Missed injuries: a Ugandan experience

BACKGROUND: Missed injuries (MIs) have been noted worldwide in all trauma centres that have studied them, and they are a significant cause of patient morbidity and mortality. OBJECTIVE: To establish the prevalence, contributing factors and short-term outcome of missed injuries in cases of multiple and major trauma. METHOD: Longitudinal prospective study involving 403 patients over 5 months. RESULTS: Missed injuries were discovered in 78 cases (prevalence 19.4%). Contributing factors included incomplete assessment (52.5%), radiological errors, surgical failures and patient's arrival time. The most affected body regions were the head and neck, extremities and pelvic girdle and contents; in the abdomen, 49.1% of injuries were missed. Among the 28 deaths in the study, 21 occurred in cases with missed injuries, and 13 (62%) of these deaths were directly attributable to missed injuries (R2=12.5, p=0.0001, 95% CI 5.5-28.35). CONCLUSION: There is need for improvement in patient assessment and monitoring, in efficiency of the trauma team, and for staff redistribution to address the increase in night arrivals.     

Missed injuries in pediatric trauma.

Missed injuries in trauma continue to be a nemesis to the trauma surgeon. Missed injuries in adult trauma patients range in frequency from 9 to 28 per cent, with some being life threatening or permanently disabling. We report the incidence of missed injuries in pediatric trauma to be 20 per cent, in our retrospective review of 107 severe pediatric trauma patients. These missed injuries, however, were neither life threatening nor permanently disabling. We also found that mechanism of injury and patient age affected the incidence of missed injuries in our population.     

Penetrating zone II neck injury: does dynamic computed tomographic scan contribute to the diagnostic sensitivity of physical examination for surgically significant injury? A prospective blinded study

OBJECTIVE: The purpose of this study was to prospectively evaluate the utility of dynamic computed tomographic (CT) scanning as a diagnostic tool and adjunct to physical examination in the identification of surgically significant penetrating zone II neck injuries. METHODS: All patients older than 14 years of age who suffered penetrating zone II neck injuries were eligible for entry into the study protocol at an urban Level I trauma center. All patients that presented with signs of surgically significant injury on physical examination underwent immediate neck exploration. Patients that did not show signs of surgically significant injury were entered into the study protocol and underwent soft tissue dynamic CT scan (1/2-cm cuts, 250-mL oral contrast) of the neck after initial resuscitation. After CT scan, all patients entered into the study protocol underwent esophagography. After completion of radiologic assessment, all study protocol patients underwent surgical exploration of the neck. The patient's surgical team was blinded to results of the CT scan and esophagography before and during surgical exploration of the neck. RESULTS: During a 42-month period from May 1997 to March 2001, 42 patients were entered into the study protocol. Thirty-six (86%) of the injuries were secondary to stab wounds and the rest were caused by gunshot wounds. Surgical exploration revealed four esophageal injuries, of which two (50%) were missed by CT scan. Esophagography missed the identical esophageal injuries, as did CT scan. Both of the missed esophageal injuries were secondary to stab wounds. Seven internal jugular vein injuries were diagnosed intraoperatively, of which four (57%) were diagnosed by CT scan. During the study period, all patients with carotid artery and tracheal injuries were diagnosed by physical examination and thus underwent immediate surgical exploration without study entry. CONCLUSION: Dynamic CT scan contributes minimally to the sensitivity of physical examination in the diagnosis of surgically significant penetrating zone II neck injury. Diagnosis of esophageal injuries with dynamic CT scan appears no better than esophagography. CT scan has greater sensitivity than physical examination for the diagnosis of jugular venous injuries; however, the majority of these injuries do not require identification or surgical intervention.     

Autopsies and death certification in deaths due to blunt trauma: What are we missing?

OBJECTIVES: To determine the frequency, body region and severity of injuries missed by the clinical team in patients who die of blunt trauma, and to examine the accuracy of the cause of death as recorded on death certificates. DESIGN: A retrospective review. SETTING: London Health Sciences Centre, London, Ont. PATIENTS: One hundred and eight deaths due to blunt trauma occurring during the period Apr. 1, 1991, to Mar. 31, 1997. Two groups were considered: clinically significant missed injuries were identified by comparing patient charts only (group 1) and more detailed injury lists from the autopsies and charts of the patients (group 2). OUTCOME MEASURES: Chart and autopsy findings. RESULTS: Of the 108 patients, 78 (72%) were male, and they had a median age of 39 years (range from 2 to 90 years). The most common cause of death was neurologic injury (27%), followed by sepsis (17%) and hemorrhage (15%). There was disagreement between the treating physicians and the causes of death listed on the death certificate in 40% of cases and with the coroner in 7% of cases. Seventy-seven clinically significant injuries were missed in 51 (47%) of the 108 patient deaths. Injuries were missed in 29% of inhospital deaths and 100% of emergency department deaths. Abdominal and head injuries accounted for 43% and 34% of the missed injuries, respectively. CONCLUSIONS: The information contained on the death certificate can be misleading. Health care planners utilizing this data may draw inaccurate conclusions regarding causes of death, which may have an impact on trauma system development. Missed injuries continue to be a concern in the management of patients with major blunt trauma.     

