Found Down Research Articles

453 Found Down and Cold… but Dead? Outcomes Following Hypothermic Out-of-Hospital Cardiac Arrest Without a Witnessed Abrupt Cause for Hypothermia

453 Found Down and Cold… but Dead? Outcomes Following Hypothermic Out-of-Hospital Cardiac Arrest Without a Witnessed Abrupt Cause for Hypothermia

Optimal Trauma Activation Criteria for "Found Down" Patients.

Patients who are found down (FD) with unknown mechanism of injury pose a triage dilemma. At the study institution, this population with any "suspicion of trauma" criteria were previously triaged as a trauma team activation (TTA) but due to high rates of mis-triage was modified to "signs of trauma." The purpose of this study is to compare injured and uninjured FD patients to identify patient characteristics and outcomes, and to evaluate triage accuracy of signs of trauma. A single-center retrospective review was conducted on adult patients who were FD between 1/2019 and 4/2021. Based on injury severity score (ISS), FD patients were categorized as injured or uninjured and these groups were compared. Sensitivity and specificity were calculated for signs and suspicion of trauma as triage criteria, where suspicion of trauma included altered mental status, confusion, seizures, intoxication, or dementia. Signs of trauma were defined as abrasions, lacerations, ecchymosis, contusions, hematomas, deformity, pain, and crepitus. 415 FD patients were identified with 273 (65.8%) sustaining injury and 142 (34.2%) uninjured. There were no differences in age, gender, Glasgow Coma Scale (GCS) score, or vital signs. Signs of trauma had high sensitivity (96.0%) and moderate specificity (82.4%) for injury, whereas suspicion of trauma had low sensitivity (2.2%) and specificity (37.3%). Injured and uninjured FD trauma patients had similar characteristics on arrival including GCS and vitals, emphasizing the challenge of identifying patients with injury requiring trauma evaluation. Signs of trauma represent a valuable indicator of injury in the FD population.

Chemical Burn and Found Down Crush Injury: A Dual Cause of Upper Extremity Compartment Syndrome

Chemical Burn and Found Down Crush Injury: A Dual Cause of Upper Extremity Compartment Syndrome

January 2021 Critical Care Case of the Month: A 35-Year-Old Man Found Down on the Street

No abstract available. Article truncated after 150 words. History of Present Illness A 35-year-old African-American man with a history of alcohol abuse presented to Emergency Department after he was found down. He was seen by a passerby on the street who witnessed the patient fall with a possible convulsive event. He was brought in by ambulance and was unconscious and unresponsive. PMH, SH, and FH The patient had a history of prior ICU admission in Yuma with septic shock secondary to a dental procedure requiring a tracheostomy in 2018. He also had a history of alcohol intoxication requiring an ED visit about 10 years ago and history of sickle cell trait. Per chart review, the patient took no home medications. Further history was unable to be obtained due to the patient's condition. Physical Examination On arrival the patient had a core temperature of 41°C, systolic blood pressure in the 70s-80s, heart rate of 185, respiratory rate of 19 …

"Found Down" Compartment Syndrome: Experience from the Front Lines of the Opioid Epidemic.

With the worsening of the opioid epidemic, there has been an increasing number of cases in which patients are "found down" following a drug overdose and develop a crush injury resulting in muscle necrosis, rhabdomyolysis, and elevated compartment pressures in a unique presentation of compartment syndrome. The purpose of the present study is to summarize our experience at a trauma center in a region with a high endemic rate of opiate abuse to provide guidance for the management of patients with "found down" compartment syndrome. We performed a retrospective review of the records of patients who had been found unconscious as the result of overdose, with findings that were concerning for compartment syndrome, and had been managed with fasciotomy or observation at the discretion of the surgeon. The patients were divided into 3 groups based on presentation (partial deficits, complete deficits, or unexaminable), and the operative findings, hospital course, laboratory values, and functional status were compared between the groups. Over 12 years, we identified 30 "found down" patients who had an examination that was concerning for compartment syndrome. Twenty-five patients were managed with fasciotomy; this group required an average of 4.2 operations and had a 20% infection rate and a 12% amputation rate. Lactate, creatine phosphokinase, and creatinine levels typically were elevated but did not correspond with muscle viability or return of function. At the time of initial debridement, 56% of patients had muscle that appeared nonviable, although muscle function returned in 28% of the patients who had questionable viability. Four patients had no motor or neurological function on initial examination, and none had meaningful return of function at the time of the latest follow-up. Of the 10 patients who had partial neurological deficits at the time of presentation and underwent fasciotomy, over half (70%) had some improvement in ultimate function. Patients who are "found down" following an opiate overdose with crush injuries resulting in compartment syndrome have a high surgical complication rate and poor recovery of function. The limited data from the present study suggest that those with absent function at the time of presentation are unlikely to gain function after fasciotomy, and the risk-benefit ratio of fasciotomy in this patient population may be different from that for patients with traumatic compartment syndrome. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Not Just Another “Found Down”: Concomitant Upper Arm and Gluteal Compartment Syndrome

