Epidemiological comparison between the Navarra Major Trauma Registry and the German Trauma Registry (TR-DGU®).

BACKGROUND: International benchmarking can help identify trauma system performance issues and determine the extent to which other countries also experience these. When problems are identified, countries can look to high performers for insight into possible responses. The objective of this study was to compare the treatment and outcome of severely injured patients in Germany and Navarra, Spain. METHODS: Data collected, from 2010 to 2013, in the Navarra Major Trauma Registry (NMTR) and the TraumaRegister DGU® (TR-DGU) were compared. Both registries followed the Utstein Trauma Template (European Core Dataset) for documentation of trauma patients. Adult patients (≥ 16 years) with New Injury Severity Score (NISS) being >15 points were included in this study. Patients who had been admitted to the hospital later than 24 h after the trauma, had been pronounced dead before hospital arrival, or had been injured by hanging, drowning or burns, were excluded. Demographic data, injury data, prehospital data, hospital treatment data, time intervals, and outcome were compared. The expected mortality was calculated using the Revised Injury Severity Classification score II (RISC II). RESULTS: A total of 646 and 43,110 patients were included in the outcome analysis from NMTR and TR-DGU, respectively. The difference between observed and expected mortality was -0.4% (standardized mortality ratio [SMR] 0.97; 95% CI 0.93-1.04) in Germany and 1.6% (SMR 1.08; 95% CI: 1.02-1.14) in Navarra. Differences in the characteristics of trauma patients and trauma systems between the regions were noted. CONCLUSION: The higher observed mortality in Navarra is consistent with the epidemiological characteristics of its population. However, to improve the quality of trauma care in the Navarra trauma system, certain improvements are necessary. There were less young adults with severe injuries in Navarra than in Germany. It is possible to compare data of severely injured patients from different countries if standardized registries are used.

Escalas para predicción de resultados tras traumatismo grave / Scales for predicting outcome after severe trauma

En este artículo se ha hecho una revisión sobre el desarrollo de las escalas más utilizadas en los pacientes con traumatismo grave desde hace 40 años. Es sabido que, las escalas anatómicas son eficaces, tanto para medir la severidad de las lesiones, como para predecir resultados. Las escalas fisiológicas miden el componente dinámico tras el trauma, con gran influencia en el pronóstico de los traumatizados. Los índices metabólicos, tanto lactato como el déficit de base, son reflejo de un estado de hipoperfusión tisular, y por tanto de shock. Las escalas combinadas sirven para la predicción y comparación evaluativa de los resultados. La incorporación de factores que influyen en el pronóstico de los traumatizados ha conllevado al desarrollo de nuevas escalas. Sin embargo, carecen de estudios de validación externa para su uso generalizado. Hasta que estos estudios se lleven a cabo, estas escalas deben usarse con precaución (AU)

In this article we review the development of the most-used scales for severe trauma patients over the past 40 years. It is well known that anatomical scales are effective for measuring the severity of injuries and for predicting results. Physiological scales measure the dynamic component after trauma, with a great influence on the prognosis of injured patients. Metabolic scales, both lactate and base deficit, are reflections of tissue hypoperfusion states and therefore shock. The combined scales are used for prediction and comparative assessment of results. The inclusion of factors that influence the prognosis of trauma patients has led to the development of new scales. However, they lack external validation studies for their widespread use. Until these validation studies are conducted caution should be taken with the use of existing scales (AU)

[Scales for predicting outcome after severe trauma]. / Escalas para predicción de resultados tras traumatismo grave.

In this article we review the development of the most-used scales for severe trauma patients over the past 40 years. It is well known that anatomical scales are effective for measuring the severity of injuries and for predicting results. Physiological scales measure the dynamic component after trauma, with a great influence on the prognosis of injured patients. Metabolic scales, both lactate and base deficit, are reflections of tissue hypoperfusion states and therefore shock. The combined scales are used for prediction and comparative assessment of results. The inclusion of factors that influence the prognosis of trauma patients has led to the development of new scales. However, they lack external validation studies for their widespread use. Until these validation studies are conducted caution should be taken with the use of existing scales.

