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Schellenberg M, Arase M, Wong MD, Demetriades D. Mild traumatic brain injury: not always a mild injury. Eur J Trauma Emerg Surg 2023:10.1007/s00068-023-02365-y. [PMID: 37845367 DOI: 10.1007/s00068-023-02365-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 09/08/2023] [Indexed: 10/18/2023]
Abstract
PURPOSE In general, risk of mortality after trauma correlates with injury severity. Despite arriving in relatively stable clinical condition, however, some patients are at risk of death following mild traumatic brain injury (TBI). The study objective was delineation of patients who die in-hospital following mild isolated TBI in order to inform Emergency Department (ED) disposition and care discussions with patients and families. METHODS In this retrospective cohort study, patients from the National Trauma Data Bank (NTDB) (2007-2018) were included if they were injured by blunt trauma and sustained a mild TBI (defined as Head Abbreviated Injury Scale [AIS] score of 1 or 2 and arrival Glasgow Coma Scale [GCS] score of 13-15). Exclusions were severe associated injuries (extracranial AIS > 2); transfers; and missing data. Patients were defined by in-hospital mortality: Survivors vs. Mortalities. Demographics, clinical/injury data, and the outcomes were collected and compared with univariate analysis. Multivariate analysis established independent factors associated with in-hospital mortality following mild TBI. RESULTS In total, 932,107 patients (10% of NTDB population) met study criteria: 928,542 (99.6%) Survivors and 3,565 (0.4%) Mortalities. In general, comorbidities (including home anticoagulation, cardiac disease, and diabetes mellitus) were significantly more common among patients who died (p < 0.001), although drug and alcohol intoxication on arrival were more common among Survivors (16% vs. 7%, p < 0.001; 13% vs. 10%, p < 0.001). In terms of insurance status, Private/Commercial insurance was more common among Survivors (39% vs. 20%, p < 0.001) while Governmental Insurance was more common among Mortalities (55% vs. 36%, p < 0.001). On multivariate analysis, age ≥ 65 was most strongly associated with death (OR 26.43, p < 0.001), followed by ED intubation (OR 10.08, p < 0.001), admission hypotension (OR 4.55, p < 0.001), and comorbidities, particularly end-stage renal disease (ESRD) (OR 3.03, p < 0.001) and immunosuppression (OR 2.18, p < 0.001). CONCLUSIONS Survivors differed substantially from Mortalities after mild TBI in terms of comorbidities, intoxicants, and insurance status. Independent variables most strongly associated with in-hospital death following mild head injury included age ≥ 65, intubation in the ED, admission hypotension, and comorbidities (particularly ESRD and immunosuppression). Increased clinical vigilance, including a mandatory period of clinical observation, for patients with these risk factors should be considered to optimize outcomes and potentially mitigate death after mild TBI.
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Affiliation(s)
- Morgan Schellenberg
- Division of Acute Care Surgery, LAC+USC Medical Center, University of Southern California, 2051 Marengo Street, Inpatient Tower, C5L100, Los Angeles, CA, 90033, USA.
