Medical Emergencies Disguised as Trauma, or “Trauma Chameleons”

Authors: Jeffrey Uribe, MD (Lincoln Medical Center Bronx New York), Muhammad Waseem, MD, MS (Lincoln Medical Center & St. Georges University Grenada West Indies), Joel Gernsheimer, MD (SUNY Downstate Medical Center, New York) // Edited by: Alex Koyfman, MD (@EMHighAK) and Brit Long, MD (@long_brit)

It is a busy night shift in the ED, and you are expecting to see some trauma, including patients involved in motor vehicle accidents, patients who were injured while under the influence of alcohol or drugs, and elderly patients who have fallen. Although these patients may present as trauma victims, it is important to consider why these patients had these accidents and to have a broad differential diagnosis as to what underlying medical emergencies may have precipitated these injuries. Sometimes the hidden causes of the trauma may be more dangerous than the trauma itself, and if not considered, diagnosed, and managed, these disguised medical emergencies may cause significant morbidity and mortality.

Background

According to the Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, nearly 199,880 people die from injury each year in the U.S. One person dies from injury every 3 minutes (1). About 27 million people were treated in the emergency department (ED) for injuries in 2014 (2). Motor vehicle crashes are the leading cause of trauma deaths in the U.S., with more than 33,700 people dying from motor vehicle in 2014 (1). In addition, 2.7 million older people are treated in the ED for injuries from falls each year (2). As the population of the U.S. and other developed countries becomes older, we can expect to see an increasing number of geriatric patients with injuries from falls in the ED. There has also been a recent increase in the abuse of opiates (“The Opioid Epidemic”) and other illicit drugs that can lead to significant trauma, as well as causing dangerous medical complications. In addition to the emergency physician being able to competently diagnose and manage this increasing number of trauma patients, it is important for the physician to keep a broad differential diagnosis in order to avoid medical diagnoses that may have lead to trauma.

This post will begin with a discussion of patients that were “found down” and were ultimately found to have underlying medical causes of their injuries. We will then discuss several case scenarios of patients that are commonly seen in the ED that present with trauma due to underlying medical illness.

Case 1

A 70-year-old man is found down in the street by EMS. Bystanders told the EMTs that he seemed to suddenly stumble and fall while walking in the street. No other history is immediately available. When he is brought to the Emergency Department, he is diaphoretic, lethargic, confused, and unable to give a reliable history. His vital signs are normal except for a tachycardia of 116. He has abrasions on his face and extremities. He is lethargic, but moves all extremities. The rest of his exam is normal. His mental status is more depressed than would be expected from the extent of relatively minor injuries.

A retrospective cohort study conducted at a Level 1 trauma center from 2008 to 2012 found acute medical diagnoses were common in undifferentiated ED patients with traumatic injuries, who were “found down” (3). In the subgroup of 158 patients who were found to have acute underlying medical diagnoses out of a total of 207 patients, the most common underlying medical conditions found were toxicological causes, especially acute alcohol intoxication, and infectious causes, especially sepsis. Neurological causes, especially seizures, renal and electrolyte abnormalities, and cardiac causes, especially acute coronary syndrome, were also frequent diagnoses in these patients. There were also a good number of patients who had syncope of unknown etiology. This study emphasizes the need to “cast a broad net” when evaluating and diagnosing these patients. It is important to take a thorough history, do a comprehensive exam and order appropriate ancillary studies in order not to miss a potentially life- threatening diagnosis.

In this case during the hectic trauma code in scenario 1, the acute physician realized the patient’s depressed mental status was not explained fully by the injuries they found and did a finger stick glucose determination. This patient’s glucose was 30. The patient was given 50 cc of 50% dextrose, and his mental status and VS normalized.

Key Points:

• The Emergency Physician should always consider why a patient, especially an elderly patient, fell and why that patient is down.
• There are many underlying medical causes that can cause trauma that must be considered, especially when the obvious clinical findings don’t make sense.
• One of the metabolic causes of falls, accidents, and abnormal mental status that should never be overlooked is hypoglycemia, as it is easily tested for and easily treated.

Case 2

EMS bring in a 40-year-old man found intoxicated lying down in the street. The patient is well known in your ED and has been treated for alcohol intoxication multiple times in the past. You begin by examining him for any obvious trauma and attempt to obtain a history. The patient, who smells of alcohol and has slurred speech, answers that he does not know how he ended up here or when he passed out, which has been his response in the past. It is important to do a thorough evaluation of this patient and avoid the knee jerk reflex of just putting this patient in a corner of the ED until he sobers up, in order to avoid missing a dangerous underlying diagnosis.

