Traumatic brain injury in the elderly after a skiing accident: A retrospective cohort study in a level 1 emergency department in Switzerland.

BACKGROUND: Skiing is a very popular sport worldwide, with increasing trends over the past decades. This study aimed to evaluate the importance of traumatic brain injury (TBI), especially in the elderly, after a ski accident, and to describe its short-term repercussions. METHODOLOGY: Patients were analyzed who were admitted to our neurotrauma center from 2012-2018 after a head trauma while skiing. Three different age groups were differentiated and analyzed for the severity of TBI depending on the initial Glasgow Coma Scale as the primary outcome and as secondary outcomes need and type of surgery, Glasgow Outcome Score, preexisting use of anticoagulant or antiplatelet drugs, time to presentation, and pattern of brain injury. TBI severity was adjusted to the time to initial medical consultation. RESULTS: No significant difference in TBI severity was found when comparing the middle (>29-54) and older (≥54) age groups to the reference group <30 years (OR:0.45, p = 0.127; OR:0.46, p = 0.17). Acute subdural hemorrhage was present in 21.2% of the ≥55 group and 14.5% of the 30-54 age group, compared to 12.8% of the youngest group (p = <0.001). Overall, 39.4% of the patients in the ≥55 group and 8.1% of the 30-54 age group presented with chronic subdural hemorrhage, whereas none of the youngest patients did (p = <0.001). CONCLUSION: No differences were observed in terms of TBI severity between age groups after acute trauma. Nonetheless, a different pattern of head injury after TBI in older patients was demonstrated. Accordingly, the management differs for these TBIs compared to those of younger patients.

Inter-hospital transfer of polytrauma and severe traumatic brain injury patients: Retrospective nationwide cohort study using data from the Swiss Trauma Register.

INTRODUCTION: Polytrauma and traumatic brain injury (TBI) patients are among the most vulnerable patients in trauma care and exhibit increased morbidity and mortality. Timely care is essential for their outcome. Severe TBI with initially high scores on the Glasgow Coma (GCS) scores is difficult to recognise on scene and referral to a Major Trauma Center (MTC) might be delayed. Therefore, we examined current referral practice, injury patterns and mortality in these patients. MATERIALS AND METHODS: Retrospective, nationwide cohort study with Swiss Trauma Register (STR) data between 01/012015 and 31/12/2018. STR includes patients ≥16 years with an Injury Severity Score (ISS) >15 and/or an Abbreviated Injury Scale (AIS) for head >2. We performed Cox proportional hazard models with injury type as the primary outcome and mortality as the dependent variable. Secondary outcomes were inter-hospital transfer and age. RESULTS: 9,595 patients were included. Mortality was 12%. 2,800 patients suffered from isolated TBI. 69% were men. Median age was 61 years and median ISS 21. Two thirds of TBI patients had a GCS of 13-15 on admission to the Emergency Department (ED). 26% of patients were secondarily transferred to an MTC. Patients with isolated TBI and those aged ≥65 years were transferred more often. Crude analysis showed a significantly elevated hazard for death of 1.48 (95%CI 1.28-1.70) for polytrauma patients with severe TBI and a hazard ratio (HR) of 1.82 (95%CI 1.58-2.09) for isolated severe TBI, compared to polytrauma patients without TBI. Patients directly admitted to the MTC had a significantly elevated HR for death of 1.63 (95%CI 1.40-1.89), compared to those with secondary transfer. CONCLUSIONS: A high initial GCS does not exclude the presence of severe TBI and triage to an MTC should be seriously considered for elderly TBI patients.

Comparison of the Incidence and Severity of Traumatic Brain Injury Caused by Electrical Bicycle and Bicycle Accidents-A Retrospective Cohort Study From a Swiss Level I Trauma Center.

