The association between head injury and facial fracture treatment: an observational study of hospitalized bicyclists from a level 1 trauma centre.

PURPOSE: To compare the types of facial fractures and their treatment in bicyclists admitted to a level 1 trauma centre with major and minor-moderate head injury. METHODS: Retrospective analysis of data from bicycle-related injuries in the period 2005-2016 extracted from the Oslo University Hospital trauma registry. RESULTS: A total of 967 bicyclists with head injuries classified according to the Abbreviated Injury Scale (AIS) were included. The group suffering minor-moderate head injury (AIS Head 1-2) included 518 bicyclists, while 449 bicyclists had major head injury (AIS Head 3-6). The mean patient age was 40.2 years (range 3-91 years) and 701 patients (72%) were men. A total of 521 facial fractures were registered in 262 patients (on average 2 facial fractures per bicyclist). Bicyclists with major head injury exhibited increased odds for facial fractures compared to bicyclists with minor-moderate head injury (sex and age adjusted odds ratio (OR) 2.75, 95% confidence interval (CI) 2.03-3.72, p < 0.001. More specifically, there was increased odds for all midface fractures, but no difference for mandible fractures. There was also increased odds for orbital reconstruction in cyclist with major head injury compared to bicyclist with minor-moderate head injury (adjusted OR 3.34, 95% CI 1.30-8.60, p = 0.012). CONCLUSION: Bicyclists with more severe head injuries had increased odds for midface fractures and surgical correction of orbital fractures. During trauma triage, the head and the face should be considered as one unit.

Facial Fractures and Their Relation to Head and Cervical Spine Injuries in Hospitalized Bicyclists.

Bicyclists are vulnerable road users. The authors aimed to characterise facial fractures and their association with head and neck injuries in bicyclists admitted to a Scandinavian Level 1 trauma center with a catchment area of ~3 million inhabitants. Data from bicycle-related injuries in the period 2005 to 2016 were extracted from the Oslo University Hospital trauma registry. Variables included were age; sex; date of injury; abbreviated injury scale (AIS) codes for facial skeletal, head and neck injuries; and surgical procedure codes for treatment of facial fractures. Anatomical injury was classified according to AIS98. A total of 1543 patients with bicycle-related injuries were included. The median age was 40 years (quartiles 53, 25), and 1126 (73%) were men. Overall, 652 fractures were registered in 339 patients. Facial fractures were observed in all age groups; however, the proportion rose with increasing age. Bicyclists who suffered from facial fractures more often had a concomitant head injury (AIS head >1) than bicyclists without facial fractures (74% vs. 47%), and the odds ratio for facial fracture(s) in the orbit, maxilla and zygoma were significantly increased in patients with AIS head >1 compared to patients with AIS head=1. In addition, 17% of patients with facial fractures had a concomitant cervical spine injury versus 12% of patients without facial fractures. This results showed that facial fractures were common among injured bicyclists and associated with both head and cervical spine injury. Thus, a neurological evaluation of these patients are mandatory, and a multidisciplinary team including maxillofacial and neurosurgical competence is required to care for these patients.

Anatomical distribution of mandibular fractures from severe bicycling accidents: A 12-year experience from a Norwegian level 1 trauma center.

BACKGROUND/AIM: The mandible makes up a substantial part of the lower face, and is susceptible to injury. Even in helmeted cyclists, accidents may lead to fractures of the mandible because conventional helmets provide little protection to the lower part of the face. In addition, some studies indicate that helmets may lead to an increased risk of mandibular fractures. Thus, the aim of this study was to examine the anatomic distribution of mandibular fractures in injured cyclists and to assess if helmet use influenced the fracture locations. MATERIAL AND METHODS: Data from a Norwegian Level 1 trauma center were collected in the Oslo University Hospital Trauma Registry over a 12-year period. Of 1543 injured cyclists, the electronic patient charts of 62 cyclists with fractures of the mandible were retrospectively evaluated in detail. Demographic data, helmet use, and fracture type were assessed. RESULTS: Sixty-two patients (4%) had fractures of the mandible, and women had an increased risk (OR 2.49, 95% CI 1.49-4.16, p < .001). The most common fracture site was the mandibular body, followed by the condyle. Isolated mandibular fractures occurred in 45% of the patients and 55% had other concomitant facial fractures. There were 42% of the patients with fractures in multiple sites of the mandible, and 42% had a concomitant dentoalveolar injury. Half of the cyclists were wearing a helmet at the time of the accident and 39% were not. There was no significant difference in fracture distribution between the helmeted and non-helmeted groups. CONCLUSIONS: Fracture of the mandibular body was the most prevalent mandibular fracture type following bicycle accidents. Women had an increased risk of mandibular fractures compared with men, whereas helmet wearing did not affect the anatomical fracture site.

