Outcomes in Pediatric Trauma Care in the Stockholm ... - Springer Link

European Journal of Trauma and Emergency Surgery

Focus on Pediatric Polytrauma

Outcomes in Pediatric Trauma Care in the Stockholm Region Kerstin Sluys1,3, Margaretha Lannge2, Lennart Iselius1, Lars E. Eriksson3

Abstract Background: Although trauma is a leading cause of pediatric mortality and morbidity in Sweden, few studies have examined the outcome of pediatric trauma. Objective: Here, we describe the age and gender distribution, injury mechanisms, injury severity, and outcome of pediatric trauma in the Stockholm region. Methods: This retrospective study comprises all trauma patients (age £ 15 years) admitted to a regional pediatric trauma center and all pediatric deaths due to trauma in Stockholm in 2002. Data from the trauma registry database were verified by comparison with medical records and autopsy reports. Outcome was measured by mortality and length of stay in a pediatric intensive care unit (PICU) and acute care hospital. Results: In all, 432 injured children were included. The median age was 10 years and 59% were males. The median injury severity score was 4 (interquartile range [IQR] 1–9) and 50% sustained head injuries. Mortality was low (1%) and the median length of hospital stay was 2 days (IQR 1–3); 19% stayed in a PICU and, of those, 89% stayed for one day. Comparison with medical records showed that much information in the trauma registry database was either incorrect or missing. Conclusions: Many injuries were minor and half of the children were discharged home from the emergency department. Head injuries were the most common injury in all age groups. The most severe head injuries were seen in the youngest group and were caused by falls. Trauma team activation criteria should be improved to avoid overutilization. The quality and completeness of data in the trauma registry must be enhanced.

Key Words Pediatric trauma Æ Triage Æ Outcomes Mortality Æ Trauma registry

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Eur J Trauma Emerg Surg 2010;36:308–17 DOI 10.1007/s00068-009-9080-6

Introduction Child injuries are a major public health problem. Every day, approximately 115 children are killed in Europe [1]. Unintentional injury is the leading cause of death among children and adolescents aged 5–19 years. Traffic accidents are the major cause of fatalities, whereas falls are the leading cause of the burden of injuries in children under 15 years and the most common cause of mortality and morbidity among young children with traumatic head injuries [1]. A recent study from Europe suggested that approximately 47% of the annual child deaths caused by unintentional injury in Europe as a whole are potentially avoidable, judging from the low mortality rates reported in Sweden [2]. In Sweden, injuries and cancer are the leading causes of death for children aged 1–15 years. In 2003, the incidence of death due to injury among children (age £ 15 years) in Sweden was 3.8/100,000 and the injury incidence was 995/100,000 [3]. The total economic impact of childhood injuries in Sweden is estimated at 3 million Euro annually [4]. Although traffic-related events account for the largest share of fatal injuries, various types of falls are the most common cause of injuries requiring hospital treatment, and the incidence has increased since 1995 [5].

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Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden, 2 Department of Pediatric Emergency, Astrid Lindgren Children’s Hospital, Karolinska University Hospital, Stockholm, Sweden, 3 Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden. Received: April 24, 2009; accepted: June 16, 2009; Published Online: September 5, 2009

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Eur J Trauma Emerg Surg 2010 Æ No. 4 URBAN & VOGEL

Sluys K, et al. Outcomes in Pediatric Trauma Care in the Stockholm Region

The majority of child injury studies in the world have focused on epidemiology and injury prevention. The few existing comparable publications on outcome after injury focus mainly on mortality and length of stay in acute care hospitals. In the United States, large population-based outcome studies have demonstrated that younger and more seriously injured children treated at designated children’s hospitals fare better than those treated at adult hospitals [6, 7]. In the Netherlands, one study has been published on shortand long-term functional outcome and quality of life in polytraumatized children [8]. In Sweden, most outcome studies focus mainly on the outcome after injuries in specific body regions, e.g., spine and head injuries [9–12]. One Swedish study has investigated outcome measured by mortality and the total length of stay on polytraumatized children after intensive care [13]. A recent literature report from the United States pointed out that few outcome studies on injured children are so comprehensive as to include pain, suffering, patient and family psychosocial measures such as posttraumatic disorders and quality of health [14]. The present study, on its own, is not comprehensive either, but is meant to be the first in a series of studies on pediatric trauma outcome in the Stockholm region. The aim of this study was to describe the age and gender distribution, injury mechanisms, injury severity, and outcome of pediatric trauma in the Stockholm region during 2002.