Réplica a los autores de la carta: Influencia de los tiempos de respuesta prehospitalarios en la supervivencia de los pacientes politraumatizados en Navarra / Replicates the authors of the letter: Influence of prehospital response times in the survival of trauma patients in Navarre

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[Influence of prehospital response times in the survival of trauma patients in Navarre]. / Influencia de los tiempos de respuesta prehospitalarios en la supervivencia de los pacientes politraumatizados en Navarra.

The relation between response times and mortality of polytrauma patients in the so-called "golden hour" continues to be a subject of debate. The purpose of this study is to determine the variables related to mortality in these patients and the influence of response times of the Emergency Medical Services in this mortality. To this end, the data in the "Major Trauma of Navarre" Register (retrospective cohort of polytrauma patients attended to by the Navarre Health Service) were analyzed for the four year period between 2010 and 2013. Of the 217 trauma cases available for the analysis, 42 (19%) died. No significant association was found in the multi-variate analysis between the different response times and mortality: arrival at the scene (odds ratio (OR) 1.0; 95% confidence interval (CI) from 0.99 to 1.01), in the scenario (OR 1.00; 95% CI from 0.98 to 1.02) and total time (OR 1.00; 95% CI from 0.99 to 1.01). The variables that influenced mortality are patient age and severity of injuries measured by the prehospital Triage-Revised Trauma Score (T-RTS) and the New Injury Severity Score (NISS). The mortality of polytrauma patients attended to by the emergency system in our region is influenced by age and by the intensity of the aggression suffered, determined by the prehospital T-RTS and by the NISS. The response times of the hospital do not have a significant influence.

Influencia de los tiempos de respuesta prehospitalarios en la supervivencia de los pacientes politraumatizados en Navarra / Influence of prehospital response times in the survival of trauma patients in Navarre

La relación entre los tiempos de respuesta y la mortalidad de los pacientes politraumatizados en la denominada "hora de oro" sigue siendo tema de debate. El objetivo del presente estudio es determinar las variables relacionadas con la mortalidad en dichos pacientes y la influencia de los tiempos de respuesta de los Servicios Médicos de Emergencia en dicha mortalidad. Para ello se analizaron los datos del Registro "Major Trauma de Navarra" (cohorte retrospectiva de pacientes politraumatizados atendidos por el sistema sanitario de Navarra) durante los cuatro años comprendidos entre 2010 y 2013. De los 217 casos de trauma disponibles para el análisis, fallecieron 42 (19%). En el análisis multivariante no se encontró asociación significativa entre los diferentes tiempos de respuesta y la mortalidad: llegada a la escena (odds ratio (OR) 1,0; intervalo de confianza al 95% (IC) de 0,99 a 1,01), en el escenario (OR 1,00; IC 95% de 0,98 a 1,02) y tiempo total (OR 1,00; IC 95% de 0,99 a 1,01). Las variables que influyen en la mortalidad son la edad del paciente y la gravedad de las lesiones medidas por el Triage-Revised Trauma Score (T-RTS) prehospitalario y el New Injury Severity Score (NISS). La mortalidad de los pacientes politraumatizados atendidos por el sistema de emergencias en nuestra región está influida por la edad, y por la intensidad de la agresión sufrida determinada por el T-RTS prehospitalario y por el NISS. Los tiempos de respuesta prehospitalarios no influyen significativamente (AU)

The relation between response times and mortality of polytrauma patients in the so-called "golden hour" continues to be a subject of debate. The purpose of this study is to determine the variables related to mortality in these patients and the influence of response times of the Emergency Medical Services in this mortality. To this end, the data in the "Major Trauma of Navarre" Register (retrospective cohort of polytrauma patients attended to by the Navarre Health Service) were analyzed for the four year period between 2010 and 2013. Of the 217 trauma cases available for the analysis, 42 (19%) died. No significant association was found in the multivariate analysis between the different response times and mortality: arrival at the scene (odds ratio (OR) 1.0; 95% confidence interval (CI) from 0.99 to 1.01), in the scenario (OR 1.00; 95% CI from 0.98 to 1.02) and total time (OR 1.00; 95% CI from 0.99 to 1.01). The variables that influenced mortality are patient age and severity of injuries measured by the prehospital Triage-Revised Trauma Score (T-RTS) and the New Injury Severity Score (NISS). The mortality of polytrauma patients attended to by the emergency system in our region is influenced by age and by the intensity of the aggression suffered, determined by the prehospital T-RTS and by the NISS. The response times of the hospital do not have a significant influence (AU)

[Gender differences in the treatment and outcome of patients with acute coronary syndrome in Navarre]. / Diferencias según sexo en el tratamiento y la evolución de los pacientes afectados de síndrome coronario agudo en Navarra.

