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

Development and evaluation of a deep learning-based model for simultaneous detection and localization of rib and clavicle fractures in trauma patients' chest radiographs

Purpose

To develop a rib and clavicle fracture detection model for chest radiographs in trauma patients using a deep learning (DL) algorithm.

Materials and methods

We retrospectively collected 56 145 chest X-rays (CXRs) from trauma patients in a trauma center between August 2008 and December 2016. A rib/clavicle fracture detection DL algorithm was trained using this data set with 991 (1.8%) images labeled by experts with fracture site locations. The algorithm was tested on independently collected 300 CXRs in 2017. An external test set was also collected from hospitalized trauma patients in a regional hospital for evaluation. The receiver operating characteristic curve with area under the curve (AUC), accuracy, sensitivity, specificity, precision, and negative predictive value of the model on each test set was evaluated. The prediction probability on the images was visualized as heatmaps.

Results

The trained DL model achieved an AUC of 0.912 (95% CI 87.8 to 94.7) on the independent test set. The accuracy, sensitivity, and specificity on the given cut-off value are 83.7, 86.8, and 80.4, respectively. On the external test set, the model had a sensitivity of 88.0 and an accuracy of 72.5. While the model exhibited a slight decrease in accuracy on the external test set, it maintained its sensitivity in detecting fractures.

Conclusion

The algorithm detects rib and clavicle fractures concomitantly in the CXR of trauma patients with high accuracy in locating lesions through heatmap visualization.

Analysis of Missed Skeletal Injuries Detected Using Whole-Body Bone Scan Applied to Trauma Patients: A Case-Control Study

(1) Background: Skeletal injuries may be missed in patients presenting multiple traumas during initial assessment. A whole-body bone scan (WBBS) may aid the detection of missed skeletal injuries, but the current level of research in this regard is insufficient. Thus, this study aimed to investigate whether a WBBS is useful for the detection of missed skeletal injuries in patients with multiple traumas. (2) Methods: This retrospective, single-region, trauma center study was conducted at a tertiary referral center from January 2015 to May 2019. The rate of missed skeletal injuries detected via WBBSs was evaluated, and factors that could influence the outcome were analyzed and divided into missed and not-missed groups. (3) Results: A total of 1658 patients with multiple traumas who underwent WBBSs were reviewed. In the missed group, the percentage of cases with an Injury Severity Score (ISS) ≥ 16 was higher than the not-missed group (74.66% vs. 45.50%). The rate of admission route through surgery and embolization was high in the missed group. Moreover, the proportion of patients that experienced shock in the missed group was higher than that in the not-missed group (19.86% vs. 3.51%). In univariate analysis, ISS ≥ 16, admission route through surgery and embolization, orthopedic surgery involvement, and shock were related to missed skeletal injuries. ISS ≥ 16 was determined to be statistically significant in multivariate analysis. Additionally, a nomogram was constructed based on multivariable analysis. (4) Conclusions: Missed skeletal injuries were significantly associated with several statistical factors, and a WBBS can be used as a screening method to detect missed skeletal injuries in patients with multiple blunt traumas.

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.

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).

Challenges associated with recovery from blunt thoracic injuries from hospital admission to six-months after discharge: A qualitative interview study

BACKGROUND

Recovery for patients presenting to trauma services globally with blunt thoracic injury (BTI) remains challenging with substantial levels of physical, psychological socio-economic burden. The aim of this study is to examine the challenges experienced by patients with BTI from hospital admission to 6-months after hospital discharge.

METHODS

Participants were recruited from trauma patients admitted with BTI and were recruited from 7 sites across England and Wales between March and June 2019. Semi-structured interviews were conducted at six-months after discharge from hospital, and in total 11 interviews were undertaken. Interviews were recorded, transcribed, and analysed with reflexive thematic analysis.

RESULTS

Two themes were identified within the data: (i) Challenges within the acute hospital admission where pain and analgesic management and the processes of investigation and treatment were the sources of most challenges to recovery. (ii) Challenges within the post-discharge recovery journey, where managing pain at home, unidentified injuries, and mental well-being impacted most on recovery.

CONCLUSIONS

This study adds to the body of qualitative evidence surrounding recovery from major trauma and the patient experience within the recovery journey after BTI and It is important that clinicians consider the whole recovery journey as a continuous process rather than two isolated processes.

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.

