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Nilsbakken I, Wisborg T, Sollid S, Jeppesen E. Functional outcome and associations with prehospital time and urban-remote disparities in trauma: A Norwegian national population-based study. Injury 2024; 55:111459. [PMID: 38490851 DOI: 10.1016/j.injury.2024.111459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 02/03/2024] [Accepted: 02/25/2024] [Indexed: 03/17/2024]
Abstract
BACKGROUND There is a lack of knowledge regarding the functional outcomes of patients after trauma. Remote areas in Norway has been associated with an increased risk of trauma-related mortality. However, it is unknown how this might influence trauma-related morbidity. The aim of this study was to assess the functional outcomes of patients in the Norwegian trauma population and the relationship between prehospital time and urban-remote disparities on functional outcome. METHODS This registry-based study included 34,611 patients from the Norwegian Trauma Registry from 2015 - 2020. Differences in study population characteristics and functional outcomes as measured on the Glasgow Outcome Scale (GOS) at discharge were analysed. Three multinomial regression models were performed to assess the association between total prehospital time and urban-remote disparities and morbidity reported as GOS categories. RESULTS Ninety-four per cent of trauma patients had no disability or moderate disability at discharge. Among patients with severe disability or vegetative state, 81 % had NISS > 15. Patients with fall-related injuries had the highest proportion of severe disability or vegetative state. Among children and adults, every minute increase in total prehospital time was associated with higher odds of moderate disability. Urban areas were associated with higher odds of moderate disability in all age groups, whereas remote areas were associated with higher odds of severe disability or vegetative state in elderly patients. NISS was associated with a worse functional outcome. CONCLUSIONS The majority of trauma patients admitted to a trauma hospital in Norway were discharged with minimal change in functional outcome. Patients with severe injuries (NISS > 15) and patients with injuries from falls experienced the greatest decline in function. Every minute increase in total prehospital time was linked to an increased likelihood of moderate disability in children and adults. Furthermore, incurring injuries in urban areas was found to be associated with higher odds of moderate disability in all age groups, while remote areas were found to be associated with higher odds of severe disability or vegetative state in elderly patients.
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Affiliation(s)
- Imw Nilsbakken
- Department of Research, Norwegian Air Ambulance Foundation, Oslo, Norway; Faculty of Health Sciences, University of Stavanger, Stavanger, Norway.
| | - T Wisborg
- Interprofessional rural research team - Finnmark, Faculty of Health Sciences, University of Tromsø - the Arctic University of Norway, Tromsø, Norway; Norwegian National Advisory Unit on Trauma, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway; Hammerfest Hospital, Department of Anaesthesiology and Intensive Care, Finnmark Health Trust, Hammerfest, Norway.
| | - S Sollid
- Prehospital Division, Oslo University Hospital, Oslo, Norway; Faculty of Medicine, University of Oslo, Oslo, Norway.
| | - E Jeppesen
- Faculty of Health Sciences, University of Stavanger, Stavanger, Norway; Faculty of Health Studies, VID Specialized University, Oslo, Norway.
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Grevfors N, Lindblad C, Nelson DW, Svensson M, Thelin EP, Rubenson Wahlin R. Delayed Neurosurgical Intervention in Traumatic Brain Injury Patients Referred From Primary Hospitals Is Not Associated With an Unfavorable Outcome. Front Neurol 2021; 11:610192. [PMID: 33519689 PMCID: PMC7839281 DOI: 10.3389/fneur.2020.610192] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Accepted: 12/03/2020] [Indexed: 01/29/2023] Open
Abstract
Background: Secondary transports of patients suffering from traumatic brain injury (TBI) may result in a delayed management and neurosurgical intervention, which is potentially detrimental. The aim of this study was to study the effect of triaging and delayed transfers on outcome, specifically studying time to diagnostics and neurosurgical management. Methods: This was a retrospective observational cohort study of TBI patients in need of neurosurgical care, 15 years and older, in the Stockholm Region, Sweden, from 2008 throughout 2014. Data were collected from pre-hospital and in-hospital charts. Known TBI outcome predictors, including the protein biomarker of brain injury S100B, were used to assess injury severity. Characteristics and outcomes of direct trauma center (TC) and those of secondary transfers were evaluated and compared. Functional outcome, using the Glasgow Outcome Scale, was assessed in survivors at 6–12 months after trauma. Regression models, including propensity score balanced models, were used for endpoint assessment. Results: A total of n = 457 TBI patients were included; n = 320 (70%) patients were direct TC transfers, whereas n = 137 (30%) were secondary referrals. In all, n = 295 required neurosurgery for the first 24 h after trauma (about 75% of each subgroup). Direct TC transfers were more severely injured (median Glasgow Coma Scale 8 vs. 13) and more often suffered a high energy trauma (31 vs. 2.9%) than secondary referrals. Admission S100B was higher in the TC transfer group, though S100B levels 12–36 h after trauma were similar between cohorts. Direct or indirect TC transfer could be predicted using propensity scoring. The secondary referrals had a shorter distance to the primary hospital, but had later radiology and surgery than the TC group (all p < 0.001). In adjusted multivariable analyses with and without propensity matching, direct or secondary transfers were not found to be significantly related to outcome. Time from trauma to surgery did not affect outcome. Conclusions: TBI patients secondary transported to a TC had surgical intervention performed hours later, though this did not affect outcome, presumably demonstrating that accurate pre-hospital triaging was performed. This indicates that for selected patients, a wait-and-see approach with delayed neurosurgical intervention is not necessarily detrimental, but warrants further research.
