Missed Injuries in Military Patients with Major Trauma: Original Study

Military Medicine, Jul 2006 by Kalemoglu, Murat, Demirbas, Sezai, Akin, Mehmet Levhi, Yildirim, Ismail, Et al

Objective: The incidence and subsequent outcomes of missed injuries and the primary factors contributing to each missed injury were analyzed. Methods: Records of 709 trauma patients were reviewed between December 2003 and December 2004. Demographic data were compared and analyzed for two patient groups: those with multiple injuries diagnosed in 24 hours and those with multiple injuries diagnosed in >24 hours. Results: Fifty-two missed injuries were determined in 34 (4.8%) patients. There were significant differences between the patients with and without delayed diagnoses, including the mean injury severity scores (23 vs. 16.9), morbidity, and mortality (p

Introduction

Missed injuries have been referred to as "the trauma surgeon's nemesis."1,2 Even though not frequently life-threatening, they may result in significant long-term disability. In addition, a missed injury may stand out as the most memorable event in a patient's course, overshadowing the heroic efforts of the trauma surgeon and trauma team. In addition to proving embarrassing to the surgeon and institution, missed injuries are a common reason for litigation.3,4

The management of the trauma patient with multiple injuries can be one of the most clinically challenging situations faced by even the most seasoned physician. In the early time period of the trauma patient, injuries may be missed after initial assessment. Several variables, both patient and physician related, have been identified in previous studies as being associated with an increased likelihood of unrecognized injuries. Missed injuries, in addition to being potential sources of morbidity and mortality, may also represent varying degrees of clinical inexperience.1,2,5-8

The objective of this study was to determine the incidence of undetected injuries, to clarify the contributing factors, and to evaluate the outcomes of the patients in trauma in whom basic errors in management occurred during the perioperative period in emergency surgery service.

Materials and Methods

Records of 709 trauma patients who admitted to Emergency Service between December 2003 and December 2004 were reviewed retrospectively. For this study, the patients were divided into two population groups: patient with missed injuries and patients without missed injuries. A missed injury was defined as any injury that was not discovered or suspected upon admission and not documented in either the trauma resuscitation notes or admission notes. An injury found after the initial complete patient assessment, diagnostic studies, or surgical exploration that was directly related to the traumatic event was considered to be missed. A clinically significant missed injury was defined as an injury in which delayed diagnosis resulted in morbidity or mortality that was potentially avoidable with earlier diagnosis.

Demographic and medical data were compared and analyzed in two patient groups. For each missed injury, one or more primary contributing factor was identified. A primary contributing factor was defined as the component in the clinical management of the patient that was determined to be the most influential in failing to diagnose the injury. The factors contributing to each undetected injury were identified and classified as unavoidable and potentially avoidable. Unavoidable was defined as a patient-related factor, such as delayed presentation or altered level of consciousness, and potentially avoidable was defined as a factor in the clinical management, such as misinterpretation of diagnostic imaging or inadequate clinical assessment. All imaging studies of patients with identified undetected injuries were reviewed to identify errors in interpretation and technically inadequate imaging.

Statistical calculations were performed by Student's t test and χ^sup 2^ analysis using SPSS version 11 (SPSS. Chicago. Illinois). Statistical significance was defined at

Results

There were 709 patients initially identified within the database during the defined study period, and 34 of these patients were initially identified with delayed diagnoses. These 34 patients ultimately met the study criteria of missed injuries, representing 4.8% of the trauma patient population studied, and were found to have a total of 52 undetected injuries. There were 25 male and 9 female patients with a median age of 38 years (range, 12-80 years). The mechanisms of undetected injuries were road traffic accidents in 17 patients (50%). fall from height in 7 cases (20.6%), gunshot wounds in 5 patients (14.7%), and others in 5 patients (14.7%). These patients had an average of 1.5 undetected injuries each, ranging from one to five undetected injuries per patient. The mean delay in diagnosis of undetected injuries was 9.3 days.

Demographic data between the undetected injury population and the patients with detected injuries within the study period is shown in Table I. The missed injury population was shown to have significantly higher (p

Anatomic distribution of missed injuries is shown in Figure 1. Of the 52 missed injuries, the limbs and head were the most common anatomic sites for missed injuries. Classification of the types of missed injuries is illustrated in Figure 2. More than one-half of the missed injuries (55.8%) were musculoskeletal (pelvic and lumbar fractures). Limbs and extremities were the most common anatomic sites for fractures (38.2%). Of the peripheral nerve injuries, cranial nerve palsies were the most common lesions missed. The remaining peripheral nerve lesions were seen in the upper extremities. The two missed vascular injuries (3.8%) both involved the carotid artery; one patient had a carotid-cavernous fistula and the other a carotid dissection. The only missed abdominal injury (1.9%) was a splenic laceration.