INTRODUCTIONPatients often present to the emergency department (ED) as “found down” with limited background history to suggest a primary traumatic or medical etiology. Because these patients typically have an abnormal mental status in the context of potential trauma, it is common to activate the trauma team prior to, or upon arrival to the ED.
Trauma team activation for the undifferentiated “found down” patient uses tremendous resources, both in manpower and costs.1,2 Trauma team activation also leads to proceeding with a trauma-focused workup initially, potentially delaying the diagnosis of time-sensitive medical conditions such as acute myocardial infarction or acute stroke.
There is a paucity of literature describing the characteristics of “found down” patients presenting to the ED. Improved understanding of these patients may improve resource utilization and appropriate management. The objective of this study was to describe characteristics of “found down” adult patients presenting to the ED as trauma, specifically the incidence of acute medical diagnoses and major trauma.
MATERIALS AND METHODSStudy Design and SettingThe study is a retrospective, cohort study conducted at a Level 1 trauma center from January 1, 2008 to December 31, 2012. The trauma program at the study site collects trauma registry variables in accordance with the National Trauma Registry Data Dictionary.3 At our study site, there are three levels of trauma activation: 933, 922 and 911 trauma codes. The emergency medicine team (resident and attending) primarily manages the 933 trauma codes. The trauma team is activated for 922 trauma codes with the emergency medicine team. The trauma team (nurse practitioners, resident and chief resident), a respiratory therapist, and a radiology technician all respond to the resuscitation bay. The highest level of activation, 911 trauma codes, includes all the same resources as a 922 with the addition of the attending trauma surgeon. Patients with suspected head injury and a Glasgow Coma Scale (GCS) score of 9 to 13 are coded as 922 trauma codes. Patients with a GCS score less than 9 are coded as 911 trauma codes.
Selection of participantsWe included adult ED patients (18 years and older) identified in our trauma registry with the cause of injury of “found down”. Patients with suspected drug or alcohol intoxication at presentation were included. We excluded patients that presented to the ED with cardiac arrest, patients that were transferred from an outside hospital, patients that present to the ED with a more than likely (>50%) traumatic (e.g., witnessed traumatic mechanism or mechanical fall) or medical (e.g., non-traumatic syncope) etiology on initial ED presentation.
Methods and MeasurementsData collection followed previously published guidelines on retrospective chart review.4 Variables abstracted from the trauma registry included age, sex, mechanism of injury, initial ED GCS score, initial systolic blood pressure (SBP), heart rate, revised trauma score (physiological scoring system based on initial GCS, SBP, and respiratory rate),5 blood alcohol level, drug screen results, initial hematocrit, computed tomography (CT) scans for head, cervical spine, abdomen, and chest, Abbreviated Injury Scale and Injury Severity Score (ISS) (anatomical scoring system),6 ED intubation, ED disposition and admission service, hospital length of stay, and in-hospital mortality. Two independent abstractors reviewed patients’ electronic medical records (EMR), blinded to the other’s assessment, for inclusion and exclusion criteria. In cases of discrepancy, a third abstractor adjudicated after EMR review. All abstractors were emergency medicine physicians.
OutcomesOur primary outcome measures were: 1) an acute medical diagnosis and, 2) major trauma. The presence of an acute medical diagnosis was defined as a non-trauma primary hospital discharge diagnosis and excluded hospital acquired or chronic conditions. Acute medical diagnosis was further categorized into the subgroups of cardiac, neurological, infectious, toxicological, pulmonary, renal/electrolyte, or other etiologies. Major trauma was defined as an ISS of 16 or more.7 Minor trauma was defined as an ISS less than 16.
AnalysisData formatting and recoding of variables were conducted using STATA 11.0 statistical software (STATA Corp, College Station, TX). The study population was characterized using descriptive statistics. Non-normal interval data were reported with medians and interquartile ranges (IQR) and proportions were presented with 95% confidence intervals (CIs). Inter-observer agreement of the inclusion and exclusion criteria was measured using the kappa statistic.
RESULTSCharacteristics of Study SubjectsThere were 659 patients identified in the trauma registry with the cause of injury of “found down”. Four-hundred fifty-two (69%) patients were excluded mostly for transfer from outside hospital and probable trauma or medical etiology. Two hundred seven (32%) patients remained for analysis (Figure). The mean age of the study cohort was 67 years (IQR 50–82 years old) and 110 were male. Median ED GCS score was 14 (IQR 12–14). See Table 1 for complete patient characteristics. There were 146 (71%) patients with a 911 or 922 trauma code activation. All patients received a cranial CT and the majority received a cervical spine (99%) and abdominal (87%) CT. See Table 2 for trauma resources used and injury severity.
Main ResultsA total of 137 (66%, 95% CI 59–73%) patients had a discharge diagnosis of an acute medical condition, 14 (7%, 95% CI 4–11%) with major trauma alone, 21 (10%, 95% CI 6–15%) with both an acute medical condition and major trauma, and 35 (17%, 95% CI 12–23%) with minor trauma. Of the 158 patients with an acute medical diagnosis, 117 (74%) had one acute medical diagnosis, 33 (21%) had two, and 8 (5%) had three. The most common subgroups of acute medical diagnoses were toxicological (56 patients, 35%; 95% CI 28–43%), other (48 patients, 30%; 95% CI 23–38%), and infectious (32 patients, 20%; 95% CI 14–27%) (Table 3). Common specific acute medical diagnoses for the various subgroups included acute alcohol intoxication, seizure, sepsis, and acute coronary syndrome. The percent agreement and kappa for meeting inclusion and exclusion criteria was 74% and 0.49 (95% CI 0.12–0.56).
DISCUSSIONWe have characterized several important features of the “found down” population. First, these patients tend to be older (mean age of 65), have an abnormal mental status (median ED GCS score 14), often require intubation in the ED (20%) and admission to the ICU (45%). Second, the majority of these patients require significant trauma resources with over 70% presenting with trauma team activation (922 and 911 trauma codes). Third, the majority of patients had an acute medical diagnosis without major trauma (66%) while a small proportion (7%) had isolated major trauma. Overall injury severity for these patients was minor, with a median ISS of 5.
Given the high proportion of acute medical conditions, our study suggests the need to maintain a broad differential diagnosis in the undifferentiated “found down” patients. While we were unable to evaluate if there were any delays in diagnosis or treatment of time sensitive acute medical conditions such as acute ischemic stroke or acute coronary syndrome, a narrow, trauma focused workup has the potential to lead to these delays.
We found that despite a relatively low incidence of major trauma, undifferentiated “found down” patients required trauma team activation (911 or 922 trauma code) approximately 71% of the time with nearly all patients receiving multiple CT scans. Future work may better identify subsets of patients that are “found down” that do or do not require trauma team activation.