A scalable physician-level deep learning algorithm detects universal trauma on pelvic radiographs

Pelvic radiograph (PXR) is essential for detecting proximal femur and pelvis injuries in trauma patients, which is also the key component for trauma survey. None of the currently available algorithms can accurately detect all kinds of trauma-related radiographic findings on PXRs. Here, we show a universal algorithm can detect most types of trauma-related radiographic findings on PXRs. We develop a multiscale deep learning algorithm called PelviXNet trained with 5204 PXRs with weakly supervised point annotation. PelviXNet yields an area under the receiver operating characteristic curve (AUROC) of 0.973 (95% CI, 0.960-0.983) and an area under the precision-recall curve (AUPRC) of 0.963 (95% CI, 0.948-0.974) in the clinical population test set of 1888 PXRs. The accuracy, sensitivity, and specificity at the cutoff value are 0.924 (95% CI, 0.912-0.936), 0.908 (95% CI, 0.885-0.908), and 0.932 (95% CI, 0.919-0.946), respectively. PelviXNet demonstrates comparable performance with radiologists and orthopedics in detecting pelvic and hip fractures.

Delayed Diagnosis of Injury in Pediatric Trauma Patients at a Level I Trauma Center

BACKGROUND

Trauma care per Advanced Trauma Life Support addresses immediate threats to life. Occasionally, delays in injury diagnosis occur. Delayed diagnosis of injury (DDI) is a common quality indicator in trauma care, and pediatric DDI data are sparse.

OBJECTIVE

Our aim was to describe the DDI rate in a severely injured pediatric trauma population and identify any factors associated with DDI in the pediatric population.

METHODS

A prospective cohort of trauma activations in 0- to 16-year-old patients admitted to a pediatric level I trauma center over 12 months with injuries prospectively recorded were followed during admission to identify DDI.

RESULTS

A total of 170 trauma activations were enrolled. Twelve patients had type I DDI (7.1%), 15 patients had type II DDI (8.8%), and 5 patients had both type I and type II DDI (2.9%). DDI patients had twice as many injuries and higher Injury Severity Scores (ISS) as non-DDI patients. DDI patients were more likely to require intensive care unit (ICU) admission, longer hospital stay, and ventilator support. Controlling for age and ISS in multivariate analysis, the number of injuries found and requiring a ventilator were significantly associated with DDI.

CONCLUSIONS

This prospective study found a type I DDI rate of 7.1% and a type II DDI rate of 8.8% in the pediatric population. DDI patients had a greater number of injuries, higher ISS, higher rate of ICU admission, and were more likely to require mechanical ventilation. This study adds prospective data to the pediatric DDI literature, increases provider awareness of pediatric DDI, and lays the foundation for future study and quality improvement.

The effectiveness of educational interventions on trauma intensive care unit nurses' competence: A systematic review and meta-analysis

OBJECTIVES

To examine the current evidence on the effect of education on intensive care unit nurses' knowledge and skills competence in caring for adult major trauma patients.

METHODOLOGY

A systematic review and meta-analysis was conducted to identify relevant studies through a comprehensive search, following strict eligibility criteria. Five databases were searched: MEDLINE, PubMed, CINAHL, Cochrane and Web of Science. A subsequent hand search was performed. The Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument tool was used to assess methodological quality.

RESULTS

Five eligible quantitative studies were identified and appraised. The overall results demonstrated that educational interventions have positive effects in improving intensive care nurses' knowledge and practice in managing major trauma patients. Meta-analysis was applied to three homogenous studies relating to knowledge outcome. Results demonstrated significant improvements immediately post-intervention and at one-to three-month follow-up [MD (mean difference) = 29.12, 95%CI (confidence interval) 10.29-47.95; P < 0.00001], and [MD = 23.70, 95%CI 8.84-38.56; P < 0.00001], respectively. A slight decrease in the knowledge and practice scores was noted from one- to three-month follow-up.

CONCLUSION

This review demonstrated the significant effects of trauma education on improving intensive care nurses' knowledge and practices. Further research should develop valid competencies and policies to drive nurses' practice and potentially improve the safety and quality of care.

Missed foot fractures in multiple trauma patients

Background

Missed or underestimated injuries are one of the central problems in trauma care. Foot injuries can easily be missed because they lay beyond the regularly screened field of a trauma computer tomography scan (CT scan). During primary and secondary survey a careful examination of the extremities often becomes of secondary interest in the severely injured patient.

Methods

Thirty-four thousand ninety-one multiple trauma patients of the TraumaRegister DGU® were evaluated from 2002 to 2014. We differentiated between patients with foot injuries, patients with missed foot injuries and patients without foot injuries. Included were ankle fractures, calcaneus fractures, talus fractures, metatarsal fractures, toe fractures, amputation, soft tissue injuries and/or ligamentous injuries.