BACKGROUND: Electrical bicycles (E-bikes) allow people of all ages to ride at high speeds but have an inherent risk of traumatic brain injury (TBI). Their sales have increased tremendously in recent years. METHODS: We performed a retrospective cohort study to compare the incidence and severity of TBI in E-bikers and conventional bicyclists. We included patients at a Swiss level 1 trauma center admitted from 2010 to 2015. The primary outcome was the association between TBI and the bicycle type. The secondary outcome was the association between helmet use and TBI severity. RESULTS: Of 557 patients injured riding an E-bike (n = 73) or a bicycle (n = 484), 60% sustained a TBI, most of which were mild (Glasgow coma scale [GCS] score, 13-15; E-bike, 78%; bicycle, 88%). TBI was more often moderate (GCS score, 9-12) or severe (GCS score, 3-8) in E-bikers than in bicyclists (P = 0.04). Intracranial hemorrhage, traumatic subarachnoid hemorrhage, and subdural hematoma occurred significantly more often in E-bikers than in bicyclists (P < 0.05). Neurosurgical intervention was necessary for 5 E-bikers (7%) and 25 (5%) bicyclists (P = 0.15). Wearing a helmet correlated with a lower risk of neurosurgical intervention in bicyclists (odds ratio [OR], 0.21; 95% confidence interval [CI], 0.06-0.73; P = 0.01) and a lower risk of calvarial fractures in both bicyclists (OR, 0.16; 95% CI, 0.06-0.42; P < 0.01) and E-bikers (OR, 0.21; 95% CI, 0.05-0.84; P = 0.03). CONCLUSIONS: E-bikers had a significantly greater risk of moderate to severe TBI compared with bicyclists. Helmet use was associated with decreased odds of severe TBI in bicyclists and a tendency toward a more favorable outcome for E-bikers.

Cohort Study on the Association Between Helmet Use and Traumatic Brain Injury in Snowboarders From a Swiss Tertiary Trauma Center.

BACKGROUND: Since the introduction of helmets in winter sports there is on-going debate on whether they decrease traumatic brain injuries (TBI). METHODS: This cohort study included 117 adult (≥ 16 years) snowboarders with TBI admitted to a level I alpine trauma center in Switzerland between 2000/2001 and 2010/2011. The primary objective was to examine the association between helmet use and moderate-to-severe TBI. Secondary objectives were to describe the epidemiology of TBI during the past decade in relation to increased helmet use. RESULTS: Of 691 injured snowboarders evaluated, 117 (17%) suffered TBI. Sixty-six percent were men (median age, 23 years). Two percent of accidents were fatal. Ninety-two percent of patients sustained minor, 1% moderate, and 7% severe TBI according to the Glasgow coma scale. Pathologic computed tomography findings were present in 16% of patients, 26% of which required surgery. Eighty-three percent of TBIs occurred while riding on-slope. There was no trend in the TBI rate during the studied period, although helmet use increased from 10% to 69%. Comparing patients with and without a helmet showed no significant difference in odds ratios for the severity of TBI. However, of the 5 patients requiring surgery only 1 was wearing a helmet. Off-piste compared with on-slope snowboarders showed an odds ratio of 26.5 (P = 0.003) for sustaining a moderate-to-severe TBI. CONCLUSIONS: Despite increased helmet use we found no decrease in TBI among snowboarders. The possibility of TBI despite helmet use and the dangers of riding off-piste should be a focus of future prevention programs.

Association between head injury and helmet use in alpine skiers: cohort study from a Swiss level 1 trauma center.

The association between helmet use during alpine skiing and incidence and severity of head injuries was analyzed. All patients admitted to a level 1 trauma center for traumatic brain injuries (TBIs) sustained from skiing accidents during the seasons 2000-2001 and 2010-2011 were eligible. Primary outcome was the association between helmet use and severity of TBI measured by Glasgow Coma Scale (GCS), computed tomography (CT) results, and necessity of neurosurgical intervention. Of 1362 patients injured during alpine skiing, 245 (18%) sustained TBI and were included. TBI was fatal in 3%. Head injury was in 76% minor (Glasgow Coma Scale, 13-15), 6% moderate, and 14% severe. Number and percentage of TBI patients showed no significant trend over the investigated seasons. Forty-five percent of the 245 patients had pathological CT findings and 26% of these required neurosurgical intervention. Helmet use increased from 0% in 2000-2001 to 71% in 2010-2011 (p<0.001). The main analysis, comparing TBI in patients with or without a helmet, showed an adjusted odds ratio (OR) of 1.44 (p=0.430) for suffering moderate-to-severe head injury in helmet users. Analyses comparing off-piste to on-slope skiers revealed a significantly increased OR among off-piste skiers of 7.62 (p=0.004) for sustaining a TBI requiring surgical intervention. Despite increases in helmet use, we found no decrease in severe TBI among alpine skiers. Logistic regression analysis showed no significant difference in TBI with regard to helmet use, but increased risk for off-piste skiers. The limited protection of helmets and dangers of skiing off-piste should be targeted by prevention programs.

