Tertiary assessment of trauma patients in a hospital in the city of São Paulo: a question of necessity

Abstract

Objective To minimize the occurrence of missed injuries, the tertiary evaluation was introduced consisting of reassessment of the patient, 24 hours after admission, with: complete history, physical examination, review of exams and diagnostic testing if necessary. Methods Observational study evaluating trauma patients admitted to a teaching hospital in São Paulo, according to a protocol for tertiary evaluation. Results Between February and May 2012, for 12 weeks, 182 patients were submitted to tertiary evaluation, 100 (55%) polytraumatized and 82 (45%) were victims of low-energy trauma. Neglected lesions were observed in 21 (11.5%) patients, who had 28 missed injuries. Of these 28 lesions, seven (25%) required surgical treatment. Conclusion Strategies including formal tertiary evaluation, the protocol applied for assessing trauma victims, seem to be beneficial in these patients, regardless of the mechanism of trauma. The method is easily applied, effective and has low cost in identifying missed injuries in the victims of trauma.

Missed Injuries in Polytrauma Patients after Trauma Tertiary Survey in Trauma Intensive Care Unit

“…Studies have shown that head injuries (4, 6, 13, 14), mechanical ventilation (5, 8), low scores on the Glasgow Coma Scale (GCS) (2, 4, 7, 15), and high Injury Severity Scores (ISS) (2, 4, 7, 15, 16) can lead to delayed diagnosis. Inadequate clinical examinations (9, 11), departures from clinical routines (11), and misinterpreted or inadequate radiographs (2, 4, 5, 8, 11, 17) also contribute to delayed diagnoses. In addition, patients from road traffic accidents are more likely to have missed injuries (4, 8, 11).…”

“…According to the current literature, the incidence of missed injuries in trauma patients varies across different studies from 0.6% to 39% (1–16, 18, 19). These differences in the results may stem from differences between the study populations and methods, and especially from differences in the criteria which determine whether an injury has been missed.…”

“…Typical missed injuries include musculoskeletal/orthopedic injuries (1,7), especially fractures (6,8). The most common body regions of missed injuries vary depending on the study, but many such studies frequently identify the head and neck (3,7,8), chest (3,6,7,9), and extremities (3,4,(6)(7)(8)(9)(10)(11)(12) as the most common regions of missed injuries.…”

Retropharyngeal hematoma secondary to cervical hyperextension in a minor collision trauma presenting with dyspnoea

“…Researches to reduce the incidence rate of missed injuries and to identify the risk factors of missed injuries in initial survey have been performed actively. [ 6 , 7 , 8 , 11 ] Risk factors associated with undetected injuries include young age, high Injury Severity Score, polytrauma, absence of soft tissue injuries, and presence of chest or pelvic injuries. [ 12 ] Interestingly, young age was one of the significant risk factors of undetected injuries in emergency department in a retrospective cohort study.…”

“…[ 7 ] Some studies demonstrate that this protocol is beneficial for the detection of missed injuries. [ 7 , 11 ] One observational study reported that neglected lesions were observed in 11.5% patients in the protocol, [ 11 ] and another literature review study reported missed injury detection rates in several studies to be better in the tertiary survey group, compared to primary and secondary survey groups, showing detection rates of missed injuries varying from 2.6% to 30.96%. [ 7 ]…”