Functional outcome and associations with prehospital time and urban-remote disparities in trauma: A Norwegian national population-based study

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.

Great variation between ICU physicians in the approach to making end-of-life decisions

INTRODUCTION

End-of-life (EOL) decision-making in the intensive care unit (ICU) is difficult, but is rarely practiced in simulated settings. We wanted to explore different strategies ICU physicians use when making EOL decisions, and whether attitudes towards EOL decisions differ between a small-group simulation setting and a large-group plenary setting.

METHODS

The study took place during a Scandinavian anaesthesiology and intensive care conference. The simulated ICU patient had a cancer disease with a grave prognosis, had undergone surgery, suffered from severe co-morbidities and had a son present demanding all possible treatment. The participants were asked to make a decision regarding further ICU care. We presented the same case scenario in a plenary session with voting opportunities.

RESULTS

In the simulation group (n = 48), ICU physicians used various strategies to come to an EOL decision: patient-oriented, family-oriented, staff-oriented and regulatory-oriented. The simulation group was more willing than the plenary group (n = 47) to readmit the patient to the ICU if the patient again would need respiratory support (32% vs. 8%, P < 0.001). Still, fewer participants in the simulation group than in the plenary group (21% vs. 38%, P = 0.019) considered the patient's life expectancy of living an independent life to be over 10%.

CONCLUSION

There was great variation between ICU physicians in the approach to making EOL decisions, and large variations in their life expectancy estimates. Participants in the simulation group were more willing to admit and readmit the patient to the ICU, despite being more pessimistic towards life expectancies. We believe simulation can be used more extensively in EOL decision-making training.

Organisation of traumatic head injury management in the Nordic countries

OBJECTIVE

The aim of this study is to map and evaluate the available resources and the premises of traumatic head injury management in the Nordic countries, before the implementation of a Nordic adaption of the Brain Trauma Foundation guidelines for prehospital management.

METHODS

The study is a synthesis of two cross-sectional surveys. Questionnaires were used to collect data on the annual number of acute head injury operations, the infrastructure, the level of education, the use of trauma protocols and the management of traumatic head injury at Nordic hospitals.

RESULTS

The proportion of acute head injury operations performed outside a neurosurgical department was 0% in Denmark, 16% in Finland, 19% in Norway and 33% in Sweden. Eighty-four per cent of Nordic hospitals had written protocols for the assessment and treatment of trauma patients and 78% had regular training in trauma management; 67% had specific protocols for the treatment of traumatic head injury. Computed tomography (CT) was available in 93% of the hospitals, and 59% of the hospitals could link CT scans to the regional neurosurgical department.

CONCLUSIONS

Most Nordic hospitals are well prepared to manage patients with acute traumatic head injury. A substantial proportion of the operations are performed at local and central hospitals without neurosurgical expertise, despite an efficient pre and interhospital transport system. The Nordic adaption of the Brain Trauma Foundation guidelines recommends that this practice is terminated.

Five-year incidence of surgery for idiopathic normal pressure hydrocephalus in Norway

OBJECTIVES

We have previously determined the incidence and prevalence of idiopathic normal pressure hydrocephalus (iNPH) in the county of Vestfold in Norway. This study aimed at determining the incidence of surgeries for iNPH.

MATERIALS AND METHODS

Information about age, sex, operation year and operation type was collected retrospectively for all patients hospitalized from 2002 to 2006 with any diagnosis of iNPH and operated with insertion of a ventriculo-peritoneal or ventriculoatrial shunt system, or with endoscopic third ventriculostomy in any of Norway's five regional neurosurgical centers.

RESULTS

Two hundred fifty-two patients were operated during the 5-year period, making the total incidence 1.09/100,000/year. The yearly incidence ranged from a minimum of 0.84/100,000 in 2006 to a maximum of 1.47/100,000 in 2004. The incidence was highest in the age group 70-79 years. There were little regional differences regarding incidence, sex, and age and operation type.

CONCLUSIONS

The data suggest that too few patients are being offered surgical treatment for iNPH in Norway.

Capnography rapidly confirmed correct endotracheal tube placement during resuscitation of extremely low birthweight babies (< 1000 g)

During neonatal resuscitation, the routine use of capnography to verify correct placement of the endotracheal tube is not an established international practice. We present four cases that illustrate the successful use of immediate capnography to verify correct tracheal tube placement even in extremely low birthweight (ELBW) prematures (< 1000 g) during resuscitation. Based on this limited experience, we reached institutional consensus among paediatricians and anaesthesiologists that capnography should become standard monitoring during all endotracheal intubations in premature babies.

[Decompression craniectomy--life-saving treatment in acute cerebral infarction]

Massive cerebral infarction is often accompanied by early death secondary to transtentorial herniation. Decompressive hemicraniectomy has been suggested as a lifesaving procedure. We report the case of a 61 year old man who had an acute infarction in the distribution area of the right middle cerebral artery. Initially, he was awake and suffered from total left-sided hemiparalysis. Over the next two days, his level of consciousness deteriorated to a Glasgow Coma Scale score of 5. Intracranial pressure (ICP) monitoring was then established. Three days later, the ICP increased from 20 to 40 mm Hg. We performed a right-sided decompressive hemicraniectomy, and the ICP was normalized immediately. Ten months after surgery the patient was at home and functioning with minimal assistance. He had moderate paresis of the left leg and was able to walk, but his left arm was paralytic. The presented case confirms that decompressive hemicraniectomy may prevent death and allow survival without severe disability in patients with massive cerebral infarction.

Arginine 210 is not a critical residue for the allosteric interactions mediated by binding of cyclic AMP to site A of regulatory (RIalpha) subunit of cyclic AMP-dependent protein kinase

The guanidinium groups of conserved arginines in the two intrachain cAMP-binding sites of regulatory (R) subunit of cAMP-dependent protein kinase have been implicated in the allosteric interactions by which cAMP binding leads to kinase activation. We have investigated the functional role of Arg-210, the conserved arginine in site A of murine type Ialpha R subunit, by analyzing the effects of nine different substitutions at this residue on cAMP binding and allosteric properties of bacterially expressed RIalpha subunits. All substitutions reduced the cAMP binding affinity of site A, but the magnitude of reduction varied from several hundredfold to 10(6)-fold. The differential effects of the different substitutions could not easily be rationalized by interactions with cAMP and might, in part, reflect interactions with other residues in the unoccupied cAMP-binding pocket. None of the Arg-210 substitutions appeared to disrupt the allosteric interaction by which occupation of site A slows dissociation of cAMP from site B, although the effect was difficult to elicit in full with mutations that had strong effects on cAMP binding. The two weakest substitutions, Arg-210 --> Ile and Arg-210 --> Thr, could be shown to have essentially no effect on the allosteric interaction by which occupation of site A reduces the affinity of R subunit for the catalytic subunit. The weaker mutations had a smaller effect on kinase activation by the suboptimal activator Rp-adenosine cyclic 3',5'-phosphorothioate than by cAMP, suggesting that the analog largely bypasses interactions with the guanidinium group of Arg-210.