Meta-analysis of the effect of tertiary survey on missed injury rate in trauma patients

Tertiary Trauma Survey on Emergency Department Observational Units: A Systematic Literature Review

In today's competitive world with a fast-paced lifestyle, trauma is on the rise and is globally recognized as the leading cause of mortality, morbidity, and disability. Despite the development of major trauma centers and the introduction of advanced trauma training courses and management guidelines, there remains a substantial risk of missed or delayed diagnosis of injuries with potentially life-changing physical, emotional, and financial implications. The proportion of such incidents is potentially higher in busy emergency departments and developing countries with fewer dedicated major trauma centers or where focused emergency and trauma training and skills development is still in its infancy. In the last decade, tertiary trauma surveys have been recognized as an important re-assessment protocol in reducing such missed injuries or delayed diagnoses in patients involved in major trauma. This naturally leads to the presumption that tertiary trauma surveys could also play an important role in observational medicine. This also brings into question whether a standardized tertiary trauma survey of major trauma patients on emergency observation units could reduce missed injuries, especially in low-income countries with fewer resources and trauma expertise. Thus, the purpose of this systematic literature review is to explore the potential role of tertiary trauma survey as a tool to reducing missed or delayed diagnosis in the emergency observation units and its applicability and feasibility in less-developed healthcare systems and in low- and middle-income countries. A broad-based systematic literature review was conducted to include electronic databases, grey literature, reference lists, and bibliographies using the keywords: tertiary trauma survey, major trauma, observational medicine, emergency observation units, clinical decision unit, adult, missed injuries, and delayed diagnosis. Over 19,000 citations were identified on initial search. Following a review of abstracts, application of inclusion and exclusion criteria, and review of the full article, 19 publications were finally selected for the purpose of this systematic literature review. Current evidence shows a general trend that tertiary trauma surveys performed 24 hours after admission play an important role in identifying injuries missed at the time of initial primary and secondary survey, and its implementation in observational medicine could prove beneficial, especially in resource-depleted healthcare systems.

The Tertiary Survey as a Quality Improvement Initiative in Pediatric Trauma Care

BACKGROUND

Patients are at risk of missed or delayed injuries in the setting of multisystem trauma, which may be identified with a tertiary trauma survey (TTS). There is limited literature to support the utilization of a TTS in pediatric trauma population. We aim to assess the impact of the TTS as a quality and performance improvement tool in identifying missed or delayed injuries and improving the quality of care among pediatric trauma population.

METHODS

A retrospective study assessing a quality improvement/performance improvement (QI/PI) project focusing on the administration of tertiary surveys to pediatric trauma patients was conducted at our level 1 trauma center between 08-2020 and 08-2021. Patients with injury severity scores (ISS) greater than 12 and/or an anticipated hospital stay greater than 72 hours met inclusion criteria and were included.

RESULTS

Of the 535 trauma patients admitted to the pediatric trauma service during the study period, 85 (16%) patients met the criteria and received a TTS. Thirteen unaddressed or undertreated injuries were found in 11 patients: 5 cervical spine injuries, 1 subdural hemorrhage, 1 bowel injury, 1 adrenal hemorrhage, 1 kidney contusion, 2 hematomas, and 2 full thickness abrasions. Following TTS, 13 patients (15%) had additional imaging, which identified 6 of the 13 injuries.

CONCLUSION

The TTS is a valuable quality and performance improvement tool in the comprehensive care of trauma patients. Standardization and implementation of a tertiary survey have the potential to facilitate the prompt detection of injuries and improve the quality of care for pediatric trauma patients.

LEVEL OF EVIDENCE

III.

Extremity Fractures as the Most Common Missed Injuries: A Prospective Cohort in Intensive Care Unit Admitted Multiple Trauma Patients

Background

Although an intensive care unit (ICU) admission is a risk factor for missed injury, there has been some disagreement on whether missed injuries in trauma ICU patients have a longer length of stay (LOS). With this in mind, these patients' frequency of missed injuries and related factors were investigated.

