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Trauma Tertiary Surveys
What, Why, When, How & Who:
Detecting Missed Injuries in the Multiply-Injured Patient


Trauma patients present a unique challenge to the healthcare team as life-threatening injuries must be rapidly identified and treated with consideration given to clinical presentation, mechanism of injury, age, co-morbid factors and pre-existing medical conditions (1). Often, these patients are uncooperative or unresponsive and are unable to furnish valuable event and medical history data. The American College of Surgeons developed the Advanced Trauma Life Support (ATLS) course to evaluate the trauma patient with a systematic approach that utilizes primary and secondary surveys to ensure that all injuries are identified. However, not all injuries are detected by these two surveys. In fact, between 2 to 50% of combined life threatening and non-life threatening injuries are missed (2). Centers that examined the incidence of missed injuries concur that patients who sustain blunt trauma have a higher rate of missed injuries than those who sustain penetrating trauma (3). As a result, a tertiary trauma survey (TTS) is increasingly being implemented to avoid missed injuries.

“What” is the TTS?

The tertiary trauma survey is defined by the ACS as a patient evaluation that identifies and catalogues all injuries after the initial resuscitation and operative intervention (4). The timing of this survey is institution specific, but typically occurs within twenty four hours after admission and is repeated when the patient is awake, responsive, and able to communicate any complaints. The tertiary trauma survey is a comprehensive review of the medical record with emphasis on the mechanism of injury and pertinent co-morbid factors such as age. It includes the repetition of the primary and secondary surveys, a review of all laboratory data, and a review of radiographic studies with an attending radiologist (2). Any new physical findings require further studies to rule out missed injuries.

“When” & “How” should the TTS be performed?

Overall, the evidence suggests further longitudinal prospective studies are needed to identify the appropriate timing of the tertiary trauma survey. However, current practice is to perform the TTS within 24 hours of admission and also prior to discharge to reassess identified injuries, to confirm suspected injuries, and to identify occult injuries (4). After this complete review of the patient’s medical record and when all injuries are identified a comprehensive care plan is developed. At San Francisco General Hospital the standardized TTS is performed by the Trauma Nurse Practitioners on Critical Care admissions within 24 hours and repeated prior to discharge. For patients admitted to the Ward, a TTS is performed prior to discharge.
The physical assessment is a complete “head to toe” evaluation with a focus on mechanism of injury. All radiographic imaging and laboratory value trends are then reviewed. If a new injury is suspected then further studies are obtained. A standardized worksheet that becomes part of the patient’s hospital record is completed to catalogue all injuries.

Download the TTS form in Adobe PDF or Microsoft Word formats

“Why” perform a Tertiary Survey?

Systematic re-evaluation of the multiply-injured trauma patient with the tertiary trauma survey revealed missed injuries that had the potential to be a clinically significant factor on patient morbidity and mortality (4). Furthermore, these studies agreed that to understand the etiology of missed injuries and to appreciate the significance of early detection improved morbidity and mortality in this patient population. The incidence of missed injuries ranged from 9% to 65% of admitted blunt trauma patients in these studies (2,5). The most frequently missed injuries in these studies were extremity and pelvic fractures, spinal cord and head injuries, and abdominal and nerve injuries, ranging from 28% to 85% of detected injuries.

Several factors have been identified as delaying the identification of injuries during the initial evaluation in the emergency department. These primary contributing factors included an altered level of consciousness from a closed head injury, alcohol or drug intoxication, use of sedation and paralytic agents for intubation, and hemodynamic instability that required emergent operative evaluation (5). Neighboring or “distracting” injuries and delayed transfer or presentation to a trauma center have also been associated with delayed diagnoses (1).

System factors also contribute to the missed injury rate - inadequate clinical assessments and radiology errors being the most commonly cited (6). Biffl, Harrington, & Cioffi (2003) furthered these claims and demonstrated that clinically significant missed injuries were detected within 24 hours of admission with Implementation of standardized tertiary trauma surveys has been shown to significantly reduced this delayed and missed injury rate (7).

“Who” should perform the Tertiary Survey?

Formal tertiary trauma surveys are performed by a myriad of providers who have included bedside critical care nurses, nurse practitioners and physicians. The literature recommends that a multiply-injured patient be evaluated with serial examinations by a provider with advanced skills. This approach provides care continuity and detects subtle changes that may indicate missed injuries and their sequelae (1).

Further investigation is needed to determine the most appropriate person to perform this evaluation. A designated trauma team member should have advanced assessment skills, provide consistent and frequent evaluations of the multiply-injured patient and be able to review laboratory findings and diagnostic studies with a radiologist (2). This role is ideally suited for a trauma nurse practitioner (TNP). As a member of the trauma team, they utilize their technical skills and experience to provide consistent, competent, and comprehensive care to the multiply-injured trauma patient. Since the TNP is an integral part of the process, they are well-positioned to detect subtle changes that may indicate an evolving injury. Moreover, consultations and interventions may be expedited; resulting in a potential decreased morbidity and mortality as well as hospital length of stay (4).