As always, assessment should start with the ABCs. Once the ABCs have been assessed and have been stabilized as needed, then thoroughly examine the patient from head to toe, and front and back, for any obvious trauma. Use the Canadian CT Head or New Orleans CT head criteria to help you in deciding whether to obtain a CT head (4, 5). The Canadian Head CT rule demonstrates better sensitivity and may be easier to use. In addition, the NEXUS criteria or Canadian C-spine rule for C-spine imaging (6) can assist in determining need for C-spine imaging, with the caveat that if the patient is very intoxicated, or the patient has significant trauma above the clavicle, consider imaging the cervical spine, even if there is no mid-line neck tenderness. A low threshold for obtaining a CT scan of the head is recommended, as these patients commonly have platelet abnormalities, may have been in an altercation or other accident, and may have coagulopathy due to liver disease. These patients are more likely to have subdural hematomas due to underlying brain atrophy associated with chronic alcohol abuse.

Frequent reassessment of the patient’s mental status is recommended. If the patient fails to improve (this should occur as the EtOH level decreases with time), then another cause, like an intracranial bleed or a concomitant overdose, should be suspected, and appropriate testing, such as a CT scan, should be obtained. The same holds true for patients who were thought to have alcohol intoxication, but the initial alcohol level is relatively low, and does not explain the patient’s altered mental status.

It is very important to evaluate the cardiac status of these patients. We have heard of the possible health benefits of moderate alcohol consumption, but many are not aware that high alcohol consumption and even moderate drinking is a risk factor for atrial fibrillation (7), including binge drinkers (8) who can develop paroxysmal atrial fibrillation known as the Holiday Heart Syndrome (HHS). Heavy alcohol use is also a major risk factor for acute coronary syndrome and myocardial infarction.

Alcoholic patients are commonly found to have electrolyte abnormalities including hypokalemia and hypomagnesemia, which can act as potential mediators of alcohol induced cardiac arrhythmias (9). In addition, many alcoholics are on psychiatric medications, which can prolong the QT interval, which can lead to Torsades de pointes and sudden death. Obtain an EKG for evaluation of the QT interval (10), as well as placing these patients on continuous cardiac monitoring while correcting any electrolyte abnormalities.

Key Points:

• Patients with acute alcohol intoxications may not “just be drunk”.
• They must be carefully evaluated for other causes of altered mental status.
• They must be thoroughly evaluated and monitored for complications of alcohol abuse, including dysrhythmias.

Case 3

A 35-year-old male with a known history of poly-substance abuse (PSA) is brought by EMS after being found down. Bystanders had witnessed the patient fall. Narcan was not given, as the patient was not hypoxic or cyanotic and had a decent respiratory rate, although he did have constricted pupils. The patient is responsive to pain, and when asked, admits that he uses heroin, but otherwise does not answer other questions and dozes off to sleep. You noticed track marks on his extremities but no signs of head trauma. You decide to place this patient under close observation.

Many drug addicts are poly-substance abusers and concomitantly may inhale, smoke, or inject multiple drugs, which may blur typical drug presentations. Many neurological complications can arise acutely from recreational drugs, and these complications can affect the brain, spinal cord, and peripheral nerves (11). These complications can occur even in young adults including seizures (12) and ischemic or hemorrhagic strokes (13).

Perform a thorough neurological exam even in the setting of heroin intoxication to avoid missing the diagnosis of any intra-cerebral pathology. Cocaine use has been shown to prolong the QT interval, increasing the risk of Torsades de Pointes and sudden death, especially in patients with chest pain (14). Consider an EKG to evaluate not only for myocardial infarction, which can occur in cocaine and even heroin users, but to evaluate the QTc interval. Many poly-substance users also concurrently take methadone, which can prolong the QT interval (15). Don’t attribute episodes of syncope to only illicit drug use. If these patients present with syncope or have a history of syncope (16), they may be at high risk for sudden death, and their syncopal episodes may actually be due to Torsades de Pointes or other potential dangerous dysrhythmias (17, 18). Place these patients on continuous cardiac monitoring while in the ED, and keep that trusty magnesium handy.

Key Points:

• Patients who abuse drugs often abuse more than one substance.
• Acute drug intoxication can cause many complications, especially neurological and cardiac complications.
• Patients with acute drug intoxication must be carefully evaluated and monitored for complications of the abused drugs, as well as for other causes of their altered mental status.

