Missed injuries during the initial assessment in a cohort of 1124 level-1 trauma patients G.F. Giannakopoulos a, *, T.P. Saltzherr b , L.F.M. Beenen c , J.B. Reitsma d , F.W. Bloemers a , J.C. Goslings b , F.C. Bakker a on behalf of the REACT study group e a Department of Trauma Surgery, VU University Medical Center, Amsterdam, The Netherlands b Trauma Unit, Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands c Radiology Department, Academic Medical Center, Amsterdam, The Netherlands d Department of Clinical Epidemiology and Biostatistics, Academic Medical Center, Amsterdam, The Netherlands Introduction During the primary assessment and treatment of severe trauma victims the attention is focused on airway, breathing, circulation and neurological status. Due to the diagnostic process in this phase, aimed at potentially life threatening injuries, and/or acute interventions some injuries can be missed. A missed injury can lead to increased morbidity, prolonged hospital stay, increased costs and even mortality. 1–5 Missed injuries may also stand out as the most memorable event in a patient’s course, even over- shadowing the heroic efforts of the trauma team. In the past decades, several diagnostic guidelines have been introduced in order to increase survival, diminish morbidity, and minimise the frequency of missed injuries during the assessment of trauma patients. The widely used Advanced Trauma Life Support guidelines (ATLS 1 ) 6 have introduced primary survey to prioritise the detection of the most life-threatening injuries and secondary survey performed in the trauma resuscitation room (TR) to address all other important injuries. However, the complexity of managing severely injured patients makes the two surveys insufficient in detecting all injuries. 4,7,8 Therefore tertiary trauma survey was introduced which is an examination after at least 24 h or when the patient has regained consciousness again to detect all injuries. 7 Despite this evaluation strategy, some injuries still remain undetected and patients may even be discharged without all their injuries being diagnosed. 1,2 A review in 2008 reported missed Injury, Int. J. Care Injured xxx (2011) xxx–xxx A R T I C L E I N F O Article history: Accepted 15 July 2011 Keywords: Missed injuries Trauma Diagnosis Tertiary survey Risk factors A B S T R A C T Introduction: Despite the presence of diagnostic guidelines for the initial evaluation in trauma, the reported incidence of missed injuries is considerable. The aim of this study was to assess the missed injuries in a large cohort of trauma patients originating from two European Level-1 trauma centres. Methods: We analysed the 1124 patients included in the randomised REACT trial. Missed injuries were defined as injuries not diagnosed or suspected during initial clinical and radiological evaluation in the trauma room. We assessed the frequency, type, consequences and the phase in which the missed injuries were diagnosed and used univariate analysis to identify potential contributing factors. Results: Eight hundred and three patients were male, median age was 38 years and 1079 patients sustained blunt trauma. Overall, 122 injuries were missed in 92 patients (8.2%). Most injuries concerned the extremities. Sixteen injuries had an AIS grade of 3. Patients with missed injuries had significantly higher injury severity scores (ISSs) (median of 15 versus 5, p < 0.001). Factors associated with missed injuries were severe traumatic brain injury (GCS  8) and multitrauma (ISS  16). Seventy-two missed injuries remained undetected during tertiary survey (59%). In total, 31 operations were required for 26 initially missed injuries. Conclusion: Despite guidelines to avoid missed injuries, this problem is hard to prevent, especially in the severely injured. The present study showed that the rate of missed injuries was comparable with the literature and their consequences not severe. A high index of suspicion remains warranted, especially in multitrauma patients. ß 2011 Elsevier Ltd. All rights reserved. * Corresponding author at: Department of Trauma Surgery VU University Medical Center, Room 7F-004, PO Box 7057 NL – 1007 MB Amsterdam, The Netherlands. Tel.: +31 20 444 4554; fax: +31 20 444 4557. E-mail address: gf.giannakopoulos@gmail.com (G.F. Giannakopoulos). e REACT study group: P.M.M. Bossuyt, M.G.W. Dijkgraaf, P.H.P. Fung Kon Jin, C.P. Henny, J.S.K. Luitse, K.J. Ponsen. G Model JINJ-4752; No. of Pages 5 Please cite this article in press as: Giannakopoulos GF, et al. Missed injuries during the initial assessment in a cohort of 1124 level-1 trauma patients. Injury (2011), doi:10.1016/j.injury.2011.07.012 Contents lists available at ScienceDirect Injury jo ur n al ho m epag e: ww w.els evier .c om /lo cat e/inju r y 0020–1383/$ – see front matter ß 2011 Elsevier Ltd. All rights reserved. doi:10.1016/j.injury.2011.07.012