Epidemiology of trauma in the subarctic regions of the Nordic countries.

BACKGROUND: The northern regions of the Nordic countries have common challenges of sparsely populated areas, long distances, and an arctic climate. The aim of this study was to compare the cause and rate of fatal injuries in the northernmost area of the Nordic countries over a 5-year period. METHODS: In this retrospective cohort, we used the Cause of Death Registries to collate all deaths from 2007 to 2011 due to an external cause of death. The study area was the three northernmost counties in Norway, the four northernmost counties in Finland and Sweden, and the whole of Iceland. RESULTS: A total of 4308 deaths were included in the analysis. Low energy trauma comprised 24% of deaths and high energy trauma 76% of deaths. Northern Finland had the highest incidence of both high and low energy trauma deaths. Iceland had the lowest incidence of high and low energy trauma deaths. Iceland had the lowest prehospital share of deaths (74%) and the lowest incidence of injuries leading to death in a rural location. The incidence rates for high energy trauma death were 36.1/100000/year in Northern Finland, 15.6/100000/year in Iceland, 27.0/100000/year in Northern Norway, and 23.0/100000/year in Northern Sweden. CONCLUSION: We found unexpected differences in the epidemiology of trauma death between the countries. The differences suggest that a comparison of the trauma care systems and preventive strategies in the four countries is required.

Clinical guided computer tomography decisions are advocated in potentially severely injured trauma patients: a one-year audit in a level 1 trauma Centre with long pre-hospital times.

BACKGROUND: The International Commission on Radiological Protection's (ICRP) justification principles state that an examination is justified if the potential benefit outweighs the risk for radiation harm. Computer tomography (CT) contributes 50% of the radiation dose from medical imaging, and in trauma patients, the use of standardized whole body CT (SWBCT) increases. Guidelines are lacking, and reviews conclude conflictingly regarding the benefit. We aimed to study the degree of adherence to ICRP's level three justification, the individual dose limitation principle, in our institution. METHODS: This is a retrospective clinical audit. We included all 144 patients admitted with trauma team activation to our regional Level 1 trauma centre in 2015. Injuries were categorized according to the Abbreviated Injury Scale (AIS) codes. Time variables, vital parameters and interventions were registered. We categorized patients into trauma admission SWBCT, selective CT or no CT examination strategy groups. We used descriptive statistics and regression analysis of predictors for CT examination strategy. RESULTS: The 144 patients (114 (79.2%) males) had a median age of 31 (range 0-91) years. 105 (72.9%) had at least one AIS ≥ 2 injury, 26 (18.1%) in more than two body regions. During trauma admission, at least one vital parameter was abnormal in 46 (32.4%) patients, and 73 (50.7%) underwent SWBCT, 43 (29.9%) selective CT and 28 (19.4%) no CT examination. No or only minor injuries were identified in 17 (23.3%) in the SWBCT group. Two (4.6%) in the selective group were examined with a complement CT, with no new injuries identified. A significantly (p < 0.001) lower proportion of children (61.5%) than adults (89.8%) underwent CT examination despite similar injury grades and use of interventions. In adjusted regression analysis, patients with a high-energy trauma mechanism had significantly (p = 0.028) increased odds (odds ratio = 4.390, 95% confidence interval 1.174-16.413) for undergoing a SWBCT. CONCLUSION: The high proportion of patients with no or only minor injuries detected in the SWBCT group and the significantly lower use of CT among children, indicate that use of a selective CT examination strategy in a higher proportion of our patients would have approximated the ICRP's justification level three, the individual dose limitation principle, better.

Injury coding in a national trauma registry: a one-year validation audit in a level 1 trauma centre.