Materials and methods

This was a prospective cohort study on multiple trauma injury patients in a tertiary referral trauma center's trauma intensive care unit (TICU) from March 2020 to March 2021. A tertiary survey was conducted in the TICU by attending physicians to find the types I and II missed injuries (any injury discovered after primary and secondary surveys during the hospital stay). A logistic regression model was designed for predictors of missed injuries in ICU-admitted multiple trauma patients.

Results

Out of 290 study participants, 1,430 injuries were found, and of those injuries, 74 cases (25.5%) had missed injuries. In other words, there were 103 missed injuries, resulting in a missed injury detection rate of 7.2%. The most frequently missed injuries (43.4%) were concluded as extremities fractures. The regression model showed that the patients with missed injuries are prone to longer TICU LOS [odds ratio (OR) = 1.15; p = 0.033], and cases who underwent a computed tomography (CT) scan are less likely to have missed injuries (OR = 0.04; p < 0.001). The abbreviated injury scale (AIS) range was 1-3 in missed injuries.

Conclusion

Our research underlines the importance of finding missed injuries and the necessity of CT scan to decrease them. In teaching centers, life-threatening injuries decrease with increasing visits and examination times. Although these missed injuries do not increase mortality, they cause longer TICU LOS and costs.

How to cite this article

Bahramian M, Shahbazi P, Hemmati N, Mohebzadeh P, Najafi A. Extremity Fractures as the Most Common Missed Injuries: A Prospective Cohort in Intensive Care Unit Admitted Multiple Trauma Patients. Indian J Crit Care Med 2023;27(3):201-204.

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.

UK-wide major trauma center tertiary trauma survey pro forma review and aggregation and consolidation into a redesigned document

Objectives

The trauma tertiary survey (TTS) is an essential part of the continued care for major trauma patients which is performed to ensure that all injuries have been identified and none have been overlooked during the patient's stay. Although the Advanced Trauma Life Support Course states a need for a tertiary survey, there is currently no standard for what this survey comprises.

Methods

Using local consultant expert opinion and a literature search we identified a set of 32 TTS potential features that may be included within a TTS pro forma. Major trauma center (MTC) documents were requested from every MTC within the UK. 4 investigators sequentially interrogated each MTC TTS document looking for (1) presence of each feature and (2) how well the feature was represented on the document (0 to 4 Likert Scale). Any previously unidentified potential TTS features were noted and later reviewed for a second round of document analysis.

Results

A total of 21 out of all 26 UK MTCs had a TTS pro forma document. A total of 68 possible features were identified. Respiratory and Abdominal assessment sections were the most frequently identified features (present in 90.4% of the TTS pro formas; n=19. Neck assessment and neurological assessment were included within 85.7% of the TTS pro formas (n=18). Further aspects identified for Round 2 analysis typically included features that were thought to be important but highly specific. For example, pregnancy test and DNACPR discussions were found in 1 MTC TTS each (4%).

Conclusion

This article presents a review of the existing documents at 21 MTCs in the UK, identification of features used and proposes a gold standard TTS which can be used by any doctor to perform the tertiary survey and reduce the risk of missed injuries in trauma patients.

Level of Evidence

3.

Characteristics of patients with hip fractures and comorbid fall-related injuries in the emergency department

Aim

Hip fracture is one of the most common fall‐related injuries in the elderly population. Although falls may cause multiple types of injuries, no study has investigated the details of fall‐related injuries accompanied by hip fractures. This study aimed to characterize the features of such injuries.

Methods

This is a cross‐sectional study using data from four tertiary emergency departments in Japan. We identified patients diagnosed with hip fracture including femoral neck fracture, trochanter fracture, or subtrochanteric fracture from May 12, 2014 to July 12, 2021. Among patients with hip fracture, we included those with fall‐related hip fracture. We excluded patients ages <40 years old and whose fall was high energy onset, defined as fall from more than three steps or 1 m.

Results

Among 326 emergency departments patients diagnosed with fall‐related hip fracture, 288 patients were eligible for the analysis. Seventeen patients (6%) had injuries in addition to hip fractures. The most frequent injury was upper limb injury (e.g., distal radial fracture; n = 5, 30%), followed by head injury (e.g., subdural hematoma; n = 4, 24%), chest injury (e.g., pneumothorax; n = 2, 12%), and trunk injury (vertebral compression fracture; n = 2, 12%). There were no significantly different clinical characteristics between patients with hip injuries and those without.

