Chapter 23 – Commonly Missed Traumatic Injuries




Abstract




The terms “missed injury” and “delayed diagnosis” have undergone evolution in their academic meaning over the last several decades of trauma care. Missed injury is typically reserved for an unidentified injury for which the opportune moment for intervention has passed. A delayed diagnosis is the term given to injuries not identified on the primary or secondary survey of the initial trauma evaluation. There is obvious overlap in the ways these terms are employed throughout trauma care, and specific institutions may possess their own interpretations. Many emergency medicine texts list a missed injury as one that is discovered after the patient has left the Emergency Department (ED), whether discharged home or admitted. This version of the “missed injury definition” would include possible injuries which were suspected in the ED (not truly “missed”), though not officially found due to appropriate delays in imaging while more acute issues are being resolved in the operating room (OR) or Intensive Care Unit (ICU). The national trauma database of the American College of Surgeons defines missed injury as an “injury-related diagnosis discovered after initial workup is completed and admission diagnosis is determined.”1 Delayed diagnosis was proposed to describe diagnoses that were not found on primary and secondary survey. The tertiary survey was intended to identify many of these injuries,2 though some literature still defines injuries found during the tertiary survey as “delayed.”3,4 In any case, the use of a tertiary survey should be employed in all trauma evaluations, as it leads to a reduction in clinically significant initially unidentified injuries.5 Trauma surgery has also created leveling algorithms based on the mechanism of injury to help activate appropriate resources for trauma patients. Finally, multiple evidence-based decision tools (i.e. Ottawa knee rules, Canadian head computed tomography rules, etc.) exist to help delineate imaging decisions.





Chapter 23 Commonly Missed Traumatic Injuries


Matthew Greer and Brian T. Wessman



Introduction


The terms “missed injury” and “delayed diagnosis” have undergone evolution in their academic meaning over the last several decades of trauma care. Missed injury is typically reserved for an unidentified injury for which the opportune moment for intervention has passed. A delayed diagnosis is the term given to injuries not identified on the primary or secondary survey of the initial trauma evaluation. There is obvious overlap in the ways these terms are employed throughout trauma care, and specific institutions may possess their own interpretations. Many emergency medicine texts list a missed injury as one that is discovered after the patient has left the Emergency Department (ED), whether discharged home or admitted. This version of the “missed injury definition” would include possible injuries which were suspected in the ED (not truly “missed”), though not officially found due to appropriate delays in imaging while more acute issues are being resolved in the operating room (OR) or Intensive Care Unit (ICU). The national trauma database of the American College of Surgeons defines missed injury as an “injury-related diagnosis discovered after initial workup is completed and admission diagnosis is determined.”1 Delayed diagnosis was proposed to describe diagnoses that were not found on primary and secondary survey. The tertiary survey was intended to identify many of these injuries,2 though some literature still defines injuries found during the tertiary survey as “delayed.”3, 4 In any case, the use of a tertiary survey should be employed in all trauma evaluations, as it leads to a reduction in clinically significant initially unidentified injuries.5 Trauma surgery has also created leveling algorithms based on the mechanism of injury to help activate appropriate resources for trauma patients. Finally, multiple evidence-based decision tools (i.e. Ottawa knee rules, Canadian head computed tomography rules, etc.) exist to help delineate imaging decisions.



Scope of the Problem


The reported rate of missed injury varies widely (from 0.4% to 65%) depending on multiple factors: how the study defines the “miss,” the specialty (i.e. orthopedics vs. vascular) the study focuses on, and whether the study is prospective or retrospective.6, 7 In 1990, Enderson et al.2 introduced the tertiary survey as a means of capturing unidentified diagnoses before they became “missed.” Yet, some studies still list all injuries found during the tertiary survey as “missed,” claiming they occur after the initial trauma survey.4, 8 The percentage of unrecognized injuries discovered in a literature review by Pfeifer and Pape8 found a range of 1.3–39%, with mean around 9%. Few studies break down the number of clinically significant missed injuries (a problem additionally confounded by publication bias), however, clinically significant missed injuries are noted to be a minority of overall missed injuries, found to range between 12% and 15% in studies reviewed by Lee and Bleetman6 and 15% and 22.3% in a series by Pfeifer and Pape.8 Another proposed way to evaluate the scope of this problem is to identify “rate of change in treatment,” with some studies showing this rate to be as high as 55.1%.4


