ASPECTS OF IN-HOSPITAL TRIAGE IN A SWEDISH TRAUMA POPULATION-EXPERIENCES AND OUTCOMES

Anna Katarina Granström

Department of Clinical Science and Education,
Södersjukhuset - KISÖS
Karolinska Institutet, Stockholm, Sweden

Early and accurate prioritization of trauma patients, known as triage, is crucial to identify those in need of emergency life-saving interventions. Excellent trauma care relies strongly on correct triage, which impacts patients' experiences and outcomes. Undertriage has been shown to be associated with an elevated risk of undetected injuries and missed interventions. However, the definition of severe trauma is still debatable. This thesis aimed to study aspects and consequences of in-hospital triage, examine over-and undertriage, trauma care processes, experiences and outcomes, providing insights to improve care for this patient group. Qualitative and quantitative approaches were used. Paper I was a 'before and after' study where the effect of a criteria-directed protocol for in-hospital triage of trauma patients in a Swedish trauma center was evaluated. The results showed that by using the protocol, overtriage was reduced from 74% to 58% while undertriage increased from 7% to 10%. No preventable deaths were detected after peer-review of those undertriaged. In Paper II, trauma patients' experiences after initial trauma management were explored, using individual face-to-face semi-structured interviews. The interviews were recorded, transcribed and analyzed using qualitative content analysis. Patients reported emotional responses to the trauma, physical discomfort and feeling prioritized or being ignored by the trauma team. The main category that emerged was: "Feeling safe in a frightening situation". In Paper III, the two scoring systems, the anatomic New Injury Severity score (NISS) and the physiology-based GAP score, for prediction on ICU-admission and 30-day mortality after trauma, were evaluated: in the Swedish trauma population. The findings showed that the GAP- score was better at predicting 30-day mortality compared to NISS, with AUROC (95% CI) values of 0.92 (0.91-0.93) and 0.84 (0.83-0.85) respectively, while NISS performed better than GAP at predicting ICU-admission. Both scoring systems were less accurate in predicting mortality in the older patient group. In Paper IV, undertriaged trauma patients were characterized and compared to non- undertriaged trauma patients, in age groups, to investigate potential differences in trauma care processes and 30-day mortality. The study results showed that undertriaged patients had fewer intubations, longer time to CT-scan and fewer admissions to ICU, were less severely injured, and had lower mortality compared to non- undertriaged patients. This demonstrates that undertriage was not associated with poorer outcomes compared to non-undertriage, in the current study.

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UNDERSTANDING LONG-TERM OUTCOMES IN TRAUMATIC INJURY

Olivia Kiwanuka
Department of Clinical Neuroscience - CNS
Karolinska Institutet, Stockholm, Sweden

Traumatic brain injury (TBI) is a complex and impactful medical condition, capable of altering the life of a patient long after the initial trauma. This thesis strives to increase our understanding of long-term outcomes following TBI, from mild to severe cases. The studies aimed to explore predictive factors that influence patient recovery and to evaluate potential treatments targeting the chronic neuroinflammation that follows such injuries.
The research project started with an experimental study (Study I) using a rodent model to assess the chronic inflammatory response after a penetrating brain injury. We employed a treatment known as Resolvin D1, a lipid mediator derived from omega-3 fatty acids, hypothesized to aid in resolving inflammation and promoting tissue repair. Although results did not show significant changes in inflammation levels or tissue loss between treated and control groups, the study provided important insights into the timeline and complexities of chronic inflammation in TBI.
In the clinical studies (Studies II-IV), we examined data from trauma registries to evaluate patient outcomes following TBI. One key focus was the relationship between pre-injury health, as measured by the American Society of Anesthesiologists (ASA) score, and patient outcomes. The ASA-score is based on the burden of comorbidities and rates a patient's overall health status.
The second study (first clinical study) explored health-related quality of life (HRQoL) two years post-TBI, an often overlooked aspect of recovery. Using tools like the RAND-36 and EQ-5D questionnaires, we assessed how 170 trauma patients perceived their physical, emotional, and social health over the long term. Interestingly, we found that TBI patients sometimes reported better HRQoL outcomes than those who experienced non-TBI (NTBI) trauma, particularly in physical functioning and daily role limitations. This could be attributed to factors such as cognitive biases, reduced expectations due to aging, or an impaired ability to fully recognize deficits after brain injury. A high ASA-score (indicating worse health before the injury) was strongly associated with a reduced HRQoL in both the TBI and NTBI cohort. Increased injury severity, measured with the head value of the abbreviated injury score (AIS), showed a trend to association with lower HRQoL, but this was not statistically significant. We found no difference in symptoms of depression, assessed with the self-assessed Montgomary-Åsberg depression score (MADRS-S), between any of the groups.
In the third study, we included 823 trauma patients and examined 90-day mortality after mild TBI with intracranial findings (complicated mTBI) compared to NTBI. We found ASA-score to be strongly associated with higher mortality rates, independent from age and injury severity, an association we did not see in the NTBI cohort. This difference could be either due to a treatment bias and under-triage of mTBI patients, a selection bias excluding frail NTBI patients, or that the ASA-score captures an important vulnerability in mTBI patients. AIS (head) was not independently associated with mortality. We also tested the predictive value of the Trauma and Injury Severity Score (TRISS). The accuracy of TRISS was very low, which suggests that this score is not useful in milder trauma.
In the fourth and final study we tested the added value of ASA-score to the well- established International Mission for Prognosis and Analysis of Clinical Trials in TBI (IMPACT) model, on a cohort of 720 patients with moderate to severe TBI (msTBI). Here we confirmed a strong and independent association between ASA-score and both 90-day mortality and 1-year functional outcome (measured with Glasgow Outcome Score). The inclusion of ASA-scoring yielded a significantly increased estimated explained variance of the already comprehensive IMPACT model. Patients with an ASA-score of 3 or above had a pronounced increase in mortality compared to healthier individuals, which held true even in younger patients. In this cohort, TRISS proved to be strongly associated with GOS, and even more to mortality, highlighting the importance of the overall burden of injury.
While these studies provided valuable insights, limitations such as the lack of baseline HRQoL data and the challenges in differentiating chronic inflammation types in experimental models point to avenues for future research. The findings stress the necessity of early and tailored interventions to improve long-term outcomes and reinforce the importance of considering a patient's overall health in management and outcome prediction.
By investigating both the biological underpinnings and clinical outcomes of TBI, this work aims to contribute to more refined and effective approaches to treatment and rehabilitation. Understanding these long-term trajectories can enhance care protocols, allowing for a more personalised approach that accounts for individual health profiles, ultimately improving patient outcomes and quality of life following TBI.