| | - Miharu Arase
- Division of Acute Care Surgery, LAC+USC Medical Center, University of Southern California, 2051 Marengo Street, Inpatient Tower, C5L100, Los Angeles, CA, 90033, USA
| | - Monica D Wong
- Division of Acute Care Surgery, LAC+USC Medical Center, University of Southern California, 2051 Marengo Street, Inpatient Tower, C5L100, Los Angeles, CA, 90033, USA
| | - Demetrios Demetriades
- Division of Acute Care Surgery, LAC+USC Medical Center, University of Southern California, 2051 Marengo Street, Inpatient Tower, C5L100, Los Angeles, CA, 90033, USA
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Plonczak AM, Dole HP, Pimblett V, Conway L, Hague A, Falder S. What the COVID pandemic taught us about the management of pediatric minor trauma. J Plast Reconstr Aesthet Surg 2023; 84:334-340. [PMID: 37390542 PMCID: PMC10228152 DOI: 10.1016/j.bjps.2023.05.055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 04/12/2023] [Accepted: 05/25/2023] [Indexed: 07/02/2023]
Abstract
The COVID-19 pandemic necessitated a change in our practice in the management of pediatric soft-tissue injuries. Patients were managed conservatively whenever possible. Our aim in this study was to see whether this more conservative approach adversely affected clinical, and patient-reported outcomes, including scarring. A prospective record of children presenting to the plastic surgery "Early Bird" clinic for pediatric trauma between 01.04.2020 and 30.06.2020 was kept. Electronic patient records were reviewed. An outpatient telephone clinic was scheduled for all patients. Parents were asked about complications and what they thought about the scar and to rate it as either: "poor," "satisfactory," "good," or "excellent." There were 240 patients, including 136 (57%) males and 104 (43%) females. The most frequent type of injury was a facial laceration in 123 patients (51.3%), followed by hand lacerations in 43 (17.9%), fingertip injuries in 31 (12.9%), and others. Ninety out of 240 (37.5%) were offered surgery. Follow-up times ranged from 17 to 20 months. Most parents (86.2%) were happy with the scarring and reported it as "good" or "excellent." The proportion rating the scar "excellent" or "good" was similar in the non-operated cohort (i.e., 85.5%) versus the operated cohort (88.5%) (p-value 0.16). The overall complication rate of patients seen during this time was 5.9%; 7.4% in the conservatively managed and 4.9% of those who went to the theater. Despite managing more wounds, including some dog bites, conservatively, patients and parents reported low complication rates and high levels of satisfaction with the final scarring.
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Affiliation(s)
- A M Plonczak
- Alder Hey Children's Hospital, E Prescot Road, Liverpool L14 5AB, United Kingdom.
| | - H P Dole
- Alder Hey Children's Hospital, E Prescot Road, Liverpool L14 5AB, United Kingdom
| | - V Pimblett
- Alder Hey Children's Hospital, E Prescot Road, Liverpool L14 5AB, United Kingdom
| | - L Conway
- Alder Hey Children's Hospital, E Prescot Road, Liverpool L14 5AB, United Kingdom
| | - A Hague
- Alder Hey Children's Hospital, E Prescot Road, Liverpool L14 5AB, United Kingdom
| | - S Falder
- Alder Hey Children's Hospital, E Prescot Road, Liverpool L14 5AB, United Kingdom
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Morisaki S, Kobayashi Y, Tsuchida S, Takahashi K. Acute compartment syndrome caused by hematoma with minor trauma in hemodialysis patients: Two case reports. Int J Surg Case Rep 2023; 109:108594. [PMID: 37566989 PMCID: PMC10432788 DOI: 10.1016/j.ijscr.2023.108594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 07/24/2023] [Accepted: 07/27/2023] [Indexed: 08/13/2023] Open
Abstract
INTRODUCTION Acute compartment syndrome is a condition that requires an immediate diagnosis and surgical management. Compartment syndrome related to hematoma caused by minor trauma in hemodialysis patients is rarely reported. CASE PRESENTATION We present two cases of hemodialysis patients diagnosed with compartment syndrome of the forearm due to hematoma caused by the disruption of blood vessels after a minor trauma. The removal of the hematoma and fasciotomy with adequate skin care significantly improved soft tissue heeling with no functional impairment. DISCUSSION A long-term history of hemodialysis may increase the vascular vulnerability and have the potential risk of disruption by minor trauma. When the blood vessel is disrupted, a hematoma is formed and necessitating emergent surgical intervention. CONCLUSION Surgeons should be aware of the potential risk of damage to blood vessels with minor trauma that results in the formation of a hematoma and compartment syndrome in hemodialysis patients.
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Affiliation(s)
- Shinsuke Morisaki
- Department of Orthopaedics, Saiseikai Shiga Hospital, Ohashi 2-4-1, Ritto, Shiga 520-3046, Japan.
