Factors affecting physicians' decision to start prehospital blood product transfusion in blunt trauma patients: A cohort study of Helsinki Trauma Registry.

BACKGROUND: Prehospital blood transfusions are increasing as a treatment for bleeding trauma patients at risk for exsanguination. Triggers for starting transfusion in the field are less studied. We analyzed the factors affecting the decision of physicians to start prehospital blood product transfusion (PHBT) in blunt adult trauma patients. STUDY DESIGN AND METHODS: Data of all adult blunt trauma patients from the Helsinki Trauma Registry between March 2016 and July 2021 were retrospectively analyzed. Univariate analysis for the identification of predictive factors and multivariate regression analysis for their importance as predictive factors for the initiation of PHBT were applied. RESULTS: There were 1652 patients registered in the database. A total of 556 of them were treated by a physician-level prehospital emergency care unit, of which by transfusion-capable unit in 394 patients. PHBT (red blood cells and/or plasma) was started in 19.8% of the patients. We identified three statistically highly important clinical triggers for starting PHBT: high crystalloid volume need, shock index ≥0.9, and need for prehospital pleural decompression. DISCUSSION: PHBT in blunt adult trauma patients is initiated in ~20% of the patients in Southern Finland. High crystalloid volume need, shock index ≥0.9 and prehospital pleural decompression are associated with the initiation of PHBT, probably reflecting patients at high risk for bleeding.

[Timing of surgical treatment of fractures of multiply iniured patients - from science to tactics]. / Monivammapotilaan murtumien leikkaus- hoidon ajoitus - tieteestä hoitostrategiaan.

Timing of the treatment of orthopaedic injuries in multiply injured patients has undergone changes. The timing of definitive fracture management has varied from several weeks to within hours of injury. In many studies a clear benefit has been identified from early definitive care of long bone fractures: early total care (ETC). The most seriously injured patients benefit from damage control orthopaedics, an approach employing primary external fixator stabilization followed by secondary intramedullary nailing. Debate over these approaches with enhanced understanding of biological response to injury has led to recent emphasis on the need for aggressive patient monitoring and continued multidisciplinary evaluation of the patient's physiological response to treatment.

Gunshot wounds in Finland.

On average 200 gunshot wounds are treated in Finland annually. Half of them are caused by firearm accidents, whereas the great majority of fatal wounds are self-inflicted. Physicians treating trauma patients should be familiar with the basics of ballistics. In practice, however, a distinction between gunshot wounds caused by handguns and those caused by rifles or shotguns is generally sufficient. Generally accepted guidelines for treating trauma patients are followed, and imaging is used for nearly all patients. Removal of bullets is generally not necessary. Most patients require operative treatment, but in certain cases a non-operative approach may be considered. In severe gunshot wounds rapidly administered antibiotics and a sufficiently radical debridement remain the mainstays of treatment.

[Simulation training for better patient safety-learning from team work]. / Simulaatiokoulutus potilasturvallisuuden parantajana--oppia tiimityöstä.

At work, healthcare personnel will encounter various emergency situations and patients who are in poor physical condition and require urgent care. A multidisciplinary team of experts must be able to carry out seamless collaboration, even when working together for the first time. Described in this review is how systematically arranged simulation rehearsals help form a united expert group from a group of individual experts.

Comparison of single bicycle crashes and collisions among severely injured cyclists-A 16-year analysis based on the Helsinki Trauma Registry (HTR).

