Undetected Injuries: A Preventable Cause of Increased Morbidity and Mortality David J.J. Muckart,
FRCS,
Sandie R. Thomson,
A prospective audit of trauma patients managed at the discretion of six different general surgical units was performed over a 6-month period. Eighteen patients were identified in whom diagnostic delay or injuries undetected at operation contributed to increased morbidity and mortality. Failure to perform investigations as indicated by the nature of the trauma was the main reason for delay in diagnosis in seven patients. Incomplete exploration at laparotomy resulted in seven undetected injuries, while unexplored retroperitoneal hematomas accounted for the remaining four. Fourteen patients (78%) requkd management in the intensive care unit. Eight patients died (4%) as a result of ongoing sepsis and multiple organ failure. Seven of the deaths occurred in patients in whom surgical treatment was inadequate. Delays in diagnosis and undetected injuries, although uncommon, are a readily preventable cause of phase 3 trauma deaths. Strict adherence to standard surgical protocols as employed in dedicated trauma’care centers does much to reduce unnecessary morbidity and mortality.
From the Departmentof Surgery, University of Natal Medical School, Durban, Republic of South Africa. Requests for reprints should be addressed to David J.J. Muckart, FRCS, Department of Surgery, University of Natal Medical School, P.O. Box 17039, Cmgella 4013, Republic of South Africa. Manuscript submitted March 13, 1990, and accepted in revised form June 28.1990.
chM, FRCS, Durban,southAfrica
elays in diagnosis and absent or inappropriate surD gical management are major contributing factors to morbidity and mortality after injury [l-3]. Although most of these errors occur in patients with multiple trauma whose major life-threatening injuries assume precedence [46], some occur because of a failure to follow well-established protocols [ 7,8]. At Ring Edward VIII Hospital, Durban, more than 2,000 penetrating chest, 1,000 penetrating torso, and 300 blunt torso injuries are treated annually by 6 surgical units, Each unit is headed by a consultant general surgeon with trauma experience and includes a senior registrar with at least 4 years of surgical training and two junior registrars on the training program. Patient management is at the discretion of the individual senior surgeon concerned. We report on the outcome of a series of patients with torso trauma in whom basic errors in management were made resulting in preoperative and intraoperative missed diagnoses. PATIENTS AND METHODS
During the 6-month period from February 1989 through July 1989, 18 patients were identified, each of whom had a single injury overlooked. There were 16 male and 2 female patients, with an age range of 16 to 5 1 years (median: 24 years). Twelve patients had penetrating wounds (8 stab; 4 low velocity gunshot), and 6 had blunt injuries (4 motor vehicle accident; 2 assault). Four patients were in shock on admission to the emergency department; all responded rapidly to resuscitation. These 18 patients constituted 2.6% and 4%, respectively, of all patients with penetrating and blunt injuries admitted during this period. In seven patients, the diagnosis was delayed as a direct result of a failure to perform investigations as indicated by the nature of the trauma (Table I). All patients had been examined by the attending consultant surgeon. Contrast radiography of the genitourinary tract was omitted in three patients despite the presence of hematuria. Diagnostic peritoneal lavage (DPL) was not performed& two patients with equivocal abdominal findings after blunt trauma. One patient with multiple injuries did not undergo routine chest radiography, and, in the remaining patient with a gunshot wound of the left upper quadrant, immediate laparotomy was not performed because of the absence of peritoneal signs. Six patients eventually underwent laparotomy after a delay ranging from 12 hours to 5 days. Five of these six patients required intensive care management postoperatively. The length of stay in the intensive care unit ranged from 2 to 30 days. In one patient with a ureteric injury, a percutaneous nephrostomy was performed and laparotomy avoided. There was one death in this group as a result of overwhelming sepsis arising from a fecal tistula into the left pleural cavity.
THE AMERICAN JOURNAL OF SURGERY
VOLUME 162 NOVEMBER 1991
457
MUCKART AND THOMSON
TABLE I Delayed Diagnosls Due to Omission of an Indicated Investigation Injury Mode Blunt Stab Blunt
Gunshot Blunt
Missed Injury
Presentation Hematuria (macroscopic) Hematuria (microscopic) Equivocal abdominal signs Equivocal abdominal signs Multiple fractures
Omitted Procedure
No.
Bladder rupture
2
Cystography
Uretericlaceration
1
Intravenous
Jejunal perforation
2
Colonic perforation
1l
Diaphragmatic hernia
1
pyelography Diagnostic peritoneal lavage Laparotomy
Chest radiography
7
Total
COMMENTS
‘Died.
TABLE II Missed lntraoperatlve Vlsceral Injuries Mode of Injury
Missed Organ Injury
No.