Predominant missed injuries by location:9




  • Limbs (33.3%)



  • Head (30.2%)



  • Thorax (19.1%)


Patients at greatest risk for missed injuries:3, 8, 10




  • Increased injury severity



  • Intubated/noncommunicative



  • Low GCS



  • Receiving blood transfusions within 24 hours



  • Undergoing emergency surgery



  • Intoxication/drugs of abuse



  • Pediatric



  • Geriatric



  • Pregnant



Missed Injuries by Location



Head




  • Systems at risk:




    • Nervous: brain, cranial nerves, eyes.



    • Skull: cranium (including sinuses) as well as skull base.




  • Common blunt injuries: motor vehicle collisions (MVC), assaults, falls.



  • Common penetrating injuries: gunshot wounds (GSW), stab wounds, shrapnel.



  • Tables 23.1 and 23.2 depict findings.




Table 23.1 Physical exam findings to consider























Halo sign


(image: Matthew Greer, MD)






Raccoon eyes


(image courtesy of Marion County Sheriff’s Office)

CSF Halo Sign:


  • Seen best on white sheet



  • Indicates fracture of ethmoid sinus/cribriform plate from nose



  • Indicates mastoid/temporal bone fracture from ear

Raccoon Eyes:


  • Indicative of basilar skull fracture






Hemotympanum with tympanic membrane perforation


(reproduced with permission of Wolters Kluwer Health Inc.)11






By Bobjgalindo (own work)


(reproduced here under CC BY-SA 4.0 license, creativecommons.org/licenses/by-sa/4.0/)

Hemotympanum:


  • Often indicates temporal bone fracture

Eye-lid laceration:


  • Make sure to pull back lid to ensure eye does not have globe injury which can be occult/hidden under lid




Table 23.2 Imaging findings to consider

















Epidural hematoma


(image courtesy of Hellerhoff, reproduced here under CC BY-SA 3.0 license; creativecommons.org/licenses/by-sa/3.0/)






Blow out fracture


(images courtesy of James Heilman, MD, reproduced here under CC BY-SA 3.0 license; creativecommons.org/licenses/by-sa/3.0)

Epidural Hematoma:


  • Look for underlying skull fracture

Maxillary sinus fracture/orbital wall blowout:


  • Look for ocular muscle entrapment



  • Patient will be unable to look up or have limited intraocular muscle movements



Neck




  • Systems at risk:




    • Nerves: recurrent laryngeal, vagus.



    • Vasculature: carotid arteries, internal/external jugular veins.



    • Respiratory: trachea.



    • Gastrointestinal (GI): esophagus.




  • Blunt neck injuries are most often from MVCs. However, assault, strangulation, and hanging may also be precipitating factors. Blunt trauma of the neck leads to a much higher incidence of missed injury (compared to penetrating trauma) due to the fact that external physical exam signs may be subtle.12



  • Penetrating neck trauma makes up approximately 0.55–5% of all traumatic injuries. Mechanisms include GSW, stab wounds, and shrapnel. Cervical-collars are believed to be of extremely low yield in penetrating neck trauma, and early removal allows for easier management of airway and vascular injuries.12



  • Table 23.3 and Box 23.1 depict exam and imaging findings requiring attention.




Table 23.3 Physical exam findings to consider12













Hard Signs

(Need Urgent Surgical Intervention)
Soft Signs

(Need Close Observation/Reevaluation)



  • Expanding hematoma



  • Severe active bleeding



  • Shock not responding to fluids



  • Decreased or absent radial pulses



  • Vascular bruit or thrills



  • Cerebral ischemia



  • Airway obstruction




  • Hemoptysis/hematemesis



  • Oropharyngeal blood



  • Dyspnea



  • Dysphonia/dysphagia



  • Subcutaneous air/mediastinal air



  • Chest tube air leak



  • Non-expanding hematoma



  • Nausea and vomiting



  • Focal neurologic deficits




Box 23.1 Imaging Findings to Consider


Air outside trachea:




  • Concern for trachea or esophageal injury/perforation



Spine





  • Systems at risk:




    • Nervous: spinal cord.



    • Vasculature: runs the entire thorax and lays next to aorta and IVC.



    • Respiratory: lungs.