Dentoalveolar injuries, bicycling accidents and helmet use in patients referred to a Norwegian Trauma Centre: A 12-year prospective study.

BACKGROUND/AIM: Despite its many benefits, bicycling carries the risk of accidents. Although numerous studies have reported the effect of helmet use on traumatic brain injury, it remains unclear if, and to what extent, helmet use reduces the risk of facial injuries. This is particularly true in regard to injuries of the lower face. In addition, there is limited evidence of the effect of helmet use on dentoalveolar injuries. Thus, the aim of this study was to determine the frequency and distribution of dentoalveolar injuries in bicycling accidents and to explore the influence of helmet use. MATERIAL AND METHODS: A total of 1543 bicyclists were included from the trauma registry of a Norwegian tertiary trauma center over a 12-year period. Data were collected prospectively, including patient characteristics, type of injury, and helmet use. The prevalence of dentoalveolar injuries was assessed in conjunction with helmet use and facial fractures. RESULTS: Twenty-five percent of the patients had maxillofacial injuries, and 18% of those with facial fractures exhibited concomitant dentoalveolar injuries. The most common type of dentoalveolar injury was tooth fracture (39%). The most frequent location of facial fractures with combined dentoalveolar injuries was the maxilla, which had fractured in 32 patients. Women had a higher risk of sustaining dentoalveolar injuries compared to men (odds ratio 1.50, 95% confidence interval 1.02-2.22). There were 1257 patients (81%) who had reliable registration of helmet use; 54% of these wore a helmet, while 46% did not. Helmet users had an increased risk of dentoalveolar injuries compared to non-helmeted bicyclists (adjusted odds ratio 1.54, 95% confidence interval 1.02-2.31). CONCLUSIONS: Dentoalveolar injuries are fairly common in trauma patients admitted to a trauma center following bicycling accidents. Bicycling helmets are associated with an increased risk of dentoalveolar injuries.

The impact of blood ethanol concentration on the classification of head injury severity in traumatic brain injury.

BACKGROUND: Traumatic brain injury (TBI) is classified into mild, moderate and severe, based on the Glasgow Coma Score (GCS). However, TBI patients are often influenced by ethanol, which in itself can attenuate the level of consciousness. This study investigated the effect of ethanol on the GCS group classification in TBI patients. METHODS: The Oslo University Hospital trauma database was searched for all patients admitted with a head injury where the blood ethanol concentration (BEC) had been measured (n = 1004). The effect of BEC on GCS groups was analysed using multivariate ordinal logistic regression. RESULTS: This study identified 546, 142 and 316 patients in the mild, moderate and severe groups, respectively. Increasing BEC by 1 g kg(-1) and pre-hospital intubation had OR = 1.34 and 16.34 for being in a more severe GCS group, respectively. Increasing head abbreviated injury scale (head-AIS) was significantly associated with being in a more severe GCS group. The modelled probability of detecting a head-AIS of 4 or 5 in a patient with BEC of 2.0 g kg(-1) was 20%, 38% and 65% in the mild, moderate and severe groups, respectively. CONCLUSIONS: Increasing BEC was associated with increasing odds of being in a more severe GCS group. However, because the modelled probability of significant brain injury was high in patients with high levels of BEC, a reduced level of consciousness in intoxicated patients mandates further radiological investigations.

Close to zero preventable in-hospital deaths in pediatric trauma patients - An observational study from a major Scandinavian trauma center.

