Johan Pillgram-Larsen

Long-term prevalence of impairments and disabilities after multiple trauma.

The prevalence of impairments and disabilities in activities of daily living (ADL), nonwork activities, and work were registered in a consecutive series (n = 69) of subjects with severe injuries. At follow-up 3 years after trauma, residual impairments prevailed in 80%. Only a few (6%) were ADL-dependent. Seventy-six percent had lost at least one nonwork activity, while vocational disability caused by the trauma occurred in 19%. Cognitive impairment was significantly associated with vocational disability, while physical impairment and pain were significantly associated with nonwork disability. Other parameters that influenced vocational disability negatively were age and blue-collar employment status. Although overall changes in social network quantity and quality were small, significantly more subjects with cognitive impairment or vocational disability experienced a decline in the quality and quantity of their social network after trauma. Furthermore, 25% of the subjects reported an increase in feelings of loneliness after trauma. We recommend the design of individualized, multidisciplinary rehabilitation plans before discharge from departments of surgery.

Scandinavian guidelines - "The massively bleeding patient"

c. gaarder, Trauma Unit, Ullevål University Hospital, Oslo, Norway p. a. naess, Trauma Unit, Ullevål University Hospital, Oslo, Norway e. Frischknecht christensen, Aarhus Trauma Centre, Aarhus University Hospital, Denmark p. hakala, Department of Anaesthesia and Intensive Care, Helsinki University Hospital, Finland l. handolin, Department of Orthopaedics and Traumatology, Helsinki University Hospital, Finland h. e. heier, Department of Immunology and Transfusion Medicine, Ullevål University Hospital, Oslo, Norway K. ivancev, Endovascular Centre, Malmö University Hospital, Malmö, Sweden p. Johansson, Department of Clinical Immunology, Rigshospitalet, Copenhagen, Denmark a. leppäniemi, Department of Surgery, Meilahti Hospital, University of Helsinki, Helsinki, Finland F. lippert, Department of Anaesthesia and Intensive Care, Rigshospitalet, Copenhagen, Denmark h. m. lossius, Norwegian Air Ambulance, Drøbak, Norway h. Opdahl, Intensive Care Unit/NBC centre, Ullevål University Hospital, Oslo, Norway J. pillgram-larsen, Department of Cardiothoracic Surgery, Ullevål University Hospital, Oslo, Norway O. Røise, Orthopaedic Centre, Ullevål University Hospital, Oslo, Norway n. O. skaga, Department of Anaesthesia, Ullevål University Hospital, Oslo, Norway e. søreide, Department of Anaesthesia and Intensive Care, Stavanger University Hospital, Stavanger, Norway J. stensballe, Department of Anaesthesia, Rigshospitalet, Copenhagen, Denmark e. Tønnessen, Department of Anaesthesia and Intensive Care, Aarhus University Hospital, Aarhus, Denmark a. Töttermann, Department of Orthopaedics, Uppsala University Hospital, Uppsala, Sweden p. ́́ Ortenwall, Trauma Unit, Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden a. ́́ Ostlund, Department of Anaesthesia and Intensive care, Karolinska University Hospital, Stockholm, Sweden

Complement activation in injured patients occurs immediately and is dependent on the severity of the trauma

In order to study the factors related to complement activation, the complement activation products C3bc and TCC were measured in plasma at admittance and during the stay in the intensive care unit in 108 consecutive patients with multiple injuries. These patients were admitted to the surgical department during a 4-month period. Complement activation occurred immediately after the trauma and correlated strongly with the Injury Severity Score and was inversely correlated to the Base Excess. Complement activation also correlated with the number of transfusions. Sepsis caused complement activation later during the stay in hospital. All seven patients developing the adult respiratory distress syndrome (ARDS) had increased complement activation, either on admission or later during the stay in the intensive care unit. Complement activation is known to contribute to organ damage following ischemia and reperfusion. Clinical studies have demonstrated the importance of early restoration of adequate circulation and the present demonstration of a strong negative correlation between complement activation and Base Excess indicates that early restoration of aerobic metabolism may reduce complement activation and the risk for organ dysfunction.