BACKGROUND: Hospitals must improve patient safety and quality continuously. Clinical quality registries can drive such improvement. Trauma registries code injuries according to the Abbreviated Injury Scale (AIS) and benchmark outcomes based on the Injury Severity Score (ISS) and New ISS (NISS). The primary aim of this study was to validate the injury codes and severities registered in a national trauma registry. Secondarily, we aimed to examine causes for missing and discordant codes, to guide improvement of registry data quality. METHODS: We conducted an audit and established an expert coder group injury reference standard for patients met with trauma team activation in 2015 in a Level 1 trauma centre. Injuries were coded according to the AIS. The audit included review of all data in the electronic health records (EHR), and new interpretation of all images in the picture archiving system. Validated injury codes were compared with the codes registered in the registry. The expert coder group's interpretations of reasons for discrepancies were categorised and registered. Inter-rater agreement between registry data and the reference standard was tested with Bland-Altman analysis. RESULTS: We validated injury data from 144 patients (male sex 79.2%) with median age 31 (inter quartile range 19-49) years. The total number of registered AIS codes was 582 in the registry and 766 in the reference standard. All injuries were concordantly coded in 62 (43.1%) patients. Most non-registered codes (n = 166 in 71 (49.3%) patients) were AIS 1, and information in the EHR overlooked by registrars was the dominating cause. Discordant coding of head injuries and extremity fractures were the most common causes for 157 discordant AIS codes in 74 (51.4%) patients. Median ISS (9) and NISS (12) for the total population did not differ between the registry and the reference standard. CONCLUSIONS: Concordance between the codes registered in the trauma registry and the reference standard was moderate, influencing individual patients' injury codes validity and ISS/NISS reliability. Nevertheless, aggregated median group ISS/NISS reliability was acceptable.

Treatment of splenic trauma in Norway: a retrospective cohort study.

BACKGROUND: Non-operative management of splenic injuries has become the treatment of choice in hemodynamically stable patients over the last decades. The aim of the study is to describe the incidence, initial treatment and early outcome of patients with splenic injuries on a national level. METHODS: All hospitals in Norway admitting trauma patients were invited to participate in the study. The study period was January through December 2013. The hospitals delivered anonymous data on primarily admitted patients with splenic injury. RESULTS: Three of the four regional trauma centers and 26 of the remaining 33 acute care hospitals delivered data on a total of 151 patients with splenic injury indicating an incidence of 4 splenic injuries per 100,000 inhabitants/year, and a median of 4 splenic injuries per hospital per year. A total of 128 (85%) patients were successfully treated non-operatively including 20 patients who underwent an angiographic procedure. The remaining 23 (15%) patients underwent open splenectomy or spleen-preserving surgery. CONCLUSION: Most patients with splenic injuries are managed non-operatively. Despite the low number of splenic injuries per hospital, the results indicate satisfactory outcome on a national level.

Evaluation of a trauma team activation protocol revision: a prospective cohort study.

BACKGROUND: Correct triage based on prehospital information contributes to a better outcome for potentially seriously injured patients. In 2011 we changed the trauma team activation (TTA) criteria in our center in order to improve the high over- and undertriage properties of the protocol. Five criteria that were unable to predict severe injury were removed. In the present study, we evaluated the protocol revision by comparing over- and undertriage in the former and present set of criteria. METHODS: All severely injured patients (Injury Severity Score (ISS) > 15) and all patients admitted with TTA in the period of 01.01.2013 - 31.12.2014 were included in the study. We defined overtriage as the fraction of patients with TTA when ISS ≤15 and undertriage as the fraction of patients without TTA when ISS > 15. We also evaluated triage with the occurrence of emergency procedures immediately after admission. RESULTS: 324 patients were included, 164 patients had ISS>15, 287 were admitted with TTA. Over- and undertriage were 74 % and 28 % respectively. When we used emergency procedure as reference, the figures were 83 % and 15 % respectively. Undertriaged patients had significantly more neurosurgical injuries and were significantly more often transferred from an acute care hospital. DISCUSSION: Over- and undertriage are almost the same as before the criteria were revised, and higher thanrecommended levels. CONCLUSIONS: Revision of the TTA criteria has not improved triage, and further measures are necessary to achieveacceptable levels.

The treatment of spleen injuries: a retrospective study.