Missed injury in major trauma patients

OBJECTIVES: To determine the incidence, aetiology and contributing factors to injuries being missed during the primary and secondary surveys in patients with major trauma managed on a general Adult Intensive Care Unit (AICU). METHODS: The records for patients admitted to the AICU following severe injury (defined as injury severity score (ISS) >16) over a 1-year period were reviewed. Diagnostic imaging performed during the resuscitation was reviewed in cases where missed injuries were discovered. RESULTS: Forty-five patients with a median injury severity score of 26 were included in the study. Twelve missed injuries were discovered in 10 patients during the intensive care admission; three required an additional surgical procedure. There was no significant difference in Glasgow Coma Score, revised trauma score, ISS or admission systolic blood pressure between patients with missed injuries and those patients where all injures were found at resuscitation (P > 0.05). Three quarters of the undetected injuries were orthopaedic. CONCLUSIONS: Significant injuries can be missed during the primary and secondary surveys in severely injured patients. A tertiary survey should be completed in all trauma patients admitted to an intensive care unit.     

Helical computed tomography of bowel and mesenteric injuries

BACKGROUND: The role of computed tomography in diagnosing hollow viscus injury after blunt abdominal trauma remains controversial, with previous studies reporting both high accuracy and poor results. This study was performed to determine the diagnostic accuracy of helical computed tomography in detecting bowel and mesenteric injuries after blunt abdominal trauma in a large cohort of patients. METHODS: One hundred fifty patients were admitted to our Level I trauma center over a 4-year period with computed tomographic (CT) scan or surgical diagnosis of bowel or mesenteric injury. CT scan findings were retrospectively graded as negative, nonsurgical, or surgical bowel or mesenteric injury. The CT scan diagnosis was then compared with surgical findings, which were also graded as negative, nonsurgical, or surgical. RESULTS: Computed tomography had an overall sensitivity of 94% in detecting bowel injury and 96% in detecting mesenteric injury. Surgical bowel cases were correctly differentiated in 64 of 74 cases (86%), and surgical mesenteric cases were correctly differentiated from nonsurgical in 57 of 76 cases (75%). CONCLUSION: Helical CT scanning is very accurate in detecting bowel and mesenteric injuries, as well as in determining the need for surgical exploration in bowel injuries. However, it is less accurate in predicting the need for surgical exploration in mesenteric injuries alone.     

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.     

Associated injuries in blunt solid organ trauma: implications for missed injury in nonoperative management

BACKGROUND: During the past decade, nonoperative management (NOM) of hemodynamically stable blunt trauma patients with liver (L) or spleen (S) injury has become the standard of care. This trend has led to concerns over missed associated intra-abdominal injuries with concomitant morbidity. To better understand the incidence and risk of missed injury, patterns of associated intra-abdominal injury were examined in all patients with blunt liver and spleen injuries, and missed injuries were reviewed in patients undergoing NOM. METHODS: Patients were identified from the registry of a Level I trauma center over a 3-year period. Records were reviewed for demographics, injury characteristics, and associated injuries. Indications for primary operation were hemodynamic instability or significant associated intra-abdominal injury. Missed injury was defined as unsuspected intra-abdominal injury requiring laparotomy in patients otherwise undergoing NOM for liver or spleen injury. RESULTS: Eight hundred three patients (338 in the L group, 345 in the S group, and 120 in the L + S group) were treated between December 1995 and December 1998. Rates of planned NOM were 89% (L group), 78% (S group), and 75% (L + S group). On examination of all patients with blunt liver or spleen injuries, the incidence of associated intra-abdominal injury was higher in the L group at 5% as compared with 1.7% in the S group (p = 0.02). The associated intra-abdominal injury rate in the L + S group was similar to the L group at 4.2%. Although in the L and S groups, rates of diaphragm (0.5% vs. 1%, p = 0.45) and intra-abdominal bladder injury (0.3% vs. 0.3%, p = 0.99) were similar, bowel injury was more common in the L group (11% vs. 0%, p = 0.0004), as was pancreatic injury (7% vs. 0%, p = 0.007). In NOM patients, missed injury occurred in seven (2.3%) L patients versus zero S patients (p = 0.012). No L + S patient had unexpected injuries. Missed injuries included two small bowel, three diaphragm, one pancreas, and one mesenteric tear. CONCLUSION: Damage to the pancreas and bowel is significantly associated with liver as opposed to spleen injuries. Actual missed intra-abdominal injury with NOM mirrors this pattern, occurring more often with liver than with spleen injuries. However, the overall incidence of missed injury is quite low, and should not influence decisions concerning eligibility for NOM. We speculate that the greater amount and/or different vector of energy transfer needed to injure the liver versus the spleen accounts for the greater rate of associated injuries to the pancreas/small bowel.     

