Analysis of misdiagnosis in patients with multiple trauma

.20.Chinese Joumal of Traumatology 2011; 14():20-24Analysis of misdiagnosis in patients with multiple traumaYANG Fan, BAI Xiang-jun* and LI Zhan-fei[Abstract] Objective: To explore the features, treat-of consciousness, critical cases and shock cases werement outcomes and reasons for misdiagnosis in patients33.78+19.64,(23.59+7.26)days,49.22%,33.01% and 47.46%,with multiple trauma, so as to decrease the incidence ofrespectively, which were significantly higher than those ofmisdiagnosis.the correct diagnosis group (P<0.01). And the data showedMethods: A total of3 163 patients with multiple traumathat the more serious the injury was, the higher the rate ofwho were admitted in our department from August 1997 tomisdiagnosis would be. The rate of primary diagnosis byAugust 2008, were retrospectively studied to compare thetrauma surgeons in correct diagmosis group was 75.78%，sig-features of diagnosis and treatment. There were 2117 malesnificantly higher than that of the misdiagnosis group( x2=382.01,(66.93%) and 1 046 females (33.07%) with the mean age ofP<0.01). The mortality rate of the misdiagnosis group was36.46 years (range, 14 80 years). Parameters such as general2.93%, which was significantly higher than that for all pa-status, traumatic condition, diagnosis and treatmenttients ( x5.22, P<0.05).situation, prognosis and mortality were analyzed. The dif-Conclusions: The resuts indicated that patients withferences between misdiagnosis group and correct diagno-severe multiple trauma are at high risk of misdiagnosis insis group were compared in terms of severity of injury, com-early treatment. The mortality rate of misdiagnosed patientsplications and treatment outcomes to elucidate the causeis higher than the correctly-diagnosed patients. To preventand prevention of misdiagnosis.misdiagnosis, physicians need to take great care to con-Results: The misdiagnosis rate of multiple trauma induct thorough clinical examinations and repeated evaluation.this study was 16.19%. The major anatomic sites misdiag-Key words: Delayed diagnosis; Diagnostic errors;nosed were limbs and pelvis (299 positions, 39.50%), ab-Muliple trauma; Prevention and control; Treatment out-dominal region and pelvic organ (148 positions, 19.55%),comeand thoracic region (109 positions, 14.40%). In misdiagno-Chin J TraumatoV 2011; 14/):2024sis group, ISS, length of hospital stay, rates of disturbanceecause of the nature of severe multiple traumaMETHODSand complex complications, misdiagnosis ofmultiple trauma often happens at the firstStandard for case selectionassessments. This may worsen the patient's conditionWe collected the data of patients treated in Trau-and even lead to death. Reducing the rate of misdiag-matic Surgery of Tongji Hospital in Wuhan, China, suchnosis is therefore an important clinical issue.as general status, traumatic condition, diagnosis andtreatment situation, prognosis and mortality. PatientsIn this study, we retrospectively analyzed the con-were selected into this study based on the followingdition of misdiagnosis in 3 163 multiple trauma patientscriteria: (1) they experienced mutiple trauma; (2) theytreated in our department from August 1997 to Augustwere hospitalized to receive treatment 24 hours after2008. The patients' data related to misdiagnosis wereinjury; and (3) recorded rescue and resuscitation infor-analyzed and discussed.mation was complete.General conditionDO: 10.3760/cma.jissn. 1008-1275 2011.01.004Department of Traumatic Surgery, Tongji Hospital,Theliaible natients amountedto3 163 cases,2 117Tongji Medical College, Huazhong University of Sciencemale中国煤化工[33.07%). Their ageand Technology, Wuhan 430030, China (Yang F, Bai XJrang|YHCNMHGft13.12)yearsonand LiZF)average. The injury types included road trfc injury in*Corresponding author: Tel: 86-27 83663669, E-mail:1 727 cases (54.60%), violence injury in 467 casesBaixiangjun@hotmail.comChinese Joumal of Traumatoloy 2011; 14/1):20-24.21.(14.76%), flling injury in 393 cases (12. 