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TREATMENT OF CHOLELITHIASIS AND ACUTE CHOLECYSTITIS
SURGICAL SAFETY IN GALLSTONE SURGERY
My Blohm 

Department of Clinical Science, Intervention and Technology, Division of Surgery, Karolinska Institutet, Stockholm, Sweden 

Den 8/12 2023 disputerade My Blohm på avhandlingen “Treatment of cholelithiasis and acute cholecystitits - Surgical safety in gallstone surgery”
 
Huvudhandledare var Johanna Österberg och opponent Frederik Helgstrand, Köpenhamns Universitet.
 
Avhandlingen består av 5 delarbeten varav 3 är baserade på Gallriks och 2 är prospektiva. Arbetena är av stort kliniskt värde för den akuta gallkirurgin.
 
I. The Sooner, the Better? The importance of Optimal Timing of
Cholecystectomy in Acute Cholecystitis: Data from the National Swedish
Registry for Gallstone Surgery, GallRiks
My Blohm et al - J Gastrointest Surg. 2017;21(1):33-40
Fördelar rapporteras att tidigt operera patienter med cholecystit.
II. Relationship between surgical volume and outcomes in elective and acute
cholecystectomy: nationwide, observational study
My Blohm et al - Br J Surg. 2023;110(3):353-61.
Ju större operationsvolym en klinik har desto bättre resultat.
III. Differences in Cholecystectomy Outcomes and Operating Time Between
Male and Female Surgeons in Sweden
My Blohm et al - JAMA surgery. Published online August 30, 2023
Kvinnliga kirurger tar lite längre tid på sig vid operation och har färre komplikationer.
IV.Learning by doing: an observational study of the learning curve for
ultrasonic fundus-first dissection in elective cholecystectomy
My Blohm et al-  Surg Endosc. 2022;36(6):4602-13
Relativt snabbt lärde sig kirurger fundus-first teknik.
V. Ultrasonic dissection in laparoscopic cholecystectomy for acute
cholecystitis, a randomized controlled trial
My Blohm et al Manuscript
Fördelar sågs med Ultraljudsdissektorn vid laparoskopisk cholecystektomi.
 
Vi gratulerar My och kirurgkliniken i Mora för ett fint arbete. Speciellt arbete 3 har rönt stor uppmärksamhet inte minst internationellt!

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Management of Gallstone Disease in Pregnancy. Aspects on Intervention, Outcome and Patient Experience
Jonas Hedström

Department of Clinical Sciences, Malmö | Lund University, Sweden

This thesis aims to further contribute to the knowledge of managing gallstone disease during pregnancy.

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Late surgical complications of Roux-en-Y gastric bypass
Hassan Zaigham

Department of Clinical Sciences, Faculty of Medicine, Lund University, Sweden

The aim of this thesis is to investigate challenges in diagnosing and managing late surgical complications of Roux-en-Y gastric bypass (RYGB) experienced by acute care surgeons.

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Mangement of acute cholecystitis. Surgery, drainage and gallbladder aspiration
Agnieszka Popowicz

Department of Clinical Science, Intervention and Technology, Division of Surgery Karolinska Institute, Stockholm, Sweden

We found that safety of cholecystectomy increases if performed more than 30 days after discharge after a conservatively treated cholecystitis. PGBA seems to be a safe treatment option in high-risk patients, although it should be evaluated in larger studies. A cholecystostomy can be safely removed early and performing a cholangiography does not seem to change the outcome.

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Evaluation and management of penetrating lower extremity arterial trauma

There have been changes in practice since the publication of the previous guidelines in 2002. Expedited triage of patients is possible with physical examination and/or the measurement of ankle-brachial indices. Computed tomographic angiography has become the diagnostic study of choice when imaging is required. Tourniquets and intravascular shunts have emerged as adjuncts in the treatment of penetrating lower extremity arterial trauma. The role of endovascular intervention warrants further investigation.
Abstract på PubMed

Randomized clinical trial of Appendicitis Inflammatory Response score-based management of patients with suspected appendicitis

AIR score-based risk classification can safely reduce the use of diagnostic imaging and hospital admissions in patients with suspicion of appendicitis.
Abstract på PubMed

An adapted Clavien-Dindo scoring system in trauma as a clinically meaningful nonmortality endpoint.​​​​​​

The ACDiT scale can be used to grade the severity of posttrauma complications in patients managed both operatively and nonoperatively. It provides clinically meaningful data for morbidity and mortality meetings and other quality improvement exercises.
Abstract på PubMed

Routine computed tomography after recent operative exploration for penetrating trauma: What injuries do we miss?

We recommend the use of immediate postoperative CT after emergent laparotomy especially when there is a high index of suspicion for spine or genitourinary injuries and in patients who have sustained ballistic penetrating injuries.
Abstract på PubMed