Conclusion

A total of 6% of patients diagnosed with hip fracture had other fall‐related injuries. The most frequent were upper limb injury and head injury. Our findings underscore the importance of whole‐body assessment in patients with fall‐related hip fracture in the emergency department.

Traumatic Hip Dislocations in Major Trauma Patients: Epidemiology, Injury Mechanisms, and Concomitant Injuries

Introduction: Traumatic hip dislocations (THDs) are severe injuries associated with considerable morbidity. Delayed recognition of fracture dislocations and neurovascular deficits have been proposed to cause deleterious long-term clinical outcomes. Therefore, in this study, we aimed to identify characteristics of epidemiology, injury mechanisms, and associated injuries to identify patients at risk. Methods: For this study based on the TraumaRegister DGU^® (January 2002–December 2017), the inclusion criterion was an Injury Severity Score (ISS) ≥9 points. Exclusion criteria were an isolated head injury and early transfer to another hospital. The THD group was compared to a control group without hip dislocation. The ISS and New ISS were used for injury severity and the Abbreviated Injury Scale for associated injuries classification. Univariate and logistic regression analyses were performed. Results: The final study cohort comprised n = 170,934 major trauma patients. We identified 1359 individuals (0.8%) with THD; 12 patients had sustained bilateral hip dislocations. Patients with THD were predominantly male (79.5%, mean age 43 years, mean ISS 22.4 points). Aortic injuries (2.1% vs. 0.9%, p ≤ 0.001) were observed more frequently in the THD group. Among the predictors for THDs were specific injury mechanisms, including motor vehicle accidents (odds ratio (OR) 2.98, 95% confidence interval (CI) 2.57–3.45, p ≤ 0.001), motorcycle accidents (OR 1.99, 95% CI 1.66–2.39, p ≤ 0.001), and suicide attempts (OR 1.36, 95% CI 1.06–1.75, p = 0.016). Despite a lower rate of head injuries and a comparable level of care measured by trauma center admission, both intensive care unit and total hospital stay were prolonged in patients with THD. Conclusions: Since early diagnosis, as well as timely and sufficient treatment, of THDs are of high relevance for long-term outcomes of severely injured individuals, knowledge of patients at risk for this injury pattern is of utmost importance. THDs are frequently related to high-energy mechanisms and associated with severe concomitant injuries in major trauma patients.

Delayed diagnosed trauma in severely injured patients despite guidelines-oriented emergency room treatment: there is still a risk

Purpose

Emergency trauma room treatment follows established algorithms such as ATLS®. Nevertheless, there are injuries that are not immediately recognized here. The aim of this study was to evaluate the residual risk for manifesting life-threatening injuries despite strict adherence to trauma room guidelines, which is different to missed injuries that describe recognizable injuries.

Methods

In a retrospective study, we included 2694 consecutive patients admitted to the emergency trauma room of one single level I trauma center between 2016 and 2019. In accordance with the trauma room algorithm, primary and secondary survey, trauma whole-body CT scan, eFAST, and tertiary survey were performed. Patients who needed emergency surgery during their hospital stay for additional injury found after guidelines-oriented emergency trauma room treatment were analyzed.

Results

In seven patients (0.26%; mean age 50.4 years, range 18–90; mean ISS 39.7, range 34–50), a life-threatening injury occurred in the further course: one epidural bleeding (13 h after tertiary survey) and six abdominal hollow organ injuries (range 5.5 h–4 days after tertiary survey). Two patients (0.07% overall) with abdominal injury died. The “number needed to fail” was 385 (95%–CI 0.0010–0.0053).

Conclusion

Our study reveals a remaining risk for delayed diagnosis of potentially lethal injuries despite accurate emergency trauma room algorithms. In other words, there were missed injuries that could have been identified using this algorithm but were missed due to other reasons. Continuous clinical and instrument-based examinations should, therefore, not be neglected after completion of the tertiary survey.

Level of evidence

Level II: Development of diagnostic criteria on the basis of consecutive patients (with universally applied reference “gold” standard).