| | - Yusuke Kobayashi
- Department of Orthopaedics, Saiseikai Shiga Hospital, Ohashi 2-4-1, Ritto, Shiga 520-3046, Japan
| | - Shinji Tsuchida
- Department of Orthopaedics, Kyoto Prefectural University of Medicine, Kawaramachi Hirokoji, Kamigyo-ku, Kyoto 602-8566, Japan
| | - Kenji Takahashi
- Department of Orthopaedics, Kyoto Prefectural University of Medicine, Kawaramachi Hirokoji, Kamigyo-ku, Kyoto 602-8566, Japan
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Lu C, Wang X, Wang Z, Duan W, Wang K, Chen Z, Wu H, Jian F. Prognostic and risk factors for the surgical efficacy of central spinal cord syndrome in patients with preexisting degenerative cervical spinal cord compression. Clin Neurol Neurosurg 2023; 227:107637. [PMID: 36857885 DOI: 10.1016/j.clineuro.2023.107637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 02/13/2023] [Accepted: 02/18/2023] [Indexed: 02/21/2023]
Abstract
OBJECTIVES To analyze the prognostic and risk factors related to surgical treatment of central spinal cord syndrome (CSS) and to find out the optimal timing of operative management. METHODS From January 2011 to January 2019, a consecutive series of 128 patients with CSS confirmed by magnetic resonance imaging (MRI) were retrospectively analyzed including their clinical records and radiologic data from a prospectively maintained database in a single center. RESULTS According to the prognosis evaluated by the modified Japanese Orthopedic Association (mJOA), American Spinal Injury Association (ASIA) motor score (AMS), and ASIA impairment scale (AIS) grade, the overall postoperative outcome was good. Finally, it was found that surgical timing, presence of myelopathy or not at baseline, AMS at admission, and compression ratio were independent factors affecting the prognosis. Surgery as soon as possible after the occurrence of CSS is still advocated. CONCLUSION Cervical myelopathy at baseline, compression ratio, and AMS score on admission were independent prognostic factors for the surgical treatment of CSS. If surgical indications are clear, early surgical intervention should be actively considered.
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Greenberg MR, Forgeon JL, Kurth LM, Barraco RD, Parikh PM. Atlantoaxial rotatory subluxation presenting as acute torticollis after mild trauma. Radiol Case Rep 2020; 15:2112-2115. [PMID: 32952749 PMCID: PMC7484527 DOI: 10.1016/j.radcr.2020.08.028] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 08/12/2020] [Accepted: 08/13/2020] [Indexed: 11/30/2022] Open
Abstract
Atlantoaxial rotatory subluxation (AARS) is a rare outcome of trauma in adults. We present a case of a 38-year-old female who presented with neck pain and stiffness after a mild trauma. On exam the patient had a “cock-robin” position, comparable to acute torticollis. Computerized tomography demonstrated findings consistent with AARS. Reduction was performed in the emergency department and the patient had no further neurological sequelae. Recognition of AARS after trauma requires a high index of suspicion and early diagnosis is important to best patient outcomes.
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Affiliation(s)
- Megan R Greenberg
- Lehigh Valley Health Network, Department of Emergency and Hospital Medicine/USF Morsani College of Medicine, Cedar Crest Boulevard & I-78, Allentown, PA 18103, USA
| | - Jason L Forgeon
- Lehigh Valley Health Network, Department of Emergency and Hospital Medicine/USF Morsani College of Medicine, Cedar Crest Boulevard & I-78, Allentown, PA 18103, USA
| | - Lisa M Kurth
- Lehigh Valley Health Network, Department of Surgery/USF Morsani College of Medicine, Cedar Crest Boulevard & I-78, Allentown, PA 18103, USA
| | - Robert D Barraco
- Lehigh Valley Health Network, Trauma Surgery/Critical Care, Department of Surgery/USF Morsani College of Medicine, Cedar Crest Boulevard & I-78, Allentown, PA 18103, USA
| | - Pratik M Parikh
- Lehigh Valley Health Network, Department of Emergency and Hospital Medicine/USF Morsani College of Medicine, Cedar Crest Boulevard & I-78, Allentown, PA 18103, USA
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Angerpointner K, Weber S, Tschech K, Schubert H, Herbst T, Ernstberger A, Kerschbaum M. Posttraumatic stress disorder after minor trauma - A prospective cohort study. Med Hypotheses 2019; 135:109465. [PMID: 31731059 DOI: 10.1016/j.mehy.2019.109465] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Accepted: 10/27/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND Posttraumatic stress disorder (PTSD) can arise as a reaction to a traumatic experience. While many data concerning PTSD in severely injured patients are available, little is known about this disease in slightly injured patients after road traffic accidents. It is rather assumed that PTSD does not exist after objectively slight injuries. METHODS In total, 36 patients (Injury Severity Score < 16) after road traffic accidents were included in this prospective cohort study. Next to demographic and accident-specific data, the PDI (Peritraumatic Distress Inventory: individual experienced distress directly during or immediately after the traumatic event), THQ (Trauma History Questionnaire) and the BDI-II (Beck Depression Inventory-II: self-report measurement tool to examine the severity of depression) were assessed immediately after trauma (t0). Six weeks (t1) and 3 months (t2) after trauma the Impact of Event Scale - Revised (IES-R), a screening instrument for PTSD, and the BDI-II were collected. RESULTS Overall 2 patients showed critical measurement values in IES-R after 6 weeks. A strong correlation between PDI and IES-R at t1 and t2 could be detected (p < 0.05). Furthermore, a significant correlation of BDI-II and IES-R after 6 weeks and 3 months was found (p < 0.05). Neither age or sex showed a significant correlation to IES-R (p ≥ 0.05). CONCLUSION The present study showed that symptoms of PTSD can also occur after minor trauma. Especially high peritraumatic distress is associated with developing a PTSD. The occurrence of PTSD should be considered not only in severely injured patients, but also in slightly injured patients after road traffic accidents.