Stab Stab Gunshot Stab Gunshot
Duodenum Diaphragm Rectum Small intestine Intestinal ischemia
2 2 1 1 1 7
Total
Alive
Dead
1
2 1 1
1 1 5
2
TABLE III Mlssed Injuries Following Failure to Explore Retroperltoneal Hematomas Mode of Injury
Zone
Missed Organ Injury
Outcome
Blunt Stab Stab Gunshot
I II II Ill
Common iliac artery Renal vein Renal pelvis External iliac artery
Died Died Alive Alive
TABLE IV Clinical Signs Necessitating a Second Laparotomy Missed Organ Injury
No.
Indications for Re-Operation
Duodenum Rectum Diaphragm
2 1 1
Progressive MOF Progressive MOF Acute respiratory failure: gastric herniation on chest radi-
Diaphragm Small intestine Renal pelvis External iliac artery
1 1 1 1
Total
8
ography Persistent pleural effusion Persistent peritonitis Persistent peritonitis Absent femoral pulse
MOF = multiple organ failure.
458
THE AMERICAN
JOURNAL
In 11 patients, the injury was missed intraoperatively. Five visceral and two diaphragmatic injuries were overlooked (Table II), and four injuries remained undiagnosed after failure to explore retroperitoneal hematomas (Table III). The senior surgeon was present at only three of these procedures. Rapid postoperative deterioration and death occurred in three patients. The other eight patients underwent a second laparotomy (Table JY). All eight required intensive care therapy postoperatively for a period of time ranging from 1 to 21 days. Four of these eight patients died as a result of multiple organ failure. Therefore, seven patients (66%) with an undetected intraoperative injury died. The total number of deaths from diagnostic delay and undetected intraoperative injuries was eight, resulting in an overall mortality rate of 44%.
OF SURGERY
VOLUME
Poor clinical judgment, inadequate use of diagnostic facilities, and admission to an inappropriate surgical ward have been incriminated as the main reasons for undetected injuries [ 2,4,6j. As a direct consequence, necessary surgical treatment is unduly delayed, inadequate, or omitted altogether. In a recent retrospective report by Anderson et al [I], 78% of patients who required surgical intervention did not undergo operation, while Kreiss et al [2] reported that 83% of preventable deaths occurred as a result of inadequate surgical management. Although undetected injuries include both delays in diagnosis and those overlooked at operation, they are best considered as separate entities. In the former type of injury, obvious symptoms and signs may be absent or equivocal, while, in the latter, symptoms and signs are invariably present and poor surgical technique is the basic error. Diagnostic delay: Not one patient who presented with hematuria underwent intravenous pyelography or cystography, and major renal tract trauma was overlooked in all three. Rapidly clearing macroscopic hematuria does not exclude major trauma to the renal tract, and significant genitourinary injury can occur with any degree of hematuria [9,10]. Early aggressive use of contrast radiography including cystography is therefore essential. Radiologic imaging of the genitourinary tract for microscopic hematuria in asymptomatic patients following penetrating trauma is usually unnecessary, because the majority of injuries are posterior stab wounds and involve only the renal parenchyma. Persistent microscopic hematuria associated with penetrating wounds should, however, be investigated [IO]. DPL has become the cornerstone of investigation in patients with blunt abdominal trauma in whom physical findings are equivocal. The procedure has diagnostic accuracy rates of between 93% to 97% in most reported series [I I]. In two patients, this investigation was omitted despite equivocal physical findings on admission. This resulted in a 48-hour delay in operative intervention with resultant septic shock and prolonged intensive care management in one patient. The technique is uncomplicated and extremely reliable [ 221 and should be done routinely in such patients if selective conservative management is to be employed. 162
NOVEMBER
1991
UNDETECTED INJURIES
Gunshot wounds that penetrate the peritoneal cavity are associated with a 97% risk of major intra-abdominal injury. As a result, use of a selective conservative policy as in patients with abdominal stab wounds is considered unjustified by most investigators [13]. Unless the wound is most definitely tangential or specific criteria exist to justify withholding intervention [ 141, laparotomy is mandatory if the peritoneal cavity has been breached. Rupture of the diaphragm after blunt abdominal trauma is most frequently associated with motor vehicle accidents, in particular high-speed, single-occupant collisions [ 151, but this injury may occur with lesser degrees of abdominal trauma [ I6J. Although the diagnosis may be difficult to establish, chest radiography is the most sensitive study and is mandatory in any patient with multiple trauma. Undetected injuries at laparotomy: Undetected intraoperative injuries, although fortunately rare, are associated with prohibitive mortality rates. In this series, such injuries accounted for 88% of the deaths. Guidelines describing the best way to perform laparotomy in trauma patients are available [17]. A generous midline incision should be used, and all viscera should be examined by both the surgeon and the surgical