The importance of a singular, knowledgeable individual to coordinate and to perform this role is likely to be a significant benefit to the multiply-injured patient. The TNP can provide the expertise and continuity of care required to perform advanced serial assessments to avoid undiagnosed, potentially life-threatening injuries.

Food for Thought: Gaps in the Literature.

A comprehensive treatment plan be developed and implemented only after the nature and severity of all injuries have been determined (4). The tertiary survey allows the cataloging of all new injuries and the re-evaluation of known injuries. Performing and documenting the tertiary survey also promotes communication and interaction between the surgical specialties, the critical care unit and the radiology department. Deficits in collaboration and communication between medical teams may hinder the timely identification and appropriate treatment of injuries. As a result, patient outcomes may be compromised (4). Similarly, a formal review of the diagnostic imaging studies by an attending radiologist is necessary to achieve “loop closure”.

Very few of the studies mentioned identified the team member(s) who performed the tertiary trauma surveys or non-standardized reassessments. A designated team member to perform serial evaluations is ideal to detect subtle changes that occur with an “evolving” injury and to provide continuity prior to discharge to the ward or to home from the hospital.

The completion of the TTS within twenty-four hours for severely injured patients with ISS>15 is an arbitrary standard, yet most studies accept this as appropriate. However, there is no data to substantiate this time interval, or this injury severity, as the foundation for the ideal trauma tertiary survey. This is an area that warrants further investigation.

The standardized use of the primary and secondary trauma surveys by pre-hospital, emergency departments, and trauma team members is routine in many countries. However, the TTS has not been standardized by organizations like the American College of Surgeons (ACS). They recommend and support the re-evaluation of the multiply-injured trauma patient, but fail to develop clear, standardized criteria. As a result, internal validity challenges arise and make it difficult to compare similar studies to determine the efficacy of the TTS (8).

Potential contributing factors to missed injuries such as a high volume and acutely ill patient admissions to the hospital, a decreased number of surgical residents available and nurse staffing shortages were not addressed in any of the studies. However, more clinically significant missed injuries have been identified as occurring in nighttime blunt trauma patients than during the daytime (2). This observation may have been related to assessment errors by junior house staff.

The literature reviewed provided strong evidence that morbidity and mortality may decrease with a re-evaluation of the multiply-injured blunt trauma patient for re-evaluation of suspected injuries, and identification of occult injuries by serial re-examinations and review of (or additional) diagnostic studies. Completion of a formal tertiary trauma survey (TTS) would strengthen the plan of care to maximize the patient’s outcome. The communication chain can be strengthened by using a standardized TTS assessment form to provide clear and ongoing documentation of injury identification and diagnostic results. As a result, the Trauma Nurse Practitioner would be instrumental in ensuring a plan of care has been set with the trauma and consulting teams to minimize the consequences of missed injuries.


1. Houshian, S., Larsen, M. S., & Holm, C. (2002). Missed injuries in a level one trauma center. The Journal of Trauma, Injury, Infection, and Critical Care 52(4), 715-719.

2. Janjua, K. J., Sugrue, M., & Deane, S. A. (1998). Prospective evaluation of early missed injuries and the role of tertiary trauma survey. The Journal of Trauma, Injury, Infection, and Critical Care, 44, 1000-1007.

3. Born, C. T., Ross, S. E., Iannacone, W. M., Schwab, C. W., & Dong, W. G. (1989). The Journal of Trauma, 29(12),1643-1646.

4. Grossman, M. D., & Born, C. (2000). Tertiary survey of the trauma patient in the intensive care unit. Surgical Clinics of North America, 80(3), 805-824.

5. Enderson, B. L., Reath, D. B., Meadors, J., Dallas, W., DeBoo, J. M., & Maull, K. I. (1990). The tertiary trauma survey: A prospective study of missed injury. The Journal of Trauma, 30(6), 666-670.

6. Buduhan, G., & McRitchie, D. I. (2000). Missed injuries in patients with multiple trauma. The Journal of Trauma, Injury, Infection, and Critical Care 49(4), 600-605.

7. Biffl, W. L., Harrington, D. T., & Cioffi, W. G. (2003). Implementation of a tertiary trauma survey decreases missed injuries. The Journal of Trauma, Injury, Infection, and Critical Care, 54(1), 38-44.

8. Burns, N. & Grove, S. K. (2001). The practice of nursing research: Conduct, critique, & utilization (4th ed.). Philadelphia, PA: W. B. Saunders.


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