Occult diaphragmatic injuries caused by stab wounds

BACKGROUND: Missed diaphragmatic perforation caused by penetrating trauma can lead to subsequent strangulation of a hollow viscus, which has prompted the use of invasive diagnostic procedures to exclude occult diaphragmatic injuries in asymptomatic, high-risk patients. The objective of this study was to determine the incidence of occult diaphragmatic injuries caused by stab wounds of the lower chest and upper abdomen, and to examine the natural history and consequences of missed diaphragmatic injuries. METHODS: On the basis of patient data from two previous randomized studies from our institution, a retrospective analysis was performed on 97 patients treated for anterior stab wounds located between the nipple line, the umbilical level, and the posterior axillary lines not having indications for immediate surgical exploration. The patients were divided into two groups on the basis of their initial randomized management (open or laparoscopic exploration vs. expectant observation). RESULTS: In the exploration group (n = 47), four diaphragmatic injuries (9%) were detected (three left-sided and one right-sided). Excluding patients with associated injuries requiring surgical repair, the incidence of occult diaphragmatic injuries was 3 of 43 (7%). In the observation group (n = 50), there were two patients (4%) with delayed presentation of missed left-sided diaphragmatic injury 2 and 23 months later, respectively. Both injuries resulted from stab wounds of the left flank and presented with herniation of the stomach or small bowel and colon. The overall incidence of occult diaphragmatic injuries in left-sided thoracoabdominal stab wounds was 4 of 24 (17%), and was much lower after stab wounds of left epigastrium (0%), right lower chest (0%), and right epigastrium (4%). CONCLUSION: In asymptomatic patients with anterior or flank stab wounds of the lower chest or upper abdominal area, the risk of an occult diaphragmatic injury is approximately 7% which, if undetected, is associated with a high risk of subsequent hollow viscus herniation. Exclusion of an occult diaphragmatic injury with invasive diagnostic methods, such as laparoscopy or thoracoscopy, should be considered at least in left-sided stab wounds of the lower chest.     

Gall bladder injuries as part of the spectrum of civilian abdominal trauma in South Africa

BACKGROUND: Trauma to the gall bladder is rare, but when missed or improperly managed it may be associated with significant morbidity. The aim of the present study was to review the management and outcomes of gall bladder trauma in a trauma centre. METHODS: Forty-three patients with gall bladder injury due to abdominal trauma were reviewed over a 3-year period. Surgical management, associated injuries, morbidity and mortality rates were determined. RESULTS: Among 1242 patients undergoing laparotomy for acute trauma, 43 patients (3.46%) with gall bladder injuries were identified. Forty patients sustained penetrating injuries (37 with gunshot wounds and three with stab wounds), and three patients suffered from blunt trauma. All patients with gall bladder injury underwent abdominal exploration because of associated intra-abdominal injuries. Thirty-six patients were treated with cholecystectomy, four patients underwent primary suture repair of the gall bladder perforation, while three patients with gall bladder injury were treated without any surgical intervention at laparotomy. No complications could be attributed to the gall bladder trauma or surgery. CONCLUSION: Cholecystectomy is the preferred procedure of choice for gall bladder injuries and is associated with no morbidity.     

