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

Incidence of intra-abdominal injuries in hemodynamically stable blunt trauma patients with a normal computed tomography scan admitted to the emergency department

OBJECTIVES

Blunt abdominal trauma is a common cause of emergency department admission. Computed tomography (CT) scanning is the gold standard method for identifying intra-abdominal injuries in patients experiencing blunt trauma, especially those with high-energy trauma. Although the diagnostic accuracy of this imaging technique is very high, patient admission and prolonged observation protocols are still common practices worldwide. We aimed to evaluate the incidence of intra-abdominal injury in hemodynamically stable patients with high-energy blunt trauma and a normal abdominal CT scan at a Level-1 Trauma Center in Colombia, South America, to assess the relevance of a prolonged observation period.

METHODS

We performed a retrospective study of patients admitted to the emergency department for blunt trauma between 2021 and 2022. All consecutive patients with high-energy mechanisms of trauma and a normal CT scan at admission were included. Our primary outcomes were the incidence of intra-abdominal injury identified during a 24-hour observation period or hospital stay, ICU admission, and death.

RESULTS

We included 480 patients who met the inclusion criteria. The median age was 33 (IQR 25.5, 47), and 74.2% were male. The most common mechanisms of injury were motor vehicle accidents (64.2%), falls from height (26%), and falls from bikes (3.1%). A total of 99.2% of patients had a Revised Trauma Score of 8. Only 1 patient (0.2%) (95% CI: 0.01-1.16) presented with an abdominal injury during the observation period. No ICU admissions or deaths were reported.

CONCLUSION

The incidence of intra-abdominal injury in patients with hemodynamically stable blunt trauma and a negative abdominal CT scan is extremely low, and prolonged observation may not be justified in these patients.

Tertiary Survey in the Days of Modern Imaging: Assessing the Detection Rate of Clinically Significant Injuries on Tertiary Survey in a Level 2 Trauma Centre

Aim: To determine the utility of tertiary survey (TS) in patients subjected to whole-body CT (WBCT) or selective CT (SCT) following trauma.

Methods: A retrospective analysis was performed on trauma patients admitted to a level 2 trauma centre following the introduction of a standardised TS form in 2017. The initial imaging protocol (WBCT versus selective CT versus x-ray), subsequently requested imaging, standardised injury data, and length of stay (LOS) were recorded. Clinically significant injuries were defined as those with an Injury Severity Score (ISS) of 1 on the Abbreviated Injury Scale (AIS).

Results: Five hundred and seven patients were included. The rate of additional significant injuries at the time of TS was 1.18% (n=6), each requiring conservative management only. There was no significant difference in injury detection based on the initial imaging protocol; however, there were three near-misses identified. Of these patients, two underwent selective CT and one was subjected to a plain film series, with clinically significant injuries identified early upon completion of trauma imaging. Overall, 2.9% (n=15) of patients had completed trauma imaging during the same admission. WBCT was associated with higher ISS and length of stay (p<0.05). After controlling for ISS, there was no difference in length of stay between imaging modalities except in those patients with an ISS of 0 (no clinically significant injuries), who appeared to have longer admissions if subject to WBCT (p<0.001).

Conclusion: The rate of missed injuries identified at TS is low. The imaging modality did not alter this. This may allow for the omission of the tertiary survey and earlier discharge in many trauma patients.

Evidence of Prolonged Monitoring of Trauma Patients Admitted via Trauma Resuscitation Unit without Primary Proof of Severe Injuries

Introductio: Although management of severely injured patients in the Trauma Resuscitation Unit (TRU) follows evidence-based guidelines, algorithms for treatment of the slightly injured are limited. Methods: All trauma patients in a period of eight months in a Level I trauma center were followed. Retrospective analysis was performed only in patients ≥18 years with primary TRU admission, Abbreviated Injury Scale (AIS) ≤ 1, Maximum Abbreviated Injury Scale (MAIS) ≤ 1 and Injury Severity Score (ISS) ≤3 after treatment completion and ≥24 h monitoring in the units. Cochran’s Q-test was used for the statistical evaluation of AIS and ISS changes in units. Results: One hundred and twelve patients were enrolled in the study. Twenty-one patients (18.75%) reported new complaints after treatment completion in the TRU. AIS rose from the Intermediate Care Unit (IMC) to Normal Care Unit (NCU) 6.2% and ISS 6.9%. MAIS did not increase >2, and no intervention was necessary for any patient. No correlation was found between computed tomography (CT) diagnostics in TRU and AIS change. Conclusions: The data suggest that AIS, MAIS and ISS did not increase significantly in patients without a severe injury during inpatient treatment, regardless of the type of CT diagnostics performed in the TRU, suggesting that monitoring of these patients may be unnecessary.

