Rebecca Maria Hasler

Systolic blood pressure below 110 mmHg is associated with increased mortality in penetrating major trauma patients: Multicentre cohort study

INTRODUCTION Non-invasive systolic blood pressure (SBP) measurement is often used in triaging trauma patients. Traditionally, SBP< 90 mm Hg has represented the threshold for hypotension, but recent studies have suggested redefining hypotension as SBP < 110 mm Hg. This study aims to examine the association of SBP with mortality in blunt trauma patients. METHODS This is an analysis of prospectively recorded data from adult (≥ 16 years) blunt trauma patients. Included patients presented to hospitals belonging to the Trauma Audit and Research Network (TARN) between 2000 and 2009. The primary outcome was the association of SBP and mortality rates at 30 days. Multivariate logistic regression models were used to adjust for the influence of age, gender, Injury Severity Score (ISS) and Glasgow Coma Score (GCS) on mortality. RESULTS 47,927 eligible patients presented to TARN hospitals during the study period. Sample demographics were: median age: 51.1 years (IQR=32.8-67.4); male 60% (n=28,694); median ISS 9 (IQR=8-10); median GCS 15 (IQR=15-15); and median SBP 135 mm Hg (IQR=120-152). We identified SBP< 110 mm Hg as a cut off for hypotension, where a significant increase in mortality was observed. Mortality rates doubled at < 100 mm Hg, tripled at < 90 mm Hg and were 5- to 6-fold at < 70 mm Hg, irrespective of age. CONCLUSION We recommend triaging adult blunt trauma patients with a SBP< 110 mm Hg to resuscitation areas within dedicated trauma units for close monitoring and appropriate management.

Severe spinal injuries in alpine skiing and snowboarding: a 6-year review of a tertiary trauma centre for the Bernese Alps ski resorts, Switzerland

Objective: To analyse the epidemiological data, injury pattern, clinical features and mechanisms of severe spinal injuries related to alpine skiing and snowboarding. Study design: A six-year review of all adult patients with severe spinal injuries sustained from alpine skiing or snowboarding. Setting: Tertiary trauma centre in Bern, Switzerland. Patients and methods: All adult patients (over 16 years of age) admitted to a tertiary trauma centre from 1 July 2000, through 30 June 2006, were reviewed using a computerised database. From these records, a total of 728 patients injured from snow sports were identified. Severe spinal injuries (defined as spinal fractures, subluxations, dislocations or concomitant spinal cord injuries) were found in 73 patients (17 female, 56 male). The clinical features of these patients were reviewed with respect to epidemiological factors, mechanism of injury, fracture pattern, and neurological status. Results: The majority of severe spinal injuries (n = 63) were related to skiing. Fatal central-nervous injuries and transient or persistent neurological symptoms occurred in 28 patients (23 skiers, 5 snowboarders). None of the snowboarders suffered from persistent neurological sequelae. Snowboarders with severe spinal injuries (n = 10) were all male (p<0.05), and were significantly younger than skiers (p<0.001). The most commonly affected site was the lumbar spine. However, 39 patients (53.4%) suffered from injury pattern at two or more levels. Conclusions: With advances in technology and slope maintenance, skiers and snowboarders progress to higher skill levels and faster speeds more rapidly than ever before. Great efforts have been focused on reducing extremity injuries in snow sports, but until recently very little attention has been given to spinal injury prevention on the slopes. Suggestions for injury prevention include the use of spine protectors, participation on appropriate runs for ability level, proper fit and adjustment of equipment, and taking lessons with the goal of increasing ability and learning hill etiquette.

Epidemiology and predictors of cervical spine injury in adult major trauma patients: a multicenter cohort study