BACKGROUND: Gender-based approaches have revealed the differing prevalence, incidence, progression and mortality of acute coronary disease by sex. This study aims to determine the difference by sex in the treatment and outcomes of patients with acute coronary syndrome (ACS) in Navarre. METHODS: Thirty-five variables were analysed from 130 users with acute coronary disease who attended the Navarre Hospital (CHN) emergency department consecutively from January to April 2012. The dependent variable was sex and independent variables were time, treatments and final outcome of the process. RESULTS: Males accounted for 74.6% of the sample, with a mean age of 67, which was less than the mean age of 72 for the female patients (p = 0.043). The median for cardiovascular risk factors was three in men and two in women (p = 0.026). The patient delay in seeking health care was 161 minutes in men compared to 266 minutes in women (p = 0.006). Treatment via revascularization by primary angioplasty or fibrinolysis was performed in 71.6% of men and 41.2% of women (p = 0.002). A 5.9% death rate was registered for women, with no deaths among the men (p = 0.017). CONCLUSIONS: In Navarre, acute coronary syndrome remains more prevalent among men yet more severe in women. Treatment differs according to gender. Greater delay in seeking health care is observed among women, as is self-discharge from hospital, which may contribute to their less favourable outcomes.

Diferencias según sexo en el tratamiento y la evolución de los pacientes afectados de síndrome coronario agudo / Gender differences in the treatment and outcome of patients with acute coronary syndrome

Fundamento: La perspectiva de género en salud nos alerta de la diferente prevalencia, incidencia, evolución y letalidad de las patologías coronarias agudas según sexo. Este estudio pretende conocer la diferencia en el tratamiento y la evolución de los pacientes afectos de Síndrome Coronario Agudo (SCA) según sexos en Navarra. Métodos: Se analizaron 35 variables de 130 usuarios que acudieron consecutivamente al servicio de Urgencias (SU) del Complejo Hospitalario de Navarra (CHN) con patología coronaria aguda desde enero hasta abril de 2012. La variable dependiente fue el sexo y las independientes los tiempos, tratamientos y evolución final del proceso. Resultados: Un 74,6% de la muestra fueron varones con una edad media de 67 años, inferior a los 72 años de la muestra femenina (p=0,043). Se obtuvo una mediana de 3 factores de riesgo cardiovascular (FRC) en los hombres y de dos en las mujeres (p=0,026). El tiempo de demora generado por los pacientes fue de 161 minutos en varones vs 266 minutos en féminas (p=0,006). El tratamiento llevado a cabo mediante revascularización por angioplastia primaria (AP) o fibrinolisis se realizó en un 71,6% de los hombres y un 41,2% de las mujeres (p=0,002). Se registró un 5,9% de muertes en mujeres, sin hallarse casos de fallecimiento en varones (p=0,017). Conclusiones: En Navarra, los procesos coronarios siguen siendo una patología de predominio masculino pero de mayor gravedad en mujeres. El tratamiento se realizó de forma distinta según sexo. Se observó un mayor retraso en la solicitud de atención sanitaria en las mujeres así como la presencia de alta voluntaria en ellas, lo que puede influir en la peor evolución de las mismas (AU)

Background: Gender-based approaches have revealed the differing prevalence, incidence, progression and mortality of acute coronary disease by sex. This study aims to determine the difference by sex in the treatment and outcomes of patients with acute coronary syndrome (ACS) in Navarre. Methods: Thirty-five variables were analysed from 130 users with acute coronary disease who attended the Navarre Hospital (CHN) emergency department consecutively from January to April 2012. The dependent variable was sex and independent variables were time, treatments and final outcome of the process. Results: Males accounted for 74.6% of the sample, with a mean age of 67, which was less than the mean age of 72 for the female patients (p = 0.043). The median for cardiovascular risk factors was three in men and two in women (p = 0.026). The patient delay in seeking health care was 161 minutes in men compared to 266 minutes in women (p = 0.006). Treatment via revascularization by primary angioplasty or fibrinolysis was performed in 71.6% of men and 41.2% of women (p = 0.002). A 5.9% death rate was registered for women, with no deaths among the men (p = 0.017). Conclusions: In Navarre, acute coronary syndrome remains more prevalent among men yet more severe in women. Treatment differs according to gender. Greater delay in seeking health care is observed among women, as is self-discharge from hospital, which may contribute to their less favourable outcomes (AU)