BACKGROUND: In line with international trends, initial treatment of trauma patients has changed substantially over the last two decades. Although trauma is the leading cause of death and disability in children globally, in-hospital pediatric trauma related mortality is expected to be low in a mature trauma system. To evaluate the performance of a major Scandinavian trauma center we assessed treatment strategies and outcomes in all pediatric trauma patients over a 16-year period. METHODS: A retrospective cohort study of all trauma patients under the age of 18 years admitted to a single institution from 1st of January 2003 to 31st of December 2018. Outcomes for two time periods were compared, 2003-2009 (Period 1; P1) and 2010-2018 (Period 2; P2). Deaths were further analyzed for preventability by the institutional trauma Mortality and Morbidity panel. RESULTS: The study cohort consisted of 3939 patients. A total of 57 patients died resulting in a crude mortality of 1.4%, nearly one quarter of the study cohort (22.6%) was severely injured (Injury Severity Score > 15) and mortality in this group decreased from 9.7% in P1 to 4.1% in P2 (p<0.001). The main cause of death was brain injury in both periods, and 55 of 57 deaths were deemed non-preventable. The rate of emergency surgical procedures performed in the emergency department (ED) decreased during the study period. None of the 11 ED thoracotomies in non-survivors were performed after 2013. CONCLUSION: A dedicated multidisciplinary trauma service with ongoing quality improvement efforts secured a low in-hospital mortality among severely injured children and a decrease in futile care. Deaths were shown to be almost exclusively non-preventable, pointing to the necessity of prioritizing prevention strategies to further decrease pediatric trauma related mortality.

Achieving balanced transfusion early in critically bleeding trauma patients: an observational study exploring the effect of attending trauma surgical presence during resuscitation.

Background: After 15 years of damage control resuscitation (DCR), studies still report high mortality rates for critically bleeding trauma patients. Adherence to massive hemorrhage protocols (MHPs) based on a 1:1:1 ratio of plasma, platelets, and red blood cells (RBCs) as part of DCR has been shown to improve outcomes. We wanted to assess MHP use in the early (6 hours from admission), critical phase of DCR and its impact on mortality. We hypothesized that the presence of an attending trauma surgeon during all MHP activations from 2013 would contribute to improving institutional resuscitation strategies and patient outcomes. Methods: We conducted a retrospective analysis of all trauma patients receiving ≥10 RBCs within 6 hours of admission and included in the institutional trauma registry between 2009 and 2019. The cohort was divided in period 1 (P1): January 2009-August 2013, and period 2 (P2): September 2013-December 2019 for comparison of outcomes. Results: A total of 141 patients were included, 81 in P1 and 60 in P2. Baseline characteristics were similar between the groups for Injury Severity Score, lactate, Glasgow Coma Scale, and base deficit. Patients in P2 received more plasma (16 units vs. 12 units; p<0.01), resulting in a more balanced plasma:RBC ratio (1.00 vs. 0.74; p<0.01), and platelets:RBC ratio (1.11 vs. 0.92; p<0.01). All-cause mortality rates decreased from P1 to P2, at 6 hours (22% to 8%; p=0.03), at 24 hours (36% vs 13%; p<0.01), and at 30 days (48% vs 30%, p=0.03), respectively. A stepwise logistic regression model predicted an OR of 0.27 (95% CI 0.08 to 0.93) for dying when admitted in P2. Conclusions: Achieving balanced transfusion rates at 6 hours, facilitated by the presence of an attending trauma surgeon at all MHP activations, coincided with a reduction in all-cause mortality and hemorrhage-related deaths in massively transfused trauma patients at 6 hours, 24 hours, and 30 days. Level of evidence: IV.

Pediatric renal trauma: 17 years of experience at a major Scandinavian trauma center.

Background: Children are at increased risk of renal injuries from blunt trauma due to their anatomic constitution. The kidney is injured in 5-20% of pediatric patients with blunt abdominal trauma. During the last decades, the management of pediatric renal injuries has evolved toward non-operative management (NOM) unless the patient is hemodynamically compromised. The aim of the present study was to assess contemporary treatment strategies and evaluate outcomes in pediatric patients with renal injuries admitted to a major Scandinavian trauma center. Methods: A retrospective cohort study of all trauma patients under 18 years admitted to our institution from January 1, 2003 to December 31, 2019 with main focus on patients with renal injury. Outcomes for two time periods were compared, 2003-2009 (Period 1; P1) and 2010-2019 (Period 2; P2), and the study cohort was also stratified into age groups, survivors and non-survivors and severity of renal injury. Results: In total, there were 4230 pediatric patients included in Oslo University Hospital Trauma Registry during this 17-year period and of these 115 (2.7%) had a renal injury. Nephrectomy was performed in four (3.5%) of the patients, angiographic embolization five (4.3%) and ureteral stent placement was performed in six patients (5.2%) due to urinary extravasation. Seven patients died, implying a crude mortality of 6.1%, with one exception secondary to traffic-related incidents. None of the deaths were attributed to renal injury and mortality fell to 1.2% in P2. Discussion: This study on contemporary pediatric renal trauma care is one of the largest from a single institution outside the USA. Our results clearly show that NOM, including minimally invasive procedures in selected cases, is achievable in more than 90% of cases with low mortality and morbidity. Level of evidence: Level IV.