BackgroundCompartment syndrome is often considered in patients with long-bone fractures and soft-tissue injuries, but is not as commonly associated with a period of unconsciousness. Case ReportA 65-year-old man was brought to our emergency department (ED) because he had lost consciousness for an unknown amount of time after snorting heroin. He had severe pain in his upper right arm. Physical examination revealed right arm edema, paresthesia, tenderness, and firmness to palpation. During the ED assessment, the patient began to experience pain in his right hip to a degree exceeding examination findings. We considered compartment syndrome affecting his upper arm as well as his gluteal muscles. The patient was taken to the operating room for fasciotomy. The triceps muscle was found to be bulging out of the compartment, demonstrating advanced compartment syndrome. A posterior approach to the hip allowed the gluteal sling and the fascia to be released, eliminating tension on the gluteus medius/minimus and gluteus maximus compartments. With physical therapy, the patient regained full flexion and extension in his arm at the elbow, partial extension of his wrist, and range of motion and strength in his hip. Why Should an Emergency Physician Be Aware of This?If not recognized, compartment syndrome can jeopardize limb and life. It should be considered in patients experiencing inordinate pain, especially if they were found unconscious at the incident scene. Pressure-induced ischemia can impair muscle function within hours. If it is not relieved with fasciotomy, the patient can sustain irreversible functional loss.

Imaging the Unconscious "Found Down" Patient in the Emergency Department.

Unconsciousness may be due to severe brain damage or to potentially reversible causes. Noncontrast head computed tomography (CT) helps identify acute ischemic and hemorrhagic lesions as well as certain patterns of toxic encephalopathy. MR imaging plays an important role in the assessment of acutely encephalopathic patients who may show no significant abnormality on CT. This review describes some of the common and infrequent entities that can lead to unconsciousness, including epilepsy and vascular, traumatic, metabolic, and toxic disorders.

Are injuries only skin deep? The quandary of the ‘Found Down’ patient

Introduction The ‘found down’ patient presents a unique circumstance for the clinician in that the patients are often unable to provide history of the events preceding their presentation to the emergency department. Studies on this population are limited. Methods The trauma and emergency department registries from January 2013 through December 2014 at an urban level one trauma center were queried for patients described as ‘found down’ and related descriptions. Basic demographic data included patient disposition, Glasgow coma score and injury severity score (ISS), patient requiring intubation, imaging performed, and injuries sustained. Patients were stratified into those managed by the trauma service versus the emergency department. Results A total of 298 patients met criteria to be included in this study, nine of whom died; the average age was 50 years old and 9% of this population was found to have an intracranial hematoma. The subset of patients who had a rapid return to Glasgow coma score 15 had a 6% incidence of having an intracranial hematoma. Four cervical fractures were identified. There was only one intra-abdominal injury. Conclusion Computerized tomography scans of the brain and cervical spine should be performed for all patients who are found down. Intra-abdominal injuries are exceedingly rare and selective use of computerized tomography should be made. Superficial injury does not indicate more significant injury in this population; however, lack of superficial injury does not preclude more significant injuries.

Triage of the Found Down Patient with No External Signs of Trauma

Geng, Thomas A. Jr. DO, FACS; McNicholas, Amanda; Jones, Pamela; McCall, Abby; Zavilla, Jared; Castor, Laura A.; Patch, John; Sherwood, Alicia; Ong, Adrian W. MD, FACS; Fernandez, Forrest B. MD, FACS Author Information

Overimaging and the “Found Down” Patient: An Opportunity to Set the Standard of Care

