Missed diagnoses in trauma patients vis-à-vis significance of autopsy
Introduction
Management of trauma patients with multiple injuries can be one of the most clinically challenging situations faced by even the most seasoned health care workers. In the acute management of the trauma patient, injuries may be missed during initial assessment. Clear guidelines, as outlined by the Advanced Trauma Life Support Course2 dictate strict priorities in the initial management of the polytraumatised patient and help minimise the incidence of missed injuries. A rapid primary survey to immediately identify and manage life-threatening injuries followed by a detailed head-to-toe secondary survey is the standard of care in trauma management. The concept of a tertiary trauma survey was introduced by Enderson et al.15 to identify injuries missed after the primary and secondary survey performed in the resuscitation room. However, despite these efforts, it is recognised that many injuries/complications can still entirely escape detection in the hospital.14 Several variables, both patient- and physician-related, have been identified as being associated with an increased likelihood of unrecognised injuries.7, 22, 32 According to a study, reviewed autopsy reports of trauma patients revealed a 34% incidence of missed injuries.1
The consequences of missed diagnoses in trauma-related deaths have been well described in the literature.27, 36, 37, 38 More recent studies3, 12, 21, 23, 31 report an incidence of 0–15% of missed diagnoses among all trauma patients contributing to death. Missed diagnoses, in addition to being potential sources of morbidity and mortality, may also represent varying degrees of clinical inexperience. The lack of extensive studies on this subject may be partly attributed to a general reluctance of clinicians to admit and account for their errors. However, in an increasingly litigious society, where public demands for accountability within the health care system are becoming the norm, it is important to provide an open forum for examination when patient management is questioned.
Furthermore, the autopsy rate in the United States has been reported to be declining during the past three decades.18, 28 This decline has been attributed to lack of time, lack of interest and a perception of a differing diagnosis after death as a physician failure. The role of autopsy in detecting missed injuries in the trauma population is well described,4, 34 but because the autopsy rate being only about 50% for trauma deaths, the true incidence of missed diagnosis is unknown. Trauma patients in the intensive care units (ICU) represent a unique challenge: diagnostic dilemmas are frequent because a large number of patients have altered consciousness or are mechanically ventilated. Consequently, few studies have specifically addressed missed injuries among trauma patients in the ICU.8, 13, 26
Section snippets
Material and methodology
This retrospective study was conducted at the Department of Forensic Medicine and Toxicology, Government Medical College and Hospital Chandigarh—a Tertiary Care Centre, catering for the health and medical needs of the city, having a population of over one million people and a referral centre for the adjoining states. Trauma victims subjected to medico-legal autopsy during the years 2000–2003, whose detailed history and case records were available, were the subjects of our study. Unclaimed,
Epidemiology (Tables 1–3)
Over a 4-year period, 11792 trauma patients were treated at Government Medical College Hospital Chandigarh. Of the trauma patients, 1034 (9%) sustained penetrating injuries, 7850 (67%) had blunt injuries and 2908 (25%) had received burns (Table 1). A total of 749 (6%) patients died with 249 (39%) deaths occurring in the ICU/Trauma ward. Of these, 163 (21.76%) had a survival period of more than twenty-four hours. Vehicular accidents were the main cause of trauma 426 cases, followed by burns 264
Discussion
The autopsy has the potential to provide an educational tool for health care providers. Despite its value in assessing quality of medical care, the autopsy rate in the United States for all causes of deaths has been reported to be 10–20% for the last 15–20 years.28 Furthermore, it has been shown to vary inversely with the age. According to a report, the autopsy rate for the deaths in a medical ICU was 60% for those aged 16–34 years and 23% for those aged 85 or more.6 The autopsy rate of
Conclusion
Missed diagnosis during initial assessment and diagnostic workup is a hard reality in a small yet significant number of trauma patients. The majority of such missed injuries are attributable to potentially avoidable factors with inadequate clinical assessment often referred to as the clinical error. Some of these injuries escape detection on secondary or even the tertiary trauma surveys and are detected only on autopsy. Autopsy thus continues to be a valuable tool for accurate data collection
References (39)
Thomsen JL detection of injuries in traumatic deaths: the significance of medicolegal autopsy
Forensic Sci Int
(1989)Missed musculoskeletal injuries in a university hospital in Riyadh: types of missed injuries and responsible factors
Injury
(1996)- et al.
Injury scaling at autopsy: the comparison with premortem clinical data
Accid Anal Prev
(1990) - et al.
Analysis of 425 consecutive trauma fatalities: an autopsy study
J Am Coll Emerg Physicians
(1974) - American College of Surgeons Committee on Trauma: Initial Assessment and Management. In Advanced Trauma Life Support...
- et al.
Retrospective study of 1000 deaths from injury in England and Wales
BMJ
(1988) - et al.
Quality control in fatally injured patients: the value of necropsy
Eur J Surg
(1993) - et al.
Incidence and significance of free fluid on abdominal CT scan in blunt trauma
J Trauma
(1998) - et al.
Age and the declining rate of autopsy
J Am Geriarr Soc
(1986) - et al.
Diagnostic failures in the multiple injured
J Trauma
(1980)
Severely injured patients in the ICU: a critical analysis of outcome and unexpected deaths identified by the TRISS methodology
Int Surg
Failure of chest X-rays to diagnose pneumothoraces after blunt trauma
Anaesthesia
Does free fluid on abdominal computed tomographic scan after blunt trauma require laparotomy?
J Trauma
The significance of critical care errors in causing preventable death in trauma patients in a trauma system
J Trauma
The management of injuries—a review of deaths in hospital
Aust N Z J Surg
Management of severe trauma in ICU and surgical wards
Med J Aust
Missed injuries: the trauma surgeon's nemesis
Surg Clin North Am
The tertiary trauma survey: a prospective study of missed injuries
J Trauma
Relatively short diagnostic delays (<8 h) produce morbidity and mortality in blunt small bowel injury: an analysis of time to operative intervention in 198 patients from a multicenter experience
J Trauma
Cited by (39)
Identifying preventable trauma death: does autopsy serve a role in the peer review process?
2017, Journal of Surgical ResearchUndetected patricide: Inaccuracy of cause of death determination without an autopsy
2015, Journal of Forensic and Legal MedicineDeaths at a Level 1 Trauma Unit: A clinical finding and post-mortem correlation study
2012, InjuryCitation Excerpt :This may have simply been an oversight in the rush of the Resuscitation Room documentation, rather than a true missed injury, however this cannot be confirmed due to the retrospective nature of the data. Missed injuries have been shown to occur in every step of the management of patients with major trauma and a substantial number of clinically important diagnoses may be missed before death.7,9,12 Information contained in death certificates can also be misleading and health care planners utilizing this data may draw inaccurate conclusions regarding causes of death, which may have an impact on trauma-care system development.11
Autopsy after traumatic death - A shifting paradigm
2011, Journal of Surgical Research