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Affiliation(s)
| | - Stefanie Weber
- AARU Audi Accident Research Unit, University Hospital Regensburg, Regensburg, Germany.
| | - Karen Tschech
- AARU Audi Accident Research Unit, University Hospital Regensburg, Regensburg, Germany.
| | - Hannah Schubert
- AARU Audi Accident Research Unit, University Hospital Regensburg, Regensburg, Germany.
| | - Tanja Herbst
- Department of Trauma Surgery, University Hospital Regensburg, Regensburg, Germany.
| | - Antonio Ernstberger
- Department of Trauma Surgery, University Hospital Regensburg, Regensburg, Germany.
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Cebeci D, Arhan E, Demir E, Uçar M, Uçar HK, Serdaroğlu A, Öztürk Z. Internal carotid artery dissection without intracranial infarct following a minor shoulder trauma: The second pediatric case and review of the literature. J Clin Neurosci 2018; 56:172-175. [PMID: 30041901 DOI: 10.1016/j.jocn.2018.07.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2018] [Accepted: 07/08/2018] [Indexed: 12/25/2022]
Abstract
INTRODUCTION Carotid artery dissections may occur in severe trauma such as motor vehicle accidents or may also develop due to minor trauma. We aimed to present a case with internal carotid artery dissection that referred to the pediatric neurology department due to speech impairment after minor shoulder trauma. CASE A previously healthy 10-year-old male patient was admitted to the pediatric emergency clinic due to headache, vomiting and speech impairment. In his story, we learned that he had bumped shoulder to shoulder with his friend about 6 h ago. He did not fall or hit his head. On his admission he could not speak and had right central facial paralysis. There was no infarct or diffusion limitation in MRI but MR angiography showed thinning in left internal carotid artery calibration. Fat-suppressed, non-contrast T1-weighted MRI showed that the left carotid artery had ring-shaped pathological signal changes. Low-molecular-weight heparin therapy was initiated with the diagnosis of carotid artery dissection (CAD). No hemiparesis or hemiplejia occurred in the follow-up of the patient. Within a few days, his speech improved. At the end of the first month, facial paralysis completely recovered. CONCLUSION In carotid artery dissections, prodromal symptoms such as transient ischemic attack, like in our patient, are rarely present in children. For good long term outcomes, it is very important to suspect, diagnose and initiate appropriate treatment in a rapid manner in carotid artery dissection before severe neurological findings such as acute ischemic stroke develops.
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Affiliation(s)
- Dilek Cebeci
- Department of Pediatric Neurology, Gazi University Faculty of Medicine, 10th Floor Besevler, Ankara, Turkey.
