Association of head, thoracic and abdominal trauma with delayed diagnosis of co-existing injuries in critical trauma patients

Prevalence of Missed Injuries in Multiple Trauma Patients at a Level-1 Trauma Center in Saudi Arabia

Background Missed injuries are defined as injuries neither detected in the emergency department (ED) nor after admission to the hospital. The objective of this research was to identify missed injury rates, contributing factors, and clinical outcomes. Methods A total of 657 trauma patients' records were retrospectively reviewed after admission to King Abdulaziz Medical City (KAMC) during the period from January 2016 to December 2018. Patients' demographic characteristics, presence of a missed injury, and Glasgow Coma Scale (GCS), Revised Trauma Score (RTS), and Injury Severity Score (ISS) were assessed. Results Among 657 patients who were admitted to our emergency department, only 11 (1.7%) patients were reported to have a missed injury during the hospital stay. None of those missed injuries contributed to the overall mortality. Higher GCS is a protective factor for missed injury with OR=0.12-0.81 and p-value=0.01. RTS and intensive care unit (ICU) stays were borderline although p-value=0.05 and OR=9 for RTS. Both longer ICU stays and high RTS were related to a higher risk of missed injury. Conclusion In our study, the prevalence of missed injuries was on the lower end of the spectrum in comparison to multiple published data. The most common missed injuries were fractures and joint dislocations of extremities. None of those missed injuries were life-threatening or contributed to overall mortality. Higher GCS was a protective factor against missed injuries while high RTS and longer ICU stays were related to a higher likelihood of developing missed injuries during the hospital course.

Missed Skeletal Trauma Detected by Whole Body Bone Scan in Patients with Traumatic Brain Injury

OBJECTIVE

Unclear mental state is one of the major factors contributing to diagnostic failure of occult skeletal trauma in patients with traumatic brain injury (TBI). The aim of this study was to evaluate the overlooked co-occurring skeletal trauma through whole body bone scan (WBBS) in TBI.

METHODS

A retrospective study of 547 TBI patients admitted between 2015 and 2017 was performed to investigate their cooccurring skeletal injuries detected by WBBS. The patients were divided into three groups based on the timing of suspecting skeletal trauma confirmed : 1) before WBBS (pre-WBBS); 2) after the routine WBBS (post-WBBS) with good mental state and no initial musculoskeletal complaints; and 3) after the routine WBBS with poor mental state (poor MS). The skeletal trauma detected by WBBS was classified into six skeletal categories : spine, upper and lower extremities, pelvis, chest wall, and clavicles. The skeletal injuries identified by WBBS were confirmed to be simple contusion or fractures by other imaging modalities such as X-ray or computed tomography (CT) scans. Of the six categorizations of skeletal trauma detected as hot uptake lesions in WBBS, the lesions of spine, upper and lower extremities were further statistically analyzed to calculate the incidence rates of actual fractures (AF) and actual surgery (AS) cases over the total number of hot uptake lesions in WBBS.

RESULTS

Of 547 patients with TBI, 112 patients (20.4 %) were presented with TBI alone. Four hundred and thirty-five patients with TBI had co-occurring skeletal injuries confirmed by WBBS. The incidences were as follows : chest wall (27.4%), spine (22.9%), lower extremities (20.2%), upper extremities (13.5%), pelvis (9.4%), and clavicles (6.3%). It is notable that relatively larger number of positive hot uptakes were observed in the groups of post-WBBS and poor MS. The percentage of post-WBBS group over the total hot uptake lesions in upper and lower extremities, and spines were 51.0%, 43.8%, and 41.7%, respectively, while their percentages of AS were 2.73%, 1.1%, and 0%, respectively. The percentages of poor MS group in the upper and lower extremities, and spines were 10.4%, 17.4%, and 7.8%, respectively, while their percentages of AS were 26.7%, 14.2%, and 11.1%, respectively. There was a statistical difference in the percentage of AS between the groups of post-WBBS and poor MS (p=0.000).

CONCLUSION

WBBS is a potential diagnostic tool in understanding the skeletal conditions of patients with head injuries which may be undetected during the initial assessment.