BACKGROUND: Patients with cervical spine injuries are a high-risk group, with the highest reported early mortality rate in spinal trauma. METHODS: This cohort study investigated predictors for cervical spine injury in adult (≥ 16 years) major trauma patients using prospectively collected data of the Trauma Audit and Research Network from 1988 to 2009. Univariate and multivariate logistic regression analyses were used to determine predictors for cervical fractures/dislocations or cord injury. RESULTS: A total of 250,584 patients were analyzed. Median age was 47.2 years (interquartile range, 29.8–66.0) and Injury Severity Score 9 (interquartile range, 4–11); 60.2% were male. Six thousand eight hundred two patients (2.3%) sustained cervical fractures/dislocations alone. Two thousand sixty-nine (0.8%) sustained cervical cord injury with/without fractures/dislocations; 39.9% of fracture/dislocation and 25.8% of cord injury patients suffered injuries to other body regions. Age ≥65 years (odds ratio [OR], 1.45–1.92), males (females OR, 0.91; 95% CI, 0.86–0.96), Glasgow Coma Scale (GCS) score <15 (OR, 1.26–1.30), LeFort facial fractures (OR, 1.29; 95% confidence interval [CI], 1.05–1.59), sports injuries (OR, 3.51; 95% CI, 2.87–4.31), road traffic collisions (OR, 3.24; 95% CI, 3.01–3.49), and falls >2 m (OR, 2.74; 95% CI, 2.53–2.97) were predictive for fractures/dislocations. Age <35 years (OR, 1.25–1.72), males (females OR, 0.59; 95% CI, 0.53–0.65), GCS score <15 (OR, 1.35–1.85), systolic blood pressure <110 mm Hg (OR, 1.16; 95% CI, 1.02–1.31), sports injuries (OR, 4.42; 95% CI, 3.28–5.95), road traffic collisions (OR, 2.58; 95% CI, 2.26–2.94), and falls >2 m (OR, 2.24; 95% CI, 1.94–2.58) were predictors for cord injury. CONCLUSIONS: 3.5% of patients suffered cervical spine injury. Patients with a lowered GCS or systolic blood pressure, severe facial fractures, dangerous injury mechanism, male gender, and/or age ≥35 years are at increased risk. Contrary to common belief, head injury was not predictive for cervical spine involvement. LEVEL OF EVIDENCE: II.

The association between admission systolic blood pressure and mortality in significant traumatic brain injury: A multi-centre cohort study

INTRODUCTION Low systolic blood pressure (SBP) is an important secondary insult following traumatic brain injury (TBI), but its exact relationship with outcome is not well characterised. Although a SBP of <90 mmHg represents the threshold for hypotension in consensus TBI treatment guidelines, recent studies suggest redefining hypotension at higher levels. This study therefore aimed to fully characterise the association between admission SBP and mortality to further inform resuscitation endpoints. METHODS We conducted a multicentre cohort study using data from the largest European trauma registry. Consecutive adult patients with AIS head scores >2 admitted directly to specialist neuroscience centres between 2005 and July 2012 were studied. Multilevel logistic regression models were developed to examine the association between admission SBP and 30 day inpatient mortality. Models were adjusted for confounders including age, severity of injury, and to account for differential quality of hospital care. RESULTS 5057 patients were included in complete case analyses. Admission SBP demonstrated a smooth u-shaped association with outcome in a bivariate analysis, with increasing mortality at both lower and higher values, and no evidence of any threshold effect. Adjusting for confounding slightly attenuated the association between mortality and SBP at levels <120 mmHg, and abolished the relationship for higher SBP values. Case-mix adjusted odds of death were 1.5 times greater at <120 mmHg, doubled at <100 mmHg, tripled at <90 mmHg, and six times greater at SBP<70 mmHg, p<0.01. CONCLUSIONS These findings indicate that TBI studies should model SBP as a continuous variable and may suggest that current TBI treatment guidelines, using a cut-off for hypotension at SBP<90 mmHg, should be reconsidered.

Are there risk factors for snowboard injuries? A case-control multicentre study of 559 snowboarders

Objective To analyse risk factors leading to injuries during snowboarding. Design A case–control multicentre survey of injured and non-injured snowboarders. Setting One tertiary and two secondary trauma centres in Bern, Switzerland. Methods All snowboard injuries admitted to our tertiary and two affiliated secondary trauma centres from 1 November 2007 to 15 April 2008 were analysed on the basis of a completed questionnaire incorporating 15 variables. The same questionnaire was applied in non-injured controls at valley stations after a snowboarding day during the same period. A multiple logistic regression was performed (dichotomous variables). Patterns of combined risk factors were calculated by inference trees. Results 306 patients and 253 controls were interviewed. The following variables were statistically significant for the injured patients: low readiness for speed (OR 0.20, 95% CI 0.06 to 0.64, p=0.0037), bad weather/visibility (OR 19.06, 95% CI 2.70 to 134.73, p=0.0031) and old snow (OR 0.11, 95% CI 0.02 to 0.68, p=0.0323). Not wearing a helmet and riding on icy slopes emerged as a combination of risk factors associated with injury. Conclusions Several risk factors and combinations exist, and different risk profiles were identified. Future research should be aimed at more precise identification of groups at risk and developing specific recommendations for each group—for example, a snow-weather conditions index at valley stations.