Risk Factors for a False-Negative Examination in Complete Upper Extremity Nerve Lacerations

Background: Many patients with complete nerve lacerations after upper extremity trauma have a documented normal peripheral nerve examination at the time of initial evaluation. The purpose of this study was to determine whether physician-, patient-, and injury-related factors increase the risk of false-negative nerve examinations. Methods: A statewide health information exchange was used to identify complete upper extremity nerve lacerations subsequently confirmed by surgical exploration at 1 pediatric and 2 adult level I trauma centers in a single city from January 2013 to January 2017. Charts were manually reviewed to build a database that included Glasgow Coma Scale score, urine drug screen results, blood alcohol level, presence of concomitant trauma, type of injury, level of injury, laterality, initial provider examination, and initial specialist examination. Bivariate and multivariable analyses were performed to evaluate risk factors for a false-negative examination. Results: Two hundred eighty-eight patients met inclusion criteria. The overall false-negative examination rate was 32.5% at initial encounter, which was higher among emergency medicine physicians compared with extremity subspecialists (P < .001) and among trauma surgeons compared with surgical subspecialists (P = .002). The false-negative rate decreased to 8% at subsequent encounter (P < .001). Risk factors for a false-negative nerve examination included physician specialty, a gunshot wound mechanism of injury, injury at the elbow, and age greater than 71 years. Conclusion: There is a high false-negative rate among upper extremity neurotmesis injuries. Patients with an injury pattern that may lead to nerve injury warrant prompt referral to an upper extremity specialist in an effort to optimize outcomes.

Improving trauma tertiary survey performance and missed injury identification using an education-based quality improvement initiative

BACKGROUND

Performance of a trauma tertiary survey (TTS) reduces rates of missed injuries, but performance has been inconsistent at trauma centers. The objectives of this study were to assess whether quality improvement (QI) efforts would increase the frequency of TTS documentation and determine if TTS documentation would increase identification of traumatic injuries. Our hypothesis was that QI efforts would improve documentation of the TTS.

METHODS

Before-and-after analysis of QI interventions at a level 1 trauma center was performed. The interventions included an electronic template for TTS documentation, customized educational sessions, and emphasis from trauma leadership on TTS performance. The primary outcome was documentation of the TTS. Detection of additional injuries based on tertiary evaluation was a secondary outcome. Associations between outcomes and categorical patient and encounter characteristics were assessed using χ2 tests.

RESULTS

Overall, 592 trauma encounters were reviewed (296 preimplementation and 296 postimplementation). Trauma tertiary survey documentation was significantly higher after implementation of the interventions (30.1% preimplementation vs. 85.1% postimplementation, p < 0.001). Preimplementation documentation of the TTS was less likely earlier in the academic year (14.3% first academic quarter vs. 46.5% last academic quarter, p < 0.001), but this temporal pattern was no longer evident postimplementation (88.5% first academic quarter vs. 77.9% last academic quarter, p = 0.126). Patients were more likely to have a missed traumatic injury diagnosed on TTS postimplementation (1.7% in preimplementation vs. 5.7% postimplementation, p = 0.009).

CONCLUSION

Documentation of the TTS and missed injury detection rates were significantly increased following implementation of a bundle of QI interventions. The association between time of year and documentation of the TTS was also attenuated, likely through reduction of the resident learning curve. Targeted efforts to improve TTS performance may improve outcomes for trauma patients at teaching hospitals.

LEVEL OF EVIDENCE

Care management, Level IV.

Trauma Tertiary Survey: Trauma Service Medical Officers and Trauma Nurses Detect Similar Rates of Missed Injuries

BACKGROUND

Trauma tertiary surveys (TTSs) can improve patient outcomes by identifying missed injuries following initial trauma reception and resuscitation. Most TTSs are conducted by medical officers despite the multidisciplinary team approach of modern trauma care.

OBJECTIVE

The study aim was to assess the accuracy of detecting missed injuries when the TTS was performed by specialist trauma nursing staff, rather than trauma service medical officers (TSMOs).