OBJECTIVE: The Finnish national Traffic Safety Strategy 2022-2026 seeks to halve the number of road fatalities and serious injuries from 2020 to 2030. The strategy states that better information on bicycle crashes is needed for safety promotion. The aim of this study was to describe the demographics, injury characteristics, alcohol involvement, and helmet use of severely injured cyclists and to compare single bicycle crashes (falling alone or hitting a fixed object) to collisions. MATERIAL AND METHODS: We identified all bicycle crashes between 2006 and 2021 from the Helsinki Trauma Registry (HTR). Variables analysed were basic patient demographics, Abbreviated Injury Scale (AIS) codes, AIS 3+ injuries, injured body regions, patient Injury Severity Score (ISS) and New Injury Severity Score (NISS), 30-day in-hospital mortality, ICU length of stay, injury mechanism, alcohol use by the injured cyclists, and helmet use. RESULTS: Of the 325 severe (NISS >15) cycling injury patients in the HTR, 53.5 % were injured in single crashes and 46.5 % in collisions with a moving object. Most (71.4 %) patients were men and mean age of all patients was 54.1 years (SD 16.7). Alcohol was detected in 23.1 % of cases and more often in single crashes (32.8 %) than in collisions (11.9 %). Less than a third (29.2 %) of all cyclists wore a helmet; those who wore a helmet had fewer serious (AIS 3+) head injuries than those who did not. Cyclists injured in collisions had higher ISS and NISS scores than those injured in single crashes. Serious (AIS 3+) injuries in extremities or in pelvic girdle were more common in collisions than in single crashes. CONCLUSIONS: Among severely injured cyclists, single bicycle crashes were more common; alcohol was more often detected in single bicycle crashes than in collisions. Overall injury severity was higher in collisions than in single crashes. Helmet users had less AIS 3+ head injuries than non-users. Attention should be focused on preventing alcohol-related cycling injuries, promoting use of bicycle helmets, and more precise and comprehensive documentation of bicycle crashes in health care units.

16-year outcomes of blunt thoracic aortic injury treated with thoracic endovascular aortic repair: A single-institution experience.

BACKGROUND: Blunt thoracic aortic injury (BTAI) is associated with considerable mortality and morbidity. Thoracic endovascular aortic repair (TEVAR) has essentially replaced open aortic repair (OAR) with superior outcome. The objective of this study was to evaluate the early and intermediate-term outcomes in patients sustaining BTAI treated with TEVAR, and to evaluate the prevalence and impact of left subclavian artery (LSA) coverage. METHODS: This retrospective analysis includes patients undergoing TEVAR for BTAI between February 2006 and December 2022 at the Helsinki University Hospital, Finland. The primary endpoints were 30-day and 2-year mortality, technical success of stent-graft system deployment, and procedural and device-related complications. The secondary endpoints pertained to reintervention events: conversion to OAR, re-TEVAR, any endovascular/surgical reinterventions for optimal stent-graft function, or any reinterventions during follow-up. RESULTS: A total of 38 consecutive BTAI patients treated with TEVAR were included in the analyses. Median patient age was 45.5 years (range, 15-79) and 66% were male. The median follow-up period was 39 months. Technical success was 100%, 30-day mortality was 0%, and 2-year mortality was 11% in the study cohort. Coverage of LSA without revascularization (13/18) resulted in one postoperative nondisabling stroke (1/13), no paraplegia, and one had ischemic left arm findings (1/13). Only one patient required reintervention (LSA embolization; 1/38). CONCLUSION: In this institutional series, we provide further evidence in favor of TEVAR for BTAI treatment. We demonstrated that TEVAR is linked to highly favorable outcomes in the short and intermediate term, and coverage of LSA without revascularization was quite well tolerated.

Severe hepatic trauma: nonoperative management, definitive repair, or damage control surgery?