Validation and reclassification of MGAP and GAP in hospital settings using data from the Trauma Audit and Research Network.

BACKGROUND: Recently, two simple clinical scores were published to predict survival in trauma patients. Both scores may successfully guide major trauma triage, but neither has been independently validated in a hospital setting. METHODS: This is a cohort study with 30-day mortality as the primary outcome to validate two new trauma scores-Mechanism, Glasgow Coma Scale (GCS), Age, and Pressure (MGAP) score and GCS, Age and Pressure (GAP) score-using data from the UK Trauma Audit and Research Network. First, an assessment of discrimination, using the area under the receiver operating characteristic (ROC) curve, and calibration, comparing mortality rates with those originally published, were performed. Second, we calculated sensitivity, specificity, predictive values, and likelihood ratios for prognostic score performance. Third, we propose new cutoffs for the risk categories. RESULTS: A total of 79,807 adult (≥16 years) major trauma patients (2000-2010) were included; 5,474 (6.9%) died. Mean (SD) age was 51.5 (22.4) years, median GCS score was 15 (interquartile range, 15-15), and median Injury Severity Score (ISS) was 9 (interquartile range, 9-16). More than 50% of the patients had a low-risk GAP or MGAP score (1% mortality). With regard to discrimination, areas under the ROC curve were 87.2% for GAP score (95% confidence interval, 86.7-87.7) and 86.8% for MGAP score (95% confidence interval, 86.2-87.3). With regard to calibration, 2,390 (3.3%), 1,900 (28.5%), and 1,184 (72.2%) patients died in the low, medium, and high GAP risk categories, respectively. In the low- and medium-risk groups, these were almost double the previously published rates. For MGAP, 1,861 (2.8%), 1,455 (15.2%), and 2,158 (58.6%) patients died in the low-, medium-, and high-risk categories, consonant with results originally published. Reclassifying score point cutoffs improved likelihood ratios, sensitivity and specificity, as well as areas under the ROC curve. CONCLUSION: We found both scores to be valid triage tools to stratify emergency department patients, according to their risk of death. MGAP calibrated better, but GAP slightly improved discrimination. The newly proposed cutoffs better differentiate risk classification and may therefore facilitate hospital resource allocation. LEVEL OF EVIDENCE: Prognostic study, level II.

The association between admission systolic blood pressure and mortality in significant traumatic brain injury: a multi-centre cohort study.

INTRODUCTION: Low systolic blood pressure (SBP) is an important secondary insult following traumatic brain injury (TBI), but its exact relationship with outcome is not well characterised. Although a SBP of <90 mmHg represents the threshold for hypotension in consensus TBI treatment guidelines, recent studies suggest redefining hypotension at higher levels. This study therefore aimed to fully characterise the association between admission SBP and mortality to further inform resuscitation endpoints. METHODS: We conducted a multicentre cohort study using data from the largest European trauma registry. Consecutive adult patients with AIS head scores >2 admitted directly to specialist neuroscience centres between 2005 and July 2012 were studied. Multilevel logistic regression models were developed to examine the association between admission SBP and 30 day inpatient mortality. Models were adjusted for confounders including age, severity of injury, and to account for differential quality of hospital care. RESULTS: 5057 patients were included in complete case analyses. Admission SBP demonstrated a smooth u-shaped association with outcome in a bivariate analysis, with increasing mortality at both lower and higher values, and no evidence of any threshold effect. Adjusting for confounding slightly attenuated the association between mortality and SBP at levels <120 mmHg, and abolished the relationship for higher SBP values. Case-mix adjusted odds of death were 1.5 times greater at <120 mmHg, doubled at <100 mmHg, tripled at <90 mmHg, and six times greater at SBP<70 mmHg, p<0.01. CONCLUSIONS: These findings indicate that TBI studies should model SBP as a continuous variable and may suggest that current TBI treatment guidelines, using a cut-off for hypotension at SBP<90 mmHg, should be reconsidered.

A 13-year analysis from Switzerland of non-fatal sledging (sledding or tobogganing) injuries.

