Age, wound severity can lead to missing injuries in multi-trauma CT patients

Multi-trauma patients over 30 years old, as well as those with severe injuries or wounds across three or more body parts, see an increased risk for missed injury during early whole-body CT interpretation, according to research published in Radiology.

“In the emergency setting, the crucial need for rapid diagnosis to start the first care and the high number of whole-body CT images that require extended interpretation time often lead to misinterpretations,” lead author Nathan Banaste, MD, of the radiology department at CHU Centre Léon Bérard in Lyon, France, and co-authors wrote in the study. “Missed injuries could potentially have serious consequences for patients with multiple traumas and also for physicians.” 

Studies on the subject have found missed injury and delayed diagnosis rates of anywhere from 3.5 percent to 71.4 percent, depending on the study population, definitions and follow-up protocol, Banaste et al. said. And while injury severity score, double readings and teleradiology have all shown promise as ways to predict risk for missed injury, severity scores are calculated too late for initial assessments, double readings might not be cost-effective and radiologists connected to a case via conference call will likely find it more difficult to assess the severity of any given trauma than an onsite physician.

“The purpose of our study was to determine radiologic and clinical markers that could help to identify patients with multiple traumas at risk for missed injury on whole-body CT scans in the setting of a large teleradiology practice,” the authors wrote. “We hypothesized that working conditions of the radiologist and trauma severity could have an effect on the rate of missed injuries.”

Indeed, in their retrospective review of 2,354 consecutive whole-body CTs from a pool of patients in their mid-30s, older patients and those with more clinically severe injuries were most prone to faulty readings, the team said. For overnight and weekend whole-body CTs performed for multiple traumas, there was a 12.9 percent rate of missed injuries at initial interpretation, with a significant missed injury rate of 2.5 percent.

Patients were also more likely to have missed injuries on an initial reading if their injuries spanned more than two body parts, Banaste and colleagues wrote. Time at the first examination, number of CT exams during the on-call duty period, day of the week and the radiologist’s emergency experience weren’t linked to missed injury.

“The number of body parts, number of injuries and the injury severity score were highly correlated, which suggested that these factors were interchangeable to predict a missed injury,” the authors said, noting the most commonly missed injuries in their study were costal fractures, transverse process fractures and small pulmonary contusions.

Banaste and his team said the phenomenon likely stems from the “satisfaction of search” effect, which sometimes occurs when one injury is overlooked in the presence of another. To avoid that, they said, it would be pertinent for radiologists to keep an eye out for the risk factors identified in this study.

“Those markers could easily be identified in early stages of management of patients with multiple trauma to warrant a double reading and reporting,” the authors wrote. “They should also be fully integrated into emergency radiology daily practice to improve patient safety and quality care.”