Sweden

Introduction

The management of severe traumatic injury has undergone major changes over the last 20 years, as Advanced Trauma Life Support (ATLS), the concept of damage control, massive transfusion protocols, new technological innovations, and improved intensive care have been implemented across the world. Even in the field of vascular trauma, there have been developments in hemostatic resuscitation and vascular damage control including the use of tourniquets, vascular shunts, endovascular occlusion balloons, endografts (i.e., stent grafts), and embolization to refine operative techniques. Computed tomography angiography (CTA) is regarded as the first line of investigation for all patients with suspected vascular trauma with no immediate indication for operative intervention. This review will provide insights into current Swedish vascular trauma practice but also discuss new nationwide trends in treatment modalities and their implementation.

The Swedish Trauma System

Sweden is the largest and most populated Scandinavian country with a total population of 10.2 million (Swedish government agency, 2019), and the fifth largest country in Europe by area. It has a low population density of 22 inhabitants per square kilometer (57/sq. mile) and about 85% of the population live in urban areas (about 40% in the metropolitan areas of Stockholm, Gothenburg, and Malmö). The country has several hard-to-reach areas, mountainous, forested, and coastal, and a harsh winter climate which imposes heavy demands on the prehospital organization. These facts point out that the conditions for trauma care differ within the country. There are currently 7 university hospitals and 57 emergency hospitals in Sweden. The university hospitals ( Fig. 31.1 ) have resources that might meet the criteria for a level-1 or level-2 trauma center, with access to 24/7 general and vascular surgery, neuro- and thoracic surgery, and also intensive care units. There has been an increasing trend towards trauma care centralization in recent years, with severely injured patients being transferred to major university hospitals when possible.

The national trauma system in Sweden is currently being reviewed after a 2015 national trauma investigation report stated that it is essential for trauma care in Sweden to be structured through the formation of networks (the National Board of Health and Welfare, 2015). Such a network consists of a trauma center as hub with fully equipped acute-care and surgical hospitals for trauma management as satellites. All emergency activities are centralized at one command center (“SOS alarm,” or “112”) that directs units as required, and arranges and controls patient transfers. The majority of severely injured patients in these networks are transported by ground ambulance, but a large and increasing proportion are transported by helicopter to university hospitals. Ground ambulances are generally equipped with basic life-support facilities and ambulance nurses. Helicopter transport is available in most regions, but there is no national helicopter service. Some regions of the country have physician-operated air and ground ambulance services. There is no dedicated trauma-ambulance service in Sweden.