Does Abdominal Seat Belt Sign Warrant Admission After a Negative CT Scan? A Cost-Utility Analysis

BACKGROUND

Rapid deceleration against a seat belt during a motor vehicle collision (MVC) may result in an abdominal seat belt sign (ASBS), which is associated with a higher risk of hollow viscus injury (HVI). After a negative abdominal CT scan, management of patients with ASBS is variable, but recent evidence suggests emergency department (ED) discharge may be safe. Therefore, we hypothesized that discharge from the ED is cost-effective compared with 23-h observation or hospital admission for patients with ASBS and a negative CT.

METHODS

A cost-utility model was developed for an evaluable patient with ASBS and negative CT scan using TreeAge software. ED discharge was compared with 23-h observation and admission. Analysis was from a health care-based third-party payer perspective. Quality-adjusted life years (QALYs) were based on 3-y expected outcomes. Probability and costs were estimated from published literature and the Healthcare Cost and Utilization Project.

RESULTS

In our base case, ED discharge was the most cost-effective strategy, yielding a cost of $706 with 2.86 QALYs. The average costs of 23-h observation and hospital admission were $2600 and $8,827, respectively, with 2.87 QALYs gained each. The strategy of ED observation becomes cost-effective when the rate of HVI after ED discharge exceeds 2.3%. In a Monte Carlo simulation, ED discharge was the optimal strategy in 91% of 1000 trials of the model.

CONCLUSIONS

ED discharge is a cost-effective strategy for evaluable patients with ASBS and a negative abdominal CT and remains so when the risk of HVI after ED discharge is higher than currently assumed.

High delayed and missed injury rate after inter-hospital transfer of severely injured trauma patients

PURPOSE

Missed injuries are reported in 1.3-65% of all admitted trauma patients. The severely injured patient that needs a higher level of care which requires an inter-hospital transfer has an increased risk for missed injuries. The aim of this study was to establish the incidence and clinical relevance of missed injuries in severely injured patients who require inter-hospital transfer to a level 1 trauma center.

METHODS

All patients with an Injury Severity Score (ISS) ≥ 16 transferred to the University Medical Center Groningen (UMCG) between January 2010 and July 2015 were included. Data were obtained from a prospective trauma database and supplemented with information from the patient records. A delayed diagnosis was defined as any injury detected within the first 24 h after the initial trauma, with or without a tertiary survey. Missed diagnoses were defined as any injury diagnosed after 24 h following trauma.

RESULTS

Two hundred and fifty-one trauma patients were included. A total of 88 patients (35%) were found to have ≥ 1 new diagnoses with 65 (26%) patients that had 1 or more delayed diagnoses and 23 (9.2%) patients had 1 or more missed diagnoses (detected > 24 h after injury) after transfer to our hospital. For 47 of the 88 patients (53%), the new diagnoses required a change of management. The Glasgow Coma Scale (GCS) was the only statistically significant risk factor for a new diagnosis upon transfer.

CONCLUSIONS

Inter-hospital transfer of severely injured patients increases the risk of a delayed detection of injuries. We found that 35% of all transferred patients with an ISS ≥ 16 have at least new diagnoses, with over half of these diagnoses requiring a change of management. Given these findings, clinicians should maintain a high index of suspicion when receiving a transferred severely injured trauma patient.

A negative computed tomography may be sufficient to safely discharge patients with abdominal seatbelt sign from the emergency department: A case series analysis

BACKGROUND

The presence of an abdominal seatbelt sign (ASBS) following a motor vehicle collision (MVC) is associated with a high risk for occult intra-abdominal injury, prompting imaging studies and a prolonged period of clinical observation. The aim of this study was to determine how a negative computed tomography (CT) of the abdomen/pelvis (A/P) can serve in the safe disposition of these patients. Our hypothesis was that in the setting of a negative CT, the presence of occult intra-abdominal injuries requiring a delayed intervention is extremely unlikely.

