An unfinished survey: a patient who cannot be asked

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Not clinically reviewed. No clinician has signed this scenario.

• Enderson BL, Reath DB, Meadors J, Dallas W, DeBoo JM, Maull KI. The tertiary trauma survey: a prospective study of missed injury. J Trauma. 1990;30(6):666-9; discussion 669-70. An initial review of trauma registry data yielded a modest 2% incidence of missed injuries in a 90% blunt trauma population; a tertiary survey was performed prospectively on all injured patients (N=399) admitted during a 3-month period, with patients reexamined immediately before ambulation or, in head-injured patients, upon regaining consciousness; 41 missed injuries were found in 36 patients (9%), including 21 extremity fractures, five spinal fractures, two facial fractures, five thoracic injuries, six abdominal injuries (including five splenic lacerations), and two vascular injuries; the most common reason for injuries to be missed was altered level of consciousness due to head injury or alcohol; none of the missed injuries resulted in death, but one caused serious disability and seven required operative correction.
• Keijzers GB, Giannakopoulos GF, Del Mar C, Bakker FC, Geeraedts LM Jr. The effect of tertiary surveys on missed injuries in trauma: a systematic review. Scand J Trauma Resusc Emerg Med. 2012;20:77. Ten observational studies met inclusion criteria; none was randomized and none reported long-term health outcomes; risk of bias varied considerably. Nine studies assessed Type I missed injury (missed at primary and secondary survey and detected by the tertiary survey) and found an overall rate of 4.3%; a single study reported Type II missed injury (missed at primary and secondary survey and by the tertiary survey, detected during hospital stay) with a rate of 1.5%. Three studies reported both control and intervention cohorts, two reporting an increase in Type I missed injuries (3% vs 7%, P<0.01) and one a decrease in Type II (2.4% vs 1.5%, P=0.01). The authors conclude the evidence is sub-optimal: few observational studies, non-uniform outcome definitions and moderate risk of bias.
• Keijzers GB, Campbell D, Hooper J, Bost N, Crilly J, Steele MC, Del Mar C, Geeraedts LM Jr. A prospective evaluation of missed injuries in trauma patients, before and after formalising the trauma tertiary survey. World J Surg. 2014;38(1):222-32. Prospective before-and-after cohort study in a single regional level II trauma hospital; 487 trauma patients (pre-formalisation n=235; post- n=252). In-hospital missed injury rate (Types I and II combined) was similar for both groups (3.8% vs 4.8%, P=0.61), as were postdischarge missed injury rates at 1 month (13.7% vs 11.5%, P=0.43) and 6 months (3.8% vs 3.3%, P=0.84). Tertiary survey performance was substantially higher in the post-group (27% vs 42%, P<0.001). Cumulative missed injury rates exceeded 15%; although performance was significantly improved by formalising the process, this did not decrease missed injury rates.