Long-lasting performance improvement after formalization of a dedicated trauma service.

BACKGROUND: Few studies have evaluated intrainstitutional improvement of trauma care. We hypothesized that the formalization of a dedicated multidisciplinary trauma service in a major Scandinavian trauma center in 2005 would result in improved outcome. METHODS: Institutional trauma registry data for 7,243 consecutive patients from the years 2002-2008 were retrospectively evaluated using variable life-adjusted display (VLAD) as one of several performance indicators. VLAD is a refinement of the cumulative sum method that adjusts death and survival by each patient's risk status (probability of survival) and provides a graphical display of performance over time. Probability of survival was calculated according to Trauma and Injury Severity Score (TRISS) methodology with National Trauma Data Bank 2005 coefficients. RESULTS: VLAD demonstrated a sharp increase in cumulative survival starting at the beginning of 2005 and continuing linearly throughout the study period, amounting to 68 additional saved lives. The increase was mainly caused by improved survival among the critically injured (injury severity score 25-75). A cutoff point t0 for analysis of differences between time periods was set at January 1, 2005, coinciding with the formalization of a dedicated trauma service. Mortality in the whole trauma population showed a 33% decrease after t0. W-statistics confirmed the increased survival to be significant. There were no significant changes in age, gender, or injury mechanism. Injury severity score decreased, but differences in case mix were adjusted for in the survival prediction model. CONCLUSION: We have shown that the start of the long-lasting performance improvement coincided with formalization of a dedicated trauma service, providing increased multidisciplinary focus on all aspects of trauma care.

Prophylactic placement of inferior vena cava filters and the risk of death or venous thromboembolism in severe trauma patients: a retrospective study comparing two hospitals with different approaches.

BACKGROUND: Prophylactic use of inferior vena cava filters to prevent pulmonary embolism in trauma is controversial. The practice varies between hospitals and countries, in part due to conflicting evidence and guidelines. PURPOSE: To compare the effects of pulmonary embolism, deep venous thrombosis and mortality in two hospitals using prophylactic inferior vena cava filter placement or prophylactic anticoagulation alone. MATERIAL AND METHODS: Patients presenting with severe trauma were recruited from two level-1 trauma centres between January 2008 and December 2013. Recruited patients from an US hospital having prophylactic inferior vena cava filter inserted were compared to a Scandinavian hospital using prophylactic anticoagulation alone. Inclusion criteria were age >15 years, Injury Severity Score >15 and survival >24 h after hospital admission. Patients with venous thromboembolism diagnosed prior to inferior vena cava filter placement were excluded. A Cox proportional hazard regression model was used with adjustment for immortal time bias and predictor variables. RESULTS: In total, 951 patients were reviewed, 282 from an US hospital having inferior vena cava filters placed and 669 from a Scandinavian hospital without inferior vena cava filters. The mean age was 45.9 vs. 47.4 years and the mean Injury Severity Score was 29.8 vs. 25.9, respectively. Inferior vena cava filter placement was not associated with the hazard of pulmonary embolism (Hazard ratio=0.43; 95% confidence interval (CI) 0.12, 1.45; P=0.17) or mortality (Hazard ratio=1.16; 95% CI 0.70, 1.95; P=0.56). However, an increased rate of deep venous thrombosis was observed with inferior vena cava filters in place (Hazard ratio=3.75; 95% CI 1.68, 8.36; P=0.001). CONCLUSION: In severely injured trauma patients, prophylactic inferior vena cava filter placement was not associated with pulmonary embolism or mortality. However, inferior vena cava filters were associated with increased rate of deep venous thrombosis.

