From the Guidelines
Injuries most likely to have a delayed presentation after trauma include diaphragmatic hernias, visceral organ injuries, vascular injuries, traumatic brain injuries, musculoskeletal injuries, and abdominal compartment syndrome. These injuries may initially present with minimal or nonspecific symptoms that worsen over hours to days following the traumatic event. The delay occurs because some injuries develop slowly as bleeding continues, inflammation progresses, or tissue damage evolves. For example, a small diaphragmatic hernia may initially be asymptomatic but later cause severe peritonitis, sepsis, and multi-organ failure as the hernia increases in size and abdominal organs become strangulated 1. Similarly, traumatic brain injuries can develop increasing intracranial pressure over time as edema worsens.
Key Injuries with Delayed Presentation
- Diaphragmatic hernias: can be asymptomatic for decades before becoming symptomatic in later stages, with nonspecific GI and respiratory symptoms caused by the herniation of intra-abdominal viscera into the thoracic cavity 1
- Visceral organ injuries: may initially be contained but later rupture, causing delayed hemorrhage, as seen in small bowel and colonic injuries which can take a longer time to produce significant signs and symptoms due to the relatively neutral pH of small bowel content and the retroperitoneal position of portions of the duodenum and colon 1
- Vascular injuries: such as arterial dissections or pseudoaneurysms, can develop slowly and may not present with immediate symptoms
- Traumatic brain injuries: including subdural hematomas and concussions, can develop increasing intracranial pressure over time as edema worsens
- Musculoskeletal injuries: like scaphoid fractures and ligament tears, may initially present with minimal symptoms but can worsen over time
- Abdominal compartment syndrome: can develop slowly and may not present with immediate symptoms, but can lead to severe consequences if left untreated Clinicians should maintain a high index of suspicion for these delayed presentations, particularly in patients with significant mechanism of injury but initially normal examinations. Serial assessments and appropriate follow-up are essential, as deterioration may occur rapidly once symptoms begin to manifest. Patients discharged after trauma should receive clear instructions about warning signs that necessitate immediate return for evaluation.
From the Research
Injuries with Delayed Presentation
The following injuries are most likely to have a delayed presentation after trauma:
- Traumatic brain injuries (TBI) and mild traumatic brain injuries (MTBI), which can lead to delayed sequelae such as post-concussive syndrome, psychiatric syndromes, and neurodegenerative diseases 2, 3, 4
- Splenic injuries, which can be managed expectantly in up to two thirds of cases, but may require surgery if complications arise 5
- Traumatic diaphragmatic injuries, which can present days, weeks, or even decades after the initial trauma, and may evolve into larger tears over time 6
Characteristics of Delayed Presentation
Delayed presentation of these injuries can be characterized by:
- Initial absence of symptoms or radiographic abnormalities, making diagnosis challenging 3
- Gradual onset of symptoms, such as insomnia, headaches, irritability, and fatigue, which can persist or worsen over time 3
- Potential for serious psychosocial dysfunction and long-term consequences, including neurodegenerative diseases and chronic traumatic encephalopathy (CTE) 2, 4
- Importance of meticulous patient history and evaluation to identify occult injuries and potential complications 6