Identification of thoracic injuries by emergency medical services providers among trauma patients

INTRODUCTION

Severe thoracic injuries are time sensitive and adequate triage to a facility with a high-level of trauma care is crucial. The emergency medical services (EMS) providers are required to identify patients with a severe thoracic injury to transport the patient to the right hospital. However, identifying these patients on-scene is difficult. The accuracy of prehospital assessment of potential thoracic injury by EMS providers of the ground ambulances is unknown. Therefore, the aim of this study is to evaluate the diagnostic accuracy of the assessment of the EMS provider in the identification of a thoracic injury and determine predictors of a severe thoracic injury.

METHODS

In this multicentre cohort study, all trauma patients aged 16 and over, transported with a ground erence standard. Prehospital variables were analysed using logistic regression to explore prehospital ambulance to a trauma centre, were evaluated. The diagnostic value of EMS provider judgment was determined using the Abbreviated Injury Scale (AIS) of ≥ 1 in the thoracic region as ref predictors of a severe thoracic injury (AIS ≥ 3).

RESULTS

In total 2766 patients were included, of whom 465 (16.8%) sustained a thoracic injury and 210 (7.6%) a severe thoracic injury. The EMS providers' judgment had a sensitivity of 54.8% and a specificity of 92.6% for the identification of a thoracic injury. Significant independent prehospital predictors were: age, oxygen saturation, Glasgow Coma Scale, fall > 2 m, and suspicion of inhalation trauma or a thoracic injury by the EMS provider.

CONCLUSION

EMS providers could identify little over half of the patients with a thoracic injury. A supplementary triage protocol to identify patients with a thoracic injury could improve prehospital triage of these patients. In this supplementary protocol, age, vital signs, and mechanism criteria could be included.

Whole-Body CT in Patients with Multiple Traumas: Factors Leading to Missed Injury

Purpose To determine radiologic and clinical markers predictive of missed injuries at early whole-body CT image interpretation. Materials and Methods For this retrospective study, 2354 consecutive whole-body CT examinations were performed in patients with multiple traumas from 26 hospitals interpreted at a teleradiology center study during on-call period from February 2011 to September 2016. All whole-body CT images were interpreted by the on-call radiologist and reviewed within 12-48 hours by another radiologist to detect missed injury as the standard of reference. The first and review reports of all examinations were retrospectively reviewed. Univariable and multivariable logistic regression with a stepwise selection method were performed to identify clinical and radiologic predictors of missed injury. Results This study included 639 women (27.1%) and 1715 men (72.8%). The median age of men, women, and the entire population was 34 years (age range, 1-96 years). On a per-scan basis, there were 304 (12.9%) missed injuries and 59 (2.5%) were clinically significant. On a per-injury basis, the missed injury rate was 530 of 5979 (8.8%). More than two injured body parts (odds ratio, 1.4 [95% confidence interval: 1.1, 1.8]; P = .01), patient age older than 30 years (odds ratio, 2.8 [95% confidence interval: 2.1, 3.8]; P < .001), and an initial clinical severity class of 1 (odds ratio, 1.9 [95% confidence interval: 1.3, 2.8]; P < .001) were independent predictive factors of missed injury. Conclusion Multiple traumas with more than two injured body parts, age older than 30 years, or an initial clinical severity class of 1 were associated with missed injury at whole-body CT. © RSNA, 2018 Online supplemental material is available for this article. See also the editorial by Novelline in this issue.

Whole-body computed tomography as a factor associated with lower mortality in severe geriatric trauma with thoracic-abdominal-pelvic injury

OBJECTIVE

To determine the relationship between the use of whole-body computed tomography (WB-CT) and hospital mortality in elderly patients with thoracic-abdominal-pelvic injury requiring admission to an intensive care unit.

PATIENTS AND METHOD

An observational, descriptive and retrospective study was conducted on 140 patients aged 65 years and older admitted to the intensive care unit after a thoracic-abdominal-pelvic injury. Two groups were established, depending on whether a WB-CT was performed as a routine part of the study or the diagnosis was established by conventional radiography or ultrasound. A comparative analysis was performed on both groups, as well as an analysis of mortality through logistic regression.