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Affiliation(s)
- Niklas Grevfors
- Division of Perioperative Medicine and Intensive Care (PMI), Department of Anesthesiology, Karolinska University Hospital, Stockholm, Sweden
| | - Caroline Lindblad
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - David W Nelson
- Division of Perioperative Medicine and Intensive Care (PMI), Department of Anesthesiology, Karolinska University Hospital, Stockholm, Sweden.,Section of Anesthesiology and Intensive Care, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Mikael Svensson
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden
| | - Eric Peter Thelin
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
| | - Rebecka Rubenson Wahlin
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden.,Department of Anesthesia and Intensive Care, Södersjukhuset, Stockholm, Sweden.,Ambulance Medical Service in Stockholm (Ambulanssjukvården i Storstockholm AB), Stockholm, Sweden.,Academic EMS, Stockholm, Sweden
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Bedard AF, Mata LV, Dymond C, Moreira F, Dixon J, Schauer SG, Ginde AA, Bebarta V, Moore EE, Mould-Millman NK. A scoping review of worldwide studies evaluating the effects of prehospital time on trauma outcomes. Int J Emerg Med 2020; 13:64. [PMID: 33297951 PMCID: PMC7724615 DOI: 10.1186/s12245-020-00324-7] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 11/21/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Annually, over 1 billion people sustain traumatic injuries, resulting in over 900,000 deaths in Africa and 6 million deaths globally. Timely response, intervention, and transportation in the prehospital setting reduce morbidity and mortality of trauma victims. Our objective was to describe the existing literature evaluating trauma morbidity and mortality outcomes as a function of prehospital care time to identify gaps in literature and inform future investigation. MAIN BODY We performed a scoping review of published literature in MEDLINE. Results were limited to English language publications from 2009 to 2020. Included articles reported trauma outcomes and prehospital time. We excluded case reports, reviews, systematic reviews, meta-analyses, comments, editorials, letters, and conference proceedings. In total, 808 articles were identified for title and abstract review. Of those, 96 articles met all inclusion criteria and were fully reviewed. Higher quality studies used data derived from trauma registries. There was a paucity of literature from studies in low- and middle-income countries (LMIC), with only 3 (3%) of articles explicitly including African populations. Mortality was an outcome measure in 93% of articles, predominantly defined as "in-hospital mortality" as opposed to mortality within a specified time frame. Prehospital time was most commonly assessed as crude time from EMS dispatch to arrival at a tertiary trauma center. Few studies evaluated physiologic morbidity outcomes such as multi-organ failure. CONCLUSION The existing literature disproportionately represents high-income settings and most commonly assessed in-hospital mortality as a function of crude prehospital time. Future studies should focus on how specific prehospital intervals impact morbidity outcomes (e.g., organ failure) and mortality at earlier time points (e.g., 3 or 7 days) to better reflect the effect of early prehospital resuscitation and transport. Trauma registries may be a tool to facilitate such research and may promote higher quality investigations in Africa and LMICs.
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Affiliation(s)
- Alexander F Bedard
- University of Colorado, Anschutz Medical Campus, 13001 E 17th Place, Aurora, CO, 80045, USA.