METHODS

The medical charts of patients admitted from January 2014 to December 2016 to a Level I trauma center following an MVC were reviewed for a documentation of an ASBS. Patients who did not have a CT A/P upon admission were excluded. The CT A/P of the remaining patients were then classified as negative if there were no findings of acute vascular, visceral or bony injury or positive if any of these findings was present. The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of CT A/P for the presence of an intra-abdominal injury were calculated.

RESULTS

Over the 3-year study period, 1,108 patients were admitted after an MVC. Of those, 196 (17.7%) had an ASBS upon presentation and 183 (93.4%) of 196 underwent a CT A/P. A total of 114 (62.3%) of 183 had a negative CT A/P. These patients remained hospitalized for a median of 2 (1-35) days with none (0.0%) requiring a delayed laparotomy. The sensitivity of CT A/P in identifying patients requiring an exploratory laparotomy was 100.0%, specificity was 67.9%, NPV was 100.0%, and PPV was 21.7%. The negative likelihood ratio was 0.00.

CONCLUSION

For patients with an ASBS following an MVC, a negative CT A/P may be sufficient for safe discharge from the emergency department without any need for additional clinical observation.

LEVEL OF EVIDENCE

Therapuetic, level IV.

Negative computed tomography can safely rule out clinically significant intra-abdominal injury in the asymptomatic patient after blunt trauma: Prospective evaluation of 1193 patients

BACKGROUND

Computed tomography of the abdomen and pelvis (CTAP) is highly specific for injury identification and commonly used in the evaluation of blunt trauma patients. Despite this, there is no consensus on the required clinical observation period after negative imaging, often impacting patient flow and hospital cost. The purpose of this study was to evaluate the use of CTAP after blunt trauma and the need for observation after negative imaging.

METHODS

A prospective analysis at a large Level I trauma center was conducted from November 2014 to May 2015. All blunt trauma patients, older than 14 years with CTAP on admission were included. Symptomatic patients were defined as having abdominal pain or external signs of trauma on admission. The main outcome was missed injury.

RESULTS

Over the study period, there were 1,468 blunt trauma admissions, of which 1,193 patients underwent CTAP. Eight hundred six (67.6%) patients were evaluable on admission (Glasgow Coma Scale score, 15), and of these, 327 (40.6%) were symptomatic, 479 (59.4%) asymptomatic. Among the evaluable asymptomatic patients, there were 65 (13.6%) positive computed tomography scans including 11 patients with grade III, IV, or V solid organ injury and three that required operation. In the 414 evaluable asymptomatic patients with negative imaging, median length of stay was 3 days, and there were zero missed injuries. All images were reviewed by an attending radiologist.

CONCLUSION

Abdominal imaging after trauma is justified in the appropriate clinical setting to evaluate for significant abdominal injury regardless of symptomatology. In asymptomatic, evaluable patients with a negative CTAP, clinically significant abdominal injury is unlikely, and these patients may be considered for early discharge or disposition to another treatment service.

LEVEL OF EVIDENCE

Diagnostic, level III; Therapy, level IV.

Is it safe to discharge blunt abdominal trauma patients with normal initial findings?

BACKGROUND

Trauma is the leading health concern among young adults. Blunt abdominal trauma (BAT) is the most common type of blunt traumas. BAT patients may prove normal in the initial clinical assessments, but since the time required for an intra-abdominal injury to be clinically apparent is not predictable, deciding when to safely discharge these patients could be a dilemma. The purpose of this study is to determine whether follow-up of the early discharged or further diagnostic assessment of the later discharged BAT patients with normal initial findings reveals any abnormal findings.

METHODS

Totally, 389 hemodynamically-stable patients suspected of BAT who arrived at the emergency department (ED) of two university hospitals in Tehran from September 2013 to September 2014 were included in this study. Upon arrival at the ED, all subjects underwent abdominal examination and FAST, and were assessed for hematocrit and base deficit levels and presence of hematuria. These assessments were repeated in the patients who were discharged after 6 h, at 6 or 12 h post-arrival. All patients were followed-up after 24 h and one week by phone call.

RESULTS

Out of all study participants, 158 patients (40.6%) had normal findings in all initial assessments. These patients were discharged from the ED after a median of 5 h. After one week of follow-up, none of them had any symptom or complication, or had sought medical attention after being discharged from the study hospitals. Out of these patients, 78 patients (49.4%) were discharged after 6 hours by their physician's decision, and underwent the same diagnostic assessments for the second or third time. None of these assessments revealed any abnormal findings.