assistant. The lesser sac should be opened routinely, and the duodenum should be mobilized if injury is suspected. Failure to perform a thorough inspection of all viscera was the most common error in this series. Failure to inspect the diaphragm during laparotomy in the symptomatic patient with a low chest or upper abdominal wound is a grave error of omission, and it is incumbent upon the surgeon to verify that the hemidiaphragms are not injured [7]. Although a complete inspec tion of all viscera is desirable at laparotomy, mobilization of all organs is unnecessary if not indicated, especially in the retroperitoneum, and may contribute to morbidity from iatrogenic injury [18,19]. Prior knowledge of all wounds is, therefore, essential, especially those situated posteriorly. Sepsis in the retroperitoneal tissues is relentless, rapidly progressive, and resistant to antimicrobial therapy. If the surgeon suspects injury in this area, every effort must be made to verify its presence. Penetrating injuries of the intestine, unless tangential in nature, are associated with both entrance and exit wounds, except when an intraluminal missile is retained. The finding of an odd number of holes should lead to a careful scrutiny for an undetected injury, with the commonest site being the mesenteric border. Small hematomas in this area should be fully explored. If a superior mesenteric vascular injury is present, intestinal viability must be verified when the procedure is terminated. If, at this time, doubt still remains, then a second laparotomy should be performed within 24 hours. Rectal injuries are associated with a high rate of pelvic sepsis, and guidelines for their management have emerged based on the experiences gained during the various military conflicts of this century [20,2I]. These have been extended to the civilian environment with good effect [22]. The preoperative omission of a rectal examination and sigmoidoscopy in the presence of a pelvic gunshot wound is a serious oversight, and failure to perform a
distal colonic washout and institute adequate drainage contribute to high mortality rates from this injury. Exploration of retroperitoneal hematomas presents a formidable challenge to the surgeon and, if performed unnecessarily, may cause iatrogenic morbidity to the patient [23]. Failure to explore these areas, however, results in a high incidence of undetected vascular injuries and an appreciable mortality rate. The need to explore all zone I hematomas is underscored by the two deaths following failure to perform this procedure, both of which were due to catastrophic postoperative hemorrhage. Although not advised by other authors [23], we believe the wound track should be followed to its termination in medial zone II injuries to avoid missing injuries of the renal pelvis. Failure to diagnose injury, whether it be from delay or error, is one of the most important avoidable causes of phase 3 trauma deaths. Undetected injuries at operation are associated with a significantly higher mortality than are preoperative delays in diagnosis. A single overlooked lesion, as occurred in each patient in this study, is enough to result in death. To avoid this, all wounds must be identified before surgery and a thorough laparotomy should be performed. Liberal exploration of retroperitoneal hematomas should be done. Failure to consider the possibility of an overlooked injury and reluctance to perform a second laparotomy are the prime reasons for the high mortality rate. Lack of the expected recovery and unexplained isolated organ failure are major indicators of an undetected injury and should prompt immediate and aggressive investigation in the form of reoperation. Healthy skepticism on the part of the surgeon is invaluable in this respect [5]. Although errors in judgment may still occur within dedicated trauma care centers, the creation of these centers has resulted in well-proven standard protocols for the management of trauma patients. Our audit suggests that stricter adherence to such guidelines, rather than individualized management, prevents unnecessary morbidity and mortality.
REFERENCES 1. Anderson ID, Woodford M, De Dombal FT, Irving M. Retrospective study of 1,000 deaths from injury in England and Wales. BMJ 1988; 296: 1305-8. 2. Kreiss DJ, Plasencia G, Angenstein D, et al. Preventable trauma deaths. Dade County, Florida. J Trauma 1986; 26: 649-53. 3. West JG, Trunkey DD, Lim RC. Systems of trauma care. Study of two counties. Arch Surg 1979; 114: 455-60. 4. Hamdan TA. Missed injuries in casualties from the Iraqi-Iranian War: a study of 35 cases. Injury 1987; 18: 15-17. 5. Scalea TM, Phillips TF, Goldstein AS, ef al. Injuries missed at operation: nemesis of the trauma surgeon. J Trauma 1988; 28: 962-7. 6. Chan RNW, Ainscow D, Sikorski JM. Diagnostic failure in multiple injuries. J Trauma 1980; 20: 684-9. 7. Feliciano DV, Cruse PA, Mattox KL, ef al. Delayed diagnosis of injuries to the diaphragm after penetrating wounds. J Trauma 1988; 28: 1135-44. 8. Gordon JA. Unexpected, unsuspected, and missed injuries in a paediatric trauma unit. S Afr J Med 1986; 70: 415-6. 9. Bergren CT, Chan FN, Bodzin JH. Intravenous pyelogram
THE AMERICAN JOURNAL OF SURGERY
VOLUME 162 NOVEMBER 1991
459
