Survival predictor for penetrating cardiac injury; a 10-year consecutive cohort from a scandinavian trauma center.

BACKGROUND: Penetrating cardiac injuries in Europe have been poorly studied. We present a 10-year outcome for patients with penetrating heart injuries at Oslo University Hospital. METHODS: Data from 01.01.2001 until 31.12.2010 was collected from the Oslo University Hospital Trauma Registry and from the patients' records. RESULTS: Thirty-one patients were admitted with a penetrating cardiac injury. Fourteen patients survived (45%). Four out of 8 patients (50%) with gunshot wounds survived compared to 10 out of 23 (44%) with stab wounds. Median (quartiles) for the following values were: Injury Severity Score 25 (21-35), Revised Trauma Score 0 (0-6,9), Probability of Survival 0,015 (0,004-0,956), Glasgow Coma Scale 3 (3-13). Thirteen patients had signs of life on admission and survived. Eighteen patients were admitted without signs of life and received emergency department thoracotomy. Eight of these had no signs of life at the scene of injury and did not survive. Out of the remaining 10 patients, one survived. CONCLUSIONS: The outcome of patients with penetrating cardiac injury reaching the emergency department with signs of life was excellent. Hemodynamic instability indicates immediate surgery. Stable patients with penetrating thoracic trauma and possible cardiac injury detected by imaging should be considered for conservative treatment.

The twin terrorist attacks in Norway on July 22, 2011: the trauma center response.

BACKGROUND: The terrorist attacks in Norway on July 22, 2011, consisted of a bomb explosion in central Oslo, followed by a shooting spree in a youth camp. We describe the trauma center response, identifying possible success factors and suggesting improvements for institutional major incident plans. METHODS: The in-hospital response is analyzed. Data on triage, patient flow, injuries, treatment, resources, and outcome were collected. RESULTS: The explosion caused a total of 98 casualties and 8 died at scene. Ten patients were triaged to the trauma center, with the first patient arriving 18 minutes after the explosion and 7 patients within the next 19 minutes. The shooting caused 68 deaths at the scene and 61 injured. The trauma center received a total of 21 patients from the shooting incident.Surgical leadership was divided between emergency department triage with control of personnel and communication as well as control and supervision of treatment with retriage and optimal use of trauma surgical resources (dual command). Surge capacity was never exceeded in the emergency department, operating rooms, or intensive care units.Of the 31 patients treated at the trauma center, 20 had an Injury Severity Score of more than 15 and 25 required repeated operation, for a total of 125 operations during the first 4 weeks. One patient died, for a critical mortality of 5%. CONCLUSION: A trauma center can handle many patients with severe injury, with low critical mortality when protected from a large number of walking wounded. Limited specific trauma surgical competence was managed by the adoption of a dual surgical command model. LEVEL OF EVIDENCE: Therapeutic/care management study, level V.

The reality of war: wounded and fallen Norwegian soldiers in Afghanistan.

BACKGROUND: Norway has been contributing military forces to Afghanistan since 2001. The following is an overview of all combat-related injuries and deaths among Norwegian soldiers in the period from 2002 to 2010. MATERIAL AND METHOD: All medical records for Norwegian military personnel in Afghanistan in the period to January 2011 were reviewed and those who fell or were injured during combat were identified. The mechanism and anatomical region of the injury were registered and an injury severity score (ISS), revised trauma score (RTS) and probability of survival score were calculated. Deaths were classified according to military trauma terminology and were additionally assessed as either "non-survivable" or "potentially survivable". RESULTS: There were 45 injury incidents with nine deaths among 42 soldiers. The injury mechanism behind seven of the deaths was an improvised explosive device (IED). All injuries resulting in deaths were "non-survivable". Seven soldiers were severely injured. The mechanisms were bullet wounds, IED, splinters from grenades and landmine explosions. Twenty nine incidents involving 28 soldiers resulted in minor injuries. The most frequent mechanism was ricochet or splinter injury from shooting or an exploding grenade. INTERPRETATION: The majority of conflict-related injuries in Afghanistan were due to explosions. The mechanism and anatomical distribution of the injuries was the same among Norwegian soldiers as among allies. The deaths were due to extensive injuries that were non-survivable.

Short and long-term survival in type A aortic dissection justifies the operative risk and effort.

OBJECTIVES: To evaluate the survival rate and complications after operation for acute aortic dissection type A. DESIGN: Chart review of all consecutive patients with aortic dissection admitted during 1999-2008 (n = 99) to Oslo University Hospital Ullevål, Oslo. RESULTS. Thirty-day mortality was 14 patients and late mortality 21 patients. Twenty-nine patients had no postoperative complications. Cerebral affection was seen in 22 patients. Seventy-nine patients were operated on with deep hypothermic circulatory arrest. Mean circulatory arrest time was 23 minutes (range 12-47). Eighty-three of the patients were cannulated through the femoral artery, with a 30-day mortality rate of 17% (n = 14) versus 0% for other cannulations (n = 16); and a stroke rate of 24% (n = 20) versus 17% (n = 2) in patients cannulated in the subclavian or axillary artery (no statistically significant difference in either mortality or stroke). CONCLUSIONS: Our study confirms that overall mortality and neurological complications are acceptable and the long-term survival rate is good in patients operated on for acute aortic dissection. Circulatory arrest time seems not to affect neurological complications when being relatively short.

