Elsevier

Injury

Volume 43, Issue 1, January 2012, Pages 73-77
Injury

Incidence and predictors of missed injuries in trauma patients in the initial hot report of whole-body CT scan

https://doi.org/10.1016/j.injury.2011.05.019Get rights and content

Abstract

Background

Whole-body CT scan is the cornerstone of trauma-related injury assessment. Several lines of evidence indicate that significant number of injuries may remain undetected after the initial hot report of CT. Missed injuries (MI) represent an important issue in trauma patients, for they may increase morbidity, mortality and costs. The aim of this study was to examine incidence and predictors of MI in trauma patients undergoing whole-body CT scan.

Methods

177 CT scan performed upon admission of trauma patients during year 2005 were reviewed by a radiologist blinded to patient's initial data. MI was defined as injuries not written in the initial report. Patients with and without MI were compared to determine predictors of MI by multivariable analysis.

Results

157 MI were diagnosed in 85 (47%) patients. MI was predominantly encoded AIS 2 (57%) or 3 (29%). Patients with MI had significantly higher SAPSII, higher ISS and were more frequently sedated. Age over 50 years (OR: 4.37, p = 0.003) and ISS over 14 (OR: 4.17, p < 0.0001) were independent predictors of MI. Median ISS after encoding MI was significantly higher than initial ISS (22 vs. 20 p < 0.0001). After adjustment for severity, mortality and length of stay were not different between patients with or without MI.

Conclusion

Trauma patients, especially aged and severe, experienced a high rate of missed injuries in the initial hot report which appeared to be predominantly minor and musculoskeletal, advocating a CT scan second reading.

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.

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