and loss of airway as well as failing to treat impending pneumonia and DVT. Trauma resuscitation was inadequate in 7.8 % of the cases. CONCLUSIONS: The most common error made was not recognising and treating traumatic coagulopathy adequately.