Delayed diagnosed trauma in severely injured patients despite guidelines-oriented emergency room treatment: there is still a risk

Abstract

Purpose Emergency trauma room treatment follows established algorithms such as ATLS®. Nevertheless, there are injuries that are not immediately recognized here. The aim of this study was to evaluate the residual risk for manifesting life-threatening injuries despite strict adherence to trauma room guidelines, which is different to missed injuries that describe recognizable injuries. Methods In a retrospective study, we included 2694 consecutive patients admitted to the emergency trauma room of one single level I trauma center between 2016 and 2019. In accordance with the trauma room algorithm, primary and secondary survey, trauma whole-body CT scan, eFAST, and tertiary survey were performed. Patients who needed emergency surgery during their hospital stay for additional injury found after guidelines-oriented emergency trauma room treatment were analyzed. Results In seven patients (0.26%; mean age 50.4 years, range 18–90; mean ISS 39.7, range 34–50), a life-threatening injury occurred in the further course: one epidural bleeding (13 h after tertiary survey) and six abdominal hollow organ injuries (range 5.5 h–4 days after tertiary survey). Two patients (0.07% overall) with abdominal injury died. The “number needed to fail” was 385 (95%–CI 0.0010–0.0053). Conclusion Our study reveals a remaining risk for delayed diagnosis of potentially lethal injuries despite accurate emergency trauma room algorithms. In other words, there were missed injuries that could have been identified using this algorithm but were missed due to other reasons. Continuous clinical and instrument-based examinations should, therefore, not be neglected after completion of the tertiary survey. Level of evidence Level II: Development of diagnostic criteria on the basis of consecutive patients (with universally applied reference “gold” standard).

The European guideline on management of major bleeding and coagulopathy following trauma: sixth edition

“…In a retrospective study between 2016 and 2019, 2694 consecutive patients were admitted to a level I trauma centre and a strict emergency room algorithm followed. Injuries were missed in seven patients (0.26%; one epidural bleeding and six abdominal hollow organ injuries; two died), which highlights the need for continuous clinical and instrument-based examinations after completion of the tertiary survey [ 80 ].…”

Tertiary Trauma Survey on Emergency Department Observational Units: A Systematic Literature Review

“…Most of the studies were conducted on ICU patients or those patients with significant and life-threatening injuries. Due to the severity of initial injuries, prioritization of management, and distraction, the number of missed injuries detected at TS in these patients is much higher [ 10 , 12 , 15 , 22 , 24 , 27 ]. Although this result is not relevant to the EDOU cohort, it emphasizes the importance of TTS in all polytrauma patients.…”

“…Most studies also concluded satisfactorily that standardized TTS at 24 hours gives better outcomes and is a cost-effective, easy, and efficient tool [ 10 - 12 , 22 - 24 , 27 ].…”

“…The selected literature included six retrospective studies, two randomized control trials (RCT), three literature reviews, one meta-analysis, and seven prospective studies [5,[10][11][12][13][14][15][16][17][18][19][20][21][22][23][24][25][26][27]. The methodology of all relevant publications included in the review was assessed individually.…”