How should tranexamic acid be administered in haemorrhagic shock? - continuous serum concentration measurements in a swine model

Background: Tranexamic acid (TXA) reduces mortality in trauma patients. Intramuscular (IM) administration could be advantageous in low-resource and military settings. Achieving the same serum concentration as intravenous (IV) administration is important to achieve equal mortality reduction. Therefore, we aimed to investigate whether dividing an IM dose of TXA between two injection sites and whether an increase in dose would lead to serum concentrations comparable to those achieved by IV administration. Methods: Norwegian landrace pigs (n = 29) from a course in hemostatic emergency surgery were given TXA 1 h after start of surgery. Blood samples were drawn at 0, 5, 10, 15, 20, 25, 35, 45, 60, and 85 min. The samples were centrifuged and serum TXA concentrations quantified with liquid chromatography-tandem mass spectrometry. The use of two injection sites was compared with distributing the dose on one injection site, and a dose of 15 mg/kg was compared with a dose of 30 mg/kg. All IM groups were compared with IV administration. Results: The groups were in a similar degree of shock. Increasing the IM dose from the standard of 15 mg/kg to 30 mg/kg resulted in significantly higher serum concentrations of TXA, comparable to those achieved by IV administration. Distributing the IM dose on two injection sites did not affect drug uptake, as shown by equal serum concentrations. Conclusions: For IM administration of TXA, 30 mg/kg should be the standard dose. With a short delay, IM administration will provide equal serum concentrations as IV administration, above what is considered necessary to inhibit fibrinolysis

Epidemiology of trauma in the subarctic regions of the Nordic countries.

To access publisher's full text version of this article, please click on the hyperlink in Additional Links field or click on the hyperlink at the top of the page marked DownloadBackground: The northern regions of the Nordic countries have common challenges of sparsely populated areas, long distances, and an arctic climate. The aim of this study was to compare the cause and rate of fatal injuries in the northernmost area of the Nordic countries over a 5-year period. Methods: In this retrospective cohort, we used the Cause of Death Registries to collate all deaths from 2007 to 2011 due to an external cause of death. The study area was the three northernmost counties in Norway, the four northernmost counties in Finland and Sweden, and the whole of Iceland. Results: A total of 4308 deaths were included in the analysis. Low energy trauma comprised 24% of deaths and high energy trauma 76% of deaths. Northern Finland had the highest incidence of both high and low energy trauma deaths. Iceland had the lowest incidence of high and low energy trauma deaths. Iceland had the lowest prehospital share of deaths (74%) and the lowest incidence of injuries leading to death in a rural location. The incidence rates for high energy trauma death were 36.1/100000/year in Northern Finland, 15.6/100000/year in Iceland, 27.0/100000/year in Northern Norway, and 23.0/100000/year in Northern Sweden. Conclusion: We found unexpected differences in the epidemiology of trauma death between the countries. The differences suggest that a comparison of the trauma care systems and preventive strategies in the four countries is required. Keywords: Epidemiology; Injury; Rural; Trauma.Finnmarkssykehuset Health Trust University of Tromso Northern Norway Regional Health Authorit

Rural High North: A High Rate of Fatal Injury and Prehospital Death

Finnmark County is the northernmost county in Norway. For several decades, the rate of mortality after injury in this sparsely inhabited region has remained above the national average. Following documentation of this discrepancy for the period 1991–1995, improvements to the trauma system were implemented. The present study aims to assess whether trauma-related mortality rates have subsequently improved. All injury-associated fatalities in Finnmark from 1995–2004 were identified retrospectively from the National Registry of Death and reviewed. Low-energy trauma in elderly individuals and poisonings were excluded. A total of 453 cases of trauma-related death occurred during the study period, and 327 of those met the inclusion criteria. Information was retrievable for 266 cases. The majority of deaths (86%) occurred in the prehospital phase. The main causes of death were suicide (33%) and road traffic accidents (21%). Drowning and snowmobile injuries accounted for an unexpectedly high proportion (12 and 8%, respectively). The time of death did not show trimodal distribution. Compared to the previous study period, there was a significant overall decline in injury-related mortality, yet there was no change in place of death, mechanism of injury, or time from injury until death. Changes in injury-related mortality cannot be linked to improvements in the trauma system. There was no change in the epidemiological patterns of injury. The high rate of on-scene mortality indicates that any major improvement in the number of injury-related deaths lies in targeted prevention