INTRODUCTION: Winter sports have evolved from an upper class activity to a mass industry. Especially sledging regained popularity at the start of this century, with more and more winter sports resorts offering sledge runs. This study investigated the rates of sledging injuries over the last 13 years and analysed injury patterns specific for certain age groups, enabling us to make suggestions for preventive measures. METHODS: We present a retrospective analysis of prospectively collected data. From 1996/1997 to 2008/2009, all patients involved in sledging injuries were recorded upon admission to a Level III trauma centre. Injuries were classified into body regions according to the Abbreviated Injury Scale (AIS). The Injury Severity Score (ISS) was calculated. Patients were stratified into 7 age groups. Associations between age and injured body region were tested using the chi-squared test. The slope of the linear regression with 95% confidence intervals was calculated for the proportion of patients with different injured body regions and winter season. RESULTS: 4956 winter sports patients were recorded. 263 patients (5%) sustained sledging injuries. Sledging injury patients had a median age of 22 years (interquartile range [IQR] 14-38 years) and a median ISS of 4 (IQR 1-4). 136 (51.7%) were male. Injuries (AIS ≥ 2) were most frequent to the lower extremities (n=91, 51.7% of all AIS ≥ 2 injuries), followed by the upper extremities (n=48, 27.3%), the head (n=17, 9.7%), the spine (n=7, 4.0%). AIS ≥ 2 injuries to different body regions varied from season to season, with no significant trends (p>0.19). However, the number of patients admitted with AIS ≥ 2 injuries increased significantly over the seasons analysed (p=0.031), as did the number of patients with any kind of sledging injury (p=0.004). Mild head injuries were most frequent in the youngest age group (1-10 years old). Injuries to the lower extremities were more often seen in the age groups from 21 to 60 years (p<0.001). CONCLUSION: Mild head trauma was mainly found in very young sledgers, and injuries to the lower extremities were more frequent in adults. In accordance with the current literature, we suggest that sledging should be performed in designated, obstacle-free areas that are specially prepared, and that children should always be supervised by adults. The effect of routine use of helmets and other protective devices needs further evaluation, but it seems evident that these should be obligatory on official runs.

Accuracy of prehospital diagnosis and triage of a Swiss helicopter emergency medical service.

BACKGROUND: Helicopter emergency medical services (HEMSs) have become a standard element of modern prehospital emergency medicine. This study determines the percentage of injured HEMS patients whose injuries were correctly recognized by HEMS physicians. METHODS: A retrospective level III evidence prognostic study using data from the largest Swiss HEMS, REGA (Rettungsflugwacht/Guarde Aérienne), on adult patients with trauma transported to a Level I trauma center (January 2006-December 2007). National Advisory Committee on Aeronautics (NACA) scores and the Injury Severity Score (ISS) were assessed to identify severely injured patients. Injured body regions diagnosed by REGA physicians were compared with emergency department discharge diagnoses. RESULTS: Four hundred thirty-three patients were analyzed. Median age was 42.1 years (interquartile range, 25.5-57.9). Three hundred twenty-three (74.6%) were men. Patients were severely injured, with an in-hospital NACA score of 4 or higher in 88.7% of patients and median ISS of 13. REGA physicians correctly recognized injuries to the head in 92.9%, to the femur in 90.5%, and to the tibia/fibula in 83.8% of patients. Injuries to these body regions were overdiagnosed in less than 30%. Abdominal injuries were missed in 56.1%, pelvic injuries in 51.8%, spinal injuries in 40.1%, and chest injuries in 31.2% of patients. CONCLUSION: This study shows that patients are adequately triaged by REGA physicians reflected by a NACA score 4 or higher in 88.7% of patients and a median ISS of 13. However, recognition of injured body regions seems to be challenging in the prehospital setting. Prospective studies on specific training of HEMS physicians for recognition of these injuries (e.g., portable ultrasonography, telemedicine) might help in the future. LEVEL OF EVIDENCE: Prognostic study, level III.

Epidemiology and predictors of cervical spine injury in adult major trauma patients: a multicenter cohort study.

