Delayed diagnoses / missed injuries are with us to stay. The typical trauma activation is a fast-paced process, with lots of things going on at once. Trauma professionals are very good about doing a thorough exam and selecting pertinent diagnostic tests to seek out the obvious and not so obvious injuries.
But we will always miss a few. The incidence varies from 1% to about 40%, depending on who your read. Most of the time, they are subtle and have little clinical impact. But some are not so subtle, and some of the rare ones can be life-threatening.
The trauma tertiary survey has been around for at least 30 years, and is executed a little differently everywhere you go. But the concept is the same. Do another exam and check all the diagnostic tests after 24 to 48 hours to make sure you are not missing the obvious.
Does it actually work? There have been a few studies over the years that have tried to find the answer. A paper was published that used meta-analysis to figure this out. The authors defined two types of missed injury:
- Type I – an injury that was missed during the initial evaluation but was detected by the tertiary survey.
- Type II – an injury missed by both the initial exam and the tertiary survey
Here are the factoids:
- Only 10 observational studies were identified, and only 3 were suitable for meta-analysis
- The average Type I missed injury rate was 4.3%. The number tended to be lower in large studies and higher in small studies.
- Only 1 study looked at the Type II missed injury rate – 1.5%
- Three studies looked at the change in missed injury rates before and after implementation of a tertiary survey process. Type I increased from 3% to 7%, and Type II decreased from 2.4% to 1.5%, both highly significant.
- 10% to 30% of missed injuries were significant enough to require operative management
Bottom line: In the complex dance of a trauma activation, injuries will be missed. The good news is that the tertiary survey does work at picking up many, but not all, of the “occult” injuries. And with proper attention to your patient, nearly all will be found by the time of discharge. Develop your process, adopt a form, and crush missed injuries!
Reference: The effect of tertiary surveys on missed injuries in trauma: a systematic review. Scand J Trauma Resusc Emerg Med 20:77, 2012.
Major trauma victims are evaluated by a team to rapidly identify life and limb threatening injuries. This is accomplished during the primary and secondary surveys done in the ED. The ATLS course states that it is more important for the team to identify that the patient has a problem (e.g. significant abdominal pain) than the exact diagnosis (spleen laceration). However, once the patient is ready for admission to the trauma center, it is desirable to know all the diagnoses.
This is harder than it sounds. Physical examination tends to direct diagnostic testing, and some patients may not be feeling pain, or be awake enough to complain of it. Injuries that are painful enough may distract the patient’s attention away from other significant injuries. Overall, somewhere between 7-13% of patients have injuries that are missed during the initial evaluation.
A well-designed tertiary survey helps identify these occult injuries before they are truly “missed.” This survey consists of a structured and comprehensive re-examination that takes place within 48-72 hours, and includes a review of every diagnostic study performed. Ideally, it should be carried out by two people: one familiar with the patient, and the other not. It is desirable that the examiners have some experience with trauma (sorry, medical students).
The patients at highest risk for a missed injury are those with severe injuries (ISS>15) and/or impaired mental status (GCS<15). These patients are more likely to be unable to participate in their exam, so a few injuries may still go undetected despite a good exam.
I recommend that any patient who triggers a trauma team activation should receive a tertiary survey. Those who have an ISS>15 should also undergo the survey. Good documentation is essential, so an easy to use form should be used. Click here to get a copy of our original paper form. We have changed over to an electronic record, and have created a dot phrase template, which you can download here.
Next post: Does the tertiary survey actually work?
Last week, I published a preliminary practice guideline for nonoperative management of abdominal stab wounds. Click here to view it. A key part of that guideline is the serial abdominal exam. Surgeons talk about this a lot, but how do you do it? I posted about many of the details here.
The serial exam is nuanced enough so that it deserves its own clinical practice guideline! You won’t find this in any doctor or nursing books. It’s really simple, but the devil is truly in the details.
Click this image or the link below to download the guideline. I’ve also posted a Microsoft publisher version in case you want to modify it to suit your center.
Please feel free to email or post comments and questions in the area below this post!
The October issue of the Trauma MedEd newsletter is now available to everyone!
This issue contains a collection of some of the most requested posts from the blog.
In this issue, you will learn about:
- How Quickly Does Hemoglobin Drop?
- How To Remember The “Classes of Hemorrhage”
- How To: The Serial Abdominal Exam
- Bathing/Showering And Wound Care
To download the current issue, just click here!
Or copy this link into your browser: https://www.traumameded.com/courses/best-of-the-blog-issue-1/
This newsletter was released to subscribers a few weeks ago. If you would like to be the first to get your hands on future newsletters, just click here to subscribe!
In my previous post, I reviewed a new paper that examined the appropriate amount of time that patients should be observed for nonoperative manage of an abdominal stab wound. Many of you know that I am a fanatic of properly crafted clinical practice guidelines (CPG). I decided to make a first pass at converting the LAC+USC group’s paper to something that will be helpful at the bedside.
This CPG incorporates the patient selection and timing information published in the paper. It breaks the process down into easily followed tasks, and fills in the blanks for shift to shift management. The CPG is displayed in an “if this, then do that” format. This firms up decision making and makes it easier for your trauma program to monitor compliance with it.
A note about CPGs: they generally cover about 90% of clinical cases. Obviously, they cannot provide guidance for certain rare combinations of circumstance. In that case, the trauma professional should do what they think is right for that situation. Most importantly, they should document this rationale in a progress note.
Here are answers to some of your questions in advance:
- Patients should not be kept at bed rest. This is always bad.
- There is no reason to keep the patient NPO. A very small percentage of patients actually fail. It makes no sense to starve everybody for the one or two patients that need to go to the OR each year. Anesthesiologists at trauma centers are very skilled at providing safe intubation in all patients. As you all know, every trauma activation patient coming into your trauma bay needing intubation has just finished a seven course meal!
- Give your patient clear discharge instructions! They need to know what they can do, and what to look for if things eventually go awry.
And please leave comments and suggestions for improvements in the reply box below or by email to [email protected] There are always ways to make CPGs even better! I have also included a Microsoft Publisher file so you can modify this guideline to better suit your trauma center.
In my next post, I’ll publish the serial abdominal observation CPG I mention in this one.
- Download a pdf file of the guideline
- Download a Publisher file of the guideline