Protective and risk factors in amateur equestrians and description of injury patterns: A retrospective data analysis and a case - control survey

BackgroundIn Switzerland there are about 150,000 equestrians. Horse related injuries, including head and spinal injuries, are frequently treated at our level I trauma centre.ObjectivesTo analyse injury patterns, protective factors, and risk factors related to horse riding, and to define groups of safer riders and those at greater riskMethodsWe present a retrospective and a case-control survey at conducted a tertiary trauma centre in Bern, Switzerland.Injured equestrians from July 2000 - June 2006 were retrospectively classified by injury pattern and neurological symptoms. Injured equestrians from July-December 2008 were prospectively collected using a questionnaire with 17 variables. The same questionnaire was applied in non-injured controls. Multiple logistic regression was performed, and combined risk factors were calculated using inference trees.ResultsRetrospective survey: A total of 528 injuries occured in 365 patients. The injury pattern revealed as follows: extremities (32%: upper 17%, lower 15%), head (24%), spine (14%), thorax (9%), face (9%), pelvis (7%) and abdomen (2%). Two injuries were fatal. One case resulted in quadriplegia, one in paraplegia.Case-control survey61 patients and 102 controls (patients: 72% female, 28% male; controls: 63% female, 37% male) were included. Falls were most frequent (65%), followed by horse kicks (19%) and horse bites (2%). Variables statistically significant for the controls were: Older age (p = 0.015), male gender (p = 0.04) and holding a diploma in horse riding (p = 0.004). Inference trees revealed typical groups less and more likely to suffer injury.ConclusionsExperience with riding and having passed a diploma in horse riding seem to be protective factors. Educational levels and injury risk should be graded within an educational level-injury risk index.

Are there risk factors in alpine skiing? A controlled multicentre survey of 1278 skiers

Objective: To analyse risk factors in alpine skiing. Design: A controlled multicentre survey of injured and non-injured alpine skiers. Setting: One tertiary and two secondary trauma centres in Bern, Switzerland. Patients and methods: All injured skiers admitted from November 2007 to April 2008 were analysed using a completed questionnaire incorporating 15 parameters. The same questionnaire was distributed to non-injured controls. Multiple logistic regression was performed. Patterns of combined risk factors were calculated by inference trees. A total of 782 patients and 496 controls were interviewed. Results: Parameters that were significant for the patients were: high readiness for risk (p = 0.0365, OR 1.84, 95% CI 1.04 to 3.27); low readiness for speed (p = 0.0008, OR 0.29, 95% CI 0.14 to 0.60); no aggressive behaviour on slopes (p<0.0001, OR 0.19, 95% CI 0.09 to 0.37); new skiing equipment (p = 0.0228, OR 59, 95% CI 0.37 to 0.93); warm-up performed (p = 0.0015, OR 1.79, 95% CI 1.25 to 2.57); old snow compared with fresh snow (p = 0.0155, OR 0.31, 95% CI 0.12 to 0.80); old snow compared with artificial snow (p = 0.0037, OR 0.21, 95% CI 0.07 to 0.60); powder snow compared with slushy snow (p = 0.0035, OR 0.25, 95% CI 0.10 to 0.63); drug consumption (p = 0.0044, OR 5.92, 95% CI 1.74 to 20.11); and alcohol abstinence (p<0.0001, OR 0.14, 95% CI 0.05 to 0.34). Three groups at risk were detected: (1) warm-up 3–12 min, visual analogue scale (VAS)speed >4 and bad weather/visibility; (2) VASspeed 4–7, icy slopes and not wearing a helmet; (3) warm-up >12 min and new skiing equipment. Conclusions: Low speed, high readiness for risk, new skiing equipment, old and powder snow, and drug consumption are significant risk factors when skiing. Future work should aim to identify more precisely specific groups at risk and develop recommendations—for example, a snow weather index at valley stations.

Association between Head Injury and Helmet Use in Alpine Skiers: Cohort Study from a Swiss Level I Trauma Center.

The association between helmet use during alpine skiing and incidence and severity of head injuries was analyzed. All patients admitted to a level 1 trauma center for traumatic brain injuries (TBIs) sustained from skiing accidents during the seasons 2000-2001 and 2010-2011 were eligible. Primary outcome was the association between helmet use and severity of TBI measured by Glasgow Coma Scale (GCS), computed tomography (CT) results, and necessity of neurosurgical intervention. Of 1362 patients injured during alpine skiing, 245 (18%) sustained TBI and were included. TBI was fatal in 3%. Head injury was in 76% minor (Glasgow Coma Scale, 13-15), 6% moderate, and 14% severe. Number and percentage of TBI patients showed no significant trend over the investigated seasons. Forty-five percent of the 245 patients had pathological CT findings and 26% of these required neurosurgical intervention. Helmet use increased from 0% in 2000-2001 to 71% in 2010-2011 (p<0.001). The main analysis, comparing TBI in patients with or without a helmet, showed an adjusted odds ratio (OR) of 1.44 (p=0.430) for suffering moderate-to-severe head injury in helmet users. Analyses comparing off-piste to on-slope skiers revealed a significantly increased OR among off-piste skiers of 7.62 (p=0.004) for sustaining a TBI requiring surgical intervention. Despite increases in helmet use, we found no decrease in severe TBI among alpine skiers. Logistic regression analysis showed no significant difference in TBI with regard to helmet use, but increased risk for off-piste skiers. The limited protection of helmets and dangers of skiing off-piste should be targeted by prevention programs.