CONCLUSIONS

A combination of normal abdominal exam, normal FAST, normal hematocrit, normal base deficit, and absence of hematuria rules out intra-abdominal injury in BAT patients. It is safe to discharge patients after they prove normal for these assessments. Longer observation and repeated diagnostic assessment of these patients does not yield any new findings, and seems to be unnecessary.

Commonly missed injuries in the accident and emergency department

Accident and emergency (A&E) medicine is a high-risk speciality in which the majority of patients are managed by junior doctors with limited clinical experience. A review of the literature identified that the rate of missed injury ranges from 0.4 to 65%. Missed injuries are by definition preventable and have multiple implications for patients and health-care workers. This article reviews the types of injury that are commonly missed in A&E departments and identifies the errors that have been made in the past, with recommendations for management strategies to reduce the incidence of missed injury.

Can clinical prediction tools predict the need for computed tomography in blunt abdominal? A systematic review

INTRODUCTION

Blunt abdominal trauma is a common reason for admission to the Emergency Department. Early detection of injuries is an important goal but is often not straightforward as physical examination alone is not a good predictor of serious injury. Computed tomography (CT) has become the primary method for assessing the stable trauma patient. It has high sensitivity and specificity but there remains concern regarding the long term consequences of high doses of radiation. Therefore an accurate and reliable method of assessing which patients are at higher risk of injury and hence require a CT would be clinically useful. We perform a systematic review to investigate the use of clinical prediction tools (CPTs) for the identification of abdominal injuries in patients suffering blunt trauma.

MATERIALS AND METHODS

A literature search was performed using Medline, Embase, The Cochrane Library and NHS Evidence up to August 2014. English language, prospective and retrospective studies were included if they derived, validated or assessed a CPT, aimed at identifying intra-abdominal injuries or the need for intervention to treat an intra-abdominal after blunt trauma. Methodological quality was assessed using a 14 point scale. Performance was assessed predominantly by sensitivity.

RESULTS

Seven relevant studies were identified. All studies were derivative studies and no CPT was validated in a separate study. There were large differences in the study design, composition of the CPTs, the outcomes analysed and the methodological quality of the included studies. Sensitivities ranged from 86 to 100%. The highest performing CPT had a lower limit of the 95% CI of 95.8% and was of high methodological quality (11 of 14). Had this rule been applied to the population then 25.1% of patients would have avoided a CT scan.

CONCLUSIONS

Seven CPTs were identified of varying designs and methodological quality. All demonstrate relatively high sensitivity with some achieving very high sensitivity whilst still managing to reduce the number of CTs performed by a significant amount. Further studies are required to validate the results obtained by the highest performing CPTs before any firm recommendation can be used regarding their use in routine clinical practice.

Intra-abdominal injury following blunt trauma becomes clinically apparent within 9 hours

BACKGROUND

The diagnosis of blunt abdominal trauma can be challenging and resource intensive. Observation with serial clinical assessments plays a major role in the evaluation of these patients, but the time required for intra-abdominal injury to become clinically apparent is unknown. The purpose of this study was to determine the amount of time required for an intra-abdominal injury to become clinically apparent after blunt abdominal trauma via physical examination or commonly followed clinical values.

METHODS

A retrospective review of patients who sustained blunt trauma resulting in intra-abdominal injury between June 2010 and June 2012 at a Level 1 academic trauma center was performed. Patient demographics, injuries, and the amount of time from emergency department admission to sign or symptom development and subsequent diagnosis were recorded. All diagnoses were made by computed tomography or at the time of surgery. Patient transfers from other hospitals were excluded.

RESULTS

Of 3,574 blunt trauma patients admitted to the hospital, 285 (8%) experienced intra-abdominal injuries. The mean (SD) age was 36 (17) years, the majority were male (194 patients, 68%) and the mean (SD) Injury Severity Score (ISS) was 21 (14). The mean (SD) time from admission to diagnosis via computed tomography or surgery was 74 (55) minutes. Eighty patients (28%) required either surgery (78 patients, 17%) or radiographic embolization (2 patients, 0.7%) for their injury. All patients who required intervention demonstrated a sign or symptom of their intra-abdominal injury within 60 minutes of arrival, although two patients were intervened upon in a delayed fashion. All patients with a blunt intra-abdominal injury manifested a clinical sign or symptom of their intra-abdominal injury, resulting in their diagnosis within 8 hours 25 minutes of arrival to the hospital.