| | - Ebru Arhan
- Department of Pediatric Neurology, Gazi University Faculty of Medicine, 10th Floor Besevler, Ankara, Turkey
| | - Ercan Demir
- Department of Pediatric Neurology, Gazi University Faculty of Medicine, 10th Floor Besevler, Ankara, Turkey
| | - Murat Uçar
- Department of Radiology, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Habibe Koç Uçar
- Department of Pediatric Neurology, Gazi University Faculty of Medicine, 10th Floor Besevler, Ankara, Turkey
| | - Ayşe Serdaroğlu
- Department of Pediatric Neurology, Gazi University Faculty of Medicine, 10th Floor Besevler, Ankara, Turkey
| | - Zeynep Öztürk
- Department of Pediatric Neurology, Gazi University Faculty of Medicine, 10th Floor Besevler, Ankara, Turkey
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Catapano M, Albano D, Pozzi G, Accetta R, Memoria S, Pregliasco F, Messina C, Sconfienza LM. Differences between orthopaedic evaluation and radiological reports of conventional radiographs in patients with minor trauma admitted to the emergency department. Injury 2017; 48:2451-2456. [PMID: 28882380 DOI: 10.1016/j.injury.2017.08.054] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Revised: 08/03/2017] [Accepted: 08/22/2017] [Indexed: 02/02/2023]
Abstract
INTRODUCTION During night and on weekends, in our emergency department there is no radiologist on duty or on call: thus, X-ray examinations (XR) are evaluated by the orthopaedic surgeon on duty and reported the following morning/monday by radiologists. The aim of our study was to examine the discrepancy rate between orthopaedists and radiologists in the interpretation of imaging examinations performed on patients in our tertiary level orthopaedic institution and the consequences of delayed diagnosis in terms of patient management and therapeutic strategy. MATERIALS AND METHODS We retrospectively reviewed all cases of discrepancy between orthopaedists and radiologists, which were categorized according to anatomical location of injury, initial diagnosis and treatment, change in diagnosis and treatment. We used the Chi square test to compare the frequencies of discrepancies between patients ≤14 and >14years of age. RESULTS From January to December 2016, 19,512 patients admitted to our emergency department performed at least an imaging examination; among these patients, 13,561 underwent XR in absence of an attending radiologist. A discrepant diagnosis was found in 337/13,561 (2.5%; 184 males; mean age: 36.7±23.7, range 2-95); 151/337 (45%) discrepancies were encountered in the lower limbs, with ankle being the most common site of misdiagnosis (64/151), and 103/337 (30%) in the upper limbs, with the elbow being the most frequent site in this district (35/103). We found 293/337 false negatives (87%) and 44/337 false positives (13%), with 134 and 13 patients needing treatment change, respectively. We found 85/337 discrepancies (25%) in patients ≤14 years of age, and 252/337 (75%) in those >14years. The distribution of discrepancies per anatomic district was significantly different (P<0.001) in these two groups of patients. CONCLUSIONS A low rate of discrepancy between orthopaedists and radiologists in evaluating images of patients admitted to our emergency department was found, although treatment change occurred in about half of cases. A thorough and accurate clinical evaluation is crucial to provide a correct treatment and prognosis.
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Affiliation(s)
- Michele Catapano
- Scuola di Specializzazione in Radiodiagnostica, Università degli Studi di Milano, Via Festa del Perdono 7, 20122 Milano, Italy
| | - Domenico Albano
- Sezione di Scienze Radiologiche, Di.Bi.Med., Università degli Studi di Palermo, Via del Vespro 127, 90127 Palermo, Italy
| | - Grazia Pozzi
- Unità Operativa di Radiologia Diagnostica ed Interventistica, IRCCS Istituto Ortopedico Galeazzi, Via Riccardo Galeazzi 4, 20161 Milano, Italy
| | - Riccardo Accetta
- Unità Operativa di Traumatologia, IRCCS Istituto Ortopedico Galeazzi, Via Riccardo Galeazzi 4, 20161 Milano, Italy
| | - Sergio Memoria
- Unità Operativa di Traumatologia, IRCCS Istituto Ortopedico Galeazzi, Via Riccardo Galeazzi 4, 20161 Milano, Italy
| | - Fabrizio Pregliasco
- Direzione Sanitaria, IRCCS Istituto Ortopedico Galeazzi, Via Riccardo Galeazzi 4, 20161 Milano, Italy; Dipartimento di Scienze Biomediche per la Salute, Università degli Studi di Milano, Via Festa del Perdono 7, 20122 Milano, Italy
| | - Carmelo Messina
- Scuola di Specializzazione in Radiodiagnostica, Università degli Studi di Milano, Via Festa del Perdono 7, 20122 Milano, Italy
| | - Luca Maria Sconfienza
- Unità Operativa di Radiologia Diagnostica ed Interventistica, IRCCS Istituto Ortopedico Galeazzi, Via Riccardo Galeazzi 4, 20161 Milano, Italy; Dipartimento di Scienze Biomediche per la Salute, Università degli Studi di Milano, Via Festa del Perdono 7, 20122 Milano, Italy.
