Evaluation of Missed Radiological Pathologies in Multiple Trauma Patients with Full-Body Computed Tomography in the Emergency Department

Introduction and Purpose: Brain, cervical, thorax and abdominal computed tomography are often preferred as the imaging method in patients with high energy multiple trauma at emergency service. Pathologies that are missed during emergency diagnosis processes in trauma patients increase morbidity and mortality. In our study, comparing the diagnoses of multiple trauma patients who received full-body CT in the emergency department with the official radiology reports evaluated after the emergency services; we aimed to detect the missed radiological diagnoses in multiple trauma patients in the emergency service and to determine the effects of these diagnoses on mortality and morbidity. Materials and Methods: For this observational, cross-sectional and retrospective study, consent was obtained from the Non-Interventional Ethics Committee of Dokuz Eylül University Medical Faculty. All patients over the age of 18 years who were admitted to the Dokuz Eylul University Emergency Department between 01.07.2016-30.06.2018 and who underwent brain, cervical, thorax and abdominal computed tomography were included in the study. The radiology official reports of the computed tomographies and the electronic file information of the emergency service were examined by the work team. Mortality assessment of patients within 48 hours and within 7 days of death, hospitalization needs for morbidity assessment, need for intensive care, additional consultation after medical service evaluation, medical and surgical additional intervention needs were recorded on the data sheet. The data were evaluated in SPSS 24.0 package program. While the difference between radiological diagnosis and emergency department diagnosis was evaluated by McNemar test, the compatibility between radiological diagnosis and emergency department diagnosis was measured by Kappa analysis. Significance level p <0.05 was accepted. Findings: In the study, 1358 patients who underwent full-body CT in the emergency room due to trauma between 01.07.2016 and 30.06.2018 and who met the inclusion criteria were evaluated. The mean age of the patients was 45.9 ± 1.1 (range: 18-99). When the trauma mechanisms were examined, it was found that they applied most frequently due to in-vehicle traffic accidents and motorcycle accidents. The presence of any intracranial hemorrhage in 138/152 patients (90.8%) and the presence of cranial fractures in 83/98 patients (84.7%) in the CT images of the patients were correctly detected in the emergency room. Among the emergency diagnosis and the official radiology report, there was a moderate, high and very high degree of compatibility in all brain CT pathologies except for the diagnosis of cerebral edema. In cervical CT pathologies, there was a high and very high degree of compatibility between emergency diagnosis and official radiology report. Lung pathologies were correctly detected in the emergency room in 209/265 patients (78.8%) on the thorax CT images of the patients. Between the emergency diagnosis and the official radiology report, there was a moderate, high and very high degree of compatibility in other thoracic region pathologies other than pneumomediastinum. When the compatibility between abdomen CT emergency department diagnosis and the official radiology report was evaluated, it was found that there was moderate, high and very high degree of compatibility in other diagnoses other than bladder injury and mesentery injury. A total of 369 diagnoses were missed in 248 (18.3%) of 1358 patients evaluated in the study. The diagnosis / patient ratio was 0.27. Of these, 73 patients had 83 brain CT pathology, 16 patients had 19 cervical CT pathology, 126 patients had 156 thorax CT pathology, and 84 patients had 111 abdominal CT pathology. There were 369 diagnoses that required consultation in 248 patients whose emergency radiological diagnosis was missed. Of these, 156 patients (62.9%) had 203 diagnoses (55%) consulted with at least one department, and although consultation was requested from the relevant branch, these diagnoses were missed in both the emergency and consultation processes. According to the frequency order of these branches, the first three were neurosurgery (n = 59, 68.6%), thoracic surgery (n = 56, 47.5%) and orthopedics (n = 51, 69.9%). At least one missed diagnosis was present in 88 (9.7%) of 907 (66.8%) patients discharged. At least one missed diagnosis was present in 18/23 (78.3%) patients who died within the first 48 hours and in 4/8 (50%) patients who died between 48 hours and 7 days. There were at least one missed diagnosis of 163/462 hospitalized patients (35.3%) and 50/105 (47.6%) hospitalized patients in intensive care units. While the discharge rate of patients with a missed diagnosis is 35.5%, the rate of being called from home is 1.2%, the intensive care hospitalization rate is 20.2%, the hospitalization rate is 65.7%, the death rate is 8.9%, these values of non-skipped diagnoses were 73.8%, 0%, 5%, 26.9% and 0.8%, respectively. Medical additional intervention in 13 (3.8%) patients whose diagnosis was noticed after hospitalization (six patients antiedema treatment, two patients oxygen support and each of these once in different patients; low molecular weight heparin, shoulder arm strap, sitting wheel, philadelphia type cervical coller and tlso corset). Eight patients underwent surgical intervention (four patients underwent tube thoracostomy, two patients intracranial decompression surgery and one patient splenectomy and femur fracture operation), and 59 additional consultations in 45 (18.5%) patients. The branches that required additional consultation were thoracic surgery (19 patients), neurosurgery (15 patients), orthopedics (12 patients), general surgery (eight patients), urology (two patients), otolaryngology diseases, cardiovascular surgery and cardiology each for one patient. Results: According to the results of our study, the compatibility between emergency diagnoses and official radiology reports is high in multiple trauma patients who underwent whole-body CT. The rate of diagnosis missed in the full-body CT in our emergency department is 18.3%. The most frequently diagnosed thoracic region pathologies are missed and the most frequent consultation related to the missed diagnoses is the branch orthopedics. In the patient group with a missed diagnosis, discharge from the emergency room is less, in-hospital death, hospitalization and intensive care are more. KEY WORDS: Emergency Department, Multiple Trauma, Full-Body Computed Tomography, Computed Tomography, Radiological Diagnoses, Missdiagnosis