I recently read a head CT study that turned out to be the 100th head CT study performed on a specific patient at our institution in the past decade. Although this sounds extreme, those of us who work in the emergency setting have unfortunately periodically come across this kind of patient: someone whose regular daily routine involves drinking to the point of unconsciousness, stumbling outside, being “found down,” by the police or other good Samaritans, and being brought to the emergency department (ED). The ED physicians understandably cannot obtain a useful history or perform a meaningful neurologic examination because the patient is heavily intoxicated, and they cannot definitively exclude some occult intracranial injury, so they order a head CT, which typically shows the chronic changes of habitual heavy alcohol use, maybe some small-vessel ischemic changes, but nothing acutely treatable. The radiologists thereafter softly scold their ED colleagues in the impression of the report, noting the extreme number of repeat imaging studies for this individual, and suggest that the ED use “risk stratification” for future imaging given the cumulative risk of radiation. And the pattern repeats. Arbitrary Radiation Dose “Limits” Must Not Set Standard of CareJournal of the American College of RadiologyVol. 15Issue 3PreviewIn his recent opinion piece, “Overimaging and the ‘Found Down’ Patient: An Opportunity to Set the Standard of Care,” Dr Mezrich poses the question, “When is a head CT scan one too many?” [1]. He specifically discusses patients who are brought to the emergency department after being found unresponsive (often due to drug or alcohol use), but the topic is applicable to any discussion of patients who receive multiple imaging examinations. Full-Text PDF

Acute Medical Diagnoses Are Common in “Found Down” Adult Patients Presenting to the Emergency Department as Trauma

BackgroundPatients often present to the emergency department (ED) as “found down,” with limited history to suggest a primary traumatic or medical etiology. ObjectiveThe study objective was to describe the characteristics of “found down” adult patients presenting to the ED as trauma, specifically the incidence of acute medical diagnoses and major trauma. MethodsUsing an institutional trauma registry, we reviewed trauma activations with the cause of injury “found down” between January 2008 and December 2012. We excluded patients with cardiac arrest, transfers from other hospitals, and patients with a more than likely (>50%) traumatic or medical etiology on initial ED presentation. Inclusion and exclusion criteria were reviewed by two independent abstractors. We abstracted demographic, clinical, injury severity, and outcomes variables. Major trauma was defined as Injury Severity Score ≥ 16. ResultsThere were 659 patients identified with the cause of injury “found down.” A total of 207 (31%) patients met inclusion criteria; median age was 67 years (interquartile range 50–82 years), and 110 (53%) were male. Among the included patients, 137 (66%, 95% confidence interval [Cl] 59–73%) had a discharge diagnosis of an acute medical condition, 14 (7%, 95% Cl 4–11%) with major trauma alone, 21 (10%, 95% Cl 6–15) with both an acute medical condition and major trauma, and 35 (17%, 95% Cl 12–23%) with minor trauma. The most common acute medical diagnoses were toxicological (56 patients, 35%; 95% Cl 28–43%) and infectious (32 patients, 20%; 95% Cl 14–27%). ConclusionAcute medical diagnoses were common in undifferentiated ED patients “found down” in an institutional trauma registry. Clinicians should maintain a broad differential diagnosis in the workup of the undifferentiated “found down” patient.

Abdominal Injuries in the “Found Down”: Is Imaging Indicated?

We sought to investigate the incidence of abdominal injuries in "found down" trauma patients to better understand the value of emergency department (ED) imaging. Found down patients are at high risk for injuries to the head or neck and low risk to the abdomen or pelvis, so imaging with CT of the abdomen/pelvis (AP) or Focused Assessment with Sonography for Trauma (FAST) is of questionable value. The trauma registry was queried over a 10-year period ending December 2013 for found down patients. Demographics, CT AP, FAST scans, and injuries were abstracted from the trauma registry and then through a confirmatory chart review. The primary outcome was significant abdominal or pelvis injury, defined as abdomen/pelvis Abbreviated Injury Scale (AIS) ≥ 3 or an abdominal injury that required operative intervention. The secondary outcome was mortality due to abdominal injury. Of the 342 patients who met inclusion criteria, mean Glasgow Coma Scale (GCS) was 11.0, and 189 (60%) of those tested for alcohol were intoxicated. Abdominal imaging included: CT AP only, 88 (57%); FAST only, 37 (24%); and CT AP and FAST, 29 (19%). Neither CT AP nor FAST scan led to a change in treatment and no patient had abdomen/pelvis AIS ≥ 3. Overall mortality was 33 (10%).The 24 trauma deaths were attributed to serious head trauma (n = 16) or traumatic arrest in the ED (n = 8); the 9 medical deaths were due to cerebral vascular accident (n = 5) or sepsis (n = 4). Although patients found down have a high mortality, abdominal injuries identified by imaging are highly unlikely. Efforts should focus on rapidly identifying and treating other causes of mortality, especially trauma to the head and neck, or medical diagnoses such as cerebral vascular accident or sepsis.

40-Year-Old Man With Nausea and Vomiting “Found Down”

A 40-year-old man with a history of prior closed head injury, insulin-dependent diabetes mellitus type 2, and nicotine dependence was evaluated at Saint Marys Hospital, a Mayo Clinic–affiliated hospital in Rochester, MN, after being found unconscious at his home.