Patients and Methods This study was designed as a retrospective descriptive study, using reviews of medical records. All children aged 15 years or under, who were admitted to the Stockholm regional pediatric trauma center, Astrid Lindgren Children’s Hospital, Karolinska University Hospital (Stockholm, Sweden) in the year 2002, and who fulfilled the hospital’s trauma team activation criteria (see Appendix) were included in this study, along with all pediatric deaths (prehospital and hospital) related to trauma events in the Stockholm region in 2002, investigated at the Department of Forensic Medicine in Stockholm. The study was approved by the Regional Ethical Vetting Board (Stockholm). At the time of the investigation, the Greater Stockholm area had a population of 1.9 million. Of these, 350,000 were children aged 0–15 years, corresponding to 25% of all children in this age group in Sweden [15]. Astrid Lindgren Children’s Hospital, part of Karolinska University Hospital, is the only hospital in the region designated as a regional pediatric trauma

Eur J Trauma Emerg Surg 2010 Æ No. 4

center with a 24-h emergency service, surgical service, and intensive care, including burn and neurointensive care and care with extracorporeal membrane oxygenation (ECMO). Children who fulfil the criteria for activation of the trauma team are routinely triaged to the trauma center. The children included in this study had either: (1) been transported directly from the scene of injury to the trauma center, or (2) been transported to the trauma center after initial assessment at any other hospital or any outpatient clinic in the region, or (3) arrived at the trauma center as walk-in patients. Definitions The Abbreviated Injury Scale (AIS) system [16] classifies injuries according to body region, type of anatomical structure, specific structure and level, and assigns severity in an ordinal scale from 1 to 6, where 6 is lethal. The AIS measures the threat to life of each separate injury and does not combine the consequences of multiple injuries. The revised AIS 1990 (AIS-90) takes age into consideration as an important variable in relation to injury severity. The maximum AIS (MAIS) is the highest AIS score in a patient with multiple injuries. The Injury Severity Score (ISS) system [17] allocates the AIS scores into six body regions and calculates the highest AIS score from the three most severely injured ISS body regions to assign the ISS score in an ordinal scale from 1 to 75, where 75 is lethal. Data Source Information was collected from the trauma registry (Kvittra, Combitech, Va¨xjo¨, Sweden) of Astrid Lindgren Children’s Hospital, Karolinska University Hospital. The hospital trauma registry contains information on demographics, physiologic status, anatomic injury diagnosis, cause of injury, treatments, and patient outcomes. All trauma team activation cases are documented as trauma cases in the emergency room and the data are entered into the registry retrospective to discharge from the emergency department or the acute care hospital. All 430 pediatric trauma cases during 2002 were identified and recoded for quality assurance using TRI-CODE (Collector, Tri-Analytics Inc., Bel Air, MD, USA). TRI-CODE injury coding software, originally developed to reduce variability in assigning injury scores on the basis of text description, was used to assign the International Classification of Disease codes, 9th revision (ICD-9), AIS90 scores, and ISS. Three children had been wrongly included in the trauma registry and were, therefore, excluded from this study: two patients were not trauma cases and one was over 15 years of age. Thus, 427

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pediatric patients were included. In addition, information was collected from the Department of Forensic Medicine (Stockholm) which carries out medico-legal autopsies when death appears not to have occurred naturally. All medical autopsy records of pediatric death aged £ 15 years in the Stockholm region in 2002 were reviewed and injuries related to trauma events were identified as the cause of death of six children. Injuries were coded using TRI-CODE. One of these children was registered in the trauma registry at Astrid Lindgren Children’s Hospital. In total, 432 pediatric patients were included in the present study. Procedures Hospital medical records for all of the patients identified were re-reviewed (i.e., registry data were not used directly) and medical records at the Department of Forensic Medicine were reviewed retrospectively prior to this follow-up survey. We divided the data into groups based on age, acute in-hospital care days, intensive care days, and ISS, which also made it possible to compare our results with other studies. In the present study, outcome was measured by mortality, length of stay in pediatric intensive care (PICU), and length of stay in an acute care hospital. Statistical Analysis Statistical analysis was performed using SPSS software version 14.0.0 (SPSS Inc. Chicago, IL, USA). Descriptive data, if normally distributed, is presented by means, standard deviation (SD), and range. If it is not normally distributed, the data is presented by the median and interquartile range (IQR).