42%), self-ac~Definition of misdiagnosiscident injury in 365 cases (11.54%), gunshot injury inMisdiagnosis was defined when: (1) new injury was26 cases (0.82%) explosion injury in 14 cases (0.44%)found during TICU after initial treatment; (2) there wasand others in 171 cases (5.41%). All the injuries wereunrecorded injury in the early case report; and (3) in-allocated to more than two anatomic regions accordingjury was found after numerous examination andto the six regions theory of injury severity score (ISS).evaluation. Misdiagnosis was not defined when: (1)The average number of regions involved was 2.55+ 1.24,patients left hospital within 24 hours; or (2) injury wasincluding double regions in 1 366 cases, triple regions inconfirmed by explorative operation.634 cases, quadruplex regions in 295 cases, and overfive regions in 82 cases, 6 241 regions in total. In detail',Statistical analysisthe regions were respectively extremity and pelvis (1 499We used士s to represent the measurement data.cases, 24.02%), head and neck (1 249 cases, 20.01%),The Student's t test and x 2test were used to analyzeabdominal region and pelvic organ (967 cases, 15.49%),the dfference between groups. SPSS Nersion 13.0)werechest (913 cases, 14.63%), body surface (872 cases,used for statistical analysis. P<0.05 was considered to13.97%) and face (741 cases, 11.87%). TheAlS 90-ISSbe statistically significant.values was between 5 and 75, 27.33+ 15.07 on average.RESULTSPatient evaluationEvaluation of patients was made according to theMisdiagnosis featuresfollowing 4 indexes: (1) number of injured areas basedTotall, 512 patients (16.19%) were misdiagnosedon the six regions divided by ISS criteria, including head(Table 1). The delayed time caused by diagnosis wasand neck, face, chest, abdomen, extremity and pelvis,(6.23+4.79)days. The rate of primary diagnosis bytraumaand body surface; (2)trauma severity, which was scoredsurgeons inmisdiagnosis groupwas 32.03%, significantybyAIS and IsS; (3) delayed and missed diagnosis rates,lower than that for all patients (x2=255.93, P<0.01). Thewhich were confimned by final afimative diagnosis; andlength of hospital stay and mortality rate in misdiagno-(4) mortality rate.sis group were significantly higher, compared with thevalues of the whole study (P<0.05). The general conditin,Treatment methodsincluding average ISS, rates of disturbance ofAll patients were treated according to the mode ofconsciousness, critical cases and shock cases, wereintegrated treatment for trauma in one setting, whichworse in misdiagnosis group than in correct diagnosiscontains emergency room, operating room, trauma in-group.tensive care unit (TICU), and rehabilitation centerorderly. The procedures indlude: (1) quick initial evalu-Anatomic regions of misdiagnosis and AIS distributionation of vital signs; (2) emergency treatment and ad-A total of 757 injury positions were missed in thevanced life support; and (3) simple initial damage con-diagnosis, 1.48 positions per case on average (range,trol operation.1-4 position, Table 2). The most frequent positions mis-diagnosed were extremity and pelvis (299 positions,A total of 4557 operations were carried out, includ-39.50%), abdomen (148 positions, 19.55%), and chesting 3126 (68. 60%) emergency operations. The opera-(109 positions, 14.40%).tions primariy consisted of debridement and suturing,evacuation of intracranial hematoma and nerve muscleThe most frequent diagnoses were pelvic fracturetendon anastomosis. There were 1 431 (31.40%) de-(71 times, 9.38%), parenchymatous organ injury (67finitive operations after the hemodynamics, respirationtimes, 8.85%), and fractures of the rib, clavicle and ster-function and coagulate function were stable three daysnum (57 times, 7.53%). The most frequent AIS valuesafter resuscitation. The majority of definitive operationswere中国煤化工9 times, 24.97%),were fracture reposition, pexis and debridement, andandYHC N M H Gaverage.suturing. A total of 48 patients died and the whole mor-tality rate was 1.52%.Outcome analysis of misdiagnosisThe study indicated that the more serious the injury.22.Chinese Joumal of Traumatology 2011; 141):20-24was, the higher the rate of misdiagnosis wouldbe (Table3).ity rate were significanty affected by the level of misdi-The delayed time caused by misdiagnosis and mortal-agnosis (P<0.01).Table 1. Analysis on features of misdiagnosis of multiple traumaDisturbance of CrtialShockPrimary diagnosis Delayed time Length ofMoralityGroupISSconsciousness casecaseby traumarate(n, %)(n, %surgeons (n, %) misdiagnosis (d) stay (d)Misdiagnosis33.78+19.64* 252 (9.22)* 169 (3.01) 243 (47.46)* 164 (32.03) 6.23+4.79 23.59+7.26* 15 (.93)#(n=512)Correct diagnosis 24.97411.57 495 (18.67) 424 (15.99) 977 (36.85) 2009 (75.78)16.61+5.3233 (1.24)(n=2651)Total (n=3163) 27.33+15.07 747 (23.62) 593 (18.75) 1220 (38.57) 2173 (68.70)1.03+0.47 18.775.8348 (1.52)*P<0.01, compared with the orret diagnosis group; "P<0.05 and *P<0.01, compared with the total group.Table 2. Anatomic regions of misdiagnosis and AIS distributionAISTotal1256(injury positions, %)Head and neck88 (11.62)Craniocerebral