Prospective evaluation of early missed injuries and the role of tertiary trauma survey

False-Negative Plain Cervical Spine X-Rays in Blunt Trauma

Although considered very accurate, false-negative plain cervical radiographs of blunt trauma patients will occur with potentially devastating complications. We sought to define the population of patients who fall into this category and the overall accuracy of adequate three-view cervical spine radiography in the blunt trauma population. A retrospective search was carried out of blunt trauma patients entered into our trauma registry. All patients with the ICD-9 codes indicating cervical spine injury with a negative three-view cervical spine radiograph reading had their charts and radiographs reviewed. Institutional statistics for blunt cervical trauma evaluation and injury were obtained from the trauma registry. Fifty-eight of 936 blunt trauma patients (6.2%) were diagnosed with cervical spine injury over the 9-month study period. Of 649 patients with adequate three-view plain radiographs, three patients were identified with negative plain radiographs and significant cervical spine injury, a false-negative rate of 0.5 per cent. Sensitivity was 90.3 per cent, specificity was 96.3 per cent, positive predictive value was 54.9 per cent, and negative predictive value was 99.5 per cent. Three-view plain radiograph series of the cervical spine remains a highly sensitive and specific test for cervical spine injury following blunt trauma. However, the fact that we identified three patients with significant fractures after negative plain radiographs suggests that serious consideration of computed tomography must be applied in treating symptomatic, high-risk blunt trauma patients when plain radiographs do not reveal an injury.

[Whiplash injury of the neck from concepts to facts]

OBJECTIVES

To focus on a topic of traumatology and rehabilitation becoming recently a much debated public health problem.

METHOD

A references search from Medline database with whiplash as keyword was carried out. Were selected articles with abstracts in french or english and focusing on accidentology, biomechanics, demonstrated lesions, epidemiology and treatments.

RESULTS

From 1664 references found, 232 were reviewed. The usual mechanism of crash is a rear-end collision inducing in the occupants of the bumped vehicle a sudden lower cervical spine extension with upper flexion followed by a global flexion. In nearly 50% of the cases, the stress occurring in the collision is comparable to that observed in bumper cars. The velocity changes are seldom up to 15 km/h. A headrest at the level of the center of gravity of the head restrict significantly the extension of the neck. Every structure of the cervical spine could be damaged and mainly the facet joints but the lesions were only demonstrated in severes traumatisms. The discrepancies in incidence among the different countries could be related to their medicolegal system. Although subjectives, the early symptoms are rather similar among patients suggesting true anatomical or functional disorders but the chronicity seems to be mainly related to social and psychological factors. The association of: no posterior midline cervical tenderness, no intoxication, normal alertness, no focal neurological deficit and no painful distracting injuries has a good predictive value of the lack of osteo-articular lesion on X-rays. Except the grade IV of the Quebec task Force (0, no symptom; 1, pain and stiffness; 2, neck complaint and physical signs; 3, neck complaint and neurological signs; 4, fracture or dislocation) the use of a collar should be avoided and the cervical spine should be mobilized.

CONCLUSION

In most whiplash injuries, the mildness should be early stated, mobilization encouraged, and procedures of compensation shortened.

Adverse drug events in trauma patients

BACKGROUND

Adverse drug events (ADEs) are noxious and unintended results of drug therapy. ADEs have been shown to be a risk to hospitalized patients. The purpose of this study was to determine the rate and nature of ADEs in trauma patients and to characterize the population at risk.

METHODS

An electronic medical record, a hospital wide computerized surveillance program, and a clinical pharmacist prospectively investigated ADEs in 4,320 trauma patients from 1996 through 1999.

RESULTS

The rate of ADEs in trauma patients (98/4320, 2.3%) was twice that of non-trauma hospital patients (1,111/96,218, 1.2%, p < 0.001). Traumatized females had ADEs 1.5 times more often than traumatized males (2.7% versus 1.8%, p = 0.052). The medication class most often associated with ADEs was analgesics with 54% involving morphine and 20% involving meperidine. The most common ADEs were nausea, vomiting, and itching. Only one ADE was directly attributed to a medical error.