METHODS

A prospective, convenience sample of adult trauma patients admitted to a tertiary trauma center and attended by the trauma service between October 2015 and August 2018 was obtained. For this sample, a TTS was completed by both the TSMO and the trauma nurse (TN). The number of radiological investigations ordered and missed injuries identified were compared between the two clinicians. Additional injuries were graded using the Clavien-Dindo system.

RESULTS

The study sample consisted of 165 patients with a dual TTS, for which at least one team member requested 35 additional radiological investigations. There was fair agreement (κ = 0.36) between the TN and the TSMO in requesting additional radiological investigations. Ten missed injuries were identified by TN-initiated review (n = 24), and 4 missed injuries were identified by TSMO-initiated review (n = 21). Injuries identified following TTSs ranged in severity grading from 0 to 3.

CONCLUSIONS

Performance of the TN on the TTS in the identification of missed injuries is similar to that of the TSMO. Trauma nurses use an appropriate and rationalized approach to ordering additional radiological investigations and contribute a valuable addition to trauma patient care.

The Impact of the Tertiary Survey in an Established Trauma Program

INTRODUCTION

The trauma tertiary survey (TTS) was first described in 1990 and is recognized as an essential practice in trauma care. The TTS remains effective in detecting secondary injuries in the modern era.

METHODS

Trauma patients discharged between August 1, 2016, and December 31, 2016, were identified in our trauma registry. Collected data include TTS completion rates, detection of injuries, type of provider, and timing. TTS documentation was qualitatively evaluated.

RESULTS

Out of 407 patients, 264 patients (65%) received a TTS. Injury detection rate was 1.1.%. Average time to TTS was 41 hours. TTS were completed by resident physicians (46%) and advanced practice providers (APPs; 46%). TTS documentation was more complete for APPs than for resident physicians.

CONCLUSION

TTS remains an integral component of modern trauma care. Ongoing education on the significance of TTS and the importance of thorough documentation is essential. Provision of real-time feedback to providers is also critical for improving current practices.

The yield of tertiary survey in patients admitted for observation after trauma

PURPOSE

Existing literature on trauma tertiary survey (TTS) focusses on multitrauma patients. This study examines the yield of the TTS in trauma patients with minor (AIS 1) or moderate (AIS 2) injury for which immediate hospitalization is not strictly indicated.

METHOD

A single center retrospective cohort study was performed in a level II trauma center. All hospitalized trauma patients with an abbreviate injury score (AIS) of one or two at the primary and secondary survey were included. The primary outcome was defined as any missed injury found during TTS (Type 1). Secondary outcomes were defined as any missed injury found after TTS but during admission (Type 2); overall missed injury rate; mortality and hospital length of stay.

RESULTS

Out of 388 included patients, 12 patients (3.1%) had a type 1 missed injury. ISS and alcohol consumption were associated with an increased risk for type 1 missed injuries (resp. OR = 1.4, OR = 5.49). A type 2 missed injury was only found in one patient. This concerned the only case of trauma related mortality. Approximately one out of five patients were admitted for more than 2 days. These patients were significantly older (66 vs. 41 years, p < 0.001), had a higher ISS (4 vs. 3, p = 0.007) and ASA score, 3-4 vs. 1-2 (42.5% vs. 12.6%, p < 0.001).

CONCLUSION

TTS showed a low rate of missed injuries in trauma patients with minor or moderate injury. TTS helped to prevent serious damage in two out of 388 patients (0.5%). ISS and alcohol consumption were associated with finding missed injury during TTS.

Retropharyngeal hematoma secondary to cervical hyperextension in a minor collision trauma presenting with dyspnoea: A case report

RATIONALE

Massive retropharyngeal hematoma secondary to a minor blunt trauma is rare and easy to be missed in emergency settings due to the absence of visible tissue injury, especially in young patients. However, missing this pathology is dangerous and can result in airway obstruction and even death. Therefore, an effective diagnostic strategy must be developed and thoroughly performed to minimize missed retropharyngeal hematoma.

PATIENT CONCERNS

A 49-year-old man with a brief cervical hyperextension secondary to a minor collision presented with mild respiratory discomfort. No externally visible injuries were found; however, dyspnea was persistent and aggravating.