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Moonen PJ, Mercelina L, Boer W, Fret T. Diagnostic error in the Emergency Department: follow up of patients with minor trauma in the outpatient clinic. Scand J Trauma Resusc Emerg Med 2017; 25:13. [PMID: 28196544 PMCID: PMC5309992 DOI: 10.1186/s13049-017-0361-5] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Accepted: 02/10/2017] [Indexed: 11/16/2022] Open
Abstract
Background The Emergency Department (ED) is prone to diagnostic error. Most frequent diagnostic errors involved “minor” trauma. Our goal was to determine how frequently a missed diagnosis was detected during follow up and to determine the frequency and causes of primary missed diagnosis and diagnostic error. Methods A retrospective single centre study review, during 6 months including all patients presenting to the outpatient clinic after ED admission with a minor trauma. We defined primary missed diagnosis versus diagnostic error. Demographic data were collected in Excel file and analyzed using Χ2 and unpaired T-test. Results Inclusion of 56 patients leading to 57 missed diagnoses representing 1.39% of all minor trauma patients presenting to the ED. History and physical examination notes were incomplete or inadequate in respectively 17/56 and 20/56. Most frequently missed diagnoses were ankle (13/57), wrist (8/57) and foot (7/57) fractures. Causes for diagnostic error could be categorized into two main groups: failure to perform adequate history taking and/or physical examination and failure to order or correctly interpret technical investigation. In 6 cases (0.14%) diagnostic error was confirmed. All other cases were defined as primary missed diagnosis. Discussion Emergency physicians have to remain vigilant to prevent and avoid primary missed diagnosis (PMD) and diagnostic error (DE), certainly in case of minor trauma patients, representing a large proportion of ED patients. We observed a prevalence of 1.39% of missed diagnoses within a six month study period. This is comparable to previous studies (1% ). However in our study both primary missed diagnoses and DE were included. Using this definition we saw that only one case could be attributed to negligence and DE had a prevalence of 0.14% (6 cases). X-rays remain the mainstay investigation for minor trauma patients, however in certain selected cases (pelvic and spinal trauma) we advise early CT-scan.Follow up in an outpatient clinic or other forms of planned follow up have to be provided and help to reduce PMD and DE. Conclusion Both primary missed diagnosis and diagnostic error have relatively low prevalence but have a serious impact on patients, hospitals and medical services. Planned follow up after adequate explanation can help to prevent diagnostic error and detect primary missed diagnosis, thereby reducing time to final diagnosis and risks for medico legal litigation. Reassessment of diagnostic error on a timely basis can be used as a key performance indicator in a quality assessment program.
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Affiliation(s)
- Pieter-Jan Moonen
- Department of Anesthesiology, Critical and Emergency Medicine and Pain Therapy, Ziekenhuis Oost Limburg Genk, Schiepsebos 11, 3600, Genk, Belgium. .,ᅟ, Ieperstraat 43, 2300, Turnhout, Belgium.
