Incidence and predictors of missed injuries in trauma patients in the initial hot report of whole-body CT scan
Highlights
► Wholebody CT scan is the cornerstone of trauma injury evaluation. ► We examined the incidence and predictors of missed injuries in trauma patients undergoing whole-body CT scan. ► Almost half of the patients experienced MI which were predominantly minor and musculoskeletal. ► Age and trauma severity were independent predictors of MI. ► These results advocate a systematic second reading of the initial CT scan.
Introduction
Implementation of healthcare algorithms devoted to trauma resuscitation is associated with a decrease in mortality in the case of trauma patients.6, 18 Whole-body CT scan is being increasingly used for the definitive assessment of injuries during early stage of trauma management. Its implementation has recently been shown to be associated with a decrease in mortality in trauma patients.14 Trauma guidelines therefore now consider the practice of whole-body CT scan as a standard of care in the early stage of trauma management.
Missed injuries represent an important issue for patients with major trauma, for they may increase morbidity, mortality and costs.8, 9, 12, 13, 22 A recent review reported a wide range in incidence of missed injuries from 1.3 to 39%.21 Such range may be related to the heterogeneity in criteria used in defining missed injuries.6, 7, 9, 10, 23 Thus, the real incidence of missed injuries and delayed diagnosis remains difficult to determine. Technical improving with the use of multi-detector CT (MDCT) may lead to subsequent reduction of incidence of missed injuries. However, this remains uncertain, for CT scan may not exclude unrecognized injuries.2 Incidence of missed injuries when using whole-body CT scan as standard practice (and particularly 64-MDCT) has not been assessed. The aim of the present study was therefore to determine incidence, outcomes and predicting factors of missed injuries when performing whole-body CT scan in trauma patients.
Section snippets
Patients and methods
This retrospective observational study was performed at Beaujon Hospital (Clichy-la-Garenne, France), an academic French trauma centre during a 12-months period, from January 2005 through December 2005. According to the organisation of out-of-hospital medical emergency services in France, patients were first managed on-scene by a mobile medical intensive care unit crew prior transport to the trauma centre. On arrival to trauma room, patients were managed according to clinical algorithms
Results
During the study period, 193 patients were eligible for inclusion. Fifteen patients died before having a whole-body CT scan, and one patient was excluded because of the lack of initial CT scan report, consequently 177 trauma patients with initial whole-body CT scan performed on admission were analysed (Fig. 1). Patients were male in 79% with a median age of 33 years [25–43]. Median initial ISS score was 20 [10–33], median SAPS II score was 28 [13–43], median initial on-scene GCS was 14 [8–15].
Discussion
An unexpectedly high rate of missed injuries in trauma patients undergoing whole-body CT scan was found in the present study. A second cold reading of whole-body CT scan in trauma patients by experienced radiologist showed indeed that 48% of severely trauma patients displayed CT scan missed injuries. Age and ISS were found predictors of CT scan missed injuries in this context. Number of CT detectors was not associated with a decreased rate of missed injuries.
One of the main results of this
Conclusion
In our centre, missed injuries may occur in up to forty-eight percent of patients experiencing severe trauma managed with whole-body CT scan in the initial hot report. Missed injuries appeared to be predominantly minor and musculoskeletal. Age and ISS were found to be predictor of missed injuries. These results advocate a systematic second cold reading of whole-body CT scan in low volume trauma centres especially in patients with particularly severe trauma. This assessment should be part of an
Conflict of interest statement
Authors declare no conflict of interest that could influence their work.
References (25)
- et al.
Value of double reading of whole body CT in polytrauma patients
J Radiol
(2008) - et al.
Missed injury in major trauma patients
Injury
(2004) - et al.
Effect of whole-body CT during trauma resuscitation on survival: a retrospective, multicentre study
Lancet
(2009) - et al.
Subsecond multi-slice computed tomography: basics and applications
Eur J Radiol
(1999) - et al.
Missed injury and the tertiary trauma survey
Injury
(2008) - et al.
The impact of injuries below the knee joint on the long-term functional outcome following polytrauma
Injury
(2005) - American College of Surgeons Commitee on Trauma. Initial assessment and management. Advanced trauma life support...
- et al.
The injury severity score: a method for describing patients with multiple injuries and evaluating emergency care
J Trauma
(1974) - et al.
Incidence, risk factors, and outcomes for occult pneumothoraces in victims of major trauma
J Trauma
(2005) - et al.
Sixteen-slice multi-detector computed tomographic angiography improves the accuracy of screening for blunt cerebrovascular injury
J Trauma
(2006)
Implementation of a tertiary trauma survey decreases missed injuries
J Trauma
Delayed identification of skeletal injury in multisystem trauma: the ‘missed’ fracture
J Trauma
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