title: Tertiary survey in trauma patients: avoiding neglected injuries.
abstract: BACKGROUND
  Medical personnel in trauma centres in several countries have realised that undiagnosed injuries are common and are now focussing their attention on reducing the incidence of these injuries. Tertiary survey is a simple and easy approach to address the issue of undiagnosed injuries in trauma patients. Tertiary survey consists of reevaluating patients 24 hours after admission by means of an anamnesis protocol, physical examination, review of complementary tests and request for new tests when necessary.
  
  
  OBJECTIVE
  To show the importance of tertiary survey in trauma patients for diagnosing injuries undetected at the time of initial survey.
  
  
  METHODS
  A standardised protocol was used to perform a prospective observational study with patients admitted through the emergency department, Department of Orthopaedics and Trauma, Santa Casa de São Paulo. The patients were reevaluated 24 hours after admission or after recovering consciousness. New physical examinations were performed, tests performed on admission were reassessed and new tests were requested, when necessary.
  
  
  RESULTS
  Between February 2012 and February 2013, 526 patients were evaluated, 81 (15.4%) were polytraumatised, and 445 (84.6%) had low-energy trauma. A total of 57 new injuries were diagnosed in 40 patients, 61.4% of which affected the lower limb. Diagnosis of 11 new injuries (19.3%) resulted in changes in procedure.
  
  
  CONCLUSIONS
  The application of the protocol for tertiary survey proved to be easy, inexpensive and beneficial to patients (particularly polytraumatised patients) because it enabled identification of important injuries that were not detected on admission in a large group of patients.
authors.affiliation: Orthopaedics and Traumatology Department of Irmandade da Santa Casa de Misericóridia de São Paulo, São Paulo, Brazil. Electronic address: caiozamboni@hotmail.com.
authors.forename: Caio
authors.initials: C
authors.lastname: Zamboni
authors.affiliation: Orthopaedics and Traumatology Department of Irmandade da Santa Casa de Misericóridia de São Paulo, São Paulo, Brazil.
authors.forename: Alexandre Maris
authors.initials: AM
authors.lastname: Yonamine
authors.affiliation: Orthopaedics and Traumatology Department of Irmandade da Santa Casa de Misericóridia de São Paulo, São Paulo, Brazil.
authors.forename: Carlos Eduardo Nunes
authors.initials: CE
authors.lastname: Faria
authors.affiliation: Orthopaedics and Traumatology Department of Irmandade da Santa Casa de Misericóridia de São Paulo, São Paulo, Brazil.
authors.forename: Marco Antonio Machado
authors.initials: MA
authors.lastname: Filho
authors.affiliation: Orthopaedics and Traumatology Department of Irmandade da Santa Casa de Misericóridia de São Paulo, São Paulo, Brazil.
authors.forename: Ralph Walter
authors.initials: RW
authors.lastname: Christian
authors.affiliation: Santa Casa de São Paulo Medical School and Orthopaedics and Traumatology Department of Irmandade da Santa Casa de Misericóridia de São Paulo, Brazil.
authors.forename: Marcelo Tomanik
authors.initials: MT
authors.lastname: Mercadante
mesh_terms: D000328:Adult; D001938:Brazil / Q000453:epidemiology; D003362:Cost-Benefit Analysis; D003951:Diagnostic Errors / Q000517:prevention & control* / Q000706:statistics & numerical data; D004632:Emergency Medical Services / Q000458:organization & administration / Q000706:statistics & numerical data*; D005260:Female; D050723:Fractures, Bone / Q000175:diagnosis* / Q000453:epidemiology; D006801:Humans; D015601:Injury Severity Score; D008297:Male; D009104:Multiple Trauma / Q000175:diagnosis* / Q000453:epidemiology; D010808:Physical Examination; D063128:Tertiary Health Care; D014193:Trauma Centers / Q000458:organization & administration / Q000592:standards*
keywords: Delayed diagnosis; Diagnostic errors; Multiple trauma; Neglected diseases