Variación de las características y epidemiología de los pacientes con neumonía adquirida en la comunidad atendidos en los servicios de urgencias hospitalarios / Variation of the characteristics and epidemiology of patients with pneumonia acquired in the community treated in hospital A and E services

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Sobre la aplicación informática “Geolocalización de caseríos de Baztan en la atención de Emergencia” / On the computer geolocation application of Baztan farmhouses in emergency care

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Implantado en Navarra el primer registro de politraumatizados de base poblacional en España / Implementation of the first Spanish population-based register for multiple-injury cases in Navarre

Se describen las características técnicas del primer registro de politraumatizados de base poblacional desarrollado en España (actualmente en fase de producción) así como la arquitectura informática, características técnicas, variables, estrategia de detección de casos, introducción y mantenimiento de los mismos y control de calidad de la base de datos. Entre el 1 de enero de 2010 y 31 de diciembre de 2011 se han recogido 243 casos. El sistema gestionado por un administrador ha soportado la entrada de 97 usuarios correspondientes a 7 servicios diferentes. El nivel de cumplimentación de las 63 variables fue del 90%. La mortalidad observada fue del 27%. Los tiempos de respuesta (llamada–entrada en el hospital, entrada en el hospital– realización de la primera tomografía computarizada, o primera intervención clave) son similares a los observados en otros registros europeos. En este momento tenemos operativo en Navarra el primer registro de politraumatizados español basado en el estilo Utstein. Su arquitectura informática nos permite introducir información de forma prospectiva y retrospectiva desde diferentes servicios con la participación de todos los escalones que atienden al paciente politraumatizado. Dicho registro nos ha permitido conocer las características de los politraumatizados, la calidad de la atención sanitaria, compararnos con otros sistemas y disponer de una base para que profesionales del Servicio Navarro de Salud dispongan de datos para sus investigaciones (AU)

To describe the technical features of the first population-based register for multiple-injury cases to be developed in Spain. Description of the system architecture and technical features of this population-based register, including the variables in the database, the case-finding strategy used, data inputting and maintenance, and quality control. Between January 1,2010 and December 31, 2011, we found 243 cases. The system was supervised by a database administrator and allowed97 users in 7 different departments to enter data. The level of reporting of 63 variables was 90%. Mortality was 27%.Response times (emergency call to hospital arrival and hospital arrival to first computed tomography scan or first key intervention) were similar to those recorded in other European registers. The first Utstein-style register for multipleinjuries in Spain is now being used in Navarre. The system architecture allows us to collect information prospectively and retrospectively from all who treat multiple-injury patients no matter their position on the staff of various hospital departments. This register has helped us determine the characteristics of multiple-injury patients and the quality of care they receive. We have been able to compare our setting with others’ and have provided a source of data for researchers in the Navarre health service (AU)

Respuesta de los autores: Suicidios violentos y fuentes forenses / No disponible

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Politraumatizados con intencionalidad suicida. Estudio epidemiológico de base poblacional en Navarra durante los años 2004-2005 / Severe multiple injuries after suicide attempts: population-based epidemiologic study in Navarre, Spain, between 2004 and 2005

