Undetected injuries: A preventable cause of increased morbidity and mortality

doi:10.1016/0002-9610(91)90260-K

The American Journal of Surgery

Volume 162, Issue 5, November 1991, Pages 457-460

https://doi.org/10.1016/0002-9610(91)90260-K Get rights and content

Abstract

A prospective audit of trauma patients managed at the discretion of six different general surgical units was performed over a 6-month period. Eighteen patients were identified in whom diagnostic delay or injuries undetected at operation contributed to increased morbidity and mortality. Failure to perform investigations as indicated by the nature of the trauma was the main reason for delay in diagnosis in seven patients. Incomplete exploration at laparotomy resulted in seven undetected injuries, while unexplored retroperitoneal hematomas accounted for the remaining four. Fourteen patients (78%) required management in the intensive care unit. Eight patients died (44%) as a result of ongoing sepsis and multiple organ failure. Seven of the deaths occurred in patients in whom surgical treatment was inadequate. Delays in diagnosis and undetected injuries, although uncommon, are a readily preventable cause of phase 3 trauma deaths. Strict adherence to standard surgical protocols as employed in dedicated trauma care centers does much to reduce unnecessary morbidity and mortality.

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Cited by (44)

Usability of fluorescence angiography with indocyanine green in the surgical management of penetrating abdominal trauma: A case series
2021, International Journal of Surgery Open
Citation Excerpt :
ICG-FA identified an additional overlooked intestinal injury in two cases, both initially operated on by 1st-year surgical registrars. Overlooked abdominal injuries during primary surgery are a common cause of relaparotomy in patients with penetrating abdominal trauma, and such injuries increase treatment costs as well as the risks of morbidity and mortality [37,38]. Although the risk of undetected injuries can be reduced by adhering to well-established trauma protocols [37], this risk increases with poor surgical techniques, haemodynamic instability, and lack of experience [39].
The surgical management of penetrating abdominal trauma can be challenging, and despite improvements in diagnostics and treatment, mortality and morbidity rates remain high. Intraoperative fluorescence angiography with indocyanine green (ICG-FA) is currently implemented in many elective surgical settings. However, there are few data regarding the usability of ICG-FA in emergency surgery, and to our knowledge, ICG-FA has not been evaluated in penetrating abdominal trauma. Hence, our objective was to determine the feasibility and usability of ICG-FA in surgical management of penetrating abdominal trauma.
A total of 20 patients undergoing emergency laparotomy for penetrating abdominal trauma were included. The usability of ICG-FA was evaluated using the System Usability Scale (SUS®). The intraoperative macroscopic assessment was compared with that using ICG-FA, and any influence of ICG-FA on surgical management was documented.
The ICG-FA was completed in all cases and rendered a “good” median SUS® score of 68.8 (interquartile range, 60.6–82.5) by first-time users. The use of ICG-FA influenced surgical management in 14 cases (70%). In six of those cases, ICG-FA significantly changed surgical management. There were no postoperative complications related to surgical management.
ICG-FA proved useable and relevant in the setting of penetrating abdominal trauma. Although this was only a small case series, the study showed that ICG-FA could substantially influence surgical management of penetrating abdominal trauma, adding considerable patient benefit.
Introduction of a mobile device based tertiary survey application reduces missed injuries: A multi-center prospective study
2019, Injury
Citation Excerpt :
All 503 patients (100%) had a complete PATS file. Missed injuries in trauma have been shown to be a significant source of morbidity and even mortality [5,19–23]. The majority of these missed injuries are preventable.
Missed 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.
Prior 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.
At 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.
The 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.
Why trauma must trump burn injuries: The spectre of missed injuries
2019, Burns Open