results in association with renal pathology and therapy in trauma patients. J Trauma 1987; 27: 515-8. 10. Nicolaisen GS, McAninch JW, Marshall GA, Bluth R, Carrol PF. Renal trauma: re-evaluation of the indications for radiographic assessment. J Ural 1985; 133: 183-7. 11. Gomez GA, Alvarez R, Plasencia G, et al.Diagnostic peritoneal lavage in the management of blunt abdominal trauma: a reassessment. J Trauma 1988; 28: l-5. 12. Lazarus HN, Nelson AJ. A technique of diagnostic peritoneal lavage without risk of complication. Surg Gynecol Obstet 1979; 149: 889-92. 13. Lowe RJ, Saletta JD, Read DR, Radhakrishnan J, Moss GS. Should japarotomy be mandatory or selective in gunshot wounds of the abdomen? J Trauma 1977; 17: 903-8. 14. Demetriades D, Rabinowitz B. Non-operative management of penetrating liver injuries: a prospective study. Br J Surg 1986; 73: 736-7. 15. Johnson CD. Blunt injuries of the diaphragm. Br j Surg 1988; 75: 226-30. 16. McDonald MA, Muckart DJJ. Diaphragmatic disruption in
blunt trauma. S Afr J Surg 1989; 27: 19-20. 17. Dudley HAF. Exploration of the abdomen. In: Champion HR, Robbs JV, Trunkey DD, editors. Rob and Smith’s operative surgery, trauma surgery. 4th ed. London: Butterworths, 1989; 1: 346-53. 18. Maynard AC, Orpeza G. Mandatory operation for penetrating wounds of the abdomen. Am J Surg 1968; 115: 307-12. 19. Nance FC, Cohn I. Surgical judgement in the management of stab wounds to the abdomen: a retrospective and prospective analysis based on a study of 600 stabbed patients. Ann Surg 1969; 170: 569-80. 20. Lavenson GS, Cohen A. Management of rectal injuries. Am J Surg 1971; 122: 225-30. 21. Lung JA, Turk RP, Miller RE. Wounds of the rectum. Ann Surg 1970; 172: 985-90. 22. Shannon FL, Moore EE, Moore FA, McCroskey BL. Value of distal colon washout in civilian rectal trauma-reducing the risk of bacterial translccation. J Trauma 1988; 28: 989-94. 23. Costa M, Robbs JV. Management of retroperitoneal haematoma following penetrating trauma. Br J Surg 1985; 72: 662-4.
EDITORIAL COMMENT
J. David Richardson, MD, Louisville,Kentucky This issue of The American Journal of Surgery contains a unique perspective on the importance of undetected injuries as a major contributor to morbidity and mortality after abdominal trauma. The article by Muckart and Thomson, from the University of Natal in South Africa, describes the impact of errors in diagnosis and management on eventual patient outcome. The review is performed in a refreshingly candid manner that is rarely seen in a paper from the United States, given our highly litigious society and a medicolegal system that places restraints on open, honest reporting of adverse results. The case reported is excellent from an overall standpoint. The authors reported on an annual experience with more than 2,300 cases of truncal trauma in which 18 patients died because of a breakdown in the trauma system. The failures observed were not due to the lack of performance of a sophisticated test or a complex operation. The errors fell into two categories. The system
From the Department of Surgery, University of Louisville, Louisville, Kentucky.
44%
THE AMERICAN
breakdowns occurred when relatively simple procedures were not performed. The omission of cystograms, peritoneal lavages, or exploratory celiotomy in clinical situations in which they were clearly indicated was a major cause of delay in diagnosis and treatment. Second, major problems were encountered in the performance of exploratory celiotomy because the abdomen was not thoroughly and adequately explored. Several key injuries were missed with disastrous consequences. The authors’ message is clear and certainly well known to experienced trauma surgeons. When injuries are diagnosed late or initially undetected, virtually all patients require management in the intensive care unit even though their wounds may have initially been simple ones. Nearly half of the patients in this review died, with the majority of deaths occurring in those whose initial operation was inappropriate. *Many trauma attending surgeons are asked by their residents whether in fact it is necessary to incise all hematomas caused by penetrating trauma. “Do you really believe it is necessary to mobilize the duodenum in
JOURNAL OF SURGERY
every case?” asks the doubting resident in the middle of the night over a case where the likelihood of duodenal injury appears small. Similarly, many trauma care surgeons correctly worry about the number of negative diagnostic studies performed. While these worries may be appropriate and refinements in diagnostic accuracy are laudatory, this report vividly demonstrates the “downside” of an undetected injury in many cases: major morbidity and death. The authors are to be commended for several aspects of this report; the incidence of undetected injuries is low in a large series of patients and speaks well for the quality of their trauma system. However, as they attempted to improve on these results, they documented that diligence in diagnosis and treatment is required to avoid unnecessary morbidity and mortality. Their results demonstrated conclusively that protocols must be strictly followed to avoid unnecessary delays and missed injuries. These types of adverse outcomes must be borne in mind as we attempt to further refine our diagnostic acumen and decrease the number of “nontherapeutic” procedures in trauma patients.