CONCLUSION

All diagnosed intra-abdominal injuries from blunt trauma manifested clinical signs or symptoms that could prompt imaging or intervention, leading to their diagnosis within 8 hours 25 minutes of arrival to the hospital. All patients who required an intervention for their injury manifested a sign or symptom of their injury within 60 minutes of arrival.

LEVEL OF EVIDENCE

Therapeutic study, level IV. Epidemiologic study, level III.

Delayed diagnosis of injury in survivors of the February 2009 crash of flight TK 1951

INTRODUCTION

On 25th February 2009, a Boeing 737 crashed nearby Amsterdam, leaving 126 victims. In trauma patients, some injuries initially escape detection. The aim of this study was to evaluate the incidence of Delayed Diagnosis of Injury (DDI) and the tertiary survey on the victims of a plane crash, and the effect of ATLS(®) implementation on DDI incidence.

PATIENTS AND METHODS

Data from all victims were analysed with respect to hospitalisation, DDI, tertiary survey, ISS, Glasgow Coma Score (GCS), injuries (number and type) and emergency intervention. Clinically significant injuries were separated from non-clinically significant injuries. The data were compared to a plane crash in the UK (1989), which occurred before ATLS(®) became widely practiced.

RESULTS

All 126 victims of the Dutch crash were evaluated in a hospital; 66 were hospitalised with a total of 171 clinically significant injuries. Twelve (7%) clinically significant DDIs were found in 8 patients (12%). In 65% of all patients, a tertiary survey was documented. The incidence of DDI in patients with an ISS ≥ 16 (n=13) was 23%, vs. 9% in patients with ISS <16. Patients with >5 injuries had a DDI incidence of 25%, vs. 12% in patients with ≤ 5 injuries. Head injury patients had a DDI incidence of 19%, patients without head injury 10%. Fifty percent of patients who needed an emergency intervention (n=4) had a DDI; 3% of patients who did not need emergency intervention. Eighty-one survivors of the UK crash had a total of 332 injuries. DDIs were found in 30.9% of the patients. Of all injuries 9.6% was a DDI. The incidence of DDI in patients with >5 injuries was 5%, vs. 8% in those with ≤ 5 injuries.

CONCLUSION

DDI in trauma still happen. In this study the incidence was 7% of the injuries in 12% of the population. In one third of the patients no tertiary survey was documented. A high ISS, head injury, more than 5 injuries and an emergency intervention were associated with DDI. The DDI incidence in our study was lower than in victims of a previous plane crash prior to ATLS implementation.

Blunt abdominal trauma patients are at very low risk for intra-abdominal injury after emergency department observation

Introduction

Patients are commonly admitted to the hospital for observation following blunt abdominal trauma (BAT), despite initially negative emergency department (ED) evaluations. With the current use of screening technology, such as computed tomography (CT) of the abdomen and pelvis, ultrasound, and laboratory evaluations, it is unclear which patients require observation. The objective of this study was to determine the prevalence of intra-abdominal injury (IAI) and death in hemodynamically normal and stable BAT patients with initially negative ED evaluations admitted to an ED observation unit and to define a low-risk subgroup of patients and assess whether they may be discharged without abdominal/pelvic CT or observation.

Methods

This was a retrospective cohort study performed at an urban level 1 trauma center and included all BAT patients admitted to an ED observation unit as part of a BAT key clinical pathway. All were observed for at least 8 hours as part of the key clinical pathway, and only minors and pregnant women were excluded. Outcomes included the presence of IAI or death during a 40-month follow-up period. Prior to data collection, low-risk criteria were defined as no intoxication, no hypotension or tachycardia, no abdominal pain or tenderness, no hematuria, and no distracting injury. To be considered low risk, patients needed to meet all low-risk criteria.

Results

Of the 1,169 patients included over the 2-year study period, 29% received a CT of the abdomen and pelvis, 6% were admitted to the hospital from the observation unit for further management, 0.4% (95% confidence interval [CI], 0.1%–1%) were diagnosed with IAI, and 0% (95% CI, 0%–0.3%) died. Patients had a median combined ED and observation length of stay of 9.5 hours. Of the 237 (20%) patients who met low-risk criteria, 7% had a CT of the abdomen and pelvis and 0% (95% CI, 0%–1.5%) were diagnosed with IAI or died.

