title: Missed injuries during the initial assessment in a cohort of 1124 level-1 trauma patients.
abstract: BACKGROUND
  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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Department of Trauma Surgery, VU University Medical Center, Amsterdam, The Netherlands.
authors.forename: G F
authors.initials: GF
authors.lastname: Giannakopoulos
authors.forename: T P
authors.initials: TP
authors.lastname: Saltzherr
authors.forename: L F M
authors.initials: LF
authors.lastname: Beenen
authors.forename: J B
authors.initials: JB
authors.lastname: Reitsma
authors.forename: F W
authors.initials: FW
authors.lastname: Bloemers
authors.forename: J C
authors.initials: JC
authors.lastname: Goslings
authors.forename: F C
authors.initials: FC
authors.lastname: Bakker
mesh_terms: D000328:Adult; D057189:Checklist; D015331:Cohort Studies; D003951:Diagnostic Errors / Q000706:statistics & numerical data*; D005260:Female; D006801:Humans; D015994:Incidence; D015601:Injury Severity Score; D008297:Male; D009104:Multiple Trauma / Q000150:complications / Q000175:diagnosis* / Q000453:epidemiology; D009426:Netherlands / Q000453:epidemiology; D017063:Outcome Assessment, Health Care; D017410:Practice Guidelines as Topic; D012042:Registries; D012189:Retrospective Studies; D014193:Trauma Centers / Q000706:statistics & numerical data*; D014947:Wounds and Injuries / Q000150:complications / Q000175:diagnosis* / Q000453:epidemiology