Results

Summarized evaluation of 34,091 trauma patients showed a share of 2532 patients with foot injuries. Time of diagnosis was documented in 2199 cases. 2055 patients had early diagnosed foot injuries and 144 patients had initially missed foot injuries. Missed foot injuries were especially found in patients with car accidents or fall from ≥3 m. Patients with higher Abbreviated Injury Scale (AIS) or lower Glasgow Coma Scale (GCS) were not significantly more affected by missed foot injuries. Missing foot injuries was also not caused by injury severity or higher age.

Conclusions

Our data highlights the need of careful evaluation of the feet during primary and secondary survey particularly when a tibia or femur fracture is diagnosed. Special attention should be turned to patients after car accidents or fall from great height. Suicide victims also need major attention. Patients with early operations also need careful examination and tertiary survey is highly recommended.

Delayed presentation or delayed diagnosis? A retrospective study of prospectively collected data of 482 foot and ankle injuries

BACKGROUND

Delayed presentation of injury cases is common in developing countries like India. It is prudent to study reasons for delayed presentations to focus preventive measures towards responsible factors. Since foot and ankle orthopaedics is in its infancy in India, it was deemed to be worthwhile to study reasons for delayed presentations of foot and ankle injuries.

METHODS

Retrospective analysis of prospectively collected data from 482 foot and ankle injuries treated at our three foot and ankle centres over past three years was undertaken. Delayed presentation was defined as cases presenting to us at or after 3 weeks of injury, but with complete records. Reasons for delayed presentations were analysed.

RESULTS

There were ninety eight such cases who fulfilled the delayed presentation criteria and within this group there were twenty different varieties of foot and ankle injuries. Of these twenty six cases were never treated by qualified orthopaedic surgeons and were labelled as direct delayed presentations, and the remaining 72 cases who were treated by qualified orthopaedic surgeons, but could not be diagnosed and presented late, were labelled as indirect delayed presentations. Failure to suspect injury (5 cases) or failure to diagnose injury (67 cases) were reasons for indirect delayed presentations. Failure to diagnose injury on part of clinicians was either due to failure of clinical and radiological analysis (analytical failure - 15 cases) or due to failure to investigate case with further radiological investigations (investigative failure - 10 cases). Forty-two cases had combined failures.

CONCLUSIONS

In developing countries like India, patients did neglect their foot and ankle injuries and presented late. In fact, by way of delayed diagnosis, clinicians were more responsible for indirect delayed presentations of foot and ankle injuries. This is contrary to the common belief that in developing countries like India, only patients would be solely responsible for delayed presentations after injury. Because delayed diagnosis by clinicians seemed more alarming than delayed presentation by patients, focus of prevention of foot and ankle injuries in developing countries should shift more towards educating clinicians than patients.

Maxillofacial and concomitant serious injuries: An eight-year single center experience

PURPOSE

Maxillofacial injuries are frequently associated with multiple trauma and can determine functional and aesthetic bad outcomes. The severity of maxillofacial injuries may be considerable and can divert clinicians' attention from other concomitant injuries which is less evident but potentially life-threatening. The aim of this study was to find out the concomitant injuries in patients referred to the Emergency Department (ED) of the University Hospital of Messina (North-East Sicily, Italy) for maxillofacial traumas.

METHODS

We retrospectively evaluated data of 240,833 patients admitted at the ED of the University Hospital of Messina from January 2008 to December 2015 because of maxillofacial injuries leading to hospitalization and surgical treatment. Patients who primarily received treatment care at different institutions, pediatric trauma patients and adult patients who were transferred in accordance with pre-existing agreements in case of paucity of beds were excluded. Finally we included 447 (0.2%) patients over the 8 years. Data were evaluated with emphasis on epidemiology (age, gender, mechanism of trauma), primary survey and abnormalities and pattern of trauma.

RESULTS

The most frequent cause of maxillofacial trauma was road accidents (319 patients, 71.4%), among which motorcycle ones were prevalent. The maxillofacial injured who presented major lesions were 98 patients and minor lesions occurred in 349 patients; 443 (99.1%) patients underwent maxillofacial surgery, immediate or delayed depending on the severity of concomitant injuries (χ² = 557.2, p < 0.0001). Five concomitant neglected lesions were found to be associated with severe maxillofacial traumas (χ² = 17.13, p < 0.0001 vs minor lesions). All of the neglected lesions occurred in paucisymptomatic patients who showed painless abdomen, no hemodynamic instability, no signs of hematoma of anterior and posterior abdominal wall or other suspicious clinical signs and symptoms.

CONCLUSION

Among the patients admitted firstly in other surgical wards different from the Maxillofacial Surgery Unit, diagnosis was more difficult, especially for blunt abdominal traumas, in which patients showed only vague and nonspecific symptoms concealing serious and life-threatening injuries. We recommend the routine use of whole body CT scan, when the maxillofacial injuries appear prevalent, mainly in patients affected by maxillofacial major lesions.