Case 4

A 71-year-old female brought to your ED by EMS for left foot pain and left arm pain after a mechanical fall two hours ago.  The patient reports she tripped on her rug at home and landed on her left side, denying any head trauma or loss of consciousness. However, she does admit that she felt “a little dizzy” before she fell and felt a little nausea. She did not vomit and now feels fine, except for the pain in her arm and leg. You attempt to examine her arm and leg, but she is in pain, so you decide to order pain medications and x-rays of the upper and lower extremities.

Determining the etiology of a fall in an elderly patient is paramount. In the elderly population, it is important to make sure that the patient did not fall because of an underlying medical condition, such as a stroke, acute coronary syndrome, or a cardiac dysrhythmia.

One retrospective study (19) found that symptoms of nausea/vomiting and dizziness had an odds ratio of 4.02 and 1.99, respectively of a missed diagnosis of stroke and were commonly associated with posterior circulation strokes. Although the majority of patients with these complaints do not have a posterior stroke, posterior stroke should be at least considered in patients who present with these symptoms and signs.

In the population of patients with posterior strokes, 41% presented with difficulty walking (19). It is thus important to obtain a thorough history, including a focused neurological history, especially asking about a history of past strokes, nausea, vomiting, and dizziness. It is also very important to perform a focused neurological exam, including the cerebellar system, evaluating the patient’s gait, and looking for subtle signs of a stroke (especially posterior circulation) (19). One should be careful “not to miss the forest for the trees” meaning even small clues for a possible stroke should be seriously considered and pursued by getting a CT scan. However, CT has poor sensitivity and should not be relied on for cerebellar stroke. Obtain an MRI if the CT scan is negative and a cerebrovascular accident involving the posterior circulation is a possibility based on the history and neurologic exam.

Consider electrolyte imbalance and dehydration as potential causes of the fall. Advanced age, underlying neurological disorders, hematologic disorders, and hyponatremia have been found to be significant predictors of falls in geriatric trauma (20). The fall may also be a non-specific presenting sign of many acute illnesses, including urinary tract infection, pneumonia (21), or an exacerbation of their chronic diseases, including diabetes or lower urinary tract symptoms (LUTS) due to increased urgency, frequency, nocturia, and urinary incontinence (22). This is especially important in elderly men who have benign prostatic hypertrophy or prostate cancer, where not only the disease, but also the therapy can cause falls (22). If the patient who has fallen has symptoms and/or signs that point to the possibility of infection, such as a UTI or pneumonia, then appropriate testing should be ordered. Educate the patient about appropriate diabetes management and consider a urology follow up for management of LUTS if the patient is discharged from the ED.

Although rare, there have been case reports of acute abdominal aortic aneurysm or acute thoraco-abdominal aortic dissection presenting as transient paralysis of lower extremities (23, 24). Be suspicious if the patient reports any back pain, numbness, tingling, weakness, or leg heaviness prior to the fall. Complete a thorough neurological exam including testing for sensation. Utilize bedside US to evaluate the aorta if suspicious of AAA.

In elderly patients who have fallen, it is very important to make sure that the fall and subsequent trauma were not due to syncope or near-syncope. The causes of syncope are broad, and a thorough history, physical examination, appropriate laboratory testing, including an EKG can evaluate for deadly causes of syncope. The differential diagnosis of etiologies of syncope, include neutrally mediated causes, such as vasovagal syncope; orthostatic causes; arrhythmias; structural cardiovascular causes such as cardiac valve disease, especially aortic stenosis; and mimickers of syncope, especially seizures and strokes (25). It should be noted that the elderly are more likely to have a dangerous cause of syncope, especially cardiac causes of syncope, than younger patients. A comprehensive history can often help differentiate between the many important etiologies of syncope, as well as between syncope and its mimics. It is especially important to consider possible cardiac causes of syncope when obtaining a history, and to inquire whether the syncope was associated with chest pain, palpitations, shortness of breath or exertion (25).

A retrospective cohort study of traumatic falls and syncope over 10 years from a large academic Level I trauma center found three independent predictors of cardiac syncope: age > 65 years, presence of coronary artery disease, and pathological Q waves. (26).  If the history is suggestive of possible syncope, an EKG should be done and the patient placed on a cardiac monitor. The patient should be evaluated for a possible dysrhythmia or ischemic cardiac event that may have caused the fall. As noted above age over 65 is a risk factor for cardiac syncope, which has a higher risk for subsequent mortality and morbidity than some other causes of syncope, such as vasovagal syncope.