BACKGROUND: Management of severe liver injuries has evolved to include the options for nonoperative management and damage control surgery. The present study analyzes the criteria for choosing between nonoperative management and early surgery, and definitive repair versus damage control strategy during early surgery. METHODS: In a retrospective analysis of 144 patients with severe (AAST grade III-V) liver injuries (94% blunt trauma), early laparotomy was performed in 50 patients. Initial management was nonoperative in 94 blunt trauma patients with 8 failures. Uni- and multivariate analyses were used to calculate predictor odds ratios (OR) with 95% confidence intervals (CI). RESULTS: Factors associated with early laparotomy in blunt trauma included shock on admission, associated grade IV-V splenic injury, grade IV-V head injury, and grade V liver injury. Only shock was an independent predictor (OR, 26.1; 95% CI, 8.9-77.1; P < 0.001). The presence of a grade IV-V splenic injury predicted damage control strategy (OR infinite; P = 0.021). Failed nonoperative management was associated with grade IV-V splenic injury (OR, 14.00; 95% CI, 1.67-117.55), and shock (OR, 6.82; 95% CI, 1.49-31.29). The hospital mortality rate was 15%; 8 of 21 deaths were liver-related. Shock (OR, 9.3; 95% CI, 2.4-35.8; P = 0.001) and severe head injury (OR, 9.25; 95% CI, 3.0-28.9; P = 0.000) were independent predictors for mortality. CONCLUSIONS: In patients with severe liver injury, associated severe splenic injury favors early laparotomy and damage control strategy. Patients who arrive in shock or have an associated severe splenic injury should not be managed nonoperatively. In addition to severe head injury, uncontrollable bleeding from the liver injury is still a major cause of early death.

Surgical strategy for femoral shaft fractures in severely injured patients: A 13-year experience from a tertiary trauma centre.

BACKGROUND: The treatment strategy of femoral shaft fractures in polytraumatised patients has evolved over the years and led to improved outcomes for these patients. However, there is still controversy regarding the optimal treatment strategy and surgical care can differ markedly from one country to another. We investigate the surgical treatment strategy (Early Definitive Care (EDC) or Damage Control Orthopaedics (DCO)) implemented in the care of severely injured patients with femoral shaft fractures treated at a single tertiary trauma centre in southern Finland and factors affecting decision making. METHODS: The Helsinki Trauma Registry (HTR) was used retrospectively to identify severely injured patients (New Injury Severity Score [NISS] ≥ 16) treated from 2006 through to 2018 with concomitant femoral shaft fractures. Patients <16 years old, with isolated head injuries, dead on arrival and those admitted >24 h following the injury were excluded. Based on their initial surgical management strategy, femoral fracture patients were divided into EDC and DCO groups and compared. RESULTS: Compared to other trauma-registry patients, those with femoral shaft fractures are younger (30.9 ± 15.9 vs. 47.0 ± 19.7, p<0.001) and more often injured in road traffic accidents (64.1% vs. 34.4%, p<0.001). The majority (78%) of included patients underwent EDC. Patients who underwent DCO were significantly more severely injured (NISS: 40.1 ± 11.5 vs. 27.8 ± 10.1, p<0.001) with longer lengths of stay in ICU (15.4 ± 9.8 vs. 7.5 ± 6.1 days, p<0.001) and in hospital (29.9 ± 29.6 vs. 13.7 ± 11.4 days, p<0.001) than patients treated with EDC. Decision making was based primarily on injury related factors, while non-injury related factors may have contributed to choosing a DCO approach in a small number of cases. CONCLUSION: Early definitive care is the prevailing treatment strategy in severely injured femoral shaft fracture patients treated at a tertiary trauma centre. Patients treated with DCO strategy are more severely injured particularly having sustained worse intracranial and thoracic injuries. In addition to injury related factors, treatment strategy decision making was influenced by non-injury related factors in only a minority of cases.

Evolution of high-energy pelvic trauma in southern Finland: a 12-year experience from a tertiary trauma centre.

PURPOSE: We compared incidence, demographics, and injury mechanisms in severely injured patients with and without a pelvic ring fracture treated at a tertiary trauma centre. We also analyzed the changes in injury mechanisms that lead to high-energy pelvic trauma. METHODS: Data on severely injured adult patients (New Injury Severity Score [NISS] ≥16) from Helsinki Trauma Registry over the years 2006-2017 were reviewed. Patients with a pelvic ring fracture (PRF) and those without (N-PRF) were analyzed. Further subgrouping regarding time of the accident (2006-2009, 2010-2013, 2014-2017) was made. A comparison between groups was performed according to age, age > 60, gender, American Society of Anesthesiologists classification, injury scoring and mechanism, and 30-day in-hospital mortality. RESULTS: We included 545 PRF and 1048 N-PRF patients. Pelvic ring fracture patients were more likely to be female (39% vs 22%, p < 0.001), to be more severely injured (NISS 35.2 vs 30.4, p < 0.001), injured due to a high fall (41% vs 25%, p < 0.001), to have self-inflicted injuries (23% vs 8%, p < 0.001), and to have higher 30-day in-hospital mortality (13% vs 9%, p = 0.005). During the study period, we noted increasing mean age and proportion of patients aged > 60, improvement in outcome (shown by decreasing 30-day in-hospital mortality rate) in both groups, and a decrease in motor vehicle accidents (MVAs) leading to pelvic trauma (30-16%). CONCLUSIONS: High-energy pelvic trauma can no longer be characterized as traffic accident injuries among young men. MVAs leading to pelvic trauma are decreasing and the most common injury mechanism is high fall. The patients are older and often female. Every fourth high-energy pelvic trauma was due to attempted suicide.