    • GI: lumbar spine can be anvil against which bowels and abdominal organs are crushed.



    • GU: none.




  • Common blunt injuries: MVCs account for approximately 40% of all spinal injuries; falls make up a lower proportion and predominantly effect the lumbar spine.13



  • Common penetrating injuries: GSWs, less often stab wounds.



  • Box 23.2 depicts important exam findings.




  • Imaging findings to consider:




    • One spine fracture should prompt the clinician to look for a second.



    • Consider vertebral artery injury with cervical spine fracture.



    • Consider descending aortic injury with a thoracic spine injury.



    • Consider abdominal aortic injury with a lumbar spine injury.






Box 23.2 Physical Exam Fndings to Consider


Abnormal abdominal breathing:




  • Consider phrenic nerve injury from possible C3/4 injury


Severe head and facial trauma:




  • 5–10% chance of cervical spine injuries



  • Consider spine immobilization until definitive imaging



Thoracic




  • Systems at risk:




    • Nervous: vagus nerve, phrenic nerve.



    • Cardiovascular: cardiac (right ventricle anteriorly, left atria posteriorly), major cardiac vessels (aorta and pulmonary arteries, superior vena cava), subclavian arteries and veins.



    • Respiratory: lungs, diaphragm.



    • GI: esophagus.



    • GU: none.




  • Common blunt injuries: MVCs are the most common cause of injuries leading to death in the United States, with immediate deaths often due to rupture of a myocardial wall or the thoracic aorta.



  • Common penetrating injuries: GSW, stab wounds, debris.



  • Tables 23.4 and 23.5 depicts important exam findings.




Table 23.4 Physical exam findings to consider














Subcutaneous emphysema


Crepitus/subcutaneous emphysema (“Rice-crispy sign”):


  • Usually indicates more serious thoracic injury



  • Consider pneumothorax


    Friction rub/Hamman’s crunch (crackling sound with each heart beat):



  • Look for pneumomediastinum



  • Could be from esophageal or tracheal injury




Table 23.5 Imaging findings to consider














Deep sulcus


(image courtesy of Braegel, reproduced here under CC BY-SA 3.0 license; creativecommons.org/licenses/by-sa/3.0/)

Deep sulcus sign:


  • Anterior pneumothorax may only be demonstrated as a deep sulcus sign on supine CXR


    Fracture of 1st or 2nd rib or scapula:



  • Consider aortic injury (dissection)


    Fracture of ribs 9–11:



  • Associated with intra-abdominal injury



  • Right sided = liver injury



  • Left sided = splenic injuries


    Two or more rib fractures at any level:



  • Higher incidence of internal injuries



Abdomen




  • Systems at risk:




    • Nervous: vagus nerve.



    • Vasculature: abdominal aorta, celiac and superior mesenteric arteries, inferior vena cava, renal arteries/veins, splenic artery/vein.



    • Respiratory: diaghragmatic injury may result in herniation of abdominal contents into the thorax, and abdominal compartment syndrome may also worsen respiratory function.



    • GI: liver/gallbladder, spleen, pancreas, stomach, small intestine, colon.



    • GU: kidneys, ureters.




  • Blunt injuries: There is greater risk of mortality and missed injuries (compared to penetrating trauma) due to unreliable symptoms/signs and more severe injuries occurring in these patients. Further caution should be exercised when co-existing severe extra-abdominal injuries are present (i.e. head trauma) which may limit the historical exam or ability for the patient to cooperate.14




    • The most commonly injured abdominal organ in blunt trauma is the spleen, followed by the liver and intestines.



    • Presence of blunt splenic and/or hepatic injuries predicts a higher risk of hollow viscus injury, and there is a correlation between severity of splenic injury and incidence of hollow viscous injury.15, 16




  • Penetrating injuries: stabbing injuries occur with 3-times more frequency than injuries from firearms, though the mortality rate is much higher from firearms.




    • The most commonly injured organ in penetrating trauma is the small intestines, followed by the liver and colon.



    • Stab wounds have a higher likelihood to injure the liver (more surface area).



    • Box 23.3 and Box 23.4 depict important exam findings.



Jan 10, 2021 | Posted by in EMERGENCY MEDICINE | Comments Off on Chapter 23 – Commonly Missed Traumatic Injuries
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