BACKGROUND: Patients with cervical spine injuries are a high-risk group, with the highest reported early mortality rate in spinal trauma. METHODS: This cohort study investigated predictors for cervical spine injury in adult (≥ 16 years) major trauma patients using prospectively collected data of the Trauma Audit and Research Network from 1988 to 2009. Univariate and multivariate logistic regression analyses were used to determine predictors for cervical fractures/dislocations or cord injury. RESULTS: A total of 250,584 patients were analyzed. Median age was 47.2 years (interquartile range, 29.8-66.0) and Injury Severity Score 9 (interquartile range, 4-11); 60.2% were male. Six thousand eight hundred two patients (2.3%) sustained cervical fractures/dislocations alone. Two thousand sixty-nine (0.8%) sustained cervical cord injury with/without fractures/dislocations; 39.9% of fracture/dislocation and 25.8% of cord injury patients suffered injuries to other body regions. Age ≥ 65 years (odds ratio [OR], 1.45-1.92), males (females OR, 0.91; 95% CI, 0.86-0.96), Glasgow Coma Scale (GCS) score <15 (OR, 1.26-1.30), LeFort facial fractures (OR, 1.29; 95% confidence interval [CI], 1.05-1.59), sports injuries (OR, 3.51; 95% CI, 2.87-4.31), road traffic collisions (OR, 3.24; 95% CI, 3.01-3.49), and falls >2 m (OR, 2.74; 95% CI, 2.53-2.97) were predictive for fractures/dislocations. Age <35 years (OR, 1.25-1.72), males (females OR, 0.59; 95% CI, 0.53-0.65), GCS score <15 (OR, 1.35-1.85), systolic blood pressure <110 mm Hg (OR, 1.16; 95% CI, 1.02-1.31), sports injuries (OR, 4.42; 95% CI, 3.28-5.95), road traffic collisions (OR, 2.58; 95% CI, 2.26-2.94), and falls >2 m (OR, 2.24; 95% CI, 1.94-2.58) were predictors for cord injury. CONCLUSIONS: 3.5% of patients suffered cervical spine injury. Patients with a lowered GCS or systolic blood pressure, severe facial fractures, dangerous injury mechanism, male gender, and/or age ≥ 35 years are at increased risk. Contrary to common belief, head injury was not predictive for cervical spine involvement.

A pilot case-control study of behavioral aspects and risk factors in Swiss climbers.

BACKGROUND: Climbing is a popular sport in Switzerland, with approximately 100 000 active participants. There is an inherent risk of falls, overuse and stress-related trauma, with a reported injury rate of 4.2 injuries per 1000 climbing hours. OBJECTIVE: Comparison of possible risk factors in patients and noninjured controls. METHODS: A case-control survey was conducted. Climbers admitted to three trauma units between June and October 2008 were surveyed using a questionnaire evaluating nine potential risk factors. The same questionnaire was distributed to noninjured climbers during the same time period. Logistic regression was performed. RESULTS: Fifty patients and 63 controls were included in this survey. Variables significant for patients were: more than 10 years versus less than 1 year of climbing experience (odds ratio: 5.34; confidence interval: 1.16-17.76; P=0.006) and no previous experiences of the climbing route (odds ratio: 2.72; confidence interval: 1.15-6.39; P=0.022). No statistical significance was detected for age, sex, difficulty level of the climbing route, warm-up, readiness for risk and abstinence from alcohol and drugs. CONCLUSION: Climbers with higher experience seem to be more prone to injuries. Larger studies on this subgroup are warranted, to identify typical risk profiles and to develop preventive strategies. Furthermore, climbers should be advised about the increased injury risk when trying new climbing routes and specific information should be given.

Spinal and pelvic injuries in airborne sports: a retrospective analysis from a major Swiss trauma centre.

BACKGROUND: Adrenalin-seeking airborne sports like BASE-jumping, paragliding, parachuting, delta-gliding, speedflying, and skysurfing are now firmly with us as outdoor lifestyle activities and are associated with a high frequency of severe injuries, especially to the spine. METHODS: Retrospective analysis of all airborne sports-associated spinal and pelvic injuries admitted to a Level I trauma centre in the Swiss Alps between 1st March 2000 and 31st October 2009. Spinal injuries were classified by the Magerl system and pelvic injuries by the AO/OTA scheme modified by Isler and Ganz. Spino-pelvic dissociation fractures in airborne sports were compared to similar injuries in the general trauma population using multiple logistic regression analysis. RESULTS: 181 patients (11 BASE-jumpers, 144 paragliders, 19 parachuters, 1 speedflyer, 4 deltagliders, 2 skysurfer) were included. 161 (89%) were male. Median age was 37.0 years (IQR=29.0-47.0) and ISS 8 (IQR=4-13). 89 (49.2%) patients sustained spinal fractures. Type A fractures were predominant (91.5%), followed by Type C (5.3%) and Type B (3.2%). The level L1 was most often affected (35.1%). 17 patients (9.4%) had pelvic ring fractures. Most frequent were Type C fractures (41.2%), followed by Types A and B (29.4% each). 8 paragliders (4.4%) suffered spino-pelvic dissociation injuries. The odds ratio for sustaining such fractures in paragliders was 21-fold higher (OR 21.04, 95% CI 7.83-56.57, p<0.001) than in the general trauma population. CONCLUSIONS: Serious spinal and pelvic injuries account for most injuries sustained during airborne sporting activities. The thoracolumbar region was most often affected, but the lumbopelvic junction is also especially vulnerable as high impact forces from vertical and horizontal deceleration need to be absorbed. The frequency of spino-pelvic dissociation was very high in paragliding injuries, with a 21-fold higher odds ratio than in the general trauma population.