Introduction of a mobile device based tertiary survey application reduces missed injuries: A multi-center prospective study

BackgroundMissed injuries during the initial assessment are a major cause of morbidity after trauma. The tertiary survey is a head-to-toe exam designed to identify any injuries missed after initial resuscitation. We designed a novel mobile device application (Physician Assist Trauma Software [PATS]) to standardize performance and documentation of the tertiary survey. This study was undertaken to assess the feasibility of introducing PATS into routine clinical practice, as well as its capacity to reduce missed injuries.MethodsPrior to implementation of PATS, the missed injury rates at a higher-volume and a medium-volume level I trauma center were assessed. The PATS program was implemented simultaneously at both centers. Missed injuries were tracked during the study period. Compliance and tertiary survey completion rates were evaluated as a marker of feasibility.ResultsAt the higher-volume trauma center, the missed injury rated decreased from 1% to 0% with the introduction of the PATS program (p = 0.04). At the medium-volume trauma center, the missed injury rate decreased from 9% to 1% (p < 0.001). Compliance and documentation increased from 68% to 100%, and from no formal documentation to 60% compliance at the higher- and medium-volume centers respectively.ConclusionsThe implementation of a mobile tertiary survey application significantly reduced missed injuries at both a higher- and medium-volume trauma center. The use of this application resulted in a significant improvement in compliance with documentation of the tertiary survey.     

The tertiary trauma survey: a prospective study of missed injury

The Advanced Trauma Life Support Course defines a primary and a secondary survey to rapidly identify life-threatening and associated injuries, respectively, in multiple trauma patients. However, circumstances during resuscitation, including multiple casualties, emergent operation, unconsciousness, etc., may interfere with this process. An initial review of our trauma registry data yielded a modest 2% incidence of missed injuries in a 90% blunt trauma population. In order to determine the true incidence of missed injuries, a tertiary survey was performed prospectively on all injured patients (N = 399) admitted during a recent 3-month period. After completion of the primary and secondary surveys (including appropriate roentgenographs), all injuries were listed in the trauma admission record. Patients were later reexamined immediately before ambulation or, in head-injured patients, upon regaining consciousness. All missed injuries were documented, including site and type of injury, reason missed, how identified, and attendant morbidity. Forty-one missed injuries were found in 36 patients (9%). These included: 21 extremity fractures, five spinal fractures, two facial fractures, five thoracic injuries, six abdominal injuries (including five splenic lacerations), and two vascular injuries. The most common reason for injuries to be missed was altered level of consciousness due to head injury or alcohol. Other reasons included severity of injury and instability requiring immediate operation, lack of symptoms at admission, technical problems, and low index of suspicion by the examiner. None of the missed injuries resulted in death. However, one missed injury caused serious disability and seven required operative correction.(ABSTRACT TRUNCATED AT 250 WORDS)     

Role of an extended tertiary survey in detecting missed injuries in children

BACKGROUND: There are limited data on the incidence of delayed diagnosis of injuries in children. We sought to investigate the role of an extended tertiary survey in pediatric trauma patients. METHODS: All children that were admitted to The Children's Hospital at Westmead with an Injury Severity Score (ISS) >/= 9 were included in the study. The trauma fellow performed the tertiary survey the day after admission. This was repeated after extubation in ventilated patients and in head injury patients when they were more mobile and cooperative. RESULTS: Seventy-six patients satisfied the criteria for the study (50 boys and 26 girls). Age ranged from 1 month to 15 years. The median ISS was 14. Sixteen (16%) of the patients had missed injuries, of which skeletal injuries were the most common (10 of 12). Delayed diagnosis of injury occurred most frequently in children involved in motor vehicle injuries. Sixty-six (66%) of the injuries were detected within the first 24 hours. Inadequate assessment and head injury were the most common contributing factors. CONCLUSION: The incidence of missed injury (16%) in our study was comparable to reported figures in the adult literature. There was no correlation between missed injuries and intensive care unit stay or ISS. Head injury often delayed diagnosis and thus ongoing evaluation in this group is recommended. Missed injuries did not result in mortality, but there was significant associated morbidity. A tertiary survey should be part of the evaluation of the pediatric trauma patient.     

外伤性十二指肠损伤漏诊的临床分析

目的：探讨如何避免十二指肠损伤的漏诊。方法：回顾性分析我院450例腹部外伤中漏诊的8例十二指肠损伤病人处理和临床特点。结果：致伤原因以车祸伤为主(6例)，复合伤6例，术前无一例正确诊断为十二指肠伤，所有病例均行手术治疗，6例治愈，死亡2例，死亡原因为严重感染及多器官功能衰竭。漏诊的主要原因为认识不足并缺乏相应的特殊检查。结论：对有严重上腹外伤史者，应高度警惕十二指肠损伤，反复的物理检查，动态的辅助检查尤其是CT检查，及时剖腹探查等可减少十二指肠损伤的漏、误诊率。     

Surgeon commitment to trauma care decreases missed injuries

Study objective

Missed injuries sustain an important issue concerning patient safety and quality of care. The purpose of this study is to examine the effect of surgeon commitment to trauma care on missed injuries. We hypothesised that surgeons committed to the trauma service has less missed injuries than surgeons not committed to the trauma service would have.