Pre-injury dispensing of psychoactive prescription drugs in a ten years trauma population: a retrospective registry analysis.

BACKGROUND: The use of psychoactive prescription drugs is associated with increased risk of traumatic injury, and has negative impact on clinical outcome in trauma patients. Previous studies have focused on specific drugs or subgroups of patients. Our aim was to examine the extent of psychoactive drug dispensing prior to injury in a comprehensive population of trauma patients. METHODS: The Oslo University Hospital Trauma Registry provided data on all trauma patients admitted to the trauma centre between 2005 and 2014. We linked the data to Norwegian Prescription Database data from 2004. Opioids, benzodiazepines, z-hypnotics, gabapentinoids, and centrally acting sympathomimetics dispensed during the year before trauma of each patient were identified. We determined the pre-trauma annual prevalence of dispensing and mean annual cumulative defined daily doses (DDD) for each drug class, and compared results with corresponding figures in the general population, using standardised ratios. For each drug class, dispensing 14 days preceding trauma was analysed in patients sustaining severe injury and compared with patients sustaining non-severe injury. RESULTS: 12,713 patients (71% male) were included. Median age was 36 years. 4891 patients (38%) presented with severe injury (Injury Severity Score > 15). The ratio between annual prevalence of dispensed prescriptions for trauma patients and the general population, adjusted for age and sex, was 1.5 (95% confidence interval 1.4-1.6) for opioids, 2.1 (2.0-2.2) for benzodiazepines, 1.7 (1.6-1.8) for z-hypnotics, 1.9 (1.6-2.2) for gabapentinoids, and 1.9 (1.6-2.2) for centrally acting sympathomimetics. Compared with the general population, mean annual cumulative DDD of opioids and benzodiazepines dispensed to trauma patients were more than two and three times as high, respectively, in several age groups below 70 years. The prevalence of dispensing 14 days pre-trauma was higher in severely injured patients for opioids, benzodiazepines, and z-hypnotics compared with patients without severe injury. CONCLUSIONS: Our results support previous findings that the prevalence of psychoactive drug use is high among trauma patients. In terms of both frequency and amounts, the pre-injury dispensing of psychoactive drugs to trauma patients supersedes that of the general population, especially in younger patients.

Impact of Preinjury Antithrombotic Therapy on 30-Day Mortality in Older Patients Hospitalized With Traumatic Brain Injury (TBI).

Objective: Elderly patients are frequently in need of antithrombotic therapy for reducing thrombotic events. The association between antithrombotic drugs and survival after traumatic brain injury (TBI) is, nevertheless, unclear. Methods: This retrospective study included patients ≥65 years admitted to a Norwegian Level 1 trauma center with TBI identified on cerebral computed tomography (cerebral-CT) during 2014-2019. Preinjury use of antiplatelets and anticoagulants was compared to the prescription rate in the general Norwegian population. The primary outcome was 30-day mortality. Uni- and multivariate logistic regression analyses estimated the association between the use of antithrombotic drugs and mortality. Results: The study includes 832 consecutive TBI patients ≥65 years. The median age was 76 years, 58% were males, 51% had moderate or severe TBI, and 39% had multiple traumas. Preinjury use of antithrombotics was registered in 471/832 (55.6%) patients; antiplatelet therapy alone in 268, anticoagulant therapy alone in 172, and combined antiplatelet and anticoagulant therapy in 31. Antiplatelet use did not differ between the study cohort and the general Norwegian population ≥65 years (31 vs. 31%, p = 0.87). Anticoagulant therapy was used more commonly in the study cohort than in the general Norwegian population (24 vs. 19%, p = 0.04). Combined use of antiplatelet and anticoagulant therapy was significantly associated with 30-day mortality, while preinjury antiplatelet or anticoagulation treatment alone was not. No difference in 30-day mortality between patients using VKA, DOACs, or LMWH was encountered. Conclusions: In this cohort, neither antiplatelet nor anticoagulant therapy alone was associated with increased 30-day mortality. Anticoagulant use was more prevalent among TBI patients than the general population, suggesting that anticoagulation might contribute to the initiation of intracranial bleeding after blunt head trauma. Combined antiplatelet and anticoagulant therapy posed increased risk of 30-day mortality.

Emergency thoracotomy saves lives in a Scandinavian hospital setting.