VOLUME 162 NOVEMBER 1991
FRCS,
Sandie R. Thomson,
A prospective audit of trauma patients managed at the discretion of six different general surgical units was performed over a 6-month period. Eighteen patients were identified in whom diagnostic delay or injuries undetected at operation contributed to increased morbidity and mortality. Failure to perform investigations as indicated by the nature of the trauma was the main reason for delay in diagnosis in seven patients. Incomplete exploration at laparotomy resulted in seven undetected injuries, while unexplored retroperitoneal hematomas accounted for the remaining four. Fourteen patients (78%) requkd management in the intensive care unit. Eight patients died (4%) as a result of ongoing sepsis and multiple organ failure. Seven of the deaths occurred in patients in whom surgical treatment was inadequate. Delays in diagnosis and undetected injuries, although uncommon, are a readily preventable cause of phase 3 trauma deaths. Strict adherence to standard surgical protocols as employed in dedicated trauma’care centers does much to reduce unnecessary morbidity and mortality.
From the Departmentof Surgery, University of Natal Medical School, Durban, Republic of South Africa. Requests for reprints should be addressed to David J.J. Muckart, FRCS, Department of Surgery, University of Natal Medical School, P.O. Box 17039, Cmgella 4013, Republic of South Africa. Manuscript submitted March 13, 1990, and accepted in revised form June 28.1990.
chM, FRCS, Durban,southAfrica
elays in diagnosis and absent or inappropriate surD gical management are major contributing factors to morbidity and mortality after injury [l-3]. Although most of these errors occur in patients with multiple trauma whose major life-threatening injuries assume precedence [46], some occur because of a failure to follow well-established protocols [ 7,8]. At Ring Edward VIII Hospital, Durban, more than 2,000 penetrating chest, 1,000 penetrating torso, and 300 blunt torso injuries are treated annually by 6 surgical units, Each unit is headed by a consultant general surgeon with trauma experience and includes a senior registrar with at least 4 years of surgical training and two junior registrars on the training program. Patient management is at the discretion of the individual senior surgeon concerned. We report on the outcome of a series of patients with torso trauma in whom basic errors in management were made resulting in preoperative and intraoperative missed diagnoses. PATIENTS AND METHODS
During the 6-month period from February 1989 through July 1989, 18 patients were identified, each of whom had a single injury overlooked. There were 16 male and 2 female patients, with an age range of 16 to 5 1 years (median: 24 years). Twelve patients had penetrating wounds (8 stab; 4 low velocity gunshot), and 6 had blunt injuries (4 motor vehicle accident; 2 assault). Four patients were in shock on admission to the emergency department; all responded rapidly to resuscitation. These 18 patients constituted 2.6% and 4%, respectively, of all patients with penetrating and blunt injuries admitted during this period. In seven patients, the diagnosis was delayed as a direct result of a failure to perform investigations as indicated by the nature of the trauma (Table I). All patients had been examined by the attending consultant surgeon. Contrast radiography of the genitourinary tract was omitted in three patients despite the presence of hematuria. Diagnostic peritoneal lavage (DPL) was not performed& two patients with equivocal abdominal findings after blunt trauma. One patient with multiple injuries did not undergo routine chest radiography, and, in the remaining patient with a gunshot wound of the left upper quadrant, immediate laparotomy was not performed because of the absence of peritoneal signs. Six patients eventually underwent laparotomy after a delay ranging from 12 hours to 5 days. Five of these six patients required intensive care management postoperatively. The length of stay in the intensive care unit ranged from 2 to 30 days. In one patient with a ureteric injury, a percutaneous nephrostomy was performed and laparotomy avoided. There was one death in this group as a result of overwhelming sepsis arising from a fecal tistula into the left pleural cavity.
THE AMERICAN JOURNAL OF SURGERY
VOLUME 162 NOVEMBER 1991
457
MUCKART AND THOMSON
TABLE I Delayed Diagnosls Due to Omission of an Indicated Investigation Injury Mode Blunt Stab Blunt
Gunshot Blunt
Missed Injury
Presentation Hematuria (macroscopic) Hematuria (microscopic) Equivocal abdominal signs Equivocal abdominal signs Multiple fractures
Omitted Procedure
No.
Bladder rupture
2
Cystography
Uretericlaceration
1
Intravenous
Jejunal perforation
2
Colonic perforation
1l
Diaphragmatic hernia
1
pyelography Diagnostic peritoneal lavage Laparotomy
Chest radiography
7
Total
COMMENTS
‘Died.
TABLE II Missed lntraoperatlve Vlsceral Injuries Mode of Injury
Missed Organ Injury
No.
