Jennifer S. Beaty, MD
Akella Chendrasekhar, MD
James Hopkins, MD
Lisa Gruelke, NREMT-P
Departments of Trauma and Surgery Education
Iowa Methodist Medical Center
Des Moines, Iowa
KEY WORDS: Missed injuries, pediatric, trauma
Background: Missed injury in pediatric trauma continues
to be a nemesis to the trauma surgeon.
Study: To determine the true incidence of missed injury
in pediatric trauma, we performed a prospective cohort analysis on
all pediatric trauma patients (n = 201) during a 6-month period at
a community hospital based, ACS-verified Level I Trauma Center. All
missed injuries were documented, including type of injury, mechanism
of injury, age of patient, type of physician seeing patient, complications
related to missed injury, and mortality related to missed injury.
Results: Thirty-seven of 201 (18.4%) patients were noted
to have missed injuries. None of the missed injuries led to any mortality
or increased length of hospitalization. Most missed injuries occurred
with motor vehicle crashes (including pedestrian vs. vehicle, vehicle
vs. vehicle, bicycle vs. vehicle). Age was not significantly related
to the frequency of missed injury. A pediatric emergency physician's
presence at initial resuscitation reduced incidence of missed injuries
(p<0.05). Injury Severity Score (ISS) did not correlate with missed
Conclusions: Missed injuries are a significant problem
in pediatric trauma. A tertiary survey to detect missed injuries should
be performed as part of routine evaluation of pediatric trauma patients.
It is well known that missed injuries in trauma patients
result in increased morbidity, increased morality, and increased length
of hospitalization.1 In the adult trauma literature, there is a reported
incidence of missed injuries between 9% to 23%.1-5 However, several
road blocks exist that make it difficult to determine the actual incidence
of missed injuries. Retrospective studies may have a selective memory
component or incomplete information, and long-term follow-up may be
difficult. Perhaps the most important reason these data are difficult
to acquire is the attitude toward missed injuries: there is reluctance
to expose our mistakes. Enderson et al.1, leaders in evaluating missed
injuries in trauma patients, provide the atmosphere in which we should
look at missed injuries, "instead of missed injuries being disregarded
as freak incidents or mishaps that happen only to the inexperienced,
missed injuries should be looked at in an open and analytical manner
so that means can be devised to avoid them."
In a retrospective study, Enderson et al.2 showed that
2% of multiple trauma patients (mostly adults) sustained injuries
that were not discovered during the primary and secondary surveys.
This same group performed a prospective study and found that their
missed injury rate was even higher, approximately 10%.2 This led to
a recommendation for a tertiary examination to be performed within
24 hours for all trauma patients. A tertiary examination is a thorough
re-examination performed outside of the trauma resuscitation, after
primary and secondary surveys, actively looking for additional injuries.
In addition to the tertiary examination, this group identified contributing
factors related to missed injuries in adults. These factors were inadequate
clinical assessment, poor use of radiologic studies, and admissions
to inappropriate wards.1 However, pediatric trauma patients have not
been well studied for the incidence of missed injuries or contributing
factors relating to the missed injuries.
Previously, we performed a retrospective study evaluating
107 pediatric trauma patients and found a 20% missed injury rate.
The increased incidence was associated with specific mechanisms of
injury and with the patient's age, with older children being more
likely to have a missed injury than younger children.6 A prospective
study is needed to help determine the actual rate of missed injuries
in the pediatric trauma population and to help determine risk factors
associated with missed injuries. If these risk factors can be clearly
identified, a conscious effort on the part of the trauma team can
be made to help decrease the overall incidence of missed injuries
in the pediatric trauma patient.
METHODS AND MATERIALS
To assess the rate of missed injuries in pediatric trauma
patients, a prospective study was performed at a community hospital-based,
level I trauma center with pediatric commitment. All pediatric trauma
patients (ages 0-17 years) who were admitted to the hospital from
March to August of 2001 were prospectively included in the study.