BACKGROUND: : Emergency thoracotomy (ET) is a life-saving procedure used to control hemorrhage and relieve cardiac tamponade. It has been in routine use at Ulleval University Hospital since 1987. Our objective was to see the outcome of patients subjected to ET in recent times. METHODS: : One hundred and nine consecutive ET performed in our emergency department during a 6-year period were analyzed. Data were drawn from the hospital's trauma registry. Demographics, mechanism of injury, anatomic injuries, physiologic status, interventions, time lapse, and outcome 30 days after injury were registered prospectively. RESULTS: : Ten of 27 patients with penetrating (37%) and 10 of 82 patients with blunt injuries (12%) survived, giving a total survival of 18%. Median (quartiles) for the following parameters were Injury Severity Score 38 (26-50), Revised Trauma Score 1.3 (0-3.9), Glasgow Coma Scale score 3 (3-6), and probability of survival 0.06 (0.001-0.22). Survivors from penetrating injuries had significantly lower Injury Severity Score (25 vs. 34, p = 0.003), higher Revised Trauma Score (3.92 vs. 0.00, p < 0.001), higher Glasgow Coma Scale score (8 vs. 3, p < 0.001), and higher probability of survival (0.74 vs. 0.01, p < 0.001) than nonsurvivors. Conversely, no such differences were found for patients with blunt injury. Multiple logistic regression analysis failed to reveal any predictors of survival. CONCLUSION: : An overall survival of 18% suggests that ET is a life saving procedure. It is difficult to find good predictors of survival from logistic regression analysis. It should, for a trained trauma team, be a liberal attitude toward performing the procedure on the agonal patient.

The number of patients hospitalized with bicycle injuries is increasing - A cry for better road safety.

INTRODUCTION: Norwegian authorities encourage people to commute by bicycle to improve public health, decrease rush-hour traffic jams and reduce pollution. However, increasing the number of bicyclists, especially in the rush-hour traffic, may increase the number of serious bicycle injuries. OBJECTIVE: To explore trends in hospitalized bicycle injuries at a Norwegian level I trauma centre during the last decade. METHODS: Data was extracted from the prospectively registered institutional trauma registry. We identified patients admitted after bicycle injuries between 2005 and 2016. RESULTS: A total of 1543 patients were identified. Median age was 40 years (range 3-91) and 73 % were males. The majority of weekday injuries occurred in the morning and during the afternoon rush-hour, peaking at 8 am. and 4 pm. The annual number of admitted bicycle injuries increased from 79 to 184 during the study period. Also, an increase in the share of bicyclists using helmets was observed. The median Injury Severity Score (ISS) of 10 remained unchanged. 63 % had serious trauma (ISS ≥ 9), while 34 % suffered severe trauma (ISS ≥ 16). The absolute number of both serious and severe trauma increased annually. 36 % had head and neck injuries, while 16 % had chest injuries graded with Abbreviated Injury Scale ≥3. Loss of consciousness with Glasgow Coma Scale score <9 was seen in 7%. Median length of hospitalization was 3 days, and 39 % had surgery in one or more body regions. The 30-day mortality was 2.3 %. CONCLUSIONS: The number of admitted bicycle injuries to our trauma centre is increasing. Rush-hour injuries dominate during weekdays. Bicycle injuries can be devastating and deserve more public attention to promote road safety.

Improvement in geriatric trauma outcomes in an evolving trauma system.

BACKGROUND: The elderly trauma patient has increased mortality compared with younger patients. During the last 15 years, initial treatment of severely injured patients at Oslo University Hospital Ulleval (OUHU) has changed resulting in overall improved outcomes. Whether this holds true for the elderly trauma population needs exploration and was the aim of the present study. METHODS: We performed a retrospective study of 2628 trauma patients 61 years or older admitted to OUHU during the 12-year period, 2002-2013. The population was stratified based on age (61-70 years, 71-80 years, 81 years and older) and divided into time periods: 2002-2009 (P1) and 2010-2013 (P2). Multiple logistic regression models were constructed to identify clinically relevant core variables correlated with mortality and trauma team activation rate. RESULTS: Crude mortality decreased from 19% in P1 to 13% in P2 (p<0.01) with an OR of 0.77 (95 %CI 0.65 to 0.91) when admitted in P2. Trauma team activation rates increased from 53% in P1 to 72% in P2 (p<0.01) with an OR of 2.16 (95% CI 1.93 to 2.41) for being met by a trauma team in P2. Mortality increased from 10% in the age group 61-70 years to 26% in the group above 80 years. Trauma team activation rates decreased from 71% in the age group 61-70 years to 50% in the age group older than 80 years. Median ISS were 17 in all three age groups and in both time periods. DISCUSSION: Development of a multidisciplinary dedicated trauma service is associated with increased trauma team activation rate as well as survival in geriatric trauma patients. As expected, mortality increased with age, although inversely related to the likelihood of being met by a trauma team. Trauma team activation should be considered for all trauma patients older than 70 years. LEVEL OF EVIDENCE: Level IV.