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Radioen synger og sola skinner der du kjører bekymringsfritt langs riksveien en vakker sommerdag. Ingen biler foran deg, ingen biler bak. Plutselig ser du den, en sølvgrå Audi som står i grøfta lenger fram. Fronten er trykket inn av en stor stein. Du slår på nødblinken, og setter opp varseltrekant. Frykten for hva som kan møte deg inne i Audien slår i mellomgulvet. I førersetet sitter en ung mann bøyd over rattet. Ville du kunnet hjelpe ham? Klart du kan Ja, alle kan hjelpe. Du trenger ikke ha noe kurs i førstehjelp eller være helsepersonell for å være den som står fram og sier «Jeg kan hjelpe!». Selvsagt står du bedre rustet om du har noen form for opplæring i førstehjelp, men i en situasjon som beskrevet, der du står alene, er all hjelp du kan gi verdifull

Death after trauma in the rural High North

The work of this thesis was initiated because Finnmark County had a mortality rate from external causes well above national average for several decades. The aims of the thesis were to 1) investigate possible reasons for Finnmark’s’ elevated death rate from external causes, 2) identify challenges that a trauma system in Scandinavia must be tailored to meet, and 3) find access points to limit the burden of injury in Finnmark. The thesis consists of four papers. The first paper gives an epidemiological description of the deaths from trauma in Finnmark for a ten-year period, and explores changes over time. In the second article the epidemiology of trauma death in Finnmark is compared to Hordaland County. The third paper describes the deaths from low energy trauma in Finnmark County for the ten-year period. The fourth paper is a review of the literature on first aid to trauma victims by bystanders. We have found an urban-rural continuum where mortality, and share of prehospital death increases with rurality. For RTAs the rate of accidents with personal injury was distributed inversely to mortality along the continuum. The most common modes of injury were fractures in elderly, suicide, and road traffic accidents. There is a potential for injury mortality reduction in first aid from laypeople, but literature in that field is very sparse. Low energy trauma constitutes a considerable and underestimated share of deaths from trauma, and the victims are older and with higher pre-injury morbidity than victims of high energy trauma. The overall mortality from external causes in Finnmark has declined from the early 90’s to the mid-2000, but the epidemiological pattern of injury is otherwise unchanged. Finnmark’s high rate of death from external causes is probably tied to the county’s rural nature and the multi-faceted disadvantage of rurality. A trauma system in Scandinavia will have to meet the challenge of mortality rates increasing with rurality, and the majority of deaths occurring in the prehospital phase. 3) Finnmark does not seem to differ greatly from other areas in one singular area, and access points will mostly be the same as other rural area

Fatal injury caused by low-energy trauma – a 10-year rural cohort

Background: Death after injury with low energy has gained increasing focus lately, and seems to constitute a significant amount of trauma-related death. The aim of this study was to describe the epidemiology of deaths from low-energy trauma in a rural Norwegian cohort. Methods: All deaths from external causes in Finnmark County, Norway, from 1995 to 2004 were identified retrospectively through the Norwegian Cause of Death Registry. Deaths caused by hanging, drowning, suffocation, poisoning, and electrocution were excluded. Trauma was categorised as high energy or low energy based on mechanism of injury. All low-energy trauma deaths were then reviewed. Results: There were 262 cases of trauma death during the period. Low-energy trauma counted for 43% of the trauma deaths, with an annual crude death rate of 13 per 100,000 inhabitants. Low falls accounted for 99% of the injuries. Fractures were sustained in 89% of cases and head injuries in 11%. Ninety per cent of patients had pre-existing medical conditions, and the median age was 82 years. Death was caused by a medical condition in 85% of cases. Fifty-two per cent of the patients died after discharge from the hospital. Conclusion: In this cohort, low-energy trauma was a significant contributor to trauma related death, especially amon

Effect and accuracy of emergency dispatch telephone guidance to bystanders in trauma: post-hoc analysis of a prospective observational study