Results Trauma Registry Recoding Results It was found that 69% (n = 297) of the cases in the hospital trauma registry were lacking data that should have been abstracted or coded or had data that were improperly coded (false-positive or false-negative coding errors) in AIS-90 and ISS scores. In the prehospital medical records, 7% (n = 32) had missing documentation of physical parameters. Three children were declared dead on arrival at the hospital. Of these, one child was miscoded as alive and two children were not registered. Information on these children was obtained from the Department of Forensic Medicine. Demographic Characteristics A total of 432 children aged £ 15 years met the criteria for this study. Of these, 254 (59%) were boys and

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178 (41%) girls. The median age was 10 years (range 8 days–15 years, IQR 5–12 years). The patients were divided into six age groups to represent different stages in childhood: < 1 year (n = 16), 1–3 years (n = 64), 4–6 years (n = 49), 7–12 years (n = 200), and 13–15 years (n = 103). The predominant age at injury was 14 years (n = 43). In the youngest age group, half of the injured children were girls. In all of the other age groups, boys dominated, with the largest difference in the oldest age group, where 66% were boys. Pediatric Trauma Deaths Six children died: four girls and two boys. Two of these children were 15 years old and four were 3 years or younger. Three of the children were pronounced dead on the scene and three on arrival to the hospital. One child died from self-inflicted penetrating injuries (AIS 6 head region). One child died from unintentional penetrating injuries (AIS 6 head region). Two children died from injuries caused by assault: one had multiple injuries caused by blunt trauma (MAIS 5 abdomen and pelvic contents region) and the other had injuries resulting from penetrating trauma (AIS 6 neck region). One child died from unintentional burn injuries (MAIS 6 external, burns, other trauma region). Another child died from unintentional blunt injuries (MAIS 6 head region). Two of the children were intubated and received cardiopulmonary resuscitation (CPR) en route to the hospital. Injury Mechanisms The great majority of the injured children (95%) sustained injuries from blunt trauma: 181 (42%) of the events were traffic-related, followed by 133 (31%) falls, seven (2%) assaults, 44 (10%) sports-related events, 17 (4%) burns, and 50 (12%) other injury mechanisms, including five cases of near-drowning. Of the trafficrelated events, 76 (18%) were related to motor vehicles, 20 (5%) to mopeds/motorcycles/all-terrain vehicles, 50 (12%) to bicycles, and in 35 (8%) cases, the children were pedestrians. Falls seem to be more common among girls and in the younger age groups, and traffic-related events seem to be more common among boys and in the older age groups. In the infant group aged < 1 year, 11 children were injured in falls: five from baby strollers, three from baby walkers, two from changing tables, and one from a baby carrier. The falls from baby strollers occurred when the strollers were being pulled up or down stairs, for example in apartment buildings. Sports-related injuries appeared to be more frequent among girls; most of the sport injuries among



girls were related to horseback riding and among boys to ice hockey. There were also more assaults among girls, with predominance in the infant group. Injury mechanism subdivided by age group is presented in Figure 1 and injury mechanism in girls vs. boys is presented in Figure 2. In 172 of the situations where injury occurred, injury prevention devices were required by law, but in 9.2% of these cases, the injury prevention devices had not been used, and in 12% of the cases, information regarding the use of injury prevention devices was missing in the medical records. It also seemed to be more common for boys not to use injury prevention devices such as seatbelts while riding in motor vehicles and helmets while biking or downhill skiing. Injury Characteristics Three hundred and nine patients (72%) had an MAIS score £ 2, 90 patients (21%) had an MAIS score of 3, 28 patients (6%) had a score of 4 or 5, and five patients (1%) had a score of 6. Fifteen (4%) patients had an MAIS score of 3 or more in at least two AIS body areas. The MAIS score in different age groups is presented in Figure 3. The injuries were distributed in the

AIS body region areas as follows: head (50%), lower extremity (29%), spine (25%), upper extremity (23%), face (19%), thorax (15%), abdomen and pelvic contents (12%), external, burns, other (9%), and neck (2%). The AIS score of 4 was most frequently seen in the infant group and was related to severe head injuries. The median ISS was 4 (IQR 1–9). One hundred and thirty-four (31%) patients had an ISS ‡ 9 and 41 patients (10%) had an ISS > 15 (Table 1). Prehospital Most children, 335 (85%), came to the hospital by ambulance; in nine cases, the children were transported from another facility. Thirty-nine children (9%) arrived by ambulance helicopter, 11 (3%) were walkin, and in 15 (4%) cases, there was no information on how the child came to the hospital. Two hundred and eighty-three (66%) prehospital cases were cared for by ambulance technicians, 78 (18%) by specialist nurses (mainly anesthetist nurses), and 39 (9%) by anesthesiologists. The mean prehospital dispatch to hospital time was 38 min (SD 13.6). Of the 402 transported children, 181 had normal physical parameters documented in the prehospital medical records.