Conclusion

Most BAT patients who have initially negative ED evaluations are at low risk for IAI but still require some combination of observation and CT. A subgroup of BAT patients may be safely discharged without CT or observation after the initial evaluation.

Rate of intra-abdominal injury after a normal abdominal computed tomographic scan in adults with blunt trauma

OBJECTIVE

The objective of this study is to determine the rate of intra-abdominal injury (IAI) in adults with blunt abdominal trauma after a normal abdominal computed tomographic (CT) scan. We hypothesize that the risk of subsequent IAI is so low that hospital admission and observation for possible IAI are unnecessary.

METHODS

We conducted a prospective, observational cohort study of adults (>18 years) with blunt trauma who underwent abdominal CT scanning in the emergency department. Computed tomographic scans were obtained with intravenous contrast but no oral contrast. Abnormalities on abdominal CT included all visualized IAIs or any finding suggestive of possible IAI. Patients were followed up to determine the presence or absence of IAI and the need for therapeutic intervention if IAI was identified.

RESULTS

Of the 3103 patients undergoing abdominal CT, 2734 (88%) had normal CT scans. The median age was 39 years (interquartile range, 26-51 years); and 2141 (78%) were admitted to the hospital. Eight (0.3%; 95% confidence interval, 0.1%-0.6%) were identified with IAIs after normal abdominal CT scans including the following injuries: pancreas (5), liver (4), gastrointestinal (2), and spleen (2). Five underwent therapy at laparotomy. Abdominal CT had a likelihood ratio (+) of 20.9 (95% confidence interval, 17.7-24.8) and likelihood ratio (-) of 0.034 (0.017-0.068).

CONCLUSION

Adult patients with blunt torso trauma and normal abdominal CT scans are at low risk for subsequently identified IAI. Thus, hospitalization for evaluation of possible IAI after a normal abdominal CT scan is unnecessary in most cases.

Whole body imaging in the diagnosis of blunt trauma, ionizing radiation hazards and residual risk

Ever since the introduction of radiographic imaging, its utility in identifying injuries has been well documented and was incorporated in the workup of injured patients during advanced trauma life support algorithms [American College of Surgeons, 8th ed. Chicago, 2008]. More recently, computerized tomography (CT) has been shown to be more sensitive than radiography in the diagnosis of injury. Due to the increased use of CT scanning, concerns were raised regarding the associated exposure to ionizing radiation [N Engl J Med 357:2277-2284, 2007]. During the last several years, a significant amount of research has been published on this topic, most of it being incorporated in the BEIR VII Phase 2 report, published by the National Research Council of the National Academies [National Academy of Sciences, Washington DC, 2006]. The current review will analyze the scientific basis for the concerns over the ionizing radiation associated with the use of CT scanning and will examine the accuracy of the typical advanced trauma life support work-up for diagnosis of injuries.

[Oversights in the care of severe injuries]

Question of missed injuries is more often a question of human errors: task execution errors, procedural errors, communication errors, decision errors and noncompliance. Missed injuries are those which are not idetified in the first three days of hospitalisaation. This theme is not popular among physicians. Literature data mention percent from 3-29% missed injuries overall. The underlying causes errors are: false attributin, false negative prediction and false lebeling. False attribution involves a tendency to incorrectly link a clinical observation with an arroneous cause. This tendency also ignores one of the fundamental principles of the management of traumatic injury: that the index of suspicion should proceed on the basis of assumed wors resonable case scenario. Weaknesses of trauma systems: high patients volume, high-risk patients, long hours, changing set of resources, and problems sush bad admission planing, defficite anamnesis, defficite diagnostic procedures, bad communication, improvisation etc.

Primary pan-computed tomography for blunt multiple trauma: can the whole be better than its parts?