Severe head injury in elderly: 6-year comparison of treatment and outcome between southern Finland and Navarra (Spain).

PURPOSE: To compare the profile, treatment and outcome of elderly patients with severe traumatic brain injuries (TBI) between southern Finland and Navarra (Spain). METHODS: Data collected from, 2010 to 2015, in the Major Trauma Registry of Navarra (MTR-N) and the Helsinki Trauma Registry (HTR) were compared. Patients with New Injury Severity Score (NISS) ≥ 16 and age ≥ 65 with isolated severe TBI were considered. Patients who had been admitted to the hospital ≥ 24 h after the trauma, had been pronounced dead before hospital arrival, or had been injured by hanging, drowning or burns, were excluded. Outcome was defined by 30-day hospital mortality. The expected mortality was calculated using the Revised Injury Severity Classification score II (RISC II). Other compared data included demographics, injury mechanism, pre-hospital and hospital treatment, and time intervals. RESULTS: A total of 305 (MTR-N) and 137 (HTR) patients were included in the outcome analysis. The standardized mortality ratio with 95% confidence interval was for MTR-N 1.4 (1.1-1.6) and for HTR 0.8 (0.6-1.1). Patients in Navarra were older (average 79.7 vs. 75.0) while in southern Finland the percentage of pre-hospital intubation in patients with GCS ≤ 8 (75.0% vs 50.0%) and ICU admission (72.2% vs 22.0%) were higher. CONCLUSION: The better adjusted outcome of elderly patients with severe TBI in southern Finland in comparison to Navarra could be due to higher rate of pre-hospital intubation and/or higher rate of ICU admissions in southern Finland. Increasing number of elderly patients with severe TBI necessitate uniformly accepted protocols in pre- and in-hospital management.

Victims of Severe Intimate Partner Violence Are Left Without Advocacy Intervention in Primary Care Emergency Rooms: A Prospective Observational Study.

Intimate partner violence (IPV) is a common cause of musculoskeletal injury. Although serious injuries are relatively rare, IPV is one of the leading causes of homicide. IPV victims seeking help in health care are known to be at specific risk of re-abuse. Previous studies of IPV victims in emergency room (ER) settings have focused on injury patterns, but little is known about the violence behind bruises and fractures. The aim of this study was to examine how violence severity and known risk factors for lethal re-abuse in IPV victims attending ERs are associated with injury severity, different patient groups, and referral to advocacy services. This was a prospective, observational, multicenter study of 146 self-reporting IPV victims in two Level IV trauma centers in Helsinki from October 2012 to November 2013. In our sample, serious injuries were rare, but patients had typically suffered severe violence, and half had at least one risk factor for lethal re-abuse. Both sexes and all age groups were represented among the patient profiles, and 88% attended ERs outside common working hours. Only 19% were referred to advocacy, and severe violence or risk factors for lethal re-abuse did not affect prevalence of referrals. Our results show that IPV victims in primary care ERs have typically either experienced severe violence or are at serious risk of re-abuse and even death. The resulting injuries do not usually require medical aftercare, and victims typically present outside common working hours. In the absence of a clear follow-up protocol, most IPV victims are left without any advocacy intervention.

Severe traffic injuries in the Helsinki Trauma Registry between 2009-2018.