Approval for the study was obtained from our Institutional Review
Board. Data collected at the time of admission included age, gender,
mechanism of injury, type of physician involved in resuscitation (trauma
surgeon, pediatric emergency room physician, both, or neither), Injury
Severity Score, and admission injuries. Mechanisms of injury were
classified as motor vehicle crash, pedestrian versus vehicle, bicycle
versus vehicle, off-road vehicle, fall, and miscellaneous. Children
were divided into groups depending on their age: infants (< 1 year),
toddlers (1-2 years), preschool (3-5 years), school age (6-11 years),
and adolescents (12-17 years). Patients were excluded from the study
if they died in the emergency room or within the first 24 hours of
hospitalization. Patients were also excluded if they were transferred
from an outside hospital after a prolonged stay (> 24 hours).
One investigator (L.G.) then followed up the patient
once admitted to the hospital. Her specific tasks were to record the
length of hospital stay and to document all injuries defined within
the first 48 hours or at the time of patient's discharge, whichever
came first. This new injury list was compared with the admission injuries.
We defined a missed injury as any injury identified as occurring as
a direct result of the patient's primary injury (not acquired in the
hospital) that was not identified in the patient's admitting diagnoses.
Data were also collected to determine whether the time
of year affected the rate of missed injuries, with new surgery residents
starting in July and August, compared wity more seasoned residents
in March through June. Trauma resuscitation at our institution usually
involves a trauma surgeon, trauma surgery resident, pediatric emergency
room physician, and pediatric resident.
The purpose of this study was to determine the actual
rate of missed injuries at this level I trauma center and to identify
risk factors associated with a higher rate of missed injuries. Data
were analyzed using multivariate analysis and chi-square statistics.
A total of 201 pediatric patients were admitted to the
trauma service, 134 boys and 67 girls. The ages ranged from 2 months
to 17 years of age, with a mean age of 9.2 years. There were 37 patients
with missed injuries in the 201 patients evaluated, representing an
incidence of 18.4%. A total of 55 injuries were missed in these 37
patients. Identified missed injuries included: abrasions, hematomas,
missing or broken teeth, fractures, subdural hematoma, splenic laceration,
spinal fracture, and ankle sprain (Table 1). No mortality or significant
disability were attributed to the missed injuries. The spinal fracture
and subdural hematoma did not result in neurologic deficits.
There was a significant association between the incidence
of missed injuries and mechanism of injury (Table 2). Patients involved
in the following mechanisms were more likely to have a missed injury:
pedestrian versus vehicle, bicycle versus vehicle, motor vehicle crash,
off-road vehicle, or fall.
Missed injuries were not related to the age of the patient
(Table 3), the specific trauma surgeon evaluating the patient, the
length of hospital stay, or the time of year the patient was evaluated.
However, there was statistically significance difference (P < 0.001)
between which type of physician evaluated the patient (Table 4). When
a trauma surgeon alone evaluated a patient, there were 21of 54 (39%)
missed injuries. However, when a pediatric emergency room doctor alone
evaluated the patients there were only 7 of 69 (11%) missed injuries.
The overall ISS
of patients without missed injuries was 8.55, whereas the mean ISS
of patients with a missed injury was 12.94 (P = 0.003). Patients evaluated
by trauma surgeons alone had higher ISS (P < 0.001) compared with
those evaluated by a pediatric emergency room physician (Table 4).
Trauma remains a leading cause of death in the first
four decades of life.1 Approximately 60 million injuries occur annually
in the United states alone, and of these, nearly 9 million are disabling.1
Before 1978, there was no standard approach to trauma patients. However,
in that year, the first ATLS Course was field-tested, and in 1979,
the American College of Surgeons Committee on Trauma incorporated
the course. This course changed the approach to trauma patients and
the classic "examine, diagnose" and treat the patient" was obsolete.
The new paradigm was to identify and treat all life-threatening problems
first, with indefinite deferment of additional diagnostics and therapeutics
for non-life-threatening problems. This is the approach currently
advocated by the Advanced Trauma Life Support program for physicians.7.