Figure 1. Injury mechanism subdivided by age group (n = 432).


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Figure 2. Injury mechanism in girls versus boys (n = 432).

Acute Care Hospital The median length of stay at the acute care hospital was 2 days (range 1–104, IQR 1–3). One hundred and ninety-two (45%) children were discharged home from the emergency department after being observed for less than 24 h, 110 (26%) stayed one day, 83 (19%) stayed 2–5 days, and 41 (10%) stayed for more than 5 days. Sixty-one (14%) children underwent surgical procedures within the first 24 h. Pediatric Intensive Care Eighty-two (19%) children were cared for in a pediatric intensive care unit (PICU). Of these, 54 (65%) were boys and 28 (35%) girls, and the mean age was 8 years (SD 4). The AIS body region most commonly injured was the head (73%), followed by upper and lower extremity (49%), thorax (23%), abdomen (18%), and spine (18%). Forty-nine (35%) children had an MAIS score of 3 and 21 (27%) had an MAIS score of 4 or 5. The median ISS was 9 (IQR 6–18), 22% had an ISS of 16–24 and 15% had an ISS above 24. Most injuries (97%) were attributable to blunt rather than penetrating trauma. The most frequent injury mechanism was falls (52%), followed by trafficrelated events (29%). Burn injuries were rare (1%).

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The majority of the children stayed only one day (86%), and the mean length of PICU days was 1 day (SD 2).

Discussion This study focuses on outcome and is the first in a series on pediatric trauma outcome studies in the Stockholm region. In total, 432 children aged 8 days– 15 years were included in this investigation. Study Strengths and Limitations The strength of the present study is that it includes a total data set from a well-defined population and geographical area (Stockholm region). Our data can, therefore, be considered as representative for the area and the time that it was conducted, as well as for the study group, with minimal bias and drop-out. The geographical area represents an urban setting. Sweden is highly urbanized, with 84% of the population living in urban areas [18] and children aged £ 15 years living in the Stockholm region comprise 25% of this age group in all of Sweden [15]. We believe that the data can be extrapolated with caution to other urbanized areas of Sweden.



Figure 3. Maximum abbreviated injury scale (MAIS) score in the different age groups (n = 432).

Table 1. Injury severity scores (ISS) and frequency (n = 432). Median 4 (interquartile range [IQR] 1–9). Scores 0–75 Frequency

0–8 298 (69%)

9–15 93 (22%)

16–24 19 (4%)

> 24 22 (5%)

The study is limited by its retrospective design in which information was extracted from the hospital trauma registry database. A prospective design would have been preferable, as the identification of patients and data analysis rely heavily on the quality of documentation and registration. All cases in the database from 2002 were recorded using medical records for quality assurance. Sixty-nine percent of the cases in the database were found to be lacking data that should have been abstracted or coded, or had data that were improperly coded in AIS-90 scores and ISS. We also found errors in 32 prehospital medical records, where physical parameters were not documented. Several other studies have reported data errors in trauma registries. In an outcome study using data from a Swedish trauma registry, Franze´n et al. [13] reported


that, for a great majority of the children, data were missing on prehospital and admission Glasgow Coma Scale (GCS) scores, 65% of the records lacked prehospital documentation on respiratory rates, and 15% lacked all prehospital documentation. A study from the United States examining types of data entry errors in a trauma registry database found substantial error rates in injury coding (9%) and admission GCS scores (55%) in the emergency department [19]. In a report from the American College of Surgeons National Trauma Data Bank, about 25% of the records were excluded from statistical analysis because of errors of inconsistency or invalid records and unknown or missing information [20]. Falk et al. [21] reported in an outcome study from Stockholm, based on medical records, that 65% of the children had missing data on admission GCS scores and that the actual management of care was only partially documented in the physician’s discharge note. These findings indicate that data validation is essential for trauma registries in order to improve registry data quality. The accuracy of medical records is equally essential, as data are abstracted and