Trends in transfusion of trauma victims--evaluation of changes in clinical practice.

BACKGROUND: The present study was performed to compare blood product consumption and clinical results in consecutive, unselected trauma patients during the first 6 months of year 2002, 2004 and 2007. METHODS: Clinical data, blood product consumption, lowest haemoglobin values on day 1-10 after admission, and 30-day mortality were extracted from in-hospital trauma registry and the blood bank data base. The subpopulation of massively transfused patients was identified and analysed separately. RESULTS: The total number of admitted trauma patients increased by 48% from 2002 to 2007, but the clinical data remained essentially unchanged. The mean number of erythrocyte units given day 1-10 decreased insignificantly from 9.4 in 2002 to 6.8 in 2007. New Injury Severity Score (NISS) increased in transfused and massively transfused patients, but not significantly. The number of patients transfused with plasma increased and the mean ratio of erythrocyte to plasma units transfused decreased by about 50%. The mean haemoglobin value in transfused patients on day 2 after admittance was significantly lower in 2007 than in 2002, while that on day 10 was significantly higher in 2007 than in 2002 and 2004. There was no change of 30-day survival from 2002 to 2007. CONCLUSIONS: Significant changes of transfusion practice occurred during the past decade, probably as a result of increased focus on haemostasis and more precise criteria for transfusion. Despite a lower consumption of erythrocytes in 2007 than in 2002 and 2004, the mean haemoglobin level of transfused patients was higher on day 10 in 2007. The low number of transfused patients in this material makes evaluation of effect on survival difficult. Larger studies with strict control of all influencing factors are needed.

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.

Coronary artery dissection and acute myocardial infarction following blunt chest trauma.

Blunt chest trauma might lead to cardiac injury ranging from simple arrhythmias to lethal conditions such as cardiac rupture. We experienced a case of initially overlooked traumatic coronary artery dissection which resulted in acute myocardial infarction (AMI). A high degree of suspicion is needed to diagnose this condition. Based on our case, we will give an overview of relevant literature on this topic. ECG, echocardiography, coronary angiography and cardiac enzymes are valuable tools in diagnosing this rare condition. The time span from coronary artery occlusion to revascularisation must be short if AMI is to be avoided.

Liver injuries--improved results with a formal protocol including angiography.

OBJECTIVE: We hypothesised that a formal treatment protocol for liver injuries including angiography would increase the non-operative management (NOM) rate and would be efficient as an adjunct to damage control surgery. METHODS: During the 4-year period from 1 August 2000, a total of 138 adult patients with liver injuries were admitted to the largest trauma centre in Norway and prospectively included in the institutional trauma registry. On 1 August 2002, a protocol mandating angiography in all NOM patients with OIS grades 3-5 liver injuries and after packing of the liver was implemented. All patients admitted during the subsequent 2-year period (group 2) were compared with the previous 2 years as historic controls (group 1). RESULTS: Fifty-five patients were included in group 1 and 59 in group 2. The groups were statistically comparable, both with a mean ISS of 31. Patients selected for NOM increased from 28 (51%) to 45 (76%) (p<0.05), without increasing failure rate, liver-related complications, mortality or transfusion rate. Angiography was performed in 26 patients in group 2 (44%). Only nine patients underwent embolisation (35%), and five of these were in the NOM group. Angiography was negative in the eight NOM stable patients with OIS grade 3 injury. CONCLUSION: The implementation of a formal NOM protocol decreased total laparotomy rate and seemed to improve patient outcome without jeopardising patient safety. Surprisingly few of the patients undergoing angiography required embolisation. Angiography is not indicated in stable OIS grade 3 liver injuries, and the protocol in our institution has been adjusted accordingly. AE seems to be a valuable adjunct to DCS with packing of liver injuries.

Nonoperative management of splenic injuries: improved results with angioembolization.