Stab Stab Gunshot Stab Gunshot
Duodenum Diaphragm Rectum Small intestine Intestinal ischemia
2 2 1 1 1 7
Total
Alive
Dead
1
2 1 1
1 1 5
2
TABLE III Mlssed Injuries Following Failure to Explore Retroperltoneal Hematomas Mode of Injury
Zone
Missed Organ Injury
Outcome
Blunt Stab Stab Gunshot
I II II Ill
Common iliac artery Renal vein Renal pelvis External iliac artery
Died Died Alive Alive
TABLE IV Clinical Signs Necessitating a Second Laparotomy Missed Organ Injury
No.
Indications for Re-Operation
Duodenum Rectum Diaphragm
2 1 1
Progressive MOF Progressive MOF Acute respiratory failure: gastric herniation on chest radi-
Diaphragm Small intestine Renal pelvis External iliac artery
1 1 1 1
Total
8
ography Persistent pleural effusion Persistent peritonitis Persistent peritonitis Absent femoral pulse
MOF = multiple organ failure.
458
THE AMERICAN
JOURNAL
In 11 patients, the injury was missed intraoperatively. Five visceral and two diaphragmatic injuries were overlooked (Table II), and four injuries remained undiagnosed after failure to explore retroperitoneal hematomas (Table III). The senior surgeon was present at only three of these procedures. Rapid postoperative deterioration and death occurred in three patients. The other eight patients underwent a second laparotomy (Table JY). All eight required intensive care therapy postoperatively for a period of time ranging from 1 to 21 days. Four of these eight patients died as a result of multiple organ failure. Therefore, seven patients (66%) with an undetected intraoperative injury died. The total number of deaths from diagnostic delay and undetected intraoperative injuries was eight, resulting in an overall mortality rate of 44%.
OF SURGERY
VOLUME
Poor clinical judgment, inadequate use of diagnostic facilities, and admission to an inappropriate surgical ward have been incriminated as the main reasons for undetected injuries [ 2,4,6j. As a direct consequence, necessary surgical treatment is unduly delayed, inadequate, or omitted altogether. In a recent retrospective report by Anderson et al [I], 78% of patients who required surgical intervention did not undergo operation, while Kreiss et al [2] reported that 83% of preventable deaths occurred as a result of inadequate surgical management. Although undetected injuries include both delays in diagnosis and those overlooked at operation, they are best considered as separate entities. In the former type of injury, obvious symptoms and signs may be absent or equivocal, while, in the latter, symptoms and signs are invariably present and poor surgical technique is the basic error. Diagnostic delay: Not one patient who presented with hematuria underwent intravenous pyelography or cystography, and major renal tract trauma was overlooked in all three. Rapidly clearing macroscopic hematuria does not exclude major trauma to the renal tract, and significant genitourinary injury can occur with any degree of hematuria [9,10]. Early aggressive use of contrast radiography including cystography is therefore essential. Radiologic imaging of the genitourinary tract for microscopic hematuria in asymptomatic patients following penetrating trauma is usually unnecessary, because the majority of injuries are posterior stab wounds and involve only the renal parenchyma. Persistent microscopic hematuria associated with penetrating wounds should, however, be investigated [IO]. DPL has become the cornerstone of investigation in patients with blunt abdominal trauma in whom physical findings are equivocal. The procedure has diagnostic accuracy rates of between 93% to 97% in most reported series [I I]. In two patients, this investigation was omitted despite equivocal physical findings on admission. This resulted in a 48-hour delay in operative intervention with resultant septic shock and prolonged intensive care management in one patient. The technique is uncomplicated and extremely reliable [ 221 and should be done routinely in such patients if selective conservative management is to be employed. 162
NOVEMBER
1991
UNDETECTED INJURIES
Gunshot wounds that penetrate the peritoneal cavity are associated with a 97% risk of major intra-abdominal injury. As a result, use of a selective conservative policy as in patients with abdominal stab wounds is considered unjustified by most investigators [13]. Unless the wound is most definitely tangential or specific criteria exist to justify withholding intervention [ 141, laparotomy is mandatory if the peritoneal cavity has been breached. Rupture of the diaphragm after blunt abdominal trauma is most frequently associated with motor vehicle accidents, in particular high-speed, single-occupant collisions [ 151, but this injury may occur with lesser degrees of abdominal trauma [ I6J. Although the diagnosis may be difficult to establish, chest radiography is the most sensitive study and is mandatory in any patient with multiple trauma. Undetected injuries at laparotomy: Undetected intraoperative injuries, although fortunately rare, are associated with prohibitive mortality rates. In this series, such injuries accounted for 88% of the deaths. Guidelines describing the best way to perform laparotomy in trauma patients are available [17]. A generous midline incision should be used, and all viscera should be examined by both the surgeon and the surgical assistant. The lesser sac should be