OBJECTIVE: The European Union (EU) has adopted the Vision Zero and Safe System approach to eliminate deaths and serious traffic injuries on European roads by 2050. Detailed information on serious injuries, injury mechanisms and consequences are needed. The aim of this study was to describe and compare by injury mechanism the demographics, injuries, injury severity, and treatment of seriously injured road traffic trauma patients. MATERIAL AND METHODS: We analysed data on severe traffic injury trauma patients aged ≥16 years of the Helsinki Trauma Registry (HTR) covering the years 2009-2018. The variables analysed were basic patient demographics, injury mechanism, Abbreviated Injury Scale (AIS) codes, injured body regions, patient Injury Severity Score (ISS) and New Injury Severity Score (NISS) values, NISS groups (NISS 16-24 and NISS ≥25), AIS 3+ injuries, trauma bay and 30-day mortality, length of stay (LOS) at ICU and in hospital, surgeries performed, pre-injury classification, and intention of injury. RESULTS: A total of 1 063 traffic injury patients were analysed; 38.6% were motor vehicle occupants, 28.5% motorcyclists or moped drivers, 17.2% bicyclists, and 15.7% pedestrians. The mean age of patients was 44.3 years (SD 20.2). Median ISS score was 22 and median NISS score was 27. Both scores were highest in pedestrians. Among all patients, total hospital LOS was 12 517 days (median 9) and total ICU LOS was 6 311 days (median 5). The most common AIS 3+ injuries according to ISS body regions were chest injuries (60%) and head or neck injuries (43.7%). Chest injuries occurred more frequently in motorcyclists and motor vehicle occupants, whereas head or neck injuries were most common among bicyclists and pedestrians. CONCLUSIONS: Severely injured pedestrians and bicyclists were older and they had higher mortality than motorcyclists and motor vehicle occupants. According to NISS, the overall severity was highest among pedestrians followed by bicyclists. However, the both median ICU LOS and hospital LOS were highest for pedestrians but lowest for bicyclists. The most common AIS 3+ injuries were chest and head or neck injuries. To specify effective injury prevention measures, hospital data should be complemented with information on the circumstances of the accident.

Severe blunt trauma in Finland and Estonia: comparison of two regional trauma repositories.

PURPOSE: Evolving trauma system of Estonia has undergone several reforms; however, performance and outcome indicators have not been benchmarked previously. Thus, we initiated a baseline study to compare demographics, management and outcomes of severely injured patients between Southern Finland and Northern Estonia utilizing regional trauma repositories. METHODS: A comparison of data fields of the Helsinki University Hospital trauma registry (HTR) and trauma registry at the North Estonia Medical Centre in Tallinn (TTR) between 1/1/2015 and 31/12/2016 was performed. The inclusion criterion was Injury Severity Score > 15. Transferred patients, patients with penetrating injuries, and pediatric patients were excluded. The data for comparison included demographics, Trauma Score-Injury Severity Score (TRISS), mortality, and standardized mortality ratio (SMR). Primary outcome was mortality and SMR per TRISS methodology. RESULTS: During the 2-year study period, 324 patients from the HTR and 152 from the TTR were included. Demographic profile was similar between the repositories with the exception of severe abdominal injuries being more prevalent at the TTR (25.0% vs. 13.3%, p = 0.002). Predominant injury mechanism was non-ground level fall in both repositories. Mortality was similar at 14.5% and 13.6% at the TTR and HTR, respectively (adj. p = 0.762; OR 1.13, 95% CI 0.64-1.99). SMR was lower at the HTR compared to the TTR (0.65 vs. 0.77, p > 0.05), however, the difference did not reach statistical significance. CONCLUSION: Benchmarking trauma repositories at a national level provides opportunities for quality and performance improvements. We observed comparable demographic profile and outcome indicators in the compared regional trauma systems.

Major blunt trauma causes increased mortality up to 12 years: Long-term survival in 3 557 patients compared to 35 502 control persons.

