HOLLYWOOD, FLA. – Imaging obtained at nontertiary trauma centers probably doesn’t tell the whole story of a trauma patent’s injuries, according to a new retrospective study.
Repeat scans done at a Level 1 trauma center identified new injuries in 76% of patients who were transferred, Morgan Bonds, MD, reported at the annual scientific assembly of the Eastern Association for the Surgery of Trauma. About half of these previously unobserved injuries were considered clinically significant, said Dr. Bonds, a surgical resident at the University of Oklahoma, Oklahoma City.
Her study examined imaging and clinical assessment of 203 trauma patients who were initially worked up at a nontertiary trauma center (NTC), and then transferred to the Level 1 University of Oklahoma tertiary trauma Center (TTC). The facility’s primary radiologist reviewed all of the initial CT scans while blinded to the NTC interpretation. The initial scans and interpretations were then compared with those done at the TTC.
The team split imaging and interpretation disconnects into four categories:
• Type A errors: A missed injury on the NTC scan. “This represents the expertise and experience of our primary radiologist,” Dr. Bonds said.
• Type B errors: Missed injuries on scans where NTC radiologists saw other injuries that the TTC radiologist did not confirm. “This represents the experience of our radiologist and also the inexperience and overreaction of the NTC radiologists.
• Type C errors: New injuries seen on additional TTC imaging of the same body area. “This represents the quality of the image.”
• Type D errors: New injuries found upon any new imaging, whether of a previously scanned or newly scanned body area. “This represents quality of work-up – the decision of the trauma team to more fully investigate the patient’s injuries, as well as the quality of the CT tech performing the scan.”
During the study period, 203 patients presented at the TTC with prior scans conducted at an NTC.
The mean age of the patients was 43 years; most (67%) were men. The mean Injury Severity Score was 16; 97% had experienced blunt trauma. Shock was present in 3% and a traumatic brain injury in 8%. Repeat scans were most common for neck and cervical spine injuries (54%) and thoracic/lumbar spine injuries (53%) and least common for chest injuries (32%).
An inadequate NTC work-up as judged by the TTC attending was the most common reason for getting new images (76%). Poor image quality was the next most common reason (31%).
Among the 203 patients, 99 (49%) had a type A error. Of these injuries missed on the initial scan, 90% were considered to be clinically significant.
Type B errors occurred in 15% of patients.
Type C errors (new injuries in different body area) occurred in 54% of patients and, of these, 76% were considered clinically significant. Type D errors (new injuries seen in any imaging of any area) occurred in 73% of patients.
“This study confirms that images are often repeated or completed after having images done at nontertiary trauma centers,” Dr. Bonds said. “Relying on NTC image interpretation can lead to undertreating our patients. One potential solution to this issue could be image sharing between NTCs and TTCs. This might reduce both the rate of missed injuries and the need for repeat scans.”
Dr. Bonds had no financial disclosures.