Systolic blood pressure below 110 mmHg is associated with increased mortality in penetrating major trauma patients: Multicentre cohort study.

INTRODUCTION: Non-invasive systolic blood pressure (SBP) measurement is a commonly used triaging tool for trauma patients. A SBP of <90mmHg has represented the threshold for hypotension for many years, but recent studies have suggested redefining hypotension at lower levels. We therefore examined the association between SBP and mortality in penetrating trauma patients. METHODS: We conducted a prospective cohort study in adult (≥16 years) penetrating trauma patients. Patients were admitted to hospitals belonging to the Trauma Audit and Research Network (TARN) between 2000 and 2009. The main outcome measure was the association between SBP and mortality at 30 days. Multivariate logistic regression models adjusted for the influence of age, gender, Injury Severity Score (ISS) and Glasgow Coma Score (GCS) on mortality were used. RESULTS: 3444 patients with a median age of 30 years (IQR 22.5-41.4), SBP of 126mmHg (IQR 107-142), ISS of 9 (IQR 9-14) and GCS of 15 (IQR 15-15), were analysed. Multivariable logistic regression analysis adjusted for age, gender, severity of injury and level of consciousness showed a cut-off for SBP at <110mmHg, after which increased mortality was observed. Compared with the reference group with SBP 110-129mmHg, mortality was doubled at SBP 90-109mmHg, was four-fold higher at 70-89mmHg and 10-fold higher at <70mmHg. SBP values ≥150mmHg were associated with decreased mortality. CONCLUSION: We recommend that penetrating trauma patients with a SBP<110mmHg are triaged to resuscitation areas within dedicated, appropriately specialised, high-level care trauma centres.

Do alpine skiers and snowboarders wear protective equipment more often after an accident?

QUESTIONS UNDER STUDY/PRINCIPLES: Analysis of changes in the behaviour of wearing protective equipment by alpine skiers and snowboarders after injury, performed at a level I trauma centre in Switzerland. METHODS: We present a study, using a standardised questionnaire, assessing behaviour on ski slopes by adult patients admitted between Oct 2007 and April 2008. Patients were re-interviewed after the 2008/2009 season. McNemar tests were used to analyse differences in protective clothing wearing rates between the two seasons. Multiple logistic regression with age, gender and injury severity score (ISS) as predictors, was used to compare findings in those who started wearing protective equipment and those who did not. RESULTS: A total of 104/132 patients from the 2007/2008 season were questioned about wearing protective equipment in 2008/2009. 20 patients could not be reassessed (7 declined, 13 had abandoned winter sports). A total of 84 patients were reassessed (61 alpine skiers and 23 snowboarders). The median age of participants was 39 years and 70.2% were male. Helmet and back protector wearing rates increased from 40.5% to 78.6% (p <0.001) and from 14.3% to 23.8% (p = 0.021), respectively. Snowboarders more than doubled their helmet wearing rate (39.1% to 82.6%, p = 0.002). Skiers showed a trend towards doubling their back protector wearing rate (6.6% to 14.8%, p = 0.063). Younger skiers started wearing back protectors more often than older skiers. CONCLUSIONS: Sustained injury might provide skiers and snowboards with a potent trigger to change their attitude towards the use of protective equipment. The psychological processes influencing the use of protective equipment require further investigation.

Epidemiology and predictors of spinal injury in adult major trauma patients: European cohort study.

