ABSTRACT
BACKGROUND: Multislice computed tomography (CT) technology has improved the diagnosis of relevant lesions within the phase of primary treatment of severely injured patients. The lack of time in this phase and the complexity of the multiple injuries there is still a risk that lesions will be missed at this stage. The purpose of this study was to evaluate the incidence, causes, implications and significance when injuries are not diagnosed until later. METHODS: The data were documented prospectively in the context of a quality management system for the care of severely injured patients in a primary urban trauma centre. Missed injuries were defined as any lesions that had not been recognised by the time the patient was admitted to the ICU. RESULTS: During a 44-month period 1,187 (ISS 21+/-17) patients were enrolled in the study, all of whom were admitted from May 1998 to April 2002 after attending the emergency room. In total 64 (4.9%) missed injuries were detected in 58 (ISS 30+/-16) patients; 26 of the 64 missed injuries were located on the torso, 8 injuries in the head and neck region, and 30 on the arms and legs. The missed injuries were categorised as follows: 1. Lesion not seen in diagnostics (n=15). 2. Incomplete diagnostics (n=8). 3. Primarily unsuspicuous examination (n=35). 4. Diagnostics interrupted due to hemodynamic instability (n=6). CONCLUSION: Despite intensified and standardised diagnostic procedures prescribed for use in trauma centres, injuries are still missed in severely injured patients. About 30% of lesions that are not diagnosed until after the patient has left the emergency room have clinically significant, but not lethal, consequences for the patient. Great importance attaches to the follow-up investigation on the intensive care station, so that lesions that have initially been overlooked can be diagnosed and treated as soon as possible so as to keep the complication rate low.
Subject(s)
Emergency Service, Hospital , Multiple Trauma/diagnosis , Shock/therapy , Adolescent , Adult , Aged , Cross-Sectional Studies , Diagnostic Errors/statistics & numerical data , Emergency Service, Hospital/statistics & numerical data , Female , Germany , Hospitals, Urban , Humans , Incidence , Injury Severity Score , Intensive Care Units , Male , Middle Aged , Multiple Trauma/epidemiology , Multiple Trauma/surgery , Resuscitation , Total Quality Management , Trauma CentersABSTRACT
A large animal model was established to investigate the feasibility and suitable dosage of intraoperative radiation therapy (IORT) to the hepatic hilum before biliary-enteric anastomosis is performed. Twenty-two Pietrain Hampshire pigs underwent gallbladder and proximal bile duct resection followed by IORT using 20-40 Gy and performing biliary-enteric anastomosis. In the follow-up period of 56 days, pigs developed dose-dependent complications like stenosis of the biliary-enteric anastomosis. Results demonstrate that IORT of the liver hilum up to 20 Gy is safe with acceptable early complications in the presented animal model. The porcine biliary-enteric anastomosis can tolerate intraoperative irradiation up to a dosage of 40 Gy without disruption.