CONCLUSIONS

Trauma patients are at double the risk for ADEs. Analgesics are particularly associated with ADEs and use should be carefully monitored.

23-Hour observation solely for identification of missed injuries after trauma: is it justified?

BACKGROUND

The use of an observation period to identify missed injuries in trauma patients has gained favor in recent years. This study was undertaken in a population of patients with minimal or no identified injuries to determine the following: whether a period of in-patient observation identifies missed injuries; demographic factors associated with missed injuries; and morbidity of missed injuries.

METHODS

Over 4 years at a Level I trauma center, 4,738 patients were observed for 23 hours. Of these patients, 630 were converted to full admission and were reviewed. All medical records were reviewed for reason for observation, reason for conversion to full admission, and presence of missed injury.

RESULTS

In the 4,738 patients observed, 35 had a missed injury identified. No clinical factors studied were associated with identifying a missed injury. Of the 35 patients that had a missed injury, 21 did not have clinically relevant injuries, whereas the 14 remaining patients did. All of the 14 required prolonged hospital admissions and 9 underwent invasive procedures.

CONCLUSION

Of over 4,700 observed trauma patients, less than 0.5% remained hospitalized for significant missed injuries. No factors were identified that predicted missed injuries. Twenty-three-hour observation for the purpose of identifying missed injuries after thorough emergency department evaluation may not be justified.

The impact of trauma case management on patient outcomes

BACKGROUND

Previous investigations demonstrate that nursing case management in the acute care setting improves patient outcomes. However, these findings provide limited information specific to trauma patients.

METHOD

The effect of trauma case management (TCM) was measured using practice-specific variables such as in-hospital complications, missed injury rates, and length of stay. Other measures included staff satisfaction and use of allied health services. Data from 148 patients with an Injury Severity Score < 16 in the 5 months after the introduction of TCM were compared with 327 patients from the previous 12 months.

RESULTS

Results demonstrated a trend toward reduced length of stay overall, more so in the older and more severely injured. TCM greatly improved missed injury detection rates (p < 0.0015) and coordinated allied health use more efficiently (p < 0.0001). Staff surveys exhibited a perceived dramatic improvement in the effectiveness of patient care (p < 0.0001).

CONCLUSION

The introduction of TCM improved the efficiency and effectiveness of trauma patient care in our institution.

Initial management of the poly-trauma patient: a practical approach in an Australian major trauma service

The initial management of the poly-trauma patient is of vital importance to minimizing both patient morbidity and mortality. We present a practical approach to the early management of a severely injured patient as practiced at Liverpool Hospital in Sydney, Australia. Specific attention is paid to innovations in care and specific controversies in early management as well as local solutions to challenging problems.

Missed injuries in a level I trauma center

BACKGROUND

Major trauma presents major diagnostic and therapeutic problems. Any delay in providing the treatment necessary may lead to increased morbidity and mortality, prolonged length of hospital stay, and increased cost. This study was undertaken to determine the extent, contributing factors, and implication of missed injuries and relate them to the three surveys in a Danish Level I trauma center.

METHODS

The records of all major traumatized patients admitted to the Odense University Hospital from January 1996 through December 1999 have been studied to determine the extent and type of missed injuries. The initial examination is carried out by the trauma team in the A&E department according to standard protocols. Resuscitation is carried out according to Advanced Trauma Life Support principles and details are documented in the patient journal and in a special trauma journal.

RESULTS

Sixty-four of 786 patients (incidence, 8.1%) had 86 missed injuries. The missed injuries averaged 1.3 injuries per patient. There were 45 male and 19 female patients, with a median age of 33 years (range, 12-81 years). The median ISS was 17 (range, 4-50); 14%, 38%, and 48% of the injuries were missed in primary, secondary, and tertiary surveys, respectively.

CONCLUSION

Our study demonstrates that missed injuries can occur at any stage of the management of patients with major trauma. Repeated assessments, both clinical and radiologic, are mandatory to diminish the problem. In initial assessment, one still has to treat the greatest threat to life before complete diagnosis of all injuries, but alertness to evolving injuries must remain throughout the patient's stay in hospital.