BACKGROUND: Hemorrhage after blunt trauma is a major contributor to death after trauma. In the abdomen, an injured spleen is the most frequent cause of major bleeding. Splenectomy is historically the treatment of choice. In 2007, non-operative management (NOM) with splenic artery embolization (SAE) was introduced in our institution. The indication for SAE is hemodynamically stable patients with extravasation of contrast, or grade 3-5 spleen injury according to the Abbreviated Organ Injury Scale 2005, Update 2008. We wanted to examine if the introduction of SAE increased the rate of salvaged spleens in our trauma center. METHOD: All patients discharged with the diagnosis of splenic injury in the period 01.01.2000 - 31.12.2013 from the University Hospital of North Norway Tromsø were included in the study. Patients admitted for rehabilitation purposes or with an iatrogenic injury were excluded. RESULTS: A total of 109 patients were included in the study. In the period 2000-7, 20 of 52 patients were splenectomized. During 2007-13, there were 6 splenectomies and 24 SAE among 57 patients. The reduction in splenectomies is significant (p < 0.001). There is an increase in the rate of treated patients (splenectomy and SAE) from 38 to 53 % in the two time periods, but not significantly (p = 0.65). CONCLUSION: The rate of salvaged spleens has increased after the introduction of SAE in our center. TRIAL REGISTRATION: The study is registered at www.clinicaltrials.gov with the identification number NCT01965548.

Sphincter training or anal injections of dextranomer for treatment of anal incontinence: a randomized trial.

OBJECTIVE: The objective is to test if the injection of a bulking agent in the anal canal is superior to sphincter training with biofeedback in the treatment of anal incontinence. BACKGROUND: Anal incontinence is traditionally treated with conservative measures, such as pads and constipating medicine. If this fails, sphincter training with biofeedback is often offered before more advanced surgical procedures are considered. The injection of a bulking agent in the anal canal is a relatively new and promising treatment option. METHODS: In a randomized, controlled, evaluator-blinded trial, 126 adult patients with anal incontinence were randomly assigned to a transanal, submucosal injection of 4 x 1 mL of dextranomer in hyaluronic acid or to sphincter training with biofeedback. The primary outcome was severity of incontinence, evaluated by St Mark's score for incontinence (0 = continence to 24 = complete incontinence) assessed at 2 years after the start of treatment. A mixed models analysis was applied. RESULTS: Of the 126 participants, 64 patients were randomly assigned to anal injections, and among them the mean St Mark's score improved from 12.9 (95% CI: 11.8-14.0) at baseline to 8.3 (95% CI: 6.7-9.8) at the end of follow up. Among the 62 patients who were assigned to sphincter training with biofeedback, there was a corresponding improvement in St Mark's score from 12.6 (95% CI: 11.4-13.8) to 7.2 (95% CI: 7.2-8.8). Comparisons of St Mark's scores between the groups showed no differences in effect between treatments. CONCLUSION: The efficacy of anal injections and biofeedback in treating anal incontinence did not differ in this randomized, single-blinded, controlled trial.

Evaluation of a university hospital trauma team activation protocol.

BACKGROUND: Admission with a multidisciplinary trauma team may be vital for the severely injured patient, as this facilitates rapid diagnosis and treatment. On the other hand, patients with minor injuries do not need the trauma team for adequate care. Correct triage is important for optimal resource utilization. The aim of the study was to evaluate our criteria for activating the trauma team, and identify suboptimal criteria that might be changed in the interest of precision. METHODS: The study is an observational, retrospective cohort-study. All patients admitted with the trauma team (n = 382), all severely injured (Injury Severity Score (ISS) >15) (n = 161), and all undergoing an emergency procedure aimed at counteracting compromised airways, respiration or circulation at our hospital (n = 142) during 2006-2007 were included. Data were recorded from the admission records and the electronic patient records. The trauma team activation protocol was evaluated against the occurrence of severe injury and the occurrence of emergency procedures. RESULTS: A total of 441 patients were included. The overtriage was 71% and undertriage 32% when evaluating against ISS >15 as the standard of reference. When occurrence of emergency procedures was held as the standard of standard of reference, the over- and undertriage was 71% and 21%, respectively. Mechanism of injury-criteria for trauma team activation contributed the most to overtriage. The emergency procedures performed were mostly endotracheal intubation and external fixation of fractures. Less than 3% needed haemostatic laparotomy or thoracotomy. Approximately 2/3 of the overtriage represented isolated head or cervical spine injuries, and/or interhospital transfers. CONCLUSIONS: The over- and undertriage of our protocol are both too high. To decrease overtriage we suggest omissions and modifications of some of the criteria. To decrease undertriage, transferred patients and patients with head injuries should be more thoroughly assessed against the trauma team activation criteria.

