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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.

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Reasons Behind Missed or Misjudged TBI Diagnosis

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  1. Reasons Behind Missed or Misjudged TBI Diagnosis Olli Tenovuo Department of Neurology University of Turku Finland

  2. 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

  3. 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

  4. Material and methods, continued • After exclusion, the database included 777 TBI patients • All possible injury-, patient-, physician- or system-related factors, leading to a misjudgement, were recorded

  5. 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.

  6. Results, continued • A factor confounding the TBI diagnosis was present in 74 % of patients. • The most common causes were a multi-trauma (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.

  7. 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.

  8. 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.

  9. Reasons behind the misjudgements (n) • PTA notassessed (114) • Injurymechanismnotassessed / underestimated (86) • LOC and itsdurationnotassessed (74) • Multipleinjuries (71) • CT-scannottaken (70) • CNS-activedrugsgiven (51) • Externalhead trauma signsmissingornotassessed (44) • Unexperiencedphysician (36)

  10. Reasons behind the misjudgements (n) • Severepainfulness (30) • Psychicfactors (27) • Significantsecondaryinjury (22) • Alcohol (18) • CT misinterpretation (14) • Earlier CNS diseaseor TBI (9) • Misleadinginformation (8) • Communicationproblems (5)

  11. 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.

  12. 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.

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