ReviewTrauma systems and early management of severe injuries in Scandinavia: Review of the current state
Introduction
The concepts of modern trauma care have developed over the past five decades. Application of lessons learned in warfare, advancements in physiological research, and life-sustaining interventions have led to greater focus on the chain of survival from the pre-hospital setting, with early intervention and rapid transport to the appropriate site of definitive care.2, 58, 89, 139
Since the 1970s the US has occupied a leading role in trauma research and system development,4 and the concept of an inclusive trauma system (Fig. 1), was initially described in the early 1990s.152
Parallel to increased research in and formalisation of trauma systems, the uniqueness of Scandinavian trauma scenarios have become apparent.14, 43, 79, 98, 116, 125 The Scandinavian countries, based on their commonalities in geography, socio-politics, epidemiology and health-services, would benefit from increased research collaboration and uniformity in the development of their trauma systems.78, 80, 82, 116
Since the initial description, several regions have reported favourable results from introducing trauma systems.18, 22, 85, 96, 132, 157 Such documentation has been scarce in the Scandinavian literature. There are also indications that the Scandinavian trauma system development may be suboptimal compared to central Europe.83 Thus, challenges exist regarding the scientific evaluation of the current trauma systems, the quality of patient care and future directions for trauma management.
In this context, we sought to explore the current status of trauma systems and early trauma management in Scandinavia by performing an extensive collective review of the Scandinavian trauma literature.
Section snippets
Materials and methods
We performed an extensive literature search of the Medline/PubMed, EMBASE and SweMed+ databases, and the Nordic language medical journals (Tidsskrift for Den Norske Legeforening, Ugeskrift for Læger, and Läkartidningen), including articles related to trauma epidemiology, trauma systems and early trauma management in Scandinavia. References from the included articles were also mined for additional relevant studies. Due to the heterogeneity of the topic, wide coverage was prioritised over
Geographical considerations
In this context, “Scandinavia” refers to Denmark, Finland, Iceland, Norway and Sweden.82 This gives a total land area of 1.35 million km2 and a total population of about 25 million inhabitants. A significant number of Scandinavian citizens live in rural areas; the mean population density is 18 per km2, ranging from 2.8 per km2 in Iceland to 125 per km2 in Denmark.78 Pre-hospital medicine and patient transfer is characterised by time-consuming transport.126 Seasonal climate changes make
Epidemiology
The incidence of major trauma (ISS > 15) in Scandinavia ranges from 30 to 52 per 100 000 inhabitants per year. Blunt trauma predominates (Fig. 2), with only 9–12% of all traumas being penetrating injuries (incidence of 2–3 per 100,000 inhabitants per year).15, 38, 43, 51, 60, 90, 91, 92, 102, 103, 104, 117, 145, 147, 163
Traumatic brain injury (TBI; Fig. 3) is a major cause of trauma morbidity and mortality.5, 32, 35, 74, 133 Sundstrøm et al.133 analysed TBI mortality during the period from 1987
Pre-hospital trauma management
While the organisational structures of emergency medical service (EMS) systems varies between the Scandinavian countries and regions, the paramedic- or nurse-manned ground ambulances constitute the main pre-hospital trauma care provider.78 As in several central European countries,121, 153 the pre-hospital physician-manned EMS are well developed and widely used to supplement paramedic-based EMS.78
The level of competency of the pre-hospital trauma care provider and the scope of procedures that
Inter-hospital transfer
Long pre-hospital distances, topography and weather conditions make organised inter-hospital transfer (Fig. 1) of the severely injured essential for efficient regional trauma systems in Scandinavia.3, 14, 27, 49, 78, 126 Patients transferred acutely from other hospitals to trauma centres are less frequently received by a multidisciplinary trauma team, despite being more severely injured and more frequently in need of emergency operative or airway interventions compared to direct admissions.75,
Trauma team triage
The concept of trauma team resuscitation is variably adopted throughout Scandinavia. Handolin et al.47 report that only 20% of trauma-receiving hospitals in Finland had trauma teams, compared to 88% in Norway.67
Successful trauma systems depend on triage to identify patients with severe injuries that will benefit from trauma team resuscitation.3, 27, 105 The triage should be specific enough to avoid inefficient utilisation of resources (over-triage), yet sensitive enough to minimise failure to
In-hospital early trauma management
Modern trauma care in Scandinavia comprises a multidisciplinary approach. Anaesthesiology has an important role in both pre- and in-hospital trauma care.78 Iceland is the only Scandinavian country with emergency medicine as a separate specialty.78 In 2006 Sweden accredited emergency medicine as a sub-specialty.21 Surgeons most commonly act as the “leader” of the trauma team and as the consultants in charge of definitive care.42 Trauma surgery is not a separate specialty in Scandinavia, and most
Head injuries
The Scandinavian countries face common challenges in the management of patients with head injuries. The majority of these patients are initially admitted to hospitals without neurosurgical facilities; thus, the need for correct assessment and triage by non-specialists in both the pre- and in-hospital setting is critical.66, 126, 127 There have been indications that decentralised operative treatment results in low volume and unfavourable outcome.155, 156
Several authors have called for
Trauma education and training
The majority of Scandinavian hospitals rarely manage severely injured patients.162 Trauma training using simulators or simulated patients is an important factor in overcoming lack of practical training.67, 160, 162 The traditional trauma education offered in Scandinavia include damage control surgery courses, e.g. the Definitive Surgical Trauma Care (DSTC™), and the trauma life support courses (ATLS®, PHTLS®, TNCC®).40, 67, 106, 142, 148
Scandinavian publications on traditional trauma education
Trauma registries in Scandinavia
Trauma registries form the basis for research and quality assessment of trauma management and inform policy makers about strategies for optimal care of injured patients.19, 116 In Scandinavia, many trauma centres have established individual trauma registries, but no nation wide or pan-Scandinavian trauma registry currently exists.
In Sweden, there have been several calls for a national trauma registry.59, 97, 98 The trauma registry KVITTRA (Kvalitet i Traumavården),97 with the intention of
Discussion and future directions
In Scandinavia, injured patients are managed in a challenging environment. The majority of Scandinavians live in urban environments, but large distances in rural areas and a harsh winter climate necessitate efficient utilisation of resources. Studies indicate that the larger hospitals perform according to US MTOS and TARN UK standards,48, 50, 79, 124, 125 but the current state of trauma system development is immature. In further developing trauma systems in Scandinavia, experiences made in
Conflict of interest
There are no conflicts of interest declared.
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