[Seriously injured patients transferred from local hospitals to a university hospital]. / Alvorlig skadede overført til universitetssykehus.

BACKGROUND: We studied diagnostics and stabilizing surgery in severely injured patients transferred from local hospitals to a university hospital. The purpose was to identify a potential for improvement of regional trauma care. MATERIAL AND METHODS: The material comprises all severely injured patients (Injury Severity [ISS] Score > 15) transferred from local hospitals to the University Hospital of Northern Norway in the period 01.01.2006 - 31.12.2007. Information about diagnostics, extent of injury and treatment during the first 24 hours after transferral was recorded by retrospective chart review. Emergency surgical interventions are defined according to plans for a national trauma system. RESULTS: 6/74 patients underwent emergency surgery at the local hospital (chest tube insertion, external fracture fixation); eight after arrival at the university hospital (chest tube insertion, hemostatic packing of the abdomen and pelvis, external fracture fixation). 66/74 were CT-scanned locally; 37 with a CT multitrauma series (CT caput, neck, thorax, abdomen and pelvis). Of the 62 who had head CT scans performed at a local hospital, the cervical spine was not imaged for 10. For eight of 55 patients who had CT scans of the thorax/abdomen/pelvis intravenous contrast agent was not administered. INTERPRETATION: Trauma care at local hospitals may be improved by more systematic imaging, a lower threshold for emergency surgery, and early communication with the university hospital.

[Assessment of anal incontinence in adults]. / Utredning av anal inkontinens hos voksne.

BACKGROUND: Anal incontinence is involuntary loss of stool and flatus through the anal canal. The condition can be severely debilitating to those affected. MATERIAL AND METHODS: The article is based on relevant literature and the authors' clinical experience. RESULTS: The first examination should include an anorectoscopy as part of a broader clinical examination, and the aim should be to find the cause and describe the condition. An assessment in hospital should comprise endoanal ultrasound for imaging and grading of the incontinence severity with a score system. CONCLUSION: Simple preliminary investigations and eventually more specialized investigations in a specialist clinic give a good impression of the condition, and is the basis for choosing treatment and later evaluation.

[Anal incontinence--assessment of a new treatment]. / Anal inkontinens--utprøvning av en ny behandlingsmetode.

BACKGROUND: Anal incontinence affects 1.4 % of the general population. Anal injections is a new treatment option for this condition; different techniques and bulking agents are used. The article presents a pilot-study with a new bulking agent (hyaluronic acid and dextranomere) and a new injection technique. MATERIAL AND METHODS: An anascope was used to inject Zuidex (4 x 1. 4 mL) submucosally (proximal to the dentate line and distally to the puborectal muscle) in 4 patients with severe faecal incontinence, who were deemed unfit for other treatment. No anaesthesia or antibiotic-prophylaxis was used. RESULTS: All patients tolerated the treatment well, and there were no adverse events. The treatment had an effect in 3 of 4 patients; there was a median fall in St. Mark's score of 3. 5 points. INTERPRETATION: The injection technique was well tolerated, easy to perform within an outpatient setting and with promising short-term results. The method has been implemented in a randomized, controlled trial.

[Results of surgical treatment of ventral hernia]. / Resultater ved operativ behandling av ventralhernie.

BACKGROUND: The aim of this study was to examine the results of incisional hernia repair in our institution. MATERIAL AND METHODS: Repairs performed in from the start of 1998 to the end of 2001 were identified and the case notes reviewed. Some patients were also interviewed by telephone. Preoperative risk factors, type of repair, complications and recurrence were registered. RESULTS: 90 repairs were performed. The patients were followed up for 36 months on average. 58 (64%) patients had preoperative risk factors. 36 (40%) patients suffered complications, mostly seroma and wound infection. 39 (43%) patients experienced recurrence. DISCUSSION: Incisional hernia repair was associated with a high risk of complications and recurrence.