Key Points:

• It is very important to find out why patients fell, as well as evaluating their injuries caused by the falls.
• The elderly patients are more likely to fall because of an underlying medical cause.
• There are many causes of syncope, including cardiac and neurological etiologies.
• The elderly patients are more likely to have a cardiac etiology as a cause of their falls.

Case 5 

A 65-year-old male is brought by EMS after a motor vehicle accident. His GCS is 15, and he reports that he does know what happened before the accident. The patient has a sling on his left arm and is unable to move due to pain, but no gross deformity is appreciated.   

The cause of a car accident in elderly patients can be difficult to determine, and a neurologic emergency is a rare but important cause of motor vehicle collision (MVC) that is necessary to identify early in order to ensure critical appropriate treatment. In a retrospective study of 110 records associated with accidents suspicious of having a neurological incident leading to the accident for a 2-year period, 54 (49%) had seizures, 7 had strokes (6.3%), and 2 (1.8%) suffered from intra-cerebral hemorrhage (27).

As noted in the study of MVCs associated with possible neurological causes of the accident (27), a significant percentage of these patients had seizures. It is very important to get a history of a seizure disorder, and if witnesses were present, to ask them if they witnessed any seizure activity. The patient should be examined for any signs of a seizure, such as tongue biting and incontinence, and a focused neurological examination should be performed. If there are any acute abnormal neurological findings, a stat head CT should be done. Metabolic causes of seizures, such as hypoglycemia and hyponatremia, should be considered. If the patient has a known seizure disorder, appropriate anticonvulsant levels, if available as a stat test in the hospital lab, should be sent. However, these labs are often not available. Toxicological causes of seizures, such as cocaine and alcohol withdrawal, should be considered. The patient should be treated appropriately based on the findings of these examinations. If there are questions about how to further evaluate or manage these patients, neurological consultation should be obtained.

Although a less common cause than seizures, ischemic stroke should be considered in the differential diagnosis of elderly patients who were involved in motor vehicle accidents. A good history and neurological examination should be performed. If these point to the possible diagnosis of a stroke then a head CT scan should be performed, and neurological consultation should be considered. Atrial fibrillation can be a major risk factor for stroke in the elderly, which can be a cause of the accident. Other risk factors for traffic injuries in patients with atrial fibrillation include age over 65, coronary artery disease (CAD), hypertension, stroke, liver disease and CHA2DS2-VASc score ≥1without any anti-thrombotic therapy (28)

Syncope is not only a possible cause of falls in the elderly, as noted above in Scenario 4, but also a cause of MVCs. Evaluation for syncope is needed. A prior history of syncope has been associated with a two-fold increase risk of motor vehicle crash compared to the general population (29). As noted above, dangerous causes of syncope should be looked for.

Key Points:

• Motor vehicle collisions may be caused by an acute neurologic event in the driver of the vehicle.
• An acute seizure is the most likely underlying neurologic event that may lead to an MVC. Syncope should also be considered.
• Other underlying medical causes in a driver involved in an MVC are strokes, especially in the elderly, and toxicological etiologies.

Summary

Trauma may be caused by an underlying medical condition that may necessitate early intervention. After stabilizing the trauma victim, it is imperative to obtain a good history if possible and perform a focused but comprehensive physical exam, including the neurologic system. This should be done not only to assess for complications from the trauma, but also to look for possible underlying medical causes of the trauma. Based on the findings from the history and physical exam, further testing, such as blood chemistry, urine analysis, toxicological studies, EKG, cardiac monitoring, and head CT scanning may be warranted. When in doubt from the history as to what may have caused the trauma, it is important to further evaluate the patient to look for possible medical causes of the trauma, with close monitoring in the ED while this evaluation is being done.

References/Further Reading:

1) Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Web-based Injury Statistics Query and Reporting System (WISQARS) Fatal Injury Data. (2016)

2) Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Web-based Injury Statistics Query and Reporting System (WISQARS) Nonfatal Injury Data. (2016)

3) Jacobs BG, Turnipseed SD, Nguyen AN, et. al. “Acute medical diagnoses are common in “found down” adult patients presenting to the emergency department as trauma.” J Emerg Med. 2015; 49(6): 992-997

4) Stiell IG, Wells GA, Vandemheen K, et. al. “The Canadian CT Head Rule for patients with minor head injury.” Lancet. 2001;357(9266): 1391-6

5) Haydel MJ, Preston CA