opened routinely, and the duodenum should be mobilized if injury is suspected. Failure to perform a thorough inspection of all viscera was the most common error in this series. Failure to inspect the diaphragm during laparotomy in the symptomatic patient with a low chest or upper abdominal wound is a grave error of omission, and it is incumbent upon the surgeon to verify that the hemidiaphragms are not injured [7]. Although a complete inspec tion of all viscera is desirable at laparotomy, mobilization of all organs is unnecessary if not indicated, especially in the retroperitoneum, and may contribute to morbidity from iatrogenic injury [18,19]. Prior knowledge of all wounds is, therefore, essential, especially those situated posteriorly. Sepsis in the retroperitoneal tissues is relentless, rapidly progressive, and resistant to antimicrobial therapy. If the surgeon suspects injury in this area, every effort must be made to verify its presence. Penetrating injuries of the intestine, unless tangential in nature, are associated with both entrance and exit wounds, except when an intraluminal missile is retained. The finding of an odd number of holes should lead to a careful scrutiny for an undetected injury, with the commonest site being the mesenteric border. Small hematomas in this area should be fully explored. If a superior mesenteric vascular injury is present, intestinal viability must be verified when the procedure is terminated. If, at this time, doubt still remains, then a second laparotomy should be performed within 24 hours. Rectal injuries are associated with a high rate of pelvic sepsis, and guidelines for their management have emerged based on the experiences gained during the various military conflicts of this century [20,2I]. These have been extended to the civilian environment with good effect [22]. The preoperative omission of a rectal examination and sigmoidoscopy in the presence of a pelvic gunshot wound is a serious oversight, and failure to perform a
distal colonic washout and institute adequate drainage contribute to high mortality rates from this injury. Exploration of retroperitoneal hematomas presents a formidable challenge to the surgeon and, if performed unnecessarily, may cause iatrogenic morbidity to the patient [23]. Failure to explore these areas, however, results in a high incidence of undetected vascular injuries and an appreciable mortality rate. The need to explore all zone I hematomas is underscored by the two deaths following failure to perform this procedure, both of which were due to catastrophic postoperative hemorrhage. Although not advised by other authors [23], we believe the wound track should be followed to its termination in medial zone II injuries to avoid missing injuries of the renal pelvis. Failure to diagnose injury, whether it be from delay or error, is one of the most important avoidable causes of phase 3 trauma deaths. Undetected injuries at operation are associated with a significantly higher mortality than are preoperative delays in diagnosis. A single overlooked lesion, as occurred in each patient in this study, is enough to result in death. To avoid this, all wounds must be identified before surgery and a thorough laparotomy should be performed. Liberal exploration of retroperitoneal hematomas should be done. Failure to consider the possibility of an overlooked injury and reluctance to perform a second laparotomy are the prime reasons for the high mortality rate. Lack of the expected recovery and unexplained isolated organ failure are major indicators of an undetected injury and should prompt immediate and aggressive investigation in the form of reoperation. Healthy skepticism on the part of the surgeon is invaluable in this respect [5]. Although errors in judgment may still occur within dedicated trauma care centers, the creation of these centers has resulted in well-proven standard protocols for the management of trauma patients. Our audit suggests that stricter adherence to such guidelines, rather than individualized management, prevents unnecessary morbidity and mortality.
REFERENCES 1. Anderson ID, Woodford M, De Dombal FT, Irving M. Retrospective study of 1,000 deaths from injury in England and Wales. BMJ 1988; 296: 1305-8. 2. Kreiss DJ, Plasencia G, Angenstein D, et al. Preventable trauma deaths. Dade County, Florida. J Trauma 1986; 26: 649-53. 3. West JG, Trunkey DD, Lim RC. Systems of trauma care. Study of two counties. Arch Surg 1979; 114: 455-60. 4. Hamdan TA. Missed injuries in casualties from the Iraqi-Iranian War: a study of 35 cases. Injury 1987; 18: 15-17. 5. Scalea TM, Phillips TF, Goldstein AS, ef al. Injuries missed at operation: nemesis of the trauma surgeon. J Trauma 1988; 28: 962-7. 6. Chan RNW, Ainscow D, Sikorski JM. Diagnostic failure in multiple injuries. J Trauma 1980; 20: 684-9. 7. Feliciano DV, Cruse PA, Mattox KL, ef al. Delayed diagnosis of injuries to the diaphragm after penetrating wounds. J Trauma 1988; 28: 1135-44. 8. Gordon JA. Unexpected, unsuspected, and missed injuries in a paediatric trauma unit. S Afr J Med 1986; 70: 415-6. 9. Bergren CT, Chan FN, Bodzin JH. Intravenous pyelogram
THE AMERICAN JOURNAL OF SURGERY