Clinical pathways--can they be used in trauma care. An analysis of their ability to fit the patient

This study prospectively evaluated the appropriateness and ability of clinical pathways to fit trauma patients in five key conditions, severe head injury, fractured ribs, fractured pelvis, fractured femur and blunt abdominal trauma, who were admitted to a single Level 1 Trauma Centre, between February and July 1999. Each pathway consisted of 14 elements of care divided into observable outcomes. Failure to achieve an outcome resulted in a variance or deviation from the pathway, which was assessed by the number of non-applicable variances. Appropriateness of clinical pathways was assessed by the applicability index (the number of non-applicable variances divided by the potential variances). Critical mismatches occurred when non-applicable variances exceeded 50% of potential variances. 146 patients, with the mean age 41.9 years (S.D. 20.7), mean ISS 11.1 (S.D. 10.7) were enrolled; 18 with severe head injury, 59 with fractured ribs, 13 with fractured pelvis, 20 with fractured femur and 36 with blunt abdominal trauma. Critical mismatch occurred in seven patients. Applicability indexes were 87 for head, 93 for ribs, 92 for blunt abdominal trauma, 91 for femur and 92 for the pelvic pathway. Patient assessment, pain management, skin integrity and patient education were the most appropriate key elements of care, discharge planning, patient satisfaction, treatment and activity were least applicable. This study identified, for the first time, that clinical pathways are clinically appropriate for major trauma conditions.

Trauma case management and clinical pathways: prospective evaluation of their effect on selected patient outcomes in five key trauma conditions

BACKGROUND

This study evaluated the implementation of clinical pathways and case management between July 1998 and July 1999 in five key trauma conditions: severe head injury, fractured ribs, fractured pelvis, blunt abdominal trauma, and fractured femurs presenting to a single trauma service.

METHODS

Thirteen key elements of care with expected outcomes were defined for each key trauma condition. Deviations from expected outcome were defined as variances. Attainment of the expected outcomes was measured before (stage 1) and after introduction (stages 2 and 3) of clinical pathways and case management. Nonattained outcomes were quantified and categorized into time of occurrence, and relationship to staff, patient, or system.

RESULTS

Two hundred thirty-five patients were studied, with a mean age of 41.8 (SD, 20.6) years and mean Injury Severity Score (ISS) of 11.7 (SD, 11.0). The mean number of observed variances per patient for stage 1 was 51.7 (SD, 43.5); stage 2, 42.3 (SD, 32.9); and stage 3, 23.2 (SD, 21.7) (p = 0.0001 for both stage 1 and stage 2 compared with stage 3). There was a significant improvement in outcomes achieved from stage 1 (92.7%; 95% confidence interval, 92.5-92.9%), to stage 3 (96.7%; 95% confidence interval, 96.5-96.9%). Of the total number of variances seen, 0.2% related to system errors, 25% related to patient factors, and 75.8% related to staff. The proportion of staff-related variances was significantly reduced in stage 3.

CONCLUSION

Clinical pathways and case management identified areas in need of remedial action and improved the delivery of patient care to our trauma population. It has set a template for the future management of our trauma service.

Missed injuries in patients with multiple trauma

BACKGROUND

Understanding the etiology of missed injuries is essential in minimizing its occurrence. A retrospective review was conducted to identify the incidence, contributing factors, and clinical outcomes of missed injuries.

METHODS

All trauma patients assessed by St Michael's Hospital trauma service from April 1, 1995, to July 31, 1997, were included in the study. Demographic and medical data were compared and statistically analyzed in two patient groups to identify factors associated with missed injuries.

RESULTS

Forty six of 567 patients (8.1%) had missed injuries. Patients with missed injuries had higher mean Injury Severity Scores and longer stays in the hospital and intensive care unit compared with patients without missed injuries (p < 0.05). Patients with missed injuries were more likely to have lower Glasgow Coma Scale scores and to have required pharmacologic paralysis (p < 0.05). Of the factors contributing to missed injuries, 56.3% were potentially avoidable and 43.8% were unavoidable. Seven patients with missed injuries had clinically significant outcomes, including one patient death. Of the seven clinically significant missed injuries, five were attributable to potentially avoidable factors.