RESULTS

The mean age of the patients was 75.16±8.89 years. The mean score on the APACHE II scale was 16.25±8.4 points, and on the Injury Severity Score scale, 22.38±15.45 points. WB-CT was performed on 102 patients (72.9%). In these patients, there was a lower mortality rate (15.7 vs. 52.6%, P˂.001), a lower need for mechanical ventilation (47.1 vs. 65.8%, P=.049), and a lower score on the APACHE II scale (14.75±7.19 vs. 20.26±10.06 points, P=.003). The multivariate analysis showed a lower mortality in the patients in whom WB-CT was performed, with an OR of 0.21 (95% CI 0.07-0.68; (P=.010), after adjusting for the APACHE II and ISS scores.

CONCLUSIONS

Performing a WB-CT scan as part of the trauma study could improve the management of elderly patients with thoracic-abdominal-pelvic involvement admitted to the intensive care unit.

Severity-dependent differences in early management of thoracic trauma in severely injured patients - Analysis based on the TraumaRegister DGU®

Background

Major trauma is associated with chest injuries in nearly 50% of multiple injuries. Thoracic trauma is a relevant source of comorbidity throughout the period of multiply-injured patient care and may require swift and well-thought-out interventions in order to avert a deleterious outcome. In this epidemiological study we seek to characterize groups of different thoracic trauma severity in severely injured patients and identify related differences in prehospital and early clinical management. This may help to anticipate necessary treatment for chest injuries.

Methods

Patients documented between 2002 and 2012 in the TraumaRegister DGU®, aged ≥ 16 years, determined Injury Severity Score ≥ 16, and documentation from European trauma centers were analyzed. Isolated brain injury and severe head injury (Abbreviated Injury Scale_Head ≥ 4) led to patient exclusion. Patient subgroups were formed according to the Abbreviated Injury Scale_Thorax as Controls, AIS-2, AIS-3, AIS-4, and AIS-5/6. Demographic and clinical characteristics comparing the aforementioned groups were evaluated using descriptive statistics.

Results

Twenty two thousand five hundred sixty five predominantly male (74%) patients, mean age 45.7 years (SD 19.3), suffering from blunt trauma (95%), and presenting a mean Injury Severity Score of 25.6 (SD 9.6) were analyzed. Higher thoracic injury severity was associated with more different thoracic injuries. The highest rate of prehospital intubation (58%) occurred in AIS_Thorax-5/6. The worse the chest trauma, the more chest tubes were placed prehospitally, peaking at 22% in AIS_Thorax-5/6. Out-of-hospital cardiopulmonary resuscitation was successfully performed in 11% in AIS_Thorax-5/6 compared to 1%–3% in lesser thoracic trauma severity. Massive transfusion and emergency surgery was highest in AIS_Thorax-5/6 compared to lesser thoracic injury (12% vs. 5%–7% and 17% vs. 3%–7%) and both were independently associated with thoracic injuries in patients with AIS_Thorax ≥ 4.

Conclusions

We provide epidemiological data on trauma mechanism, concomitant injuries, frequencies of emergency interventions and outcome associated with different thoracic trauma severity. Prehospital and early clinical management is more complex when AIS_Thorax is ≥ 4. Severely injured patients with critical thoracic trauma are most challenging to take care of with highest rates in prehospital intubation, cardiopulmonary resuscitation, chest tube placements, blood transfusions as well as emergency surgery.

Missed Injuries in Polytrauma Patients after Trauma Tertiary Survey in Trauma Intensive Care Unit

BACKGROUND AND AIMS

Injuries are often missed during the primary and secondary surveys in trauma patients. Studies have suggested that a formal tertiary survey protocol lowers the number of missed injuries. Our aim was to determine the number, severity, and consequences of injuries missed by a non-formalized trauma tertiary survey, but detected within 3 months from the date of injury in trauma patients admitted to a trauma intensive care unit.

MATERIAL AND METHODS

We conducted a cohort study of trauma patients admitted to a trauma intensive care unit between 1 January and 17 October 2013. We reviewed the electronic medical records of patients admitted to the trauma intensive care unit in order to register any missed injuries, their delay, and possible consequences. We classified injuries into four types: Type 0, injury detected prior to trauma tertiary survey; Type I, injury detected by trauma tertiary survey; Type II, injury missed by trauma tertiary survey but detected prior to discharge; and Type III, injury missed by trauma tertiary survey and detected after discharge.

