Prediction of blunt traumatic injuries and hospital admission based on history and physical exam

Abstract

BackgroundWe evaluated the ability of experienced trauma surgeons to accurately predict specific blunt injuries, as well as patient disposition from the emergency department (ED), based only on the initial clinical evaluation and prior to any imaging studies. It would be hypothesized that experienced trauma surgeons’ initial clinical evaluation is accurate for excluding life-threatening blunt injuries and for appropriate admission triage decisions.MethodsUsing only their history and physical exam, and prior to any imaging studies, three (3) experienced trauma surgeons, with a combined Level 1 trauma experience of over 50 years, predicted injuries in patients with an initial GCS (Glasgow Coma Score) of 14–15. Additionally, ED disposition (ICU, floor, discharge to home) was also predicted. These predictions were compared to actual patient dispositions and to blunt injuries documented at discharge.ResultsA total of 101 patients with 92 blunt injuries were studied. 43/92 (46.7 %) injuries would have been missed by only performing an initial history and physical exam (“Missed injury”). A change in treatment, though often minor, was required in 19/43 (44.2 %) of the missed injuries. Only 1/43 (2.3 %) of these “missed injuries” (blunt aortic injury) required surgery. Sensitivity, specificity, and accuracy for injury prediction were 53.2, 95.9, and 92.3 % respectively. Positive and negative predictive values were 53.8 and 95.8 % respectively. Prediction of disposition from the ED was 77.8 % accurate. In 7/34 (20.6 %) patients, missed injuries led to changes in disposition. “Undertriage” occurred in 9/99 (9.1 %) patients (Predicted for floor but admitted to ICU). Additionally, 8/84 (9.5 %) patients predicted for floor admission were sent home from the ED; and 5/13 (38.5 %) patients predicted for ICU admission were actually sent to the floor after complete evaluations, giving an “overtriage” rate of 13/99 (13.1 %) patients.ConclusionsIn a neurologically-intact group of trauma patients, experienced trauma surgeons would have missed 46.7 % of the actual injuries, based only on their history and physical exam. Once accurate diagnoses of injuries were completed, usually with the help of CT scans, admission dispositions changed in 20.6 % of patients. Treatment changes occurred in 44.2 % of the missed injuries, though usually minimal. Broad elimination of early imaging studies in alert, blunt trauma patients cannot be advocated.

The Utility of Additional Imaging in Trauma Consults with Mild to Moderate Injury

“…The literature has shown that history and physical examination alone are not effective strategies to identify and quantify the extent of internal injuries. [17][18][19] In the present study, attempts to minimize radiation for trauma consultations resulted in additional imaging in a third of our patient sample that revealed new injuries in another third and increased ISS in more than 10 per cent. We propose that the attempts to limit the use of CT imaging may be overzealous and result in significant injuries remaining hidden and untreated.…”

Multiple trauma management in mountain environments - a scoping review

“…Exposure may cause or worsen hypothermia, a common condition in trauma patients that contributes to coagulopathy and acidosis [ 166 – 168 ]. History and physical exam alone have a low accuracy in detecting injuries in blunt trauma, missing almost half of injuries, even in a hospital environment [ 169 ]. Prehospital injury assessment by physicians can miss up to one-third of significant injuries [ 170 ].…”

Incidence of traumatic carotid and vertebral artery dissections: results of cervical vessel computed tomography angiogram as a mandatory scan component in severely injured patients

“… 2 – 4 In multiply injured patients, diagnoses and decisions only based on history and clinical examination are prone to error with missed injuries in up to 47%. 9 Thus, multiply injured patients at risk for carotid or VAD have to be identified via a combination of trauma and patient characteristics including the pattern of obvious injuries or all patients eligible for a whole-body CT need to be screened for carotid and vertebral artery injuries by making the CTA of supra-aortal arteries a part of the routine scan protocol. 3 For example, as shown in Figure 4 , a young man was diagnosed with an aortic arch rupture after a motorcycle crash and was secondarily admitted to our Level I trauma center for endovascular aortic repair; the in-house control CTA revealed a missed CAD on the right.…”

“… 2 While a contrast-enhanced multidetector computed tomography (CT) of thorax, abdomen, and pelvis is regarded as a diagnostic standard in severely and/or multiply injured patients, 5 no compulsory consensus exists for the routine imaging and rule out of CeAD. 6 , 7 Most of the polytrauma guidelines “recommend” a CT angiogram (CTA) in patients with an ill-defined “relevant trauma” to the head-and-neck region; 8 it is known that even for highly experienced trauma surgeons, prediction of blunt injuries exclusively based on history and physical examination miss ~50% of injuries, 9 underlining the need for standardized protocols and algorithms for head-and-neck CTA in trauma patients. Depending on the study population and preassessment, incidence of carotid artery dissections (CADs) and vertebral artery dissections (VADs) ranges from 1.7% and 4.9%.…”