CONCLUSION

Patients with missed injuries tend to be more severely injured with initial neurologic compromise. The majority of missed injuries are potentially avoidable with repeat clinical assessments and a high index of suspicion.

Whiplash Injuries

The term "whiplash" is not a medical diagnosis, but is the result of soft-tissue trauma to the neck. A whiplash injury occurs as a result of a sudden acceleration or deceleration of the head and neck with respect to the body. This article recommends that patient treatment be individualized.

Tertiary survey of the trauma patient in the intensive care unit

The issues surrounding the arrival of trauma patients to the ICU have been defined. By necessity, many of these topics are dealt with elsewhere in greater detail. The basic framework within which this phase of care could be optimized has been provided. Pitfalls related to patients' mode of arrival to the ICU affect subsequent management and should direct specific clinical activity. The tertiary survey is a complete summation and cataloguing of a patient's injuries. The need for ongoing resuscitation determines how much attention can be paid to the tertiary survey. Clinical suspicion based on mechanism and pattern of injury and thorough, repeated, complete physical examination are the essential elements of the tertiary survey. The survey is affected by factors that alter patients' mental status because examination is most reliable in patients who can localize pain. Medications, intoxication, and head injuries are common factors that interfere with the reliability of the tertiary survey for variable periods. Radiographic assessment is used to identify injuries suspected on the basis of mechanism of injury, injury pattern, and findings on physical examination. Some studies may be done portably; others require transport within the hospital. The intensivist must prioritize these ongoing diagnostic studies based on patient stability and the need for ongoing resuscitation.

Alterations of preliminary readings on radiographic examinations minimally affect outcomes of trauma patients discharged from the emergency department

BACKGROUND

We hypothesized that trauma patients could be discharged safely from the emergency department (ED) before the availability of official readings for their radiologic examinations. We also sought to determine whether trauma patients were more prone to alterations of preliminary interpretations than other ED patients.

METHODS

Alterations of preliminary readings (PR) for patients discharged from the ED were reviewed. If the official readings conflicted with the PR used for the patient's disposition, attempts were made to contact the patient and provide the appropriate follow-up. Data recorded included the type of radiographic examination, the presence of a missed injury, and the follow-up. By using institutional data, the incidence of inaccurate PR were compared for trauma patients and other ED patients (chi2 test, Fisher exact test, p < 0.05).

RESULTS

Between January of 1998 and December of 1998, 102 of 38,260 discharged ED patients had official readings differing from PR. Forty-three of the changed readings involved 42 of the 1,073 discharged trauma patients, who were more likely to harbor inaccurate PR (<0.0001) than other discharged ED patients. Twenty-eight altered readings involved plain films and 15 involved computed tomographic scans. The most common altered readings involved computed tomographic scans of the head and face (n = 13). Twelve missed injuries were detected, most commonly related to a missed injury of the extremity (7 cases). Nine other cases involved the detection of incidental pathologic conditions. Eight patients required repeat ED visits for clinical and radiographic evaluation, and one patient required subsequent hospital admission.

CONCLUSION

Discharged trauma patients are more likely to harbor alterations of preliminary interpretations than other ED patients. Although the official readings for these trauma patients will occasionally reveal previously undetected pathologic conditions, the majority of such cases can be managed with outpatient follow-up.

Prevention of multiple organ failure

Physicians are still largely ignorant of the underlying biology of SIRS and multiple organ failure. Nonetheless, strategies to prevent multiple organ failure are possible. These include aggressive resuscitation of hemodynamically unstable patients, careful assessment to avoid missing clinically significant injuries, early operative treatment of all possible injuries with debridement of all nonviable tissue, early nutritional support, and the early diagnosis and prompt treatment of infectious complications. Treatment of patients with established multiple organ failure is still largely supportive and has made little impact on the patient mortality rate over the past 20 years. Future treatment strategies must focus on multimodality combination therapy aimed at specifically suppressing excessive activation of the inflammatory response while preserving immune competence and normal antimicrobial defenses. Only then are physicians likely to begin to see a reduction in the mortality rate of patients with this complex and challenging condition.