BACKGROUND: Trauma registries usually report 30-day or in-hospital mortality as an outcome measure. However, some studies criticize this measure as inadequate; the impact of a major trauma could last longer than 1 month after the injury. We studied the long-term mortality of patients who sustained a major trauma. METHODS: The Helsinki University Hospital's trauma registry was used for patient identification from 2006 to 2015 (New Injury Severity Score ≥ 16 and blunt mechanism of injury). For each trauma registry patient, 10 control persons matched by age, sex, and county of residency were obtained from the Population Register Center of Finland. Cause of death information was obtained from Statistics Finland. RESULTS: We included 3 557 trauma registry patients and 35 502 control persons. Follow-up ranged from 1 year 7 months to 11 years 7 months. The 1-year mortality was 11 times higher in the trauma-patient group (22% vs. 2%). The long-term (approximately 12 years) mortality after the injury was 2.6 times higher in the trauma-patient group (46% vs. 18%). For patients surviving at least 1 year post-trauma, the mortality at 12 years was 2.2 times higher than in the control group (31% vs. 14 %). The cause of death was a disease in 73.3% of the trauma patients and 93.6% of the controls. Accidents were more often a cause of death in the patient population than in the control population (21.2% vs. 4.1%). Suicide was the cause of death in 3.0% of patients and 1.1% in controls. Several factors associated with increased mortality were identified. CONCLUSIONS: Major trauma patients had significantly higher long-term mortality compared to controls. To the best of our knowledge, this is the first study on this subject with a follow up of this duration with patients this severely injured and a cohort this large.

Feasibility and Clinical Outcome of Reboa in Patients with Impending Traumatic Cardiac Arrest.

BACKGROUND: Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) may improve Systolic Blood Pressure (SBP) in hypovolemic shock. It has, however, not been studied in patients with impending traumatic cardiac arrest (ITCA). We aimed to study the feasibility and clinical outcome of REBOA in patients with ITCA using data from the ABOTrauma Registry. METHODS: Retrospective and prospective data on the use of REBOA from 16 centers globally were collected. SBP was measured both at pre- and post-REBOA inflation. Data collected included patients' demography, vascular access technique, number of attempts, catheter size, operator, zone and duration of occlusion, and clinical outcome. RESULTS: There were 74 patients in this high-risk patient group. REBOA was performed on all patients. A 7-10Fr catheter was used in 66.7% and 58.5% were placed on the first attempt, 52.1% through blind insertion and 93.2% inflated in Zone I, 64.8% for a period of 30 to 60 min, 82.1% by ER doctors, trauma surgeons, or vascular surgeons. SBP significantly improved to 90 mm Hg following the inflation of REBOA. 36.6% of the patients survived. CONCLUSIONS: Our study has shown that REBOA may be performed in patients with ITCA, SBP can be elevated, and 36.6% of the patients survived if REBOA placement is successful.

Aortic balloon occlusion (REBOA) in pelvic ring injuries: preliminary results of the ABO Trauma Registry.

EndoVascular and Hybrid Trauma Management (EVTM) has been recently introduced in the treatment of severe pelvic ring injuries. This multimodal method of hemorrhage management counts on several strategies such as the REBOA (resuscitative endovascular balloon occlusion of the aorta). Few data exist on the use of REBOA in patients with a severely injured pelvic ring. The ABO (aortic balloon occlusion) Trauma Registry is designed to capture data for all trauma patients in hemorrhagic shock where management includes REBOA placement. Among all patients included in the ABO registry, 72 patients presented with severe pelvic injuries and were the population under exam. 66.7% were male. Mean and median ISS were respectively 43 and 41 (SD ± 13). Isolated pelvic injuries were observed in 12 patients (16.7%). Blunt trauma occurred in 68 patients (94.4%), penetrating in 2 (2.8%) and combined in 2 (2.8%). Type of injury: fall from height in 15 patients (23.1%), traffic accident in 49 patients (75.4%), and unspecified impact in 1 patient (1.5%). Femoral access was gained pre-hospital in 1 patient, in emergency room in 43, in operating room in 12 and in angio-suite in 16. REBOA was positioned in zone 1 in 59 patients (81,9%), in zone 2 in 1 (1,4%) and in zone 3 in 12 (16,7%). Aortic occlusion was partial/periodical in 35 patients (48,6%) and total occlusion in 37 patients (51,4%). REBOA associated morbidity rate: 11.1%. Overall mortality rate was 54.2% and early mortality rate (≤ 24 h) was 44.4%. In the univariate analysis, factors related to early mortality (≤ 24 h) are lower pH values (p = 0.03), higher base deficit (p = 0.021), longer INR (p = 0.012), minor increase in systolic blood pressure after the REBOA inflation (p = 0.03) and total aortic occlusion (p = 0.008). None of these values resulted significant in the multivariate analysis. In severe hemodynamically unstable pelvic trauma management, REBOA is a viable option when utilized in experienced centers as a bridge to other treatments; its use might be, however, accompanied with severe-to-lethal complications.

