More than meets the eye: the continuing importance of tertiary trauma survey even in moderate (ISS 9-15) trauma.

Abstract

Tertiary Trauma Surveys (TTS) are designed to identify injuries which are not recognised during the primary and secondary surveys. These injuries occur in up to 40% of patients and are commonly referred to in the literature as "missed", we prefer the term "unrecognised" as this term does not infer the failure of primary and secondary survey, rapid assessments designed to identify life and limb threatening injuries. The incidence and definition of unrecognised injuries varies across studies, and several risk factors have been identified internationally. The aim of our study was to investigate the sensitivity and specificity of TTS and the incidence and risk factors for unrecognised injuries in a large UK Major Trauma Centre (MTC). Data was prospectively collected for all major trauma patients admitted to our MTC over six months. All patients over 16 years with an ISS≥ 9 were included. Patients with a length of stay of less than 24 h or palliated were excluded. All patients were examined using a specific TTS protocol. Patient records were reviewed one year post admission to identify any injuries diagnosed after discharge. A total of 293 patients were included. Unrecognised injuries were identified at TTS in 18.8% (55/293) patients, most commonly affecting the face or head and eyes. Patients with unrecognised injuries had a higher admission ISS (p = 0.020) and were more likely to present out of hours (40/179 vs 15/104; adjusted OR 2.23 [95% CI 1.12-4.28], p = 0.030). In patients with ISS 9-15, unrecognised injuries occurred in 27/170 (15.9%). Injuries identified after discharge occurred in 1/263 (0.38%). The sensitivity and specificity of the TTS were 53/55 (96.3%) and 238/238 (100%), respectively. Injuries identified at TTS remain common in major trauma patients including those with ISS between 9-15. TTS is an essential component of major trauma patient assessment and can be highly sensitive and specific. It should include examination of the head and eyes.