Se estudia las características epidemiológicas de los politraumatizados atendidos por el Sistema de Emergencias de Navarra los años 2004 y 2005 cuya motivación fue el suicidio. Para ello, se incluyó pacientes con una o varias lesiones traumáticas graves, producidas por energía mecánica, que pueden comprometer su vida o provocar graves secuelas, y cuya intencionalidad fue el suicidio. Se incluyeron pacientes que en el momento de su atención presentaron un New Injury Severity Score (NISS) superior a 15 o fallecieron. La tasa de incidencia anual por 100.000 habitantes fue de 5,7. La relación hombres: mujeres fue de 3:1. El mecanismo más frecuentemente utilizado es la precipitación de altura, en segundo lugar el atropello por ferrocarril y las lesiones por arma de fuego en tercer lugar. Falleció el 80% de los pacientes, con una edad media de 50 años. La mujer utiliza preferentemente la precipitación de altura y el hombre también otros métodos. El NISS medio fue de 37 puntos. Se concluye que el suicidio por métodos violentos presenta bajas tasas de incidencia en Navarra. Es un método con una alta mortalidad por la gravedad de las lesiones es utilizado fundamentalmente por varones. Las mujeres utilizan preferentemente la precipitación de altura mientras que los hombres utilizan también otros métodos (AU)

We to study the epidemiologic characteristics of patients with multiple injuries after attempted suicide who were treated by the emergency health system of Navarre between 2004 and 2005. The patients that had 1 or more severe injuries from mechanical force after a suicide attempt were included. The injuries were life-threatening or could be the cause of severe complications or sequelae. An inclusion criterion was a New Injury Severity Score (NISS) of more than 15, or death. The annual incidence of such injuries was 5.7 per 100 000 population. The ratio of men to women was 3:1. In order of frequency, the most common methods were jumping from a high place, jumping in front of an oncoming train, and gunshot. Eighty percent of the patients died. The mean age was 50 years. Jumping from heights was chosen most often by both men and women, but men also chose the other methods (train and gunshot) more often than women. The mean NISS was 37 points. We conclude that the incidence of violent suicide is low in Navarre. Mortality is high because of the severity of injuries caused by the methods chosen mainly by men. Women mainly choose jumping from heights whereas men use additional methods (AU)

[Risk for injuries in traffic accidents among drivers under the effect of alcohol in Navarra]. / El riesgo de lesión en accidente de tráfico por conducir bajo los efectos del alcohol en Navarra.

We conducted a retrospective analysis of the levels of alcohol in the blood of a group of 54 drivers who required hospital emergency care after having suffered a traffic accident on roads in the Health Area III of Navarra (Spain) from June to September 1989, and compared them to another group of 219 drivers, not victims of traffic accidents, submitted to the breathalyser (test of alcoholaemia) on the roads of the same Health Area over the same period of time. In the group of 54 accident victims, the median alcoholaemia was 100 mg/dl, with a quartile deviation of 88 mg/dl, and the percentage of positives (alcoholaemia equal to or greater than 80 mg/dl) was 50.9%. In the group of 219 drivers not victims of traffic accidents, the median alcoholaemia was 16 mg/dl, the quartile deviation 18.5 mg/dl and the percentage of positive alcoholaemia was 1.8%. Drivers with a level of blood alcohol equal to or greater than 80 mg/dl have an estimated risk (Odds Ratio) of being injured in a traffic accident 55.82 times higher than drivers with a lower level.

[Voluntary acute drug poisoning in the health unit Navarra I, in 1989. Descriptive epidemiologic study]. / "Intoxicaciones medicamentosas agudas voluntarias--IMAV--en el área sanitaria Navarra I, durante 1989. Estudio epidemiológico descriptivo".

Acute voluntary medicinal intoxications (AVMI) constitute a serious social-medical problem, frequently related to other problems, such as drug addiction and psychopathies. By means of a prospective study of AVMI cases seen in 1989 by the Emergency Room of Internal Medicine in our Hospital, and for persons over the age of 13 in the Health Area Navarra I, we can conclude that there is an incidence of 70.4/100,000 inhabitants, with a relative and absolute majority of females and of residents in urban areas. One third of cases had psychopathological case histories, while another third have a prior history of drug and/or alcohol abuse. The majority of patients are under 30. The peristaltic data seem to have only a tenuous relationship to the onset of AVMI, which mainly occurs at night. In 85% of cases, we are able to determine the causing factor. Psychopharmaceuticals are present in more than 60% of autolytic cases, the highest frequency belonging to benzodiazepines. In our environment, there is a high percentage of admittances despite the fact that a positive outcome is reached in virtually all cases: only 1 exitus out of 103 cases.