Efficacy of intranasal naloxone as a needleless alternative for treatment of opioid overdose in the prehospital setting

Prehospital providers are at increased risk for blood-borne exposure and disease due to the nature of their environment. The use if intranasal (i.n.) medications in high-risk populations may limit this risk of exposure. To determine the efficacy of i.n. naloxone in the treatment of suspected opiate overdose patients in the prehospital setting, a prospective, nonrandomized trial of administering i.n. naloxone by paramedics to patients with suspected opiate overdoses over a 6-month period was performed. All adult patients encountered in the prehospital setting as suspected opiate overdose (OD), found down (FD), or with altered mental status (AMS) who met the criteria for naloxone administration were included in the study. i.n. naloxone (2 mg) was administered immediately upon patient contact and before i.v. insertion and administration of i.v. naloxone (2 mg). Patients were then treated by EMS protocol. The main outcome measures were: time of i.n. naloxone administration, time of i.v. naloxone administration, time of appropriate patient response as reported by paramedics. Ninety-five patients received i.n. naloxone and were included in the study. A total of 52 patients responded to naloxone by either i.n. or i.v., with 43 (83%) responding to i.n. naloxone alone. Seven patients (16%) in this group required further doses of i.v. naloxone. In conclusion, i.n. naloxone is a novel alternative method for drug administration in high-risk patients in the prehospital setting with good overall effectiveness. The use of this route is further discussed in relation to efficacy of treatment and minimizing the risk of blood-borne exposures to EMS personnel.

DIAGNOSING ACUTE COMPARTMENT SYNDROME

Compartment syndrome has been defined as “a condition in which increased pressure within a limited space compromises the circulation and function of the tissues within that space”.1 It is most commonly seen after injuries to the leg2-5 and forearm6-8 but may also occur in the arm,9 thigh,10 foot,11-13 buttock,14 hand15 and abdomen.16 It typically follows traumatic injury, but may also occur after ischaemic reperfusion injuries,17 burns,18 prolonged limb compression after drug overdose19 or poor positioning during surgery.20-24 Furthermore, subclinical compartment syndromes may explain the occurrence of a variety of postoperative disabilities which have been identified after the treatment of fractures of long bones using intramedullary nails.25 Approximately 40% of all acute compartment syndromes occur after fractures of the tibial shaft26 with an incidence in the range of 1% to 10%.26-30 A further 23% of compartment syndromes are caused by soft-tissue injuries with no fracture and fractures of the forearm account for 18%.26 Acute compartment syndrome is seen more commonly in younger patients, under 35 years of age31 and therefore leads to loss of function and long-term productivity in patients who would otherwise contribute to the country’s workforce for up to 40 years.

“Insignificant” mechanism of injury: not to be taken lightly

BACKGROUND:Trauma resources should be spent rationally. The mechanism of trauma is used extensively to triage patients to appropriate levels of care. We examine the hypothesis that patients with “insignificant” mechanism of trauma may have major injuries that require expert trauma care.STUDY DESIGN:Over 9 months at a high-volume Level I trauma center, a prospective study was done on patients who sustained ground-level falls (GLF), low-level falls (LLF) from less than 10 feet, or were found down (FD) with no external evidence of significant trauma, and required evaluation by the trauma team. Of 301 patients included, 110 (37%) had GLF, 95 (31%) LLF, and 96 (32%) FD. Our main outcomes measure was significant injuries, defined as visceral or intracranial injuries, long-bone, pelvic, facial, or spinal fractures.RESULTS:One hundred ten patients (37%) had significant injuries, 20 (7%) were admitted to the ICU, 14 (5%) required an operation, and 4 (1%) died. The most common injuries were intracranial and skeletal. Almost all patients were evaluated by CT (95%), but only one-quarter had abnormal findings on it. LLF, age more than 55 years, and the absence of severe intoxication (blood alcohol level of less than 200 mg/dL) were independent risk factors for significant injuries. A statistical prediction model showed that, when all risk factors are present, the probability of significant injuries is 73%; when all risk factors are absent, there is still a 16% chance for significant injuries. Patients with significant injuries had more operations, longer hospital stays, and higher hospitalization costs compared with patients without significant injuries.CONCLUSIONS:Low-energy trauma may produce significant injuries, predominantly intracranial and skeletal. Trauma care providers should be cautious about dismissing such patients based on the trivial mechanism of injury. Patients with LLF who are older than 55 years and not severely intoxicated have a high likelihood for significant injuries. Resources should be spent rationally for patients who do not have these characteristics, because the probability of significant injuries among them is low, but not zero.