injury13260352 (6.87)Tracheo-asophageal injury14 (1.85)Cervical cord and brain stem injury 022 (2.91)Face79 (10.44)Nerve injury221846 (6.08)Prosopo-jaw injury17833 (4.36)Thoracic region109 (14.40)Hemopneumothorax26 (3.43)Fracture of rib/clavicle/stemum1057 (7.53)Thoracic cord injuryAbdomen148 (19.55)Retrpertoneal hematoma34 (4.49)Parenchymatous organ injury3867 (8.85)Viscus organ injury29 (3.83)Diaphragmatocele and entocele918 (2.38)Extremity and pelvis299 (39.50)Hand fracture162(43 (5.68)Foot fracture27Patellar fracture25 (3.30)Spine fracturePelvic fracture71 (9.38)Ligament and meniscus injuny3753 (7.00)Nerves and blood vessel injuryBody surface中国煤化工20 (2.64)Foreign object persistenceMHCNMHG.OthersTotal (injury positins, %)163 (21.53) 219 (28.93) 189 (24.97) 147 (19.42) 38 (5.02)1(0.13) 757 (100)Chinese Jourmal o1 Traumetology 2011; 14/1):20-24.23.Table 3. Outcome analysis of misdiagnosis groupMisdiagnosis groupIndexMild injury (ISS<16) Moderate injury(16≤ISS<25) Severe injury (ISS≥25)Total (n, %)Misdiagnosed cases (n, %)29 (.66)132 (25.78)*351 (68.55)*512 (100)Misdiagnosed positions (n, %)36 (4.76)185 (24.44)*536 (70.81)**757 (100)Delayed time caused by misdiagnosis (d) 2.39+1.244.74+1.86*8.15+3.35**6.23+4.79Death (n. %).1 (0.60)14 (4.64)*15 (2.93)_*P<0.01, compared with mild injuny group; "P<0.01, compared with severe injury group.DISCUSSIONwith similar symptoms to traumatic signs, and thus wehope that surgeons could increase their awareness ofMultiple injury is a severe trauma with complex com-the similar presentation of other diseases.plications which largely increase the mortality rate.Misdiagnosis of multiple trauma, which often occurs atPhysical examination and axiliary examinationsfirst or later examinations,' delays efctve treatment,pro should be emphatically conducted to avoidlongs hospital stay, and increases the mortality rate.misdiagnosis. Systemic physical and auxiliary exami-nations should be done as follows. (1)A patient is car-In this study, because of the nature of severe injury,ried to the emergency room according to the ABCDEsome patients were not sucestslly treated. From Table 1,rule.' (2) Asphyxia, shock, and other severe conditionswe can easily confrm that the rate of misdiagnosisare promptly treated. (3) A patient is taken to havecaused by trauma surgeons is significantly lower thanmedical examination according to the CRASHPLAN.that for all patients. Improper primary diagnosis may (4) A patient is taken to undergo defntive auxilianybe the main cause of misdiagnosis.examinations, such as chest and cervical vertebra X-ray test. Every surgeon should be highly suspicious ofInjuries to these regions, including extremity andcerical spine injury in blunt trauma patients with positivepelvis, abdomen and chest, are misdiagnoseddinical examination results and radiologic evidences, andfrequenty, as showed in Table 2. The average AIS werefocused assessment with sonography for trauma. But2.58, which certainly infuenced the diagnosis and treat-patients with high ISS are at an increased risk of lowerment of patients in this study. But some new evidencesaccuracy of ultrasound examination compared withthoseshow that vascular and heart injuries become the new having low and moderate ISS.10 Therefore, change ofthehotspot of misdiagnosis.24patient's conditionneeds to be observed dymamically andCT scan or MRI should be used to prevent misdiagnosisFrom Table 3, we can see that an increased injurywhen the state of the patient is stable.severity is associated with an increased delay in diag-nosis and length of hospital stay, meanwhile higher mis-The results of auxiliary examination should be re-diagnosis rate and morality rate.evaluated by an experienced senior doctor within 24hours if the patient's condition is complicated, becauseThe findings in this study are signifcant in prevent-this helps to discover and treat insidious injuries," e.g.ing future misdiagnosis. A number of points are highlya medical history of severe blunt trauma could provokerecommended, including careful collection of relativea high suspicion of diaphragmatic rupture.12 We pro-case history, present and past medical history, andpose tertiary examinations, which is a comprehensivethorough check of all trauma conditions. Meanwhile pa-reevaluation that includes a repeated head-to-toe ex-tients' case history should be recollected when theiramination and review of all laboratory and radiologicconditions are improved and consciousness is regained.studies completed within 24 hours after admission. 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