Does arrival time affect outcomes among severely injured blunt trauma patients at a tertiary trauma centre?

BACKGROUND AND AIMS: We aimed to determine whether the outcome of severely injured patients differs based on admission time (office hours vs. non-office hours) at a tertiary trauma centre without an in-house trauma surgeon consultant available at all times. We also studied subgroups of patients presenting with a New Injury Severity Score (NISS) ≥ 25 and patients experiencing major bleeding. PATIENTS AND METHODS: This trauma registry study consisted of severely injured patients (NISS > 15) with blunt trauma treated between 2006 and 2017 at a single institute. Causes of deaths were obtained from autopsy reports and classified as resulting from brain injury; exsanguination; multi-organ failure, adult respiratory distress syndrome, or sepsis; or other. RESULTS: Among 1853 patients, 497 (27%) were admitted during office hours (OH) and 1356 (73%) during non-office hours (NOH). Further subgroup analysis consisted of 211 OH and 611 NOH patients with NISS ≥ 25, and 51 OH and 154 NOH patients experiencing major bleeding. The 30-day in-hospital mortality was 3.8%-7.4% lower in the NOH groups. We found no significant differences between the study groups in neither the standardised mortality ratio (SMR, defined as the ratio of observed to expected mortality) nor in the causes of death. In both groups, the primary cause of death resulted from brain injury. CONCLUSIONS: We found that arrival time did not affect mortality among patients with severe blunt trauma treated at a tertiary trauma centre without an in-house trauma surgeon consultant available at all times. Thus, this type of unit can maintain a standard of care during non-office hours by investing in precise treatment protocols and continuous education. However, our results do not apply to penetrating trauma injury patients.

The reliability of the ICD-AIS map in identifying serious road traffic injuries from the Helsinki Trauma Registry.

OBJECTIVE: The EU has recommended that its member countries compile statistics on the number of serious road traffic injuries. In Finland, the number of seriously injured road traffic patients is assessed using the International Classification of Diseases, 10th Revision (ICD-10) and the automatic conversion tool (ICD-AIS map) developed by The Association for the Advancement of Automotive Medicine (AAAM). The aim of this study was to assess how reliably the ICD-AIS map identifies both serious injuries and seriously injured patients due to road traffic accidents. METHODS: Data was derived from the Helsinki Trauma Registry (HTR) and included 215 severe (New Injury Severity Score >15) trauma patients injured in road traffic accidents from the years 2016 and 2017. The severity ratings of injuries (Abbreviated Injury Scale, AIS 3+) and patients (Maximum Abbreviated Injury Scale, MAIS 3+) were determined by direct AIS coding of the HTR and were also generated by the ICD-AIS map based on ICD-10 injury codes. These two ratings were compared by injury mechanism and Injury Severity Score (ISS) body regions. The strength of agreement was described using Cohen's κ. The most common injury codes with errors in severity rating by the ICD-AIS map were presented. RESULTS: The number of seriously injured patients by the ICD-AIS map was 21% lower, and the number of serious injuries was 36% lower than the corresponding numbers by direct coding. The exact agreement of the injury ratings was 72% (κ = 0.44, 95% CI 0.42-0.46). Most of the conversion errors were due to the simplicity of the ICD-10 codes used in Finland compared to those used in the ICD-AIS map (ICD-10-CM) and the missing codes from the ICD-AIS map. The most frequent misclassifications were due to multiple rib fractures, visceral organ injuries, some open fractures of extremities, and specific head injuries. Missing codes were most common in face, chest, and limb injuries. CONCLUSIONS: The ICD-10 injury codes presently used in Finland should be more specific to permit reliable conversion results by the ICD-AIS map. The problem with missing codes should be considered more closely. When implementing the ICD-11, all detailed injury codes should be introduced.

