The "found down" patient: a diagnostic dilemma

"Found down" patients present to the emergency department (ED) after being discovered unconscious and are selected for trauma or medical evaluation based on ED triage. Occult injury is an important part of the differential diagnosis in these patients. Rational use of trauma resources and optimal care of these patients requires clear triage criteria and timely evaluation.

After an institutional review board approval was obtained, we retrospectively identified 201 "found down" patients from ED triage logs at an urban Level I trauma center between 2007 and 2011. Physician researchers reviewed these records for demographics, injuries, medical diagnoses, and mortality.

Of the 201 "found down" patients, 86 (42.7%) had injuries on evaluation in the ED and 9 (4.5%) required urgent surgical intervention. Previous ED visits, homelessness, psychiatric diagnoses, and alcohol and substance use were strikingly common. The 41 patients (20.4%) triaged to admission by the trauma service were younger, predominantly male, and more likely to be intoxicated. Overall, 28 patients (13.4%) required consultation by the service to which they were not initially triaged. Nineteen (11.9%) of the medically triaged patients required trauma service consultation. Eight (19.5%) of the patients triaged to the trauma service required medical consultation, and 4 patients (9.8%) were ultimately admitted to a medicine service after a complete trauma evaluation. Six (14.6%) of the trauma patients and 3 (1.9%) of the medical patients had a delay in diagnosis of occult injuries.

Nearly half of "found down" patients had clinically significant injuries, and late identified injuries were present in both trauma and medical patients. Twenty-eight (13.4%) of patients required consultation by the medical or trauma surgery service to which they were not initially triaged, highlighting pervasive triage discordance in this population. Early trauma surgery consultation and triage flexibility are critical to avoid missed injuries in "found down" patients.

Epidemiological study, level IV.