Accuracy of prehospital diagnosis and triage of a Swiss helicopter emergency medical service.

BACKGROUND Helicopter emergency medical services (HEMSs) have become a standard element of modern prehospital emergency medicine. This study determines the percentage of injured HEMS patients whose injuries were correctly recognized by HEMS physicians. METHODS A retrospective level III evidence prognostic study using data from the largest Swiss HEMS, REGA (Rettungsflugwacht/Guarde Aérienne), on adult patients with trauma transported to a Level I trauma center (January 2006–December 2007). National Advisory Committee on Aeronautics (NACA) scores and the Injury Severity Score (ISS) were assessed to identify severely injured patients. Injured body regions diagnosed by REGA physicians were compared with emergency department discharge diagnoses. RESULTS Four hundred thirty-three patients were analyzed. Median age was 42.1 years (interquartile range, 25.5–57.9). Three hundred twenty-three (74.6%) were men. Patients were severely injured, with an in-hospital NACA score of 4 or higher in 88.7% of patients and median ISS of 13. REGA physicians correctly recognized injuries to the head in 92.9%, to the femur in 90.5%, and to the tibia/fibula in 83.8% of patients. Injuries to these body regions were overdiagnosed in less than 30%. Abdominal injuries were missed in 56.1%, pelvic injuries in 51.8%, spinal injuries in 40.1%, and chest injuries in 31.2% of patients. CONCLUSION This study shows that patients are adequately triaged by REGA physicians reflected by a NACA score 4 or higher in 88.7% of patients and a median ISS of 13. However, recognition of injured body regions seems to be challenging in the prehospital setting. Prospective studies on specific training of HEMS physicians for recognition of these injuries (e.g., portable ultrasonography, telemedicine) might help in the future. LEVEL OF EVIDENCE Prognostic study, level III.

Spinal and pelvic injuries in airborne sports: A retrospective analysis from a major Swiss trauma centre

BACKGROUND Adrenalin-seeking airborne sports like BASE-jumping, paragliding, parachuting, delta-gliding, speedflying, and skysurfing are now firmly with us as outdoor lifestyle activities and are associated with a high frequency of severe injuries, especially to the spine. METHODS Retrospective analysis of all airborne sports-associated spinal and pelvic injuries admitted to a Level I trauma centre in the Swiss Alps between 1st March 2000 and 31st October 2009. Spinal injuries were classified by the Magerl system and pelvic injuries by the AO/OTA scheme modified by Isler and Ganz. Spino-pelvic dissociation fractures in airborne sports were compared to similar injuries in the general trauma population using multiple logistic regression analysis. RESULTS 181 patients (11 BASE-jumpers, 144 paragliders, 19 parachuters, 1 speedflyer, 4 deltagliders, 2 skysurfer) were included. 161 (89%) were male. Median age was 37.0 years (IQR=29.0-47.0) and ISS 8 (IQR=4-13). 89 (49.2%) patients sustained spinal fractures. Type A fractures were predominant (91.5%), followed by Type C (5.3%) and Type B (3.2%). The level L1 was most often affected (35.1%). 17 patients (9.4%) had pelvic ring fractures. Most frequent were Type C fractures (41.2%), followed by Types A and B (29.4% each). 8 paragliders (4.4%) suffered spino-pelvic dissociation injuries. The odds ratio for sustaining such fractures in paragliders was 21-fold higher (OR 21.04, 95% CI 7.83-56.57, p<0.001) than in the general trauma population. CONCLUSIONS Serious spinal and pelvic injuries account for most injuries sustained during airborne sporting activities. The thoracolumbar region was most often affected, but the lumbopelvic junction is also especially vulnerable as high impact forces from vertical and horizontal deceleration need to be absorbed. The frequency of spino-pelvic dissociation was very high in paragliding injuries, with a 21-fold higher odds ratio than in the general trauma population.