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results in association with renal pathology and therapy in trauma patients. J Trauma 1987; 27: 515-8. 10. Nicolaisen GS, McAninch JW, Marshall GA, Bluth R, Carrol PF. Renal trauma: re-evaluation of the indications for radiographic assessment. J Ural 1985; 133: 183-7. 11. Gomez GA, Alvarez R, Plasencia G, et al.Diagnostic peritoneal lavage in the management of blunt abdominal trauma: a reassessment. J Trauma 1988; 28: l-5. 12. Lazarus HN, Nelson AJ. A technique of diagnostic peritoneal lavage without risk of complication. Surg Gynecol Obstet 1979; 149: 889-92. 13. Lowe RJ, Saletta JD, Read DR, Radhakrishnan J, Moss GS. Should japarotomy be mandatory or selective in gunshot wounds of the abdomen? J Trauma 1977; 17: 903-8. 14. Demetriades D, Rabinowitz B. Non-operative management of penetrating liver injuries: a prospective study. Br J Surg 1986; 73: 736-7. 15. Johnson CD. Blunt injuries of the diaphragm. Br j Surg 1988; 75: 226-30. 16. McDonald MA, Muckart DJJ. Diaphragmatic disruption in
blunt trauma. S Afr J Surg 1989; 27: 19-20. 17. Dudley HAF. Exploration of the abdomen. In: Champion HR, Robbs JV, Trunkey DD, editors. Rob and Smith’s operative surgery, trauma surgery. 4th ed. London: Butterworths, 1989; 1: 346-53. 18. Maynard AC, Orpeza G. Mandatory operation for penetrating wounds of the abdomen. Am J Surg 1968; 115: 307-12. 19. Nance FC, Cohn I. Surgical judgement in the management of stab wounds to the abdomen: a retrospective and prospective analysis based on a study of 600 stabbed patients. Ann Surg 1969; 170: 569-80. 20. Lavenson GS, Cohen A. Management of rectal injuries. Am J Surg 1971; 122: 225-30. 21. Lung JA, Turk RP, Miller RE. Wounds of the rectum. Ann Surg 1970; 172: 985-90. 22. Shannon FL, Moore EE, Moore FA, McCroskey BL. Value of distal colon washout in civilian rectal trauma-reducing the risk of bacterial translccation. J Trauma 1988; 28: 989-94. 23. Costa M, Robbs JV. Management of retroperitoneal haematoma following penetrating trauma. Br J Surg 1985; 72: 662-4.
EDITORIAL COMMENT
J. David Richardson, MD, Louisville,Kentucky This issue of The American Journal of Surgery contains a unique perspective on the importance of undetected injuries as a major contributor to morbidity and mortality after abdominal trauma. The article by Muckart and Thomson, from the University of Natal in South Africa, describes the impact of errors in diagnosis and management on eventual patient outcome. The review is performed in a refreshingly candid manner that is rarely seen in a paper from the United States, given our highly litigious society and a medicolegal system that places restraints on open, honest reporting of adverse results. The case reported is excellent from an overall standpoint. The authors reported on an annual experience with more than 2,300 cases of truncal trauma in which 18 patients died because of a breakdown in the trauma system. The failures observed were not due to the lack of performance of a sophisticated test or a complex operation. The errors fell into two categories. The system
From the Department of Surgery, University of Louisville, Louisville, Kentucky.
44%
THE AMERICAN
breakdowns occurred when relatively simple procedures were not performed. The omission of cystograms, peritoneal lavages, or exploratory celiotomy in clinical situations in which they were clearly indicated was a major cause of delay in diagnosis and treatment. Second, major problems were encountered in the performance of exploratory celiotomy because the abdomen was not thoroughly and adequately explored. Several key injuries were missed with disastrous consequences. The authors’ message is clear and certainly well known to experienced trauma surgeons. When injuries are diagnosed late or initially undetected, virtually all patients require management in the intensive care unit even though their wounds may have initially been simple ones. Nearly half of the patients in this review died, with the majority of deaths occurring in those whose initial operation was inappropriate. *Many trauma attending surgeons are asked by their residents whether in fact it is necessary to incise all hematomas caused by penetrating trauma. “Do you really believe it is necessary to mobilize the duodenum in
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every case?” asks the doubting resident in the middle of the night over a case where the likelihood of duodenal injury appears small. Similarly, many trauma care surgeons correctly worry about the number of negative diagnostic studies performed. While these worries may be appropriate and refinements in diagnostic accuracy are laudatory, this report vividly demonstrates the “downside” of an undetected injury in many cases: major morbidity and death. The authors are to be commended for several aspects of this report; the incidence of undetected injuries is low in a large series of patients and speaks well for the quality of their trauma system. However, as they attempted to improve on these results, they documented that diligence in diagnosis and treatment is required to avoid unnecessary morbidity and mortality. Their results demonstrated conclusively that protocols must be strictly followed to avoid unnecessary delays and missed injuries. These types of adverse outcomes must be borne in mind as we attempt to further refine our diagnostic acumen and decrease the number of “nontherapeutic” procedures in trauma patients.
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