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collected from the medical documentation to trauma registries and used for research. Mortality The mortality was low (1%). Three children died on the scene and three children were declared dead in the emergency department. None of these deaths were associated with traffic-related events, even though traffic accidents are the most common cause of mortality related to injury in children in Sweden and the world [1, 3–5]. In the Stockholm region during 2000– 2003, no children or adolescents were killed in trafficrelated events [22]. In a Swedish epidemiological trend analysis, Jansson et al. [23] found that a combination of such factors as urban planning, social welfare development, and safety measures was associated with reduced child injury mortality. Safety measures in traffic environments, such as seat belts, child car seats, and bike helmets, as well as changes in the physical environment to keep children away from the roads, have resulted in tremendous reductions in child injury mortality and morbidity in Sweden since the 1980s. Although none of the children in this present study were killed in traffic-related events, it is alarming that, in cases where the use of protection devices was required by law, close to 10% had not been using them and for another 12%, the medical records had no information regarding whether injury prevention devices had been in use. Morbidity Injuries were most frequent in children aged 10– 15 years. Boys dominated in all age groups except in the infant group, where half of the children injured were girls. Traffic-related events were the main cause of morbidity, primarily in older age groups, followed by falls, predominantly observed in the younger age groups. More than 50% of the children in the present study sustained injuries to the head. The most severe head injuries were found in the infant group, and falls were the main cause of injury. Several studies report that the highest incidence of traumatic brain injury requiring hospital emergency care is found in young children, and that, in all age groups, falls are the most common injury mechanism, causing head injuries with a significant risk of long-term neurological damage [1, 5, 24, 25]. Head injuries are also the most common type of childhood injury presenting at emergency departments in most countries in the WHO European Region [1]. In Sweden, 50% of mild brain injuries in children aged 0– 4 years have been reported to be associated with falls

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from nursery furniture, and in this category, the baby walker caused the most severe injuries [26]. A recent investigation from the United States reported that falls commonly occur from car seat carriers being used outside cars and that these falls caused significantly more severe intracranial injuries and longer hospitalizations than other types of falls [27]. In this present study, falls from a baby stroller on stairs were the most common cause of severe infant head injuries, followed by falls from stairs with baby walkers and from changing tables. In Sweden, strategies such as home visiting programs for new mothers that include education to prevent childhood falls have been proven effective [1]. Still, Sweden reports an increasing number of falls since 1995 [5]. A few studies have attempted to look at the association between childhood injuries and socioeconomic status. Although this was not investigated in the present study, others have shown correlations between higher incidences of injuries and such risk factors as households on welfare, single parenting, and mothers with low income [28]. A study including data from several European countries reported significantly increased risk of death due to injury associated with low-status occupations and low income [29]. To reverse the trend of increasing prevalence of childhood falls in Sweden, we suggest targeted programs for parental risk groups to complement existing programs. Pediatric Intensive Care Nineteen percent of the injured children were admitted to a PICU. The mean age was 8 years (SD 4) and the median ISS was 9 (IQR 6–18). In this group, the most frequent injury mechanism was falls and over 70% received head injuries. The majority of the children stayed for one day. A study from the New York State Trauma registry on children below 13 years of age with blunt trauma showed that children with major trauma who were sent to a children’s hospital with a PICU had a lower mortality rate compared to children treated in adult intensive care units [30]. Another investigation from the State of Florida found significantly lower mortality rates in designated trauma centers compared to acute care hospitals without a specialized trauma center and in a designated pediatric trauma center compared to nonpediatric trauma centers [31]. Potoka et al. [6], in a retrospective analysis using the Pennsylvania Trauma Outcome Study, found a significantly better overall survival rate at pediatric trauma centers (PTC) compared to adult trauma centers with added qualifications to treat children. The study also found significant differences in outcome after injuries to the



head, liver, and spleen: the overall outcome was best for children treated in pediatric trauma centers. Densmore et al., using a pediatric database from 27 states representing 70% of the total pediatric inpatient population in the United States, have demonstrated significantly lower mortality, shorter length of stay, and lower total cost in children’s hospitals vs. adult hospitals [7]. In the Swedish context, it is likely that further investigations are needed to determine possible differences in outcome for injured children treated in designated children’s hospitals with PICUs compared to adult hospitals and adult intensive care units (ICU) with and without added qualifications to treat children. In a report on outcome of pediatric trauma, Dowd [14] pointed out that a comparison of trauma systems is hampered by an inability to determine the effects of various components and settings in trauma care. Studies on each phase or setting in trauma care, such as prehospital care, acute care, and rehabilitation, are essential to derive evidence-based best practice for injured children. We conclude that there is a need for research in all phases and settings in trauma care to establish the best quality of care for injured children in Stockholm and Sweden. Child Abuse There were very few assault cases. Injuries resulting from maltreatment were more common among girls, particularly in the younger age groups. Two girls, both 3 years old, were physically abused to death. In the present study, only cases where abused children fulfilled the hospital trauma team activation criteria were included. A Swedish study found that cases involving maltreated children who are very young, female, or in good health run a high risk of non-detection, of being considered non-serious, and of not being reported [32]. A study from the United States found that official statistics underestimate the burden of child maltreatment: the incidence of physical abuse was 40 times greater and sexual abuse was 15 times greater than that of official reports [33]. Professionals who work with children in any environment need to have updated knowledge of risk factors to prevent or stop maltreatment that, otherwise, would continue undetected. Overtriage There were many minor injuries. Seventy-two percent had a maximum AIS score £ 2, including six children with an AIS score of 0, and 42 children had normal physical parameters documented in the prehospital medical records. In the cases of normal physical parameters, the trauma team had probably been acti-