Methods

By retrospective analysis of 976 adult patients admitted to the trauma intensive care unit (ICU) at an urban, university-based trauma centre. Missed injuries were compared between two groups; in group 1 the patients were evaluated and treated by the surgeons who were committed to the trauma service and in group 2 the patients were evaluated and treated by surgeons practicing mainly in other specialties.

Results

Patients had significantly lower rates of missed major or life-threatening injuries when treated by group 1 surgeons. Logistic regression model revealed significant factors associated with missed major or life-threatening injuries including ISS and groups in which patients were treated by different group surgeons.

Conclusions

Physicians will perform better when they are trained and interested in a specific area than those not trained, or even not having any particular interest in that specific area. Surgeons committed to the trauma service had less missed injuries in severely injured patients, and it is vital to improve patient safety and quality of care for trauma patients. Staff training and education for assessing severely injured patients and creating an open culture with detection and reduction of the potential for error are important and effective strategies in decreasing missed injuries and improving patient safety.     

Prospective evaluation of screening multislice helical computed tomographic angiography in the initial evaluation of penetrating neck injuries

BACKGROUND: The optimal management strategy for patients sustaining penetrating neck injury without an urgent indication for operative exploration remains controversial. The objective of this study was to prospectively assess multislice helical computed tomography angiography (MCTA) as a stand alone screening modality for the initial evaluation of hemodynamically stable patients with penetrating neck injuries. Our hypothesis was that MCTA is a sensitive diagnostic screening test that could noninvasively evaluate the vascular and aerodigestive structures of the neck. METHODS: After Institutional Review Board approval, all penetrating neck injuries assessed during a 16-month period were prospectively evaluated at a Level I trauma center. Patients without an indication for urgent neck exploration underwent MCTA screening. MCTA accuracy was tested against an aggregate gold standard of final diagnosis encompassing all imaging, surgical procedures and clinical follow-up obtained. RESULTS: In all, 106 injuries penetrated the platysma; 15 required urgent exploration and 91 underwent MCTA (34 gunshot wounds/57 stab wounds). Nineteen external wounds were in zone 1, 39 were in zone 2, 10 in zone 3, and 23 traversed multiple zones. MCTA was nondiagnostic in 2.2% secondary to artifact from retained missile fragments. Follow-up was achieved in 84.5% of patients for a mean of 33.3 days (range: 2-150). MCTA achieved 100% sensitivity and 93.5% specificity in detecting all vascular and aerodigestive injuries sustained. MCTA correctly identified two tracheal and two carotid artery injuries requiring operative or endovascular repair in asymptomatic patients. No injuries requiring intervention were missed by MCTA. CONCLUSION: In the initial evaluation of stable penetrating neck injuries, MCTA appears to be a sensitive and safe screening modality. Further investigation is warranted.     

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

BACKGROUND: The use of an observation period to identify missed injuries in trauma patients has gained favor in recent years. This study was undertaken in a population of patients with minimal or no identified injuries to determine the following: whether a period of in-patient observation identifies missed injuries; demographic factors associated with missed injuries; and morbidity of missed injuries. METHODS: Over 4 years at a Level I trauma center, 4,738 patients were observed for 23 hours. Of these patients, 630 were converted to full admission and were reviewed. All medical records were reviewed for reason for observation, reason for conversion to full admission, and presence of missed injury. RESULTS: In the 4,738 patients observed, 35 had a missed injury identified. No clinical factors studied were associated with identifying a missed injury. Of the 35 patients that had a missed injury, 21 did not have clinically relevant injuries, whereas the 14 remaining patients did. All of the 14 required prolonged hospital admissions and 9 underwent invasive procedures. CONCLUSION: Of over 4,700 observed trauma patients, less than 0.5% remained hospitalized for significant missed injuries. No factors were identified that predicted missed injuries. Twenty-three-hour observation for the purpose of identifying missed injuries after thorough emergency department evaluation may not be justified.     