The effect of ICP monitoring in severe traumatic brain injury: a propensity score-weighted and adjusted regression approach.

OBJECTIVE: The use of intracranial pressure (ICP) monitoring has been postulated to be beneficial in patients with severe traumatic brain injury (TBI), although studies investigating this hypothesis have reported conflicting results. The objective of this study was to evaluate the effect of inserting an ICP monitor on survival in patients with severe TBI. METHODS: The Oslo University Hospital trauma registry was searched for the records of all patients admitted between January 1, 2002, and December 31, 2013, who fulfilled the Brain Trauma Foundation criteria for intracranial hypertension and who survived at least 24 hours after admission. The impact of ICP monitoring was investigated using both a logistic regression model and a multiple imputed, propensity score-weighted logistic regression analysis. RESULTS: The study involved 1327 patients, in which 757 patients had an ICP monitor implanted. The use of ICP monitors significantly increased in the study period (p < 0.01). The 30-day overall mortality was 24.3% (322 patients), divided into 35.1% (200 patients, 95% confidence interval [CI] 31.3%-39.1%) in the group without an ICP monitor and 16.1% (122 patients, 95% CI 13.6%-18.9%) in the group with an ICP monitor. The impact of ICP monitors on 30-day mortality was found to be beneficial both in the complete case analysis logistic regression model (odds ratio [OR] 0.23, 95% CI 0.16-0.33) and in the adjusted, aggregated, propensity score-weighted imputed data sets (OR 0.22, 95% CI 0.15-0.35; both p < 0.001). The sensitivity analysis indicated that the findings are robust to unmeasured confounders. CONCLUSIONS: The authors found that the use of an ICP monitor is significantly associated with improved survival in patients with severe head injury.

Treatment-limiting decisions in patients with severe traumatic brain injury in a Norwegian regional trauma center.

BACKGROUND: Treatment-limiting decisions (TLD) for severe traumatic brain injury (sTBI) have been sparsely studied. This study determine prevalence, main reason for, categories and timing of TLDs in a Norwegian regional trauma setting. METHODS: A retrospective study of a 2-year cohort of 579 sTBI patients admitted to Oslo University Hospital (OUH). Prospectively collected data in the OUH Trauma Registry were combined with retrospective data from a chart review regarding TLDs. RESULTS: TLDs were documented for 101/579 sTBI patients (17%). The situation was evaluated as futile in 59 cases and as potentially inappropriate in 42 cases. The three most frequent types of TLDs were withholding of neurosurgery, do not resuscitate orders and withdrawing of organ support. In 70% of cases, the first TLD was made within 2 days after injury, while in 14%, the first TLD was made later than day 7. Twenty percent (20/101) of the first TLDs were later adjusted, revoked in 4 patients and broadening of TLDs in 16 patients. The median time from the decision to death was 2 days (range 1-652). TLDs were documented in 93% of in-hospital death cases (n = 79). In-hospital deaths occurred in 73% of TLD group cases and 1% of non-TLD group cases. Family interaction and multi-team discussions were documented in >88% of cases, but no advanced directives were found, and notifications of patients' preferences were found in only 7% of cases. DISCUSSION: Clinicians should consider limiting treatment if continued treatment is not in the patients best interest. A range of different types of TLDs were applied for patients after sTBI in the trauma hospital setting. CONCLUSION: TLDs were found in 17% of sTBI patients. Value considerations behind TLDs in this care context need to be further explored.

Comparison of risk-adjusted survival in two Scandinavian Level-I trauma centres.