This is a European cohort study on predictors of spinal injury in adult (≥16 years) major trauma patients, using prospectively collected data of the Trauma Audit and Research Network from 1988 to 2009. Predictors for spinal fractures/dislocations or spinal cord injury were determined using univariate and multivariate logistic regression analysis. 250,584 patients were analysed. 24,000 patients (9.6%) sustained spinal fractures/dislocations alone and 4,489 (1.8%) sustained spinal cord injury with or without fractures/dislocations. Spinal injury patients had a median age of 44.5 years (IQR = 28.8-64.0) and Injury Severity Score of 9 (IQR = 4-17). 64.9% were male. 45% of patients suffered associated injuries to other body regions. Age <45 years (≥45 years OR 0.83-0.94), Glasgow Coma Score (GCS) 3-8 (OR 1.10, 95% CI 1.02-1.19), falls >2 m (OR 4.17, 95% CI 3.98-4.37), sports injuries (OR 2.79, 95% CI 2.41-3.23) and road traffic collisions (RTCs) (OR 1.91, 95% CI 1.83-2.00) were predictors for spinal fractures/dislocations. Age <45 years (≥45 years OR 0.78-0.90), male gender (female OR 0.78, 95% CI 0.72-0.85), GCS <15 (OR 1.36-1.93), associated chest injury (OR 1.10, 95% CI 1.01-1.20), sports injuries (OR 3.98, 95% CI 3.04-5.21), falls >2 m (OR 3.60, 95% CI 3.21-4.04), RTCs (OR 2.20, 95% CI 1.96-2.46) and shooting (OR 1.91, 95% CI 1.21-3.00) were predictors for spinal cord injury. Multilevel injury was found in 10.4% of fractures/dislocations and in 1.3% of cord injury patients. As spinal trauma occurred in >10% of major trauma patients, aggressive evaluation of the spine is warranted, especially, in males, patients <45 years, with a GCS <15, concomitant chest injury and/or dangerous injury mechanisms (falls >2 m, sports injuries, RTCs and shooting). Diagnostic imaging of the whole spine and a diligent search for associated injuries are substantial.

Systolic blood pressure below 110 mm Hg is associated with increased mortality in blunt major trauma patients: multicentre cohort study.

INTRODUCTION: Non-invasive systolic blood pressure (SBP) measurement is often used in triaging trauma patients. Traditionally, SBP< 90 mm Hg has represented the threshold for hypotension, but recent studies have suggested redefining hypotension as SBP < 110 mm Hg. This study aims to examine the association of SBP with mortality in blunt trauma patients. METHODS: This is an analysis of prospectively recorded data from adult (≥ 16 years) blunt trauma patients. Included patients presented to hospitals belonging to the Trauma Audit and Research Network (TARN) between 2000 and 2009. The primary outcome was the association of SBP and mortality rates at 30 days. Multivariate logistic regression models were used to adjust for the influence of age, gender, Injury Severity Score (ISS) and Glasgow Coma Score (GCS) on mortality. RESULTS: 47,927 eligible patients presented to TARN hospitals during the study period. Sample demographics were: median age: 51.1 years (IQR=32.8-67.4); male 60% (n=28,694); median ISS 9 (IQR=8-10); median GCS 15 (IQR=15-15); and median SBP 135 mm Hg (IQR=120-152). We identified SBP< 110 mm Hg as a cut off for hypotension, where a significant increase in mortality was observed. Mortality rates doubled at < 100 mm Hg, tripled at < 90 mm Hg and were 5- to 6-fold at < 70 mm Hg, irrespective of age. CONCLUSION: We recommend triaging adult blunt trauma patients with a SBP< 110 mm Hg to resuscitation areas within dedicated trauma units for close monitoring and appropriate management.

Improving prehospital trauma management for skiers and snowboarders - need for on-slope triage?

