Tag Archives: missed injury

General

Missed Injury / Delayed Diagnosis

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Missed injuries (or delayed diagnosis in polite conversation) are the bane of any trauma program.Trauma professionals want to know that they’ve identified all significant injuries in their patients so no future harm will occur due to them.

But what exactly is a missed injury? The definitions tend to vary a bit, which is why their incidence varies so widely in the literature (1 – 39%). The simplest way to describe one is any injury that is identified after a set amount of time. But what is a reasonable time frame? Some define it as the time spent in the emergency department (highest incidence). Others count any injury found after a predetermined period of time (typically 24-48 hours). Some use even longer time intervals, so they obviously look the best and have the lowest incidence.

And what are the factors that contribute to us “missing” these injuries? As you can imagine, there are quite a few, but they boil down to two major categories:

  • Inadequate diagnostic technique (physical exam and/or technology) – I can’t see it
  • Inadequate recognition – I didn’t think of it

A good physical exam with the focused use of appropriate imaging is paramount. Sure, you could use a shotgun approach and just scan everything. The problem is that CT scans have limitations, but we tend to forget that. So we believe that if we don’t see anything on scan, it must not exist. Wrong! The physical exam may pick up suspicious findings that tell the clinician that a specialized study is necessary to rule a potential injury out.

The failure to recognize that an injury is present can occur with everyone that “touches” the patient. The EMT or physician may not appreciate a subtle injury. The radiologist may miss a problem on the images they read. The surgeon might even fail to notice another injury separate from the one she is operating for. Obviously, experience plays a large part in this factor. Students will fail to appreciate a potential injury that a senior clinician will detect rapidly. 

What to do about it? Tomorrow, I’ll review a recent paper that tries to correlate missed injuries with time of admission. And on Friday, I’ll discuss some strategies to try to help keep it from happening to you.

General

The Tertiary Survey for Trauma

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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.