Significant burn injury in the setting of trauma poses a challenging clinical dilemma and can be a diversion to providers not familiar with such injuries. Approximately 5–7% of burn center admissions include patients with multiple traumatic injuries. A 44 year old male with poly-trauma due to a factory explosion presented with significant burns, and a pneumothorax, compartment syndromes of bilateral hands and forearms, and a missed axillary vein injury. In burn-trauma patient evaluations, thorough primary, secondary, and especially the tertiary surveys of the Advanced Trauma Life Support (ATLS®) and Advanced Burn Life Support (ABLS®) protocols must be performed and frequently reevaluated to avoid missed trauma injuries in the presence of thermal injury. This is especially important in blasts, explosions, assaults, and terror attacks at anytime and anywhere, when combined burn and trauma injuries are common. Early resuscitation of these patients mandates that frequent assessments uncover all other traumatic injuries, which may be less dramatic but more lethal than the burn.
Double jeopardy revisited: Clinical decision making in unstable patients with, thoraco-abdominal stab wounds and, potential injuries in multiple body cavities
2011, Injury
In the setting of the hypovolaemic patient with a thoraco-abdominal stab wound and potential injuries in both the chest and abdomen, deciding which cavity to explore first may be difficult. Opening the incorrect body cavity can delay control of tamponade or haemorrhage and exacerbate hypothermia and fluid shifts. This situation has been described as one of double jeopardy.
All stab victims from July 2007 to July 2009 requiring a thoracotomy and laparotomy at the same operation were identified from a database. Demographics, site and nature of injuries, admission observations and investigations as well as operative sequence were recorded. Correct sequencing was defined as first opening the cavity with most lethal injury. Incorrect sequencing was defined as opening a cavity and finding either no injury or an injury of less severity than a simultaneous injury in the unopened cavity. The primary outcome was survival or death.
Sixteen stab victims underwent thoracotomy and laparotomy during the same operation. All were male with an age range of 18–40 (mean/median 27). Median systolic blood pressure on presentation was 90 mm Hg. (quartile range 80–90 mm Hg). Median base excess was −6.5 (quartile range −12 to −2.2). All the deaths were the result of cardiac injuries. Incorrect sequencing occurred in four patients (25%). In this group there were four negative abdominal explorations prior to thoracotomy with two deaths. There was one death in the correct sequencing group.
Incorrect sequencing in stab victims who require both thoracotomy and laparotomy at the same sitting is associated with a high mortality. This is especially true when the abdomen is incorrectly entered first whilst the life threatening pathology is in the chest. Clinical signs may be confusing, leading to incorrect sequencing of exploration. The common causes for confusion include failure to appreciate that cardiac tamponade does not present with bleeding and difficulty in assessing peritonism in an unstable patient with multiple stab wounds. In the setting of the unstable patient with stab wounds and suspected dual cavity injuries the chest should be opened first followed by the abdomen.
The spectrum of diaphragmatic injury in a busy metropolitan surgical service
2009, Injury
Citation Excerpt :
The development of a significant empyema should raise suspicions of an intra-abdominal complication and sepsis and should prompt a thorough reassessment of the abdomen. Missed injuries are an ever present possibility in trauma surgery4,10,18 and it is essential to exclude specific injury patterns. A breach of the diaphragm may be overlooked if the operator does not follow the path of the wounding implement and does not adequately inspect the diaphragm.
The diaphragm may be injured by penetrating or blunt trauma. Diaphragmatic breach without visceral injury or herniation may be difficult to detect due to a paucity of clinical signs and herniation may be misdiagnosed following the erroneous interpretation of chest radiology. If not recognized there is a considerable risk of late morbidity and mortality. This prospective study reviews our experience with diaphragmatic injury in a busy general surgical service with a large trauma component.
A trauma database is maintained by the general surgical service of the Pietermaritzburg metropolitan complex. All patients who sustained a diaphragmatic injury between September 2006 and September 2007 were included in this study.