vated on the criterion of mechanism of injury. The median length of hospital stay was 2 days and 45% were discharged home from the emergency department. Based on these findings, we presume an overutilization [34] (cases transported to a trauma center, although they did not require this high a level of trauma care) of the trauma team based on current trauma team activation criteria. We cannot exclude the possibility of underutilization [34] (cases who required a high level of trauma care at a trauma center but did not receive it), since this study was not designed to investigate prehospital triage specifically. However, in one such study on injured children aged 0–15 years, Engum et al. [35], using a simplified version of the American College of Surgeons guidelines, found a 71% prehospital overtriage rate. The most accurate triage criterion found for major injury was a systolic blood pressure £ 90 mmHg, GCS score £ 12, and respiratory rate less than 10 breaths per minute or greater than 29 breaths per minute. The GCS score was also found to be a more accurate indicator of major trauma in children than in adult trauma patients. The study also found that injury mechanism was less accurate as a triage criterion, as were the Pediatric Trauma Score [36] and Revised Trauma Score systems of triage [37]. Studies in the United States and Denmark report similar findings [38, 39]. These studies also found that the use of anatomic and physiologic criteria retains a high sensitivity for identifying children in need of resuscitative interventions and reduces overtriage. Overuse of the trauma team can contribute to a significant increase in health care cost, which has been demonstrated in a study from the United States [40]. We conclude that further investigations of trauma team activation criteria for pediatric trauma in the Stockholm region are needed to establish a triage system that will make more efficient use of our limited health care resources.

Conclusions This study revealed that major pediatric trauma in the Stockholm region is rare. There were many minor injuries and nearly half of the children were discharged to their homes from the emergency department. Head injuries were the most common injury in all age groups: the most severe head injuries were seen in the youngest age group and were caused by falls. The results indicate that vigorous injury prevention programs are needed in the Stockholm region to prevent falls resulting in head injuries in young children. Substantial improvement is also needed in the current pediatric

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trauma team activation criteria to avoid overutilization of the trauma team. It is imperative to improve the quality and completeness of the data in the trauma registry. Continued research is needed in the pediatric population with a comprehensive approach to establish evidence-based high quality pediatric care.

13. 14.

15. 16.

Acknowledgments We gratefully acknowledge the assistance of Petra Ra˚sten Almqvist, MD, PhD, National Board of Forensic Medicine, Department of Forensic Medicine, Stockholm, Sweden. This study received financial support from the Queen Silvia’s Jubilee Fund.

Conflict of interest statement The authors declare that there is no actual or potential conflict of interest in relation to this article.

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19. 20.

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Address for Correspondence Kerstin Sluys Department of Molecular Medicine and Surgery Karolinska Institutet Karolinska University Hospital Stockholm Sweden e-mail: [email protected]


Appendix Trauma team activation criteria at Astrid Lindgren Children’s Hospital, Karolinska University Hospital, Stockholm, Sweden. Physiological criteria Respiratory impairment Hypotension Altered consciousness or neurological impairment and/or Anatomical criteria Penetrating injuries to head, neck, torso, and extremities proximal to elbow and knee Two or more long bones fractures Pelvic fractures Paralysis after trauma mechanism Amputation proximal to wrist and ankle Burn injuries or hypothermia combined with other trauma mechanism Near drowning combined with other trauma mechanism Flail chest and/or Mechanisms of injury High-speed crash > 70 km/h with restraint use or air bag > 50 km/h without restraint use or air bag Vehicle entrapment, rollover Ejection from vehicle, death in same vehicle Pedestrian/bicyclist struck by vehicle Fall of > 3 m Crush injuries torso

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