Resource use and clinical outcomes in blunt thoracic injury: a 10-year trauma registry comparison between southern Finland and Germany.

PURPOSE: Serious thoracic injuries are associated with high mortality, morbidity, and costs. We compared patient populations, treatment, and survival of serious thoracic injuries in southern Finland and Germany. METHODS: Mortality, patient characteristics and treatment modalities were compared over time (2006-2015) in all patients with Abbreviated Injury Scale (AIS) thorax ≥ 3, Injury Severity Score (ISS) > 15, age > 15 years, blunt trauma mechanism, and treatment in Intensive Care Unit (ICU) in Level 1 hospitals included in the Helsinki Trauma Registry (HTR) and the TraumaRegister DGU® (TR-DGU). RESULTS: We included 934 patients from HTR and 25 448 patients from TR-DGU. Pre-hospital differences were seen between HTR and TR-DGU; transportation in the presence of a physician in 61% vs. 97%, helicopter use in 2% vs. 42%, intubation in 31% vs. 55%, and thoracostomy in 6% vs. 10% of cases, respectively. The mean hospital length of stay (LOS) and ICU LOS was shorter in HTR vs. TR-DGU (13 vs. 25 days and 9 vs. 12 days, respectively). Our main outcome measure, standardised mortality ratio, was not statistically significantly different [1.01, 95% confidence interval (CI) 0.84-1.18; HTR and 0.97, 95% CI 0.94-1.00; TR-DGU]. CONCLUSIONS: Major differences were seen in pre-hospital resources and use of pre-hospital intubation and thoracostomy. In Germany, pre-hospital intubation, tube thoracostomy, and on-scene physicians were more prevalent, while patients stayed longer in ICU and in hospital compared to Finland. Despite these differences in resources and treatment modalities, the standardised mortality of these patients was not statistically different.

Recommendation of use of checklists in tibial intramedullary nail removal: Retrospective study of mechanical complications related to nail removal.

BACKGROUND: The removal of implants such as intramedullary nails is one of the most common operations in orthopedic surgery. The indications for orthopedic implants removal will always remain a subject of conversation and hardly supported by literature. The aim of this study to report injuries of treatment in tibial nail removal and to determine if there are fracture characteristics, patient demographics, or surgical details that may predict a complication. METHODS: This is a retrospective seven-year (2010-2016) study including a total of 389 tibial intramedullary nail removals at the Helsinki University Hospital's orthopedic unit. Patients with tibial fracture and removal of intramedullary nail were identified from the hospital discharge register and analyzed. RESULTS: A total of 21 (5,4%) nail removal related mechanical complications (iatrogenic fractures, nerve injuries, failures to remove the nail) were noted. The most common complication was iatrogenic fracture (n = 15, 3,8%). In 6/15 cases the fracture was caused by broken interlocking screws, In 5/15 cases the iatrogenic fracture was caused accidentally by extracting the nail without prior removal of all distal interlocking screws. In one case, new condensed bone had formed around the nail's distal end and case the forced nail extraction caused a re-fracture in both tibia and fibula. CONCLUSION: Nail removal can be a challenging operation which does not always receive the necessary preoperative planning or operative expertise. Iatrogenic fractures were most often caused by inadequate preoperative planning or assuming that a broken interlocking screw tilts during the extraction. We suggest the use of checklists in preoperative planning to avoid fractures caused by broken or undetected interlocking screws.