RESULTS

During the study period, we identified a total of 841 injuries in 115 patients. Of these injuries, 93% were Type 0 injuries, 3.9% were Type I injuries, 2.6% were Type II injuries, and 0,1% were Type III injuries. Although most of the missed injuries in trauma tertiary survey (Type II) were fractures (50%), only 2 of the 22 Type II injuries required surgical intervention. Type II injuries presumably did not cause extended length of stay in the intensive care unit or in hospital and/or morbidity.

CONCLUSION

In conclusion, the missed injury rate in trauma patients admitted to trauma intensive care unit after trauma tertiary survey was very low in our system without formal trauma tertiary survey protocol. These missed injuries did not lead to prolonged hospital or trauma intensive care unit stay and did not contribute to mortality. Most of the missed injuries received non-surgical treatment.

Tertiary survey in polytrauma patients should be an ongoing process

INTRODUCTION

Due to prioritisation in the initial trauma care, non-life threatening injuries can be overlooked or temporally neglected. Polytrauma patients in particular might be at risk for delayed diagnosed injuries (DDI). Studies that solely focus on DDI in polytrauma patients are not available. Therefore the aim of this study was to analyze DDI and determine risk factors associated with DDI in polytrauma patients.

METHODS

In this single centre retrospective cohort study, patients were considered polytrauma when the Injury Severity Score was ≥ 16 as a result of injury in at least 2 body regions. Adult polytrauma patients admitted from 2007 until 2012 were identified. Hospital charts were reviewed to identify DDI.

RESULTS

1416 polytrauma patients were analyzed of which 12% had DDI. Most DDI were found during initial hospital admission after tertiary survey (63%). Extremities were the most affected regions for all types of DDI (78%) with the highest intervention rate (35%). Most prevalent DDI were fractures of the hand (54%) and foot (38%). In 2% of all patients a DDI was found after discharge, consisting mainly of injuries other than a fracture. High energy trauma mechanism (OR 1.8, 95% CI 1.2-2.7), abdominal injury (OR 1.5, 95% CI 1.1-2.1) and extremity injuries found during initial assessment (OR 2.3, 95% CI 1.6-3.3) were independent risk factors for DDI.

CONCLUSION

In polytrauma patients, most DDI were found during hospital admission but after tertiary survey. This demonstrates that the tertiary survey should be an ongoing process and thus repeated daily in polytrauma patients. Most frequent DDI were extremity injuries, especially injuries of the hand and foot.

Intelligence Care: A Nursing Care Strategy in Respiratory Intensive Care Unit

BACKGROUND

Working in respiratory intensive care unit (RICU) is multidimensional that requires nurses with special attributes to involve with the accountability of the critically ill patients.

OBJECTIVES

The aim of this study was to explore the appropriate nursing care strategy in the RICU in order to unify and coordinate the nursing care in special atmosphere of the RICU.

MATERIALS AND METHODS

This conventional content analysis study was conducted on 23 health care providers working in the RICU of Sina and Shariati hospitals affiliated to Tehran university of medical sciences and the RICU of Baqiyatallah university of medical sciences from August 2012 to the end of July 2013. In addition to in-depth semistructured interviews, uninterrupted observations, field notes, logs, patient's reports and documents were used. Information saturation was determined as an interview termination criterion.

RESULTS

Intelligence care emerged as a main theme, has a broad spectrum of categories and subcategories with bridges and barriers, including equality of bridges and barriers (contingency care, forced oriented task); bridges are more than barriers (human-center care, innovative care, cultural care, participatory care, feedback of nursing services, therapeutic-professional communication, specialized and independent care, and independent nurse practice), and barriers are higher than bridges (personalized care, neglecting to provide proper care, ineffectiveness of supportive caring wards, futility care, nurse burnout, and nonethical-nonprofessional communications).

CONCLUSIONS

Intelligence care is a comprehensive strategy that in addition to recognizing barriers and bridges of nursing care, with predisposing and precipitating forces it can convert barriers to bridges.