BACKGROUND: Assessment of trauma-system performance is important for improving the care of injured patients. The aim of the study was to compare risk-adjusted survival in two Scandinavian Level-I trauma centres. METHODS: This was an observational, retrospective study of prospectively-collected trauma registry data for patients >14 years from Karolinska University Hospital - Solna (KUH), Sweden, and Oslo University Hospital - Ullevål (OUH), Norway, from 2009-2011. Probability of survival (Ps) was calculated according to the Trauma and Injury Severity Score (TRISS) method. Risk-adjusted survival per patient was calculated by assigning every patient a value corresponding to gained or lost fractional life: Each survivor contributed a reward of 1-Ps and each death a penalty of -Ps. The sum of penalties and rewards, corresponding to the difference between expected and actual mortality, was compared between the centres. We present the data as excess survivors per 100 trauma patients. RESULTS: There were 4485 admissions at KUH and 3591 at OUH. The proportion of severely injured patients was higher at OUH compared with KUH (Injury Severity Score [ISS] >15: 33.9 % vs. 21.1 %, p <0.001). OUH had a larger proportion of patients >65 years (16.0 % vs. 13.4 %, p <0.001) and greater comorbidity (ASA-PS ≥3: 14.6 % vs. 6.9 %, p <0.001) compared with KUH. The frequency of helicopter transport and presence of prehospital physicians was higher at OUH compared with KUH (27.6 % vs. 15.5 % and 30.5 % vs. 3.7 %, both p <0.001). Secondary admissions were 5.2-fold more common at OUH compared with KUH (p <0.001). There were no differences in 30-day mortality for severely injured patients (ISS >15). Risk-adjusted survival rate was higher at OUH than at KUH for primary (0.59 vs. 0.51) but lower for secondary (1.41 vs. 2.85) admissions (both p <0.001). CONCLUSION: Adjustments for age as a continuous variable and comorbidity should be made when comparing risk-adjusted survival between hospitals, but this is not possible with the TRISS model. A survival prediction model that takes this into account may be a better choice for Scandinavian trauma populations. The current study could not rule out the influence of the system differences between the centres on risk-adjusted survival.

Reduced need for extraperitoneal pelvic packing for severe pelvic fractures is associated with improved resuscitation strategies.

BACKGROUND: Extraperitoneal pelvic packing (EPP) was introduced at Oslo University Hospital Ulleval (OUHU) in 1994. Published studies from other institutions have advocated its application as a first-line therapy in lieu of angiography. Extraperitoneal pelvic packing is invasive with a high risk of complications, and its role remains an issue of discussion. In line with international trends, an updated massive hemorrhage protocol was implemented at OUHU in 2007. We hypothesized a decreased need for EPP owing to the major changes in resuscitation strategies. METHODS: Retrospective analysis of data from the OUH Trauma Registry and patient charts for the period 2002-2012 was performed. All pelvic fractures with Abbreviated Injury Severity (AIS) score of 3 or higher and/or transfused during the period before intensive care unit admission regardless of the pelvic AIS were included. The population was analyzed for trends and differences between 2002-2006 (P1) and 2007-2012 (P2). Further analysis was performed on the group of patients transfused five or more units of red blood cells (RBCs). RESULTS: We included 648 patients (P1, 297; P2, 351). There was no difference in median injury severity score, pelvic AIS, or age between the two periods. Median base deficit on admission was higher in P2 (4.2 vs 3.3 mmol/L; p < 0.01). The EPP rate decreased from P1 to P2 (17-10%; p < 0.01). A similar reduction in the angiography rate (15% vs 9%; p < 0.01) was observed, with a concomitant decrease in hemorrhage-related deaths (10% vs 5%; p = 0.01). The subgroup analysis of patients transfused five or more units of RBCs revealed significant increase in the use of plasma and platelets in P2. Multiple logistic regression models for the subgroup transfused five or more units of RBCs confirm the change in resuscitation strategy to be significantly associated with reduced EPP, and identifying admission in P2 to be associated with a 63% decreased odds ratio for EPP. CONCLUSIONS: The EPP and angiography rates for exsanguinating pelvic injuries have decreased with improved resuscitation strategies, reducing RBC requirements and hemorrhage-related deaths. LEVEL OF EVIDENCE: Therapeutic study, level IV.