- United States Air Force Medical Corps, 7700 Arlington Boulevard, Falls Church, VA, 22042, USA.
| | - Lina V Mata
- University of Colorado, Anschutz Medical Campus, 13001 E 17th Place, Aurora, CO, 80045, USA
| | - Chelsea Dymond
- University of Colorado, Anschutz Medical Campus, 13001 E 17th Place, Aurora, CO, 80045, USA
- Denver Health and Hospital Authority, 777 Bannock St, Denver, CO, 80204, USA
| | - Fabio Moreira
- Western Cape Government, Emergency Medical Services, 9 Wale Street, Cape Town, 8001, South Africa
| | - Julia Dixon
- University of Colorado, Anschutz Medical Campus, 13001 E 17th Place, Aurora, CO, 80045, USA
| | - Steven G Schauer
- US Army Institute of Surgical Research, 3698 Chambers Rd., San Antonio, TX, 78234, USA
| | - Adit A Ginde
- University of Colorado, Anschutz Medical Campus, 13001 E 17th Place, Aurora, CO, 80045, USA
| | - Vikhyat Bebarta
- University of Colorado, Anschutz Medical Campus, 13001 E 17th Place, Aurora, CO, 80045, USA
| | - Ernest E Moore
- University of Colorado, Anschutz Medical Campus, 13001 E 17th Place, Aurora, CO, 80045, USA
- Ernest E. Moore Shock Trauma Center at Denver Health, 777 Bannock St, Denver, CO, 80204, USA
| | - Nee-Kofi Mould-Millman
- University of Colorado, Anschutz Medical Campus, 13001 E 17th Place, Aurora, CO, 80045, USA
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Sörbo A, Eiving I, Theodorsson E, Rydenhag B, Jonsdottir IH. Pre-traumatic conditions can influence cortisol levels before and after a brain injury. Acta Neurol Scand 2020; 141:342-350. [PMID: 31879940 DOI: 10.1111/ane.13212] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Revised: 12/01/2019] [Accepted: 12/21/2019] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Satisfactory anabolic reactions, including the activation of the hypothalamic-pituitary-adrenal (HPA) axis, are essential following severe traumatic brain injury (TBI) and aneurysmal subarachnoid hemorrhage (SAH). Many factors may influence this activation. This study aimed to investigate whether individuals who reported chronic diseases, psychosocial afflictions, or stressful events before a severe brain injury display a different pattern regarding cortisol levels retrospectively and up to three months compared with those who did not report stressful experiences. MATERIALS AND METHODS Fifty-five patients aged 16-68 years who were admitted to the neurointensive care unit (NICU) were included. Hair cortisol measurements offer a unique opportunity to monitor cortisol levels retrospectively and after the trauma. Hair strands were collected as soon as possible after admission to the NICU and every month until three months after the injury/insult. The participants/relatives were asked about stressful events, psychosocial afflictions and recent and chronic diseases. RESULTS The group who reported chronic diseases and/or stressful events before the brain injury had more than twice as high median hair cortisol levels before the brain injury compared with those who did not report stress, but the difference was not statistically significant (P = .12). Those who reported stress before the brain injury had statistically significantly lower hair cortisol values after the brain injury and they remained until three months after the injury. CONCLUSIONS Stressful events and/or chronic disease before brain injury might affect mobilization of adequate stress reactions following the trauma. However, the large variability in cortisol levels in these patients does not allow firm conclusions and more studies are needed.
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Affiliation(s)
- Ann Sörbo
- Department of Neurology and Rehabilitation Södra Älvsborg Hospital Borås Sweden
- Department of Neurology and Rehabilitation Uddevalla Hospital Uddevalla Sweden
- Institute of Neuroscience and Physiology Sahlgrenska Academy University of Gothenburg Gothenburg Sweden
| | - Ingrid Eiving
- Neurointensive Care Unit Department of Anesthesiology and Intensive Care Sahlgrenska University Hospital Gothenburg Sweden
| | - Elvar Theodorsson
- Department of Clinical Chemistry and Department of Clinical and Experimental Medicine Linköping University Linköping Sweden
| | - Bertil Rydenhag
- Institute of Neuroscience and Physiology Sahlgrenska Academy University of Gothenburg Gothenburg Sweden
- Department of Neurosurgery Sahlgrenska University Hospital Gothenburg Sweden
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Olivecrona Z, Dahlqvist P, Koskinen LOD. Acute neuro-endocrine profile and prediction of outcome after severe brain injury. Scand J Trauma Resusc Emerg Med 2013; 21:33. [PMID: 23601250 PMCID: PMC3637196 DOI: 10.1186/1757-7241-21-33] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2012] [Accepted: 04/02/2013] [Indexed: 01/24/2023] Open
Abstract