Background:Emergency medical communication centres (EMCCs) dispatch and allocate ambulance resources, and provide first-aid guidance to on-scene bystanders. We aimed to 1) evaluate whether dispatcher guidance improved bystander first aid in trauma, and 2) to evaluate whether dispatchers and on-scene emergency medical services (EMS) crews identified the same first aid measures as indicated.Methods:For 18 months, the crew on the first EMS crew responding to trauma calls used a standard form to assess bystander first aid. Audio recordings of the corresponding telephone calls from bystanders to the EMCC were reviewed.Results:A total of 311 trauma calls were included. The on-scene EMS crew identified needs for the following first-aid measures: free airway in 26 patients, CPR in 6 patients, and hypothermia prevention in 179 patients. EMCC dispatchers advised these measures, respectively, in 16 (62%), 5 (83%), and 54 (30%) of these cases. Dispatcher guidance was not correlated with correctly performed bystander first aid. For potentially life saving first aid measures, all (20/20) callers who received dispatcher guidance attempted first aid, while only some few (4/22) of the callers who did not receive dispatcher guidance did not attempt first aid.Discussion:Overall, the EMCC dispatchers had low sensitivity and specificity for correctly identifying trauma patients requiring first-aid measures. Dispatcher guidance did not significantly influence whether on-scene bystander first aid was performed correctly or attempted in this study setting, with a remarkably high willingness to perform first-aid. However, the findings for potentially lifesaving measures suggests that there may be differences that this study was unable to detect.Conclusion:This study found a high rate of first-aid willingness and performance, even without dispatcher prompting, and a low precision in dispatcher advice. This underlines the need for further knowledge about how to increase EMCC dispatchers’ possibility to identify trauma patients in need of first aid. The correlation between EMCC-guidance and bystander first aid should be investigated in study settings with lower spontaneous first-aid rates

A nationwide survey of first aid training and encounters in Norway

Background: Bystander first aid can improve survival following out-of-hospital cardiac arrest or trauma. Thus, providing first aid education to laypersons may lead to better outcomes. In this study, we aimed to establish the prevalence and distribution of first aid training in the populace, how often first aid skills are needed, and selfreported helping behaviour. Methods: We conducted a telephone survey of 1000 respondents who were representative of the Norwegian population. Respondents were asked where and when they had first aid training, if they had ever encountered situations where first aid was necessary, and stratified by occupation. First aid included cardio-pulmonary resuscitation (CPR) and basic life support (BLS). To test theoretical first aid knowledge, respondents were subjected to two hypothetical first aid scenarios. Results: Among the respondents, 90% had received first aid training, and 54% had undergone first aid training within the last 5 years. The workplace was the most common source of first aid training. Of the 43% who had been in a situation requiring first aid, 89% had provided first aid in that situation. There were considerable variations among different occupations in first aid training, and exposure to situations requiring first aid. Theoretical first aid knowledge was not as good as expected in light of the high share who had first aid training. In the presented scenarios 42% of respondent would initiate CPR in an unconscious patient not breathing normally, and 46% would provide an open airway to an unconscious road traffic victim. First aid training was correlated with better theoretical knowledge, but time since first aid training was not. Conclusions: A high proportion of the Norwegian population had first aid training, and interviewees reported high willingness to provide first aid. Theoretical first aid knowledge was worse than expected. While first aid is part of national school curriculum, few have listed school as the source for their first aid training

Assessing bystander first aid: development and validation of a First Aid Quality Assessment (FAQA) tool

Background Injuries are one of the leading causes of death worldwide. Bystanders at the scene can perform first aid measures before the arrival of health services. The quality of first aid measures likely affects patient outcome. However, scientifc evidence on its efect on patient outcome is limited. To properly assess bystander first aid quality, measure effect, and facilitate improvement, validated assessment tools are needed. The purpose of this study was to develop and validate a First Aid Quality Assessment (FAQA) tool. The FAQA tool focuses on first aid measures for injured patients based on the ABC-principle, as assessed by ambulance personnel arriving on scene. Methods In phase 1, we drafted an initial version of the FAQA tool for assessment of airway management, control of external bleeding, recovery position and hypothermia prevention. A group of ambulance personnel aided presenta‑ tion and wording of the tool. In phase 2 we made eight virtual reality (VR) films, each presenting an injury scenario where bystander performed frst aid. In phase 3, an expert group discussed until consensus on how the FAQA tool should rate each scenario. Followingly, 19 respondents, all ambulance personnel, rated the eight films with the FAQA tool. We assessed concurrent validity and inter-rater agreement by visual inspection and Kendall’s coefficient of concordance. Results FAQA-scores by the expert group concurred with±1 of the median of the respondents on all first aid meas‑ ures for all eight films except one case, where a deviation of 2 was seen. The inter-rater agreement was “very good” for three first aid measures, “good” for one, and “moderate” for the scoring of overall quality on first aid measures. Conclusion Our findings show that it is feasible and acceptable for ambulance personnel to collect information on bystander first aid with the FAQA tool and will be of importance for future research on bystander first aid for injured patients