DIAGNOSIS

Lateral neck X-ray, neck computed tomography, and spine magnetic resonance imaging revealed a huge retropharyngeal hematoma obstructing the upper airway, without any severe fracture or ligament injury.

INTERVENTIONS

An emergent orotracheal intubation followed by imaging studies was performed to resolve the aggravating dyspnea. Neck exploration surgery was immediately performed for rapid absorption of the hematoma, bleeding control, and identification of the reason of the pathology.

OUTCOMES

The surgery was successful, and the patient was discharged without any postoperative sequelae on the 30 postoperative day.

CONCLUSION

Retropharyngeal hematoma that develops in young patients without visible injuries or severe symptoms after a minor trauma can easily go undetected. Although most hematomas under observation resolve spontaneously, the retropharyngeal hematomas missed at initial assessment may result in critical complications. High level of suspicion, repeated neck CT, and thorough tertiary survey in emergency rooms are helpful in avoiding missed life-threatening retropharyngeal hematoma.

ICU Management of Trauma Patients

OBJECTIVES

To describe the current state of the art regarding management of the critically ill trauma patient with an emphasis on initial management in the ICU.

DATA SOURCES AND STUDY SELECTION

A PubMed literature review was performed for relevant articles in English related to the management of adult humans with severe trauma. Specific topics included airway management, hemorrhagic shock, resuscitation, and specific injuries to the chest, abdomen, brain, and spinal cord.

DATA EXTRACTION AND DATA SYNTHESIS

The basic principles of initial management of the critically ill trauma patients include rapid identification and management of life-threatening injuries with the goal of restoring tissue oxygenation and controlling hemorrhage as rapidly as possible. The initial assessment of the patient is often truncated for procedures to manage life-threatening injuries. Major, open surgical procedures have often been replaced by nonoperative or less-invasive approaches, even for critically ill patients. Consequently, much of the early management has been shifted to the ICU, where the goal is to continue resuscitation to restore homeostasis while completing the initial assessment of the patient and watching closely for failure of nonoperative management, complications of procedures, and missed injuries.

CONCLUSIONS

The initial management of critically ill trauma patients is complex. Multiple, sometimes competing, priorities need to be considered. Close collaboration between the intensivist and the surgical teams is critical for optimizing patient outcomes.

Who should lead a trauma team: Surgeon or non-surgeon? A systematic review and meta-analysis

Background:

Presence of a trauma team leader (TTL) in the trauma team is associated with positive patient outcomes in major trauma. The TTL is traditionally a surgeon who coordinates the resuscitation and ensures adherence to Advanced Trauma Life Support (ATLS) guidelines. The necessity of routine surgical leadership in the resuscitative component of trauma care has been questioned by some authors. Therefore, it remains controversial who should lead the trauma team. We aimed to evaluate outcomes associated with surgeon versus non-surgeon TTLs in management of trauma patients.

Methods:

In accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement standards, we performed a systematic review. Electronic databases MEDLINE, EMBASE, CINAHL and the Cochrane Central Register of Controlled Trials (CENTRAL) were searched to identify randomized and non-randomized studies investigating outcomes associated with surgeon versus non-surgeon TTL in management of trauma patients. The Newcastle-Ottawa scale was used to assess the methodological quality and risk of bias of the selected studies. Fixed-effect model was applied to calculate pooled outcome data.

Results:

Three retrospective cohort studies, enrolling 2,519 adult major trauma patients, were included. Our analysis showed that there was no difference in survival [odds ratio (OR): 0.82, 95% confidence interval (CI) 0.61-1.10, P=0.19] and length of stay when trauma team was led by surgeon or non-surgeon TTLs; however, fewer injuries were missed when the trauma team was led by a surgeon (OR: 0.48, 95% CI 0.25-0.92, P=0.03).

Conclusions:

Despite constant debate, the comparative evidence about outcomes associated with surgeon and non-surgeon trauma team leader is insufficient. The best available evidence suggests that there is no significant difference in outcomes of surgeon or non-surgeon trauma team leaders. High quality randomized controlled trials are required to compare the effectiveness of surgeon and non-surgeon trauma team leaders in order to resolve the controversy about who should lead the trauma team. Clinically significant missed injuries should be considered as important outcome in future studies.