Cognitive performance in multiple trauma patients 3 years after injury.

OBJECTIVES Patients with sequelae from multiple trauma commonly display cognitive disturbances, specifically in the areas of attention and memory. This study was designed to assess cognitive functioning 3 years after severe multiple trauma and to investigate how cognitive performance is related to head injury severity and psychological distress respectively. METHODS Sixty-eight multiple trauma patients were tested with a screening battery consisting of six neuropsychological tasks 3 years after injury. A measure of psychological distress (20-item General Health Questionnaire, or GHQ-20) was also administered. RESULTS Patients who neither showed signs of reduced consciousness on admission to the hospital nor reported significant psychological distress at follow-up tended to have normal test performance. In five of the six tasks, cognitive impairment was related to the severity of the traumatic brain injury as measured by the Glasgow Coma Scale (GCS). In both attention span tasks, patients designated as cases by the GHQ had significantly lower scores than noncase patients. These bivariate relationships were upheld in multiple regression analyses, in which age, sex, and GCS and GHQ scores were entered as independent variables. When patients with severe head injuries were excluded from the analyses, GCS scores still contributed to the variance in tests of verbal attention span and delayed recall, but performance on attentional tasks was more strongly related to psychological distress than to GCS scores. CONCLUSIONS Cognitive deficits in multiple trauma patients were related both to the severity of the traumatic brain injury and to the degree of psychological distress. The strength of the association between brain injury as indicated by GCS scores and cognitive performance differed between different tasks. Neuropsychological testing may assist in differentiating primary organic from secondary psychogenic impairments.

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 hospitals 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.

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.

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.

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.

Initial axial computerized tomography examination in chest injuries

A total of 41 injured patients examined by both chest radiography and axial computerized tomography (CT) of the chest within the first 24 h after the accident were reviewed. In all, 10 patients died, eight from cerebral or cervical injuries, two from haemorrhage. Of the 27 cases with a haemothorax, 13 were seen on a chest radiograph. In only one case was a haemothorax seen on CT large enough to warrant intervention. CT revealed one minor pneumothorax. Nine patients already treated with a chest drain had some residual air demonstrated by CT, two being significant pneumothoraces. CT showed 28 cases of lung contusion as opposed to 23 on a chest radiograph. Of five cases with a mediastinal haematoma, three were seen on a chest radiograph, including the only patient with aortic rupture. Clinically important pathology was revealed in ordinary chest radiographs. Contusions, small pneumothoraces and minor effusions were sometimes overlooked. CT scan of the chest alone is rarely warranted in the injured patient, given a liberal indication for chest drainage and ready access to arch aortography.

Assessment of probability of survival in penetrating injuries using the TRISS methodology

By the TRISS methodology, probability of survival in injury can be estimated. It is based on a statistical analysis of outcome which is influenced by the severity of the injuries as expressed in the Injury Severity Score (ISS), the physiological function as expressed in the Trauma Score (TS) and the patients age. We have used the TRISS formula in 206 patients with penetrating injury. Of these patients, 149 sustained stab wounds, 32 gunshot wounds and 25 others. ISS ranged from 2 to 38, the mean ISS being 9. The function was good (TS greater than 14) in 85 per cent. Estimated probability of survival ranged from 1.00 to 0.42. Three patients (1.5 per cent) died. The probability of their survival was 0.92, 0.96 and 0.98, respectively. All the fatal cases had serious predisposing conditions: chronic pulmonary disease, alcoholism, and psychiatric illness. In penetrating injury, the patients functional status at the start of treatment is of greater importance for the outcome than the anatomical severity. The concept of the methodology of TRISS for assessment of probability of survival seems useful for review and comparison in injury care.