OBJECT The aim of the study was to evaluate the early changes in pituitary hormone levels after severe traumatic brain injury (sTBI) and compare hormone levels to basic neuro-intensive care data, a systematic scoring of the CT-findings and to evaluate whether hormone changes are related to outcome. METHODS Prospective study, including consecutive patients, 15-70 years, with sTBI, Glasgow Coma Scale (GCS) score ≤ 8, initial cerebral perfusion pressure > 10 mm Hg, and arrival to our level one trauma university hospital within 24 hours after head trauma (n = 48). Serum samples were collected in the morning (08-10 am) day 1 and day 4 after sTBI for analysis of cortisol, growth hormone (GH), prolactin, insulin-like growth factor 1 (IGF-1), thyroid-stimulating hormone (TSH), free triiodothyronine (fT3), free thyroxine (fT4), follicular stimulating hormone (FSH), luteinizing hormone (LH), testosterone and sex hormone-binding globulin (SHBG) (men). Serum for cortisol and GH was also obtained in the evening (17-19 pm) at day 1 and day 4. The first CT of the brain was classified according to Marshall. Independent staff evaluated outcome at 3 months using GOS-E. RESULTS Profound changes were found for most pituitary-dependent hormones in the acute phase after sTBI, i.e. low levels of thyroid hormones, strong suppression of the pituitary-gonadal axis and increased levels of prolactin. The main findings of this study were: 1) A large proportion (54% day 1 and 70% day 4) of the patients showed morning s-cortisol levels below the proposed cut-off levels for critical illness related corticosteroid insufficiency (CIRCI), i.e. <276 nmol/L (=10 ug/dL), 2) Low s-cortisol was not associated with higher mortality or worse outcome at 3 months, 3) There was a significant association between early (day 1) and strong suppression of the pituitary-gonadal axis and improved survival and favorable functional outcome 3 months after sTBI, 4) Significantly lower levels of fT3 and TSH at day 4 in patients with a poor outcome at 3 months. 5) A higher Marshall CT score was associated with higher day 1 LH/FSH- and lower day 4 TSH levels 6) In general no significant correlation between GCS, ICP or CPP and hormone levels were detected. Only ICPmax and LH day 1 in men was significantly correlated. CONCLUSION Profound dynamic changes in hormone levels are found in the acute phase of sTBI. This is consistent with previous findings in different groups of critically ill patients, most of which are likely to be attributed to physiological adaptation to acute illness. Low cortisol levels were a common finding, and not associated with unfavorable outcome. A retained ability to a dynamic hormonal response, i.e. fast and strong suppression of the pituitary-gonadal axis (day 1) and ability to restore activity in the pituitary-thyroid axis (day 4) was associated with less severe injury according to CT-findings and favorable outcome.
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Affiliation(s)
- Zandra Olivecrona
- Department of Pharmacology and Clinical Neuroscience, Division of Neurosurgery, Umeå University, SE 90185, Umeå, Sweden
| | - Per Dahlqvist
- Department of Public Health and Clinical Medicine, Umeå University, SE 90185, Umeå, Sweden
| | - Lars-Owe D Koskinen
- Department of Pharmacology and Clinical Neuroscience, Division of Neurosurgery, Umeå University, SE 90185, Umeå, Sweden
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Chang LC, Raty SR, Ortiz J, Bailard NS, Mathew SJ. The emerging use of ketamine for anesthesia and sedation in traumatic brain injuries. CNS Neurosci Ther 2013; 19:390-5. [PMID: 23480625 DOI: 10.1111/cns.12077] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2012] [Revised: 01/15/2013] [Accepted: 01/26/2013] [Indexed: 01/02/2023] Open
Abstract
Traditionally, the use of ketamine for patients with traumatic brain injuries is contraindicated due to the concern of increasing intracranial pressure (ICP). These concerns, however, originated from early studies and case reports that were inadequately controlled and designed. Recently, the concern of using ketamine in these patients has been challenged by a number of published studies demonstrating that the use of ketamine was safe in these patients. This article reviews the current literature in regards to using ketamine in patients with traumatic brain injuries in different clinical settings associated with anesthesia, as well as reviews the potential mechanisms underlying the neuroprotective effects of ketamine. Studies examining the use of ketamine for induction, maintenance, and sedation in patients with TBI have had promising results. The use of ketamine in a controlled ventilation setting and in combination with other sedative agents has demonstrated no increase in ICP. The role of ketamine as a neuroprotective agent in humans remains inconclusive and adequately powered; randomized controlled trials performed in patients undergoing surgery for traumatic brain injury are necessary.
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Affiliation(s)
- Lee C Chang
- Department of Anesthesiology, Baylor College of Medicine, Houston, TX 77030, USA.
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Gilbert M, Sollid S. Good results from advanced trauma care in rural areas. Acta Anaesthesiol Scand 2011; 55:905-6. [PMID: 22092163 DOI: 10.1111/j.1399-6576.2011.02482.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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