Single-pass, whole-body computed tomography (pan-CT) was proposed in the late 1990s as a new concept for the diagnostic work-up of severely injured patients. Since its introduction, it has led to considerable debate among clinicians and scientists, triggered by concerns about its immediate safety, questionable therapeutic advantages and exposure to radiation. However, it was recently shown that pan-CT scanning may be associated with a reduction in trauma mortality. In this article, we provide an overview of current knowledge of the value of this compelling concept. The diagnostic accuracy of multidetector row CT (MDCT) for clearing various anatomical regions in trauma patients is, at best, unclear. Little is known about the accuracy of pan-CT as a whole, which weakens statements about its effectiveness and prevents inferences about survival advantages. This last point may be explained by a stage-migration or "Will Rogers" phenomenon: Pan-CT increases injury severity by detecting lesions that would not have been recognized by conventional methods but still do not affect treatment decisions, thus artificially lowering the ratio of observed to expected deaths. In order to maintain the credibility of pan-CT technology for trauma, a rigorous, large-scale evaluation of its accuracy is required. Such an evaluation requires consensus about the definition of true and false positive and negative findings in the setting of blunt multiple trauma. In addition, triage criteria need to be refined to increase specificity and reduce the number of unnecessary scans.

Missed injury and the tertiary trauma survey

Missed injury in the context of major trauma remains a persistent problem, both from a clinical and medico-legal point-of-view. Estimates of the incidence vary widely, dependent on the precise parameters of the studied population, the definition of missed injury and the extent of follow-up, but may be as high as 38%. The tertiary survey, in which formal repeated examination of the patient is undertaken after initial resuscitation and treatment have taken place, has been suggested as a way of identifying injuries not found at presentation. This paper appraises the concept of the tertiary survey, and also reviews the literature on missed injury in order to identify the risk factors, the types of injury and the reasons for error.

Do we need neurosurgical coverage in the trauma center?

The undersupply and maldistribution of neurosurgeons coupled with the apparent abandonment of trauma care by a significant number of rank and file neurosurgeons, and perhaps an over demand for their services, has created a crisis in access to neurotrauma care across the country. There is evidence to support that the immediate availability of a neurosurgeon to participate in the care of all trauma patients, including those who have documented head injury, may not be essential to providing optimal care, calling the American College of Surgeons' mandated criterion for trauma center verification into question. Given the volume, nature, and timeliness of head injury and its care, it seems this crisis can be resolved to a great extent by having trauma surgeons or other properly trained, credentialed, and monitored providers assume nonoperative, in-patient neurotrauma care when hospital admission is actually indicated. Although part of the solution lies in increased supply of neurotrauma services regardless of provider type, a second component rests in decreasing demand for these services in cases of mild and extremely severe head injury. Such a solution seems feasible and advantageous in several respects and should be seriously considered by healthcare policy makers, trauma system planners, and the leaders of the neurosurgical and trauma surgery disciplines. What is truly needed in hospitals treating trauma patients (ie, trauma centers) is a philosophy centered on patient services rather than the specific provider. What is needed is a provider who is committed, capable, and competent, who recognizes and meets the patients' needs and provides the appropriate services. These providers, regardless of pedigree, must be supported and valued by the healthcare system and society. In the future this may require regionalization of services. In some hospitals and systems the primary person responsible for providing these services will be a neurosurgeon. In others, it may not and perhaps need not be.

An evaluation of emergency physician selection of observation unit patients

OBJECTIVE

Appropriate patient selection is critical for maximal observation unit (OU) effectiveness. We hypothesized emergency physicians underuse the OU for admitted patients and overuse the OU for patients who would otherwise be discharged.

METHODS

Treating emergency physicians were asked about patient suitability for admission to an OU at a busy, urban, academic emergency department (ED) as part of a prospective cohort study of ED patients who were admitted or had an ED length of stay exceeding 4 hours. The OU was closed for renovation during the 2-month study, so physician opinion could be compared with patient course in the absence of observation services. Two blinded emergency physicians reviewed charts using structured forms and explicit definitions to determine actual patient course. Hospitalized patients were considered potential OU candidates according to a priori criteria: (1) hospital length of stay less than 48 hours, (2) no procedure or diagnosis requiring hospitalization, and (3) no death.

RESULTS

Of 1747 enrolled patients, 131 were excluded with incomplete data. Median age was 45 years. Patients were 40% white and 48% men. Emergency physicians identified 363 (23%) patients as observation candidates. Of these, 182 (50%) were actually discharged directly. The remaining 181 (50%) were hospitalized; 101 (56%) were observation candidates based on chart review. Of 799 admitted patients not selected for observation, 232 (29%) were suitable for observation by chart review.