BACKGROUND: Injuries from skiing and snowboarding became a major challenge for emergency care providers in Switzerland. In the alpine setting, early assessment of injury and health status is essential for the initiation of adequate means of care and transport. Nevertheless, validated standardized protocols for on-slope triage are missing. This article can assist in understanding the characteristics of injured winter sportsmen and exigencies for future on-slope triage protocols. METHODS: Six-year review of trauma cases in a tertiary trauma centre. Consecutive inclusion of all injured skiers and snowboarders aged >15 (total sample) years with predefined, severe injury to the head, spine, chest, pelvis or abdomen (study sample) presenting at or being transferred to the study hospital. Descriptive analysis of age, gender and injury pattern. RESULTS: Amongst 729 subjects (total sample) injured from skiing or snowboarding, 401 (55%, 54% of skiers and 58% of snowboarders) suffered from isolated limb injury. Amongst the remaining 328 subjects (study sample), the majority (78%) presented with monotrauma. In the study sample, injury to the head (52%) and spine (43%) was more frequent than injury to the chest (21%), pelvis (8%), and abdomen (5%). The three most frequent injury combinations were head/spine (10% of study sample), head/thorax (9%), and spine/thorax (6%). Fisher's exact test demonstrated an association for injury combinations of head/thorax (p < 0.001), head/abdomen (p = 0.019), and thorax/abdomen (p < 0.001). CONCLUSION: The data presented and the findings from previous investigations indicate the need for development of dedicated on-slope triage protocols. Future research must address the validity and practicality of diagnostic on-slope tests for rapid decision making by both professional and lay first responders. Thus, large-scale and detailed injury surveillance is the future research priority.

Protective and risk factors in amateur equestrians and description of injury patterns: A retrospective data analysis and a case - control survey.

BACKGROUND: In Switzerland there are about 150,000 equestrians. Horse related injuries, including head and spinal injuries, are frequently treated at our level I trauma centre. OBJECTIVES: To analyse injury patterns, protective factors, and risk factors related to horse riding, and to define groups of safer riders and those at greater risk METHODS: We present a retrospective and a case-control survey at conducted a tertiary trauma centre in Bern, Switzerland.Injured equestrians from July 2000 - June 2006 were retrospectively classified by injury pattern and neurological symptoms. Injured equestrians from July-December 2008 were prospectively collected using a questionnaire with 17 variables. The same questionnaire was applied in non-injured controls. Multiple logistic regression was performed, and combined risk factors were calculated using inference trees. RESULTS: RETROSPECTIVE SURVEY: A total of 528 injuries occured in 365 patients. The injury pattern revealed as follows: extremities (32%: upper 17%, lower 15%), head (24%), spine (14%), thorax (9%), face (9%), pelvis (7%) and abdomen (2%). Two injuries were fatal. One case resulted in quadriplegia, one in paraplegia. CASE-CONTROL SURVEY: 61 patients and 102 controls (patients: 72% female, 28% male; controls: 63% female, 37% male) were included. Falls were most frequent (65%), followed by horse kicks (19%) and horse bites (2%). Variables statistically significant for the controls were: Older age (p = 0.015), male gender (p = 0.04) and holding a diploma in horse riding (p = 0.004). Inference trees revealed typical groups less and more likely to suffer injury. CONCLUSIONS: Experience with riding and having passed a diploma in horse riding seem to be protective factors. Educational levels and injury risk should be graded within an educational level-injury risk index.

Are there risk factors for snowboard injuries? A case-control multicentre study of 559 snowboarders.

OBJECTIVE: To analyse risk factors leading to injuries during snowboarding. DESIGN: A case-control multicentre survey of injured and non-injured snowboarders. SETTING: One tertiary and two secondary trauma centres in Bern, Switzerland. METHODS: All snowboard injuries admitted to our tertiary and two affiliated secondary trauma centres from 1 November 2007 to 15 April 2008 were analysed on the basis of a completed questionnaire incorporating 15 variables. The same questionnaire was applied in non-injured controls at valley stations after a snowboarding day during the same period. A multiple logistic regression was performed (dichotomous variables). Patterns of combined risk factors were calculated by inference trees. RESULTS: 306 patients and 253 controls were interviewed. The following variables were statistically significant for the injured PATIENTS: low readiness for speed (OR 0.20, 95% CI 0.06 to 0.64, p=0.0037), bad weather/visibility (OR 19.06, 95% CI 2.70 to 134.73, p=0.0031) and old snow (OR 0.11, 95% CI 0.02 to 0.68, p=0.0323). Not wearing a helmet and riding on icy slopes emerged as a combination of risk factors associated with injury. CONCLUSIONS: Several risk factors and combinations exist, and different risk profiles were identified. Future research should be aimed at more precise identification of groups at risk and developing specific recommendations for each group-for example, a snow-weather conditions index at valley stations.