Missed urological injuries in children with polytrauma

Errors in imaging of traumatic injuries

The advent of multi-detector computed tomography (MDCT) has drastically improved the outcomes of patients with multiple traumatic injuries. However, there are still diagnostic challenges to be considered. A missed or the delay of a diagnosis in trauma patients can sometimes be related to perception or other non-visual cues, while other errors are due to poor technique or poor image quality. In order to avoid any serious complications, it is important for the practicing radiologist to be cognizant of some of the most common types of errors. The objective of this article is to review the various types of errors in the evaluation of patients with multiple trauma injuries or polytrauma with MDCT.

Errors in imaging assessment of polytrauma patients

Although the use of multidetector computed tomography (MDCT) has increased the diagnostic quality by reducing the number of missed diagnoses in polytraumatized patients, errors remain a common phenomenon in emergency room setting. MDCT errors, contributing more commonly to missed or delayed diagnoses in polytrauma patients, are diagnostic errors commonly related to perceptual errors or to nonvisual errors. However, in some cases, misdiagnoses can be attributed to technical and methodological errors leading to incomplete or poor-quality imaging. Knowledge of common patterns of error is the most effective way to avoid future errors. The purpose of this article is to highlight the most frequent types of diagnostic errors in evaluating with MDCT of polytrauma patients.

Pediatric polytrauma management

Appropriate care of pediatric polytrauma patients requires the knowledge and expertise of a variety of subspecialists. Though most of pediatric polytrauma patients survive, long-term sequelae are common. The most common causes of long-term functional deficits after pediatric polytrauma involve injuries to the central nervous and musculoskeletal systems. Orthopaedic care of polytrauma patients is important to facilitate early mobilization and care of these children, as well as to minimize late impairment.

Diagnostic errors in polytrauma: a structured review of the recent literature

Clinically important diagnostic errors are relatively common among polytrauma patients (2-40%). Errors are not random; they are more frequent in the spine and periarticular appendicular skeleton, especially in hemodynamically unstable patients who require resuscitation or operative intervention before completion of secondary or tertiary clinical survey. Misleading history, distracting findings, and misjudgments all contribute to risks of diagnostic errors.

Missed injuries in a level I trauma center

BACKGROUND

Major trauma presents major diagnostic and therapeutic problems. Any delay in providing the treatment necessary may lead to increased morbidity and mortality, prolonged length of hospital stay, and increased cost. This study was undertaken to determine the extent, contributing factors, and implication of missed injuries and relate them to the three surveys in a Danish Level I trauma center.

METHODS

The records of all major traumatized patients admitted to the Odense University Hospital from January 1996 through December 1999 have been studied to determine the extent and type of missed injuries. The initial examination is carried out by the trauma team in the A&E department according to standard protocols. Resuscitation is carried out according to Advanced Trauma Life Support principles and details are documented in the patient journal and in a special trauma journal.

RESULTS

Sixty-four of 786 patients (incidence, 8.1%) had 86 missed injuries. The missed injuries averaged 1.3 injuries per patient. There were 45 male and 19 female patients, with a median age of 33 years (range, 12-81 years). The median ISS was 17 (range, 4-50); 14%, 38%, and 48% of the injuries were missed in primary, secondary, and tertiary surveys, respectively.

CONCLUSION

Our study demonstrates that missed injuries can occur at any stage of the management of patients with major trauma. Repeated assessments, both clinical and radiologic, are mandatory to diminish the problem. In initial assessment, one still has to treat the greatest threat to life before complete diagnosis of all injuries, but alertness to evolving injuries must remain throughout the patient's stay in hospital.

Preoperative Radiographic Staging for Ureteral Injuries is Not Warranted in Patients Undergoing Celiotomy for Trauma

Preoperative radiographic staging of the urinary tract has been shown to be inaccurate with regard to the ureter. The purpose of this study was to assess the need for radiographic staging of the injured patient for the diagnosis of ureteral injury before operative exploration. We conducted a retrospective review of all patients who sustained injury of the ureter as the result of external trauma over an 8 ½-year period at an urban and suburban Level I trauma center. All patients were injured through penetrating mechanisms and underwent laparotomy. Only three patients had preoperative radiographic staging of the urinary tract. No ureteral injuries were missed. We conclude that surgical exploration of the ureter is sufficiently accurate to obviate the need for preoperative radiographic staging of the ureters in patients who have sustained penetrating injury and warrant laparotomy.