CONCLUSIONS

Selection of patients for observation was suboptimal; emergency physicians routinely identified patients as OU candidates who were not ultimately admitted, and they missed many admitted patients who might have been appropriate OU candidates. Both over- and underuse should be addressed to maximize the effectiveness of OUs.

Clinical and Autopsy Analysis of Delayed Diagnosis and Missed Injuries in Trauma Patients

Delayed diagnosis of injury (DDI) during hospitalization and missed injuries (MI) on autopsy in trauma deaths result in untoward outcomes. Autopsy is an effective educational tool for health care providers to evaluate trauma care. A retrospective study of trauma registry patients and coroner's records was categorized into groups 1 (alive patients) and 2 (trauma deaths) and analyzed. DDI incidence was similar in group 1 (1.8%) and group 2 (1.9%). Autopsy analysis (163 patients) yielded 139 MI in 94 patients (57.6%), <3 per cent of MI had negative impact on survival. Bony injuries comprised 68 per cent of DDI and 19 per cent of MI. Group 1 DDI patients were sicker with higher injury severity score (ISS: 16.07) than their cohorts (ISS 7.13, P value <0.05). These patients had higher Glasgow Coma Scale (14.41) and lower ISS (16.07) as compared with group 2 MI patients (ISS: 33.49, GCS: 6.45, P value <0.05). Autopsy rate was 99.5 per cent in trauma deaths, 57 per cent for nontrauma deaths, and 79 per cent for all deaths. Less than 3 per cent of MI had negative impact on survival. Routine ongoing patient assessment with pertinent diagnostic workup is essential in reducing DDI. Trauma autopsies reveal MI, which aid performance improvement (PI).

Diagnostic errors in polytrauma: a structured review of the recent literature

Clinically important diagnostic errors are relatively common among polytrauma patients (2-40%). Errors are not random; they are more frequent in the spine and periarticular appendicular skeleton, especially in hemodynamically unstable patients who require resuscitation or operative intervention before completion of secondary or tertiary clinical survey. Misleading history, distracting findings, and misjudgments all contribute to risks of diagnostic errors.

Neurosurgical coverage: essential, desired, or irrelevant for good patient care and trauma center status

SUMMARY AND BACKGROUND DATA

As a result of many factors, the availability of neurosurgeons (NS) to care for trauma patients (TP) is increasingly sparse. This has precipitated a crisis in access to neurosurgical support in many trauma systems, often placing undue burden on level I centers. This study examines the profile of head-injured (HI) trauma patients and their actual need for the specific expertise of a neurosurgeon.

METHODS

The National Trauma Data Bank (NTDB) was queried for specific information relating to the volume, nature, timeliness, and outcome of HI TP. Study patients were identified by reported International Classification of Diseases, 9th Edition (ICD-9) codes denoting open (OHI) or closed head injury (CHI) in isolation or in combination with other injuries.

RESULTS

Total number of NTDB patients studied was 731,823, of which 213,357 (29%) had a reported HI. CHI represented 22% of all TP and 74% of HI. OHI was reported in 8% of all TP and was 26% of HI. Craniotomy (crani) was performed in 3.6% of all HI (1% of all TP). This was in 2.8% of OHI and 2.6% of CHI. Mean Glasgow Coma Scale score (GCS) of crani patients was 9, and 13 for the noncrani group. Subdural hematoma occurred in 18% of HI (5% of TP), with 13% undergoing crani. Epidural hematoma occurred in 10% of HI (3% of all TP), with 17% undergoing crani. Median time to OR for all cranis was 195 minutes (195 for CHI; 183 for OHI). Of all cranis, 6.5% were performed within 1 hour of hospital admission. Intracranial pressure (ICP) monitoring was reportedly used in 0.7% of TP and 2.2% of HI.

CONCLUSIONS

Care of TP with HI rarely requires the explicit expertise and immediate presence of a neurosurgeon due to volume and nature of care. HI was diagnosed in <30% of TP reported to the NTDB. Over 95% required nonoperative management alone, with only 1% of all TP and 2%-4% of HI TP requiring crani and/or ICP monitoring. Immediate availability of NS is not essential if a properly trained and credentialed trauma surgeon or other health care provider can appropriately monitor patients for neurologic demise and effect early transfer to a center capable of, and committed to, operative and postoperative neurosurgical care. A subgroup of patients known to have a high propensity for the specific expertise of a neurosurgeon may be able to be identified for direct transport to these committed centers.