It’s that dreaded mechanism of injury: “found down.” What really happened? Did they fall, or get assaulted? Or did the patient suffer a medical problem that led to them falling down? Trauma professionals rely heavily on what I call “context.” Is the patient elderly and frail? Are they intoxicated? What was their location when found? Are there pre-existing medical conditions?
All of these factors allow us to begin building a story in our mind that tells us what might have happened, and what the injuries might be. But with little or no context, we are flying by the seat of our pants. We end up suspecting everything, which means we image everything. With CT scans. And IV contrast. There is always a chance that we can add to the harm already suffered by this patient, or waste time and money.
The abdomen is a black box in a patient with an unreliable or absent physical exam. The emergency medicine group at Cedars-Sinai in Los Angeles looked at the utlity of CT scanning the abdomen in this group of patients. They retrospectively reviewed 10 years of their data. They found 342 patients, of which 154 underwent some type of abdominal imaging (CT, FAST).
Here are the factoids:
- About 60% had alcohol present, and 98% of those had a level greater than 0.08 g/dL
- Overall mortality was 10%. 24 were trauma related (severe TBI, traumatic arrest in ED), and 9 were medical (CVA, sepsis)
- 55% did not undergo any abdominal imaging, and their mortality was 6% (TBI, stroke, MI). None manifested a late abdominal injury.
- Of the 45% who did have abdominal imaging, 57% had CT, 24% FAST, and 19% both
- 14 patients in the imaged group had a positive abdominal CT, but all were minor (Abbreviated Injury Score (AIS) <3)
- 5 patients had a positive FAST, and all had an abdominal AIS<3
Bottom line: Patients who are “found down” seldom have significant intra-abdominal injuries. Keep in mind that this is a small study group, but it does seem to correlate with personal experience and reviews of many charts. Although you can’t completely ignore the abdomen in this group of patients, you should place a higher priority on head and neck trauma, or CVA/sepsis in patient without other obvious injury.
Reference: Abdominal injuries in the “found down”: is imaging indicated? J Am Col Surg 221(1):17-25, 2015.