With this step forward and new paradigm in dealing with trauma patients,
missed injuries were a natural result. Because of this, Enderson and
Maull1 advocate the tertiary examination to actively search for additional
injuries in trauma patients, because nearly 10% of their patients
had missed injuries.1
These missed injuries have lead to increased morbidity and
mortality in the adult population. However, missed injuries in children,
both in our previous retrospective study and in this prospective study,
have failed to show an association with increased mortality or significant
disability. Furthermore, the hospital stay was not lengthened for
patients diagnosed with missed injuries, suggesting no increase in
complications with missed injuries.
When the trauma surgeons alone evaluated the patients,
they had a higher rate of missed injuries. However, the ISS of these
patients is significantly higher than in any other group. The higher
the ISS the more likely the patient will have a missed injury. Having
a second staff physician, in this case a pediatric emergency room
physician, also evaluate the patient decreased the incidence of missed
Although none of the missed injuries resulted in serious
morbidity or mortality, it does seem that the presence of the pediatric
emergency room physician is beneficial in the initial evaluation of
pediatric trauma patients. Perhaps the higher miss rate when only
a trauma surgeon evaluated the patient was due to the trauma surgeon
focusing in on life-threatening injuries as per training. Or perhaps
the trauma surgeons are not taking the time to accurately document
abrasions and contusions, which were the majority of the missed injuries.
Clearly, having a second physician evaluate the patient resulted in
fewer missed injuries found during the tertiary examination.
This raises the question of whether specific children's
level I trauma centers are needed. This was recently studied by Rhodes
et al.8 in a retrospective study of more than 1000 pediatric trauma
patients evaluated in an adult level I trauma center. They did not
find any unpreventable deaths, and complications rates in the pediatric
patients were comparable to the adult complication rates. This is
important in dealing with pediatric trauma patients in the community
because there are few centers designated specifically for pediatric
trauma patients. In the adult level I trauma centers, having a pediatric
emergency room physician present for the initial resuscitation will
probably decrease missed injuries.
injuries in the pediatric trauma population approach 20% in this prospective
study, but do not appear to significantly alter mortality or morbidity
as in the adult population. Clearly, as was the case with adult trauma
patients, a tertiary examination is needed to assess for missed injuries.
Closer attention should be paid to patients involved in motor vehicle
crashes, because they were associated with a much higher rate of missed
injury. Having a pediatric trained emergency room physician present
for critically injured pediatric trauma patients may help decrease
the number of missed injuries.
Enderson BL, Maull KI:. Missed injuries: The trauma surgeon's
nemesis. Surg Clin North Am 71:399-417, 1991.
Enderson BL, Reath DB, Meadors J, et al: The tertiary trauma
survey: A prospective study of missed injury. J Trauma 30:666-670,
Chan RNW, Aiscow D, Sikorski JM: Diagnostic failures in the
multiply injured. J Trauma 20:684-687, 1980.
Houshian S, Larsen MS, Holm C: Missed injuries in a level I
trauma center. J Trauma 52:715-719, 2002.
Buduhan G, McRitchie DI: Missed injuries in patients with multiple
trauma. J Trauma 49:600-605, 2000.
Peery CL, Chendrasekhar A, Paradise NF, et al: Missed injuries
in pediatric trauma. Am Surg 65:1067-1069, 1999.
American College of Surgeons Committee on Trauma: Advanced
Trauma Life Support Program. Chicago: American College of Surgeons;
Rhodes M, Smith S, Boorse D: Pediatric trauma patients in an
'adult' trauma center. J Trauma 35:384-392, 1993.
Table 1. Missed
Type of Injury Missed Number Missed
or Missing Teeth
Table 2. Mechanism
Mechanism Missed Missed
of Injury (n) (%) (n)
vs 6 11 55
vs 4 8 50
Vehicle 10 30 33
Off-road 3 14 15
Other 5 78 6
Table 3. Age
Age Group Missed Injured
of Injury (n) (%) (%)
Infants 1 11
Table 4. Type
of Physician Evaluating the Patient and ISS
Injuries ISS for
Surgeon 21 54
Emergency 7 69 11 6.60
Room Doctor Only
Surgeon + 7 39
Neither 2 39