Transcript Reasons Behind Missed or Misjudged TBI Diagnosis

Reasons Behind Missed or
Misjudged TBI Diagnosis
Olli Tenovuo
Department of Neurology
University of Turku
Finland
Introduction + purpose of the
study
• Earlier studies and clinical experience
indicate that a significant portion of
acute TBIs remain undiagnosed or that
their true severity is misjudged
• The purpose of this study was to clarify
factors that have led to a missed or
misjudged (in regard to severity)
diagnosis of acute TBI
Material and methods
• From a database of 1041 TBI patients, treated
at a neurological outpatient university clinic
during the years 1993 – 2005, we selected
those in whom a diagnosis of TBI was either
totally missed or where the TBI severity was
gravely underestimated during the first
contact with a treating physician
• Patients < 15 or > 80 years of age, with a
chronic subdural haematoma, with an injury
before 1990, with a minimal TBI, or with
unavailable documents concerning the first
attendance, were excluded
Material and methods, continued
• After exclusion, the database included
777 TBI patients
• All possible injury-, patient-, physicianor system-related factors, leading to a
misjudgement, were recorded
Results
• In 171 of the 777 patients (= 22 %) the
diagnosis of TBI was either missed (=
74 %) or severely misjudged (= 26 %).
• Of these, 121 patients were selected at
random and their documents analyzed
in detail.
Results, continued
• A factor confounding the TBI diagnosis
was present in 74 % of patients.
• The most common causes were a multitrauma (in 42 % of victims), painfulness
(40 %), centrally acting drugs given in
emergency ward (40 %), and surgical
procedures (24 %).
• Several confounding factors were
found in 46 % of patients.
Results, continued
• An indication for acute head CT
(according to a national guideline) was
fulfilled in 96 % of patients, yet it was
done in only 43 % of patients.
• Of these CT scans, 27 % were
interpreted erroneously, with the
trauma signs remaining unnoticed.
Results, continued
• In 27 % of patients, there were no notes
of external head injuries and in 17 % no
notes of the neurological state.
• The presence of amnesia had been
recorded in only seven of these 121
patients (= 6 %).
• The delay to TBI diagnosis was more
than one year in nearly half of these
patients.
Reasons behind the misjudgements (n)
 PTA not assessed (114)
 Injury mechanism not assessed /
underestimated (86)
 LOC and its duration not assessed (74)
 Multiple injuries (71)
 CT-scan not taken (70)
 CNS-active drugs given (51)
 External head trauma signs missing or not
assessed (44)
 Unexperienced physician (36)
Reasons behind the misjudgements (n)
 Severe painfulness (30)
 Psychic factors (27)
 Significant secondary injury (22)
 Alcohol (18)
 CT misinterpretation (14)
 Earlier CNS disease or TBI (9)
 Misleading information (8)
 Communication problems (5)
Discussion
• There are multiple reasons for missed
or misjudged diagnosis of an acute TBI.
• Among the most common causes were
inadequate recording of TBI symptoms
and signs, the presence of confounding
factors (making the diagnosis difficult),
and misinterpretation of imaging
results.
Conclusions
• The guidelines for TBI diagnostics do not
realize in practice.
• The assessment of acute TBI may face
several caveats.
• Should the diagnostics of acute TBIs:
- be concentrated to specialized units?
- be on the response of neurologists?
At least education on this are should be
strongly promoted, and there is a great need
for a reliable TBI marker.