SP9.1.9 Are Tertiary Trauma Surveys a worthwhile use of time and resource?

Introduction Patients sustaining major trauma undergo primary and secondary surveys in the emergency department to rapidly identify and treat injuries. Tertiary trauma surveys (TTS) are performed once the patient has been stabilised, within 24 hours of admission, to assess for further injuries. In December 2019, the major trauma service at our trauma centre was reconfigured to include a larger clinical team. Following this, we have assessed compliance with TTS completion and rate of new injuries identified. Methods Data was prospectively collected via hospital and TARN databases from 100 consecutive major trauma patients admitted over a two-month period from 1/8/20. Demographic data and key measures including, date and time of arrival to the hospital, date and time of TTS, performing clinician, injuries identified, mechanism of injury and ISS were collected. Results TTS was completed on 79/100 patients during their admission with 16.5% (13/79) of TTS performed identifying at least one additional injury. 18 separate injuries were identified which were categorized by AIS score: 22.2% AIS 1, 61.1% AIS 2 and 16.7% AIS 3. Of these injuries, 17/18 required further imaging and 3 required operative management. In 38.5% (5/13) of cases, the additional injuries increased the patients overall ISS. Conclusion This data demonstrates the importance of tertiary survey completion to ensure that all injuries sustained during major trauma are identified and treated promptly. Further development of this project will include expansion to a larger data set over a prolonged period to further evaluate the rate and significance of injuries discovered via TTS.

Delayed diagnosed trauma in severely injured patients despite guidelines-oriented emergency room treatment: there is still a risk

Purpose Emergency trauma room treatment follows established algorithms such as ATLS®. Nevertheless, there are injuries that are not immediately recognized here. The aim of this study was to evaluate the residual risk for manifesting life-threatening injuries despite strict adherence to trauma room guidelines, which is different to missed injuries that describe recognizable injuries. Methods In a retrospective study, we included 2694 consecutive patients admitted to the emergency trauma room of one single level I trauma center between 2016 and 2019. In accordance with the trauma room algorithm, primary and secondary survey, trauma whole-body CT scan, eFAST, and tertiary survey were performed. Patients who needed emergency surgery during their hospital stay for additional injury found after guidelines-oriented emergency trauma room treatment were analyzed. Results In seven patients (0.26%; mean age 50.4 years, range 18–90; mean ISS 39.7, range 34–50), a life-threatening injury occurred in the further course: one epidural bleeding (13 h after tertiary survey) and six abdominal hollow organ injuries (range 5.5 h–4 days after tertiary survey). Two patients (0.07% overall) with abdominal injury died. The “number needed to fail” was 385 (95%–CI 0.0010–0.0053). Conclusion Our study reveals a remaining risk for delayed diagnosis of potentially lethal injuries despite accurate emergency trauma room algorithms. In other words, there were missed injuries that could have been identified using this algorithm but were missed due to other reasons. Continuous clinical and instrument-based examinations should, therefore, not be neglected after completion of the tertiary survey. Level of evidence Level II: Development of diagnostic criteria on the basis of consecutive patients (with universally applied reference “gold” standard).

The Impact of the Tertiary Survey in an Established Trauma Program

Introduction The trauma tertiary survey (TTS) was first described in 1990 and is recognized as an essential practice in trauma care. The TTS remains effective in detecting secondary injuries in the modern era. Methods Trauma patients discharged between August 1, 2016, and December 31, 2016, were identified in our trauma registry. Collected data include TTS completion rates, detection of injuries, type of provider, and timing. TTS documentation was qualitatively evaluated. Results Out of 407 patients, 264 patients (65%) received a TTS. Injury detection rate was 1.1.%. Average time to TTS was 41 hours. TTS were completed by resident physicians (46%) and advanced practice providers (APPs; 46%). TTS documentation was more complete for APPs than for resident physicians. Conclusion TTS remains an integral component of modern trauma care. Ongoing education on the significance of TTS and the importance of thorough documentation is essential. Provision of real-time feedback to providers is also critical for improving current practices.

Trauma and burns

This chapter discusses trauma and burns and includes discussion on initial management of major trauma (ABCDE), head injury (both primary and secondary, but also clinical management, general intensive care unit care, and specific treatment of raised intracranial pressure), spinal trauma, chest trauma, pelvic trauma, the fluid management of burns and the general management of burns, and penetrating trauma. The concepts of permissive hypotension, ongoing resuscitation, and injury severity scores are discussed, together with the importance of the tertiary survey. The need for treatment in a centre that can deal with all aspects of multiple trauma and the rapid transfer to such a centre is emphasized. Burns treatment includes the effect of inhalational injury to the airway. The need for treatment in a centre that can deal with all aspects of multiple trauma and the rapid transfer to such a centre is emphasized.