Missed injuries in combat casualties: Lessons from Iraq and Afghanistan

IntroductionOnce injured in the battlefield in Iraq and Afghanistan, U.S. and NATO troops receive medical treatment through tiered echelons of care with varying resources, from austere to state-of-the-art. Similar to civilian trauma systems, the aim is to provide rapid and safe patient movement toward definitive management. A consequence of the rapid transfer of patients is the possibility of missed or delayed diagnosis of injuries. With the new injury patterns seen during these conflicts, we aimed to identify and characterize which injuries are missed and what consequences do they have on our troops’ road to recovery.Patients and MethodsA retrospective review of a PI database (established 2007) for consecutively admitted combat casualties was performed between 2007–2013. Baseline patient characteristics, injury year, admitting service, injury type, and subsequent management decisions were categorized and analyzed.ResultsThere were 301 missed injuries (MI) identified in 248 patients. The annual missed injury rate was 25 per 1000 admissions. Missed injuries were associated with a penetrating mechanism (82.7% vs 58.5%, p < 0.001), ICU admission (58.5% vs 27.4%, p < 0.001), higher ISS (median 14 vs 8, p < 0.001), and a longer length of stay (median 3 versus 2 days, p < 0.001). 194 (64.5%) missed injuries led to a change in management, with 68 (22.6%) requiring a surgical procedure. 1.3% of missed injuries were life threatening, 28.2% major and 65.4% minor. The most common injuries were distal extremity fractures (23.9%), followed by spine fractures (13.3%) and traumatic tympanic membrane rupture (12.6%), There were no deaths attributed to a missed injury.DiscussionMissed injuries during combat operations occur on a low but consistent basis. Most injuries are orthopedic in nature and typically occur in critically ill patients admitted to the ICU. It is rare that a missed injury results in a life-threatening condition.ConclusionAs healthcare practitioners prepare for future deployments, this analysis may serve as a resource to focus on frequently missed injuries and possibly improve their detection.     

严重多发脏器损伤的临床特点及诊治

目的探讨严重多发脏器损伤的临床特点和诊治方法.方法对1988～1998年间收治的合并有闭合性腹内脏器损伤的严重多发伤、ISS大于16的165例患者进行回顾性分析.结果3个或3个以上部位多发伤占28.5%.63例有腹内多脏器损伤.腹腔穿刺是确诊的主要检查手段,部分病例选用了腹部B超和CT,3项诊断检查阳性率均在90%以上.全组漏诊腹内伤21例(12.7%),死亡29例(17.6%).死亡病例平均ISS41.6,明显高于非死亡病例24.8(t=15.21,P<0.01).结论严重多发伤病例应常规行诊断性腹腔穿刺,酌情选择腹部B超和CT等检查,以排除腹内脏器损伤.对全身多发伤并存腹内伤的病例,要根据伤情确定急救处理顺序.剖腹手术中要注意多脏器损伤.ISS大于40提示预后不良.     

The significance of delayed diagnosis of lesions in multiply traumatised patients. A study of 1,187 shock room patients

BACKGROUND: Multislice computed tomography (CT) technology has improved the diagnosis of relevant lesions within the phase of primary treatment of severely injured patients. The lack of time in this phase and the complexity of the multiple injuries there is still a risk that lesions will be missed at this stage. The purpose of this study was to evaluate the incidence, causes, implications and significance when injuries are not diagnosed until later. METHODS: The data were documented prospectively in the context of a quality management system for the care of severely injured patients in a primary urban trauma centre. Missed injuries were defined as any lesions that had not been recognised by the time the patient was admitted to the ICU. RESULTS: During a 44-month period 1,187 (ISS 21+/-17) patients were enrolled in the study, all of whom were admitted from May 1998 to April 2002 after attending the emergency room. In total 64 (4.9%) missed injuries were detected in 58 (ISS 30+/-16) patients; 26 of the 64 missed injuries were located on the torso, 8 injuries in the head and neck region, and 30 on the arms and legs. The missed injuries were categorised as follows: 1. Lesion not seen in diagnostics (n=15). 2. Incomplete diagnostics (n=8). 3. Primarily unsuspicuous examination (n=35). 4. Diagnostics interrupted due to hemodynamic instability (n=6). CONCLUSION: Despite intensified and standardised diagnostic procedures prescribed for use in trauma centres, injuries are still missed in severely injured patients. About 30% of lesions that are not diagnosed until after the patient has left the emergency room have clinically significant, but not lethal, consequences for the patient. Great importance attaches to the follow-up investigation on the intensive care station, so that lesions that have initially been overlooked can be diagnosed and treated as soon as possible so as to keep the complication rate low.