BACKGROUND: Nonoperative management (NOM) of patients with severe splenic injuries carries a significant risk of failure. We hypothesized that adding angiographic embolization (AE) to the NOM protocol would decrease the laparotomy rate, and increase the success rate of NOM and splenic salvage rate. METHODS: A protocol introducing AE in the treatment of splenic injuries was implemented. AE was performed in OIS splenic injury grades 3 to 5 and in all cases where signs of ongoing bleeding were encountered regardless of injury grade. Patients included in a prospective study during a 24-month period were compared with a historic control group. RESULTS: Group 1 (before AE) consisted of 69 patients with a mean Injury Severity Score (ISS) of 31, and group 2 (after introducing AE) included 64 patients with a mean ISS of 30. In group 1, 30 patients underwent immediate laparotomy (43%), and the NOM success rate was 79%. After introducing AE, 17 patients underwent immediate laparotomy (27%; p = 0.04), with a NOM success rate of 96% (p = 0.02). Overall splenic salvage rate increased from 57% to 75% (p = 0.02). Angiography was performed in 31 patients in group 2. Embolization was performed in 27 of these patients. AE failure rate was 4%. NOM was successful in 14 of 15 patients with OIS injury grades 4 and 5 after the introduction of AE (93%). CONCLUSION: A formal protocol adding mandatory AE to NOM for severe splenic injuries increased the percentage of patients in whom NOM was attempted, the NOM success rate, and the splenic salvage rate.

The impact of patient volume on surgical trauma training in a Scandinavian trauma centre.

OBJECTIVE: Some of the problems faced in trauma surgery are increasing non-operative management of abdominal injuries, decreasing work hours and increasing sub-specialisation. We wanted to document the experience of trauma team leaders at the largest trauma centre in Norway, hypothesising that the patient volume would be inadequate to secure optimal trauma care. METHODS: Patients registered in the hospital based Trauma Registry during the 2-year period from 1 August 2000 to 31 July 2002 were included. RESULTS: Of a total of 1667 patients registered, 645 patients (39%) had an Injury Severity Score (ISS)>15. Abdominal injuries were diagnosed in 205 patients with a median ISS of 30. An average trauma team leader assessed a total of 119 trauma cases a year (46 patients with ISS>15) and participated in 10 trauma laparotomies. CONCLUSION: Although the total number of trauma cases seems adequate, the experience of the trauma team leaders with challenging abdominal injuries is limited. With increasing sub-specialisation and general surgery vanishing, fewer surgical specialties provide operative competence in dealing with complicated torso trauma. A system of additional education and quality assurance measures is a prerequisite of high quality, and has consequently been introduced in our institution.

Advanced surgical trauma care training with a live porcine model.

OBJECTIVE: To evaluate the benefit of a compulsory operative trauma care course for general surgeons in Norway utilising a live porcine model. METHODS: The participants rated their expertise in 23 situations pre- and post-session on a scale 1-5, where 1 meant "not competent" and 5 meant "fully competent". RESULTS: Mean total score increased 43% from pre- to post-session. The increase reached significance with all levels of experience. Procedures rarely performed, like suturing on a beating heart, showed a greater educational benefit than more frequently performed procedures, like inserting a chest tube. CONCLUSION: The operative trauma care animal session increased the participants' perceived competence significantly. Its use seems justified for education in trauma related lifesaving surgical procedures.

[Vacuum pack technique--a good method for temporal abdominal closure]. / Vakuumpakking--en god metode for midlertidig bukveggslukking.

UNLABELLED: Abdominal compartment syndrome(ACS) is a clinical entity characterised by increased intraabdominal pressure leading to multiple organ failure, fatal if left untreated. The treatment of abdominal compartment syndrome is surgical decompression with a temporary abdominal wall substitute. To avoid the development of abdominal compartment syndrome, temporary abdominal closure (TAC) should be considered after celiotomy for trauma. A new method for TAC was introduced at Ullevaal University Hospital in 2002, the "vac pac". METHOD: The "vac pac" technique is described and the patients treated with "vac pac" during the first year after introduction are presented. RESULTS: Five patients were treated using the "vac pac". One patient had acute pancreatitis and developed abdominal compartment syndrome. The other patients were severely injured and the indication for TAC was abdominal compartment syndrome in one patient, intestinal oedema in another, and damage control surgery with packing in two patients. Delayed primary closure was achieved within five days in all our patients. There were no fatalities and no complications related to the use of "vac pac" were registered. CONCLUSION: The "vac pac" technique seems to be a good method for TAC.

Challenges of major incident management when excess resources are allocated: experiences from a mass casualty incident after roof collapse of a military command center.

During a military exercise in northern Norway in March 2000, the snow-laden roof of a command center collapsed with 76 persons inside. Twenty-five persons were entrapped and/or buried under snow masses. There were three deaths. Seven patients had serious injuries, three had moderate injuries, and 16 had minor injuries. A military Convalescence Camp that had been set up in a Sports Hall 125 meters from the scene was reorganized as a causality clearing station. Officers from the Convalescence Camp initially organized search and rescue. In all, 417 persons took part in the rescue work with 36 ambulances, 17 helicopters, three ambulance airplanes and one transport plane available. Two ambulances, five helicopters and one transport aircraft were used. Four patients were evacuated to a civilian hospital and six to a field hospital. The stretcher and treatment teams initially could have been more effectively organized. As resources were ample, this was a mass casualty, not a disaster. Firm incident command prevented the influx of excess resources.