| | - Luc Mercelina
- Department of General Surgery, Ziekenhuis Oost Limburg Genk, Schiepsebos 11, 3600, Genk, Belgium
| | - Willem Boer
- Department of Anesthesiology, Critical and Emergency Medicine and Pain Therapy, Ziekenhuis Oost Limburg Genk, Schiepsebos 11, 3600, Genk, Belgium
| | - Tom Fret
- Department of Anesthesiology, Critical and Emergency Medicine and Pain Therapy, Ziekenhuis Oost Limburg Genk, Schiepsebos 11, 3600, Genk, Belgium
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Lutze M, Fry M, Gallagher R. Minor injuries in older adults have different characteristics, injury patterns, and outcomes when compared with younger adults: an emergency department correlation study. Int Emerg Nurs 2014; 23:168-73. [PMID: 25511132 DOI: 10.1016/j.ienj.2014.10.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2014] [Revised: 10/23/2014] [Accepted: 10/27/2014] [Indexed: 11/25/2022]
Abstract
AIM To examine the injury patterns, characteristics, and outcomes of older adults presenting with minor injuries compared with younger adults. BACKGROUND Sustaining a minor injury is one of the most common reasons people present to an Emergency Department. Many presentations involve older Australians and greater than 50% of older adults are discharged from the Emergency Department. However, little is known about the characteristics, injury patterns, and outcomes of minor injuries in older adults compared to younger adults. METHODS A 12-month exploratory correlational study was conducted using Emergency Department electronic medical record data from a single metropolitan hospital located in Sydney, Australia. Older adults were defined as ≥65 years with younger adults defined as 18-64 years. Minor injuries were classified by diagnoses as fractures/dislocations, sprains/strains, wounds/burns/infections, minor head injuries, eye/ear/nose/oral injuries. Exclusion criteria included: triage category 1 or 2, major trauma, critical care admission, or injuries and fractures to the hip or neck of femur. RESULTS There were 36,671 Emergency Department presentations of which 7582 (21%) were for older adults and 19,234 (52%) were younger adults (aged 18-64). Injuries represented 21% (n = 7754) of all Emergency Department presentations with 1294 (17%) occurring in those aged 65 years and older and 3937 (20%) in younger adults. Of the minor injuries (n = 3594; 10%), the most common presentation in younger adults was sprains/strains (n = 1045; 36%) but in older adults it was fractures (n = 229; 32%). There was a statistical (Pearson's χ(2) test 63.4, df = 4, P < 0.001) difference with injury pattern when comparing age groups. Older adults were allocated proportionately higher triage categories when compared with younger adults (Pearson's χ(2) test 26.3, df = 2, P < 0.001). Older adults with minor injuries had a longer mean stay (315 min; SD 238.9 min; younger adults 198 min, SD 132.3 min) and this difference was statistically (P ≤ 0.001) and clinically significant. Fewer older adults were discharged home (n = 531, 73%; n = 2648, 92%; P < 0.001) and more were admitted for minor injuries (n = 179, 25%; n = 156, 5%; P < 0.001) when compared with younger adults. CONCLUSION Older adults with minor injuries have different injury patterns, higher acuity, longer length of stay, and lower discharge rates compared with younger adults. Clinicians may need to modify their approach and differential diagnoses when treating older adults with minor injuries. Further research is needed to explore the reasons for these differences and whether older adults have different service needs compared with younger adults with minor injuries.
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Affiliation(s)
- Matthew Lutze
- Emergency Department, Canterbury Hospital, Sydney Local Health District, Australia; University of Sydney, Sydney Nursing School, Australia.
| | - Margaret Fry
- University of Sydney, Sydney Nursing School, Australia; Director of Research and Practice Development, Northern Sydney Local Health District, Australia
| | - Robyn Gallagher
- Charles Perkins Centre and Sydney Nursing School, University of Sydney, Australia
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Koçer U, Aksoy HM, Tiftikcioðlu YÖ, Ertoy D, Karaaslan O. Giant eccrine acrospiroma: A case report and review of the literature. Can J Plast Surg 2003; 11:43-6. [PMID: 24115850 DOI: 10.1177/229255030301100105] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Acrospiromas are histologically distinct cutaneous tumours of sweat duct origin and usually measure 1 to 2 cm in size. OBJECTIVE We describe a patient with a large benign eccrine acrospiroma. METHODS Case report and literature review. RESULTS A 50-year-old woman underwent excision of a 5.5×5.0 cm cystic mass located on the left gluteal region, and the resulting defect was closed by a local flap. A diagnosis of benign eccrine acrospiroma was made after histopathological examination. On histological examination, the lesion was characterized by multilobular dermal masses composed of a biphasic cell population. There was no recurrence five months after the operation. CONCLUSION Although eccrine acrospiromas are usually benign, they can, on rare occasions, undergo malignant transformation. In addition, the clinical appearance of this lesion is not specific and differential diagnosis from other lesions, both benign and malignant, can only be done after the complete removal of the lesion.
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Affiliation(s)
- Uður Koçer
- Plastic and Reconstructive Surgery Department, Ankara Training and Research Hospital, Ankara, Turkey
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