A total of 54 patients with diaphragmatic injury were treated in the period under review. There were three broad groups, namely those with simple breach of the diaphragm (37), acute diaphragmatic hernias (11) and chronic diaphragmatic hernias (6). Thirty-seven patients had a diaphragmatic breach confirmed at either laparotomy or laparoscopy. The mechanisms of injury were stab (24), gunshot wound (10), blunt trauma (2), and shotgun (1). There were seven (19%) deaths. In 19 asymptomatic patients laparoscopy was performed because of the presence of a stab wound to the left thoraco-abdominal region. Five (38%) of these patients were shown to have a diaphragmatic breach at laparoscopy. Eleven patients presented with an acute diaphragmatic hernia. The mechanisms of injury were stab (5), blunt trauma (5), and gunshot (1). The hernia contents were stomach (10), colon (1), and spleen (2). The operative approach was a laparotomy in 10 patients and a thoraco-laparotomy in one. Six patients presented with a chronic diaphragmatic hernia of longer than six months duration. The mechanisms of injury were stab (4), blunt trauma (1) and gunshot wound (1). The average delay from injury to presentation was 3.5 years. The contents were colon (3) and stomach (3). All were managed by laparotomy.
If there is an established indication for laparotomy diaphragmatic breach is usually recognized and dealt with appropriately although failure to follow standard principles may result in the injury being overlooked. Isolated diaphragmatic injury without associated visceral damage cannot be diagnosed clinically or radiologically. Direct video-endoscopic inspection confirms or excludes the diagnosis and has a high pick up rate. Diaphragmatic herniation can present acutely after trauma or at a time remote from the original injury. Acute diaphragmatic injury may be confused with other pathologies and there is a risk of inappropriate intervention. Most diaphragmatic hernias can be repaired via laparotomy.
Autopsies following death due to traumatic injuries in the Netherlands: An evaluation of current practice
2008, Injury
Citation Excerpt :
Although autopsy can be considered as the reference standard for determining the cause of death, there has been a steady decline in autopsy rates over the years.5,10,16 Not only are the findings at autopsy a source of important epidemiological data, but also autopsies can provide valuable feedback to the physicians in charge and can potentially result in the adjustment of treatment protocols or preventive measures.3,11 It is our hypothesis that the autopsy rate among fatal trauma cases in the Amsterdam region is low and that feedback to physicians is minimal.
Because of a steady decline in the number of autopsies following death due to traumatic injuries, valuable information concerning possible missed injuries and potential improvements in management is lost. This retrospective study describes current practice in the Amsterdam region of the Netherlands regarding such autopsies, and their rates.
The current protocols for autopsies were reviewed. Data from government databases and hospitals for the year 2005 were collected. For all patients included that died an unnatural death due to traumatic injury, causes of death and recommendations for autopsy were reviewed. The number of clinical and medico-legal autopsies was determined.
Of 872 registered unnatural deaths, 414 were due to traumatic injuries; 63% of these died before reaching hospital and 37% died in hospital. There were more male deaths, and average age was 54 years. In 23% an autopsy was advised by the medical examiners, more often for pre-hospital deaths. The rate of autopsies was 46% when advice was given for a medico-legal autopsy.
The rates of both medico-legal and clinically desirable autopsies are very low. Currently, the system in Amsterdam focuses mainly on the former, and the latter with its attendant educational aspects is largely ignored. The role of the government should be expanded to optimise the autopsy system in unnatural deaths following traumatic injuries.

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¹: From the Department of Surgery, University of Natal Medical School, Durban, Republic of South Africa.

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Scientific paperUndetected injuries: A preventable cause of increased morbidity and mortality

Abstract

Injury

Retrospective study of 1,000 deaths from injury in England and Wales

BMJ

Preventable trauma deaths

J Trauma

Systems of trauma care. Study of two counties

Arch Surg

Injuries missed at operation: nemesis of the trauma surgeon

J Trauma

Diagnostic failure in multiple injuries

J Trauma

Delayed diagnosis of injuries to the diaphragm after penetrating wounds

J Trauma

Unexpected, unsuspected, and missed injuries in a paediatric trauma unit

S Afr J Med

Intravenous pyelogram results in association with renal pathology and therapy in trauma patients

J Trauma

Renal trauma: re-evaluation of the indications for radiographic assessment

J Urol

Diagnostic peritoneal lavage in the management of blunt abdominal trauma: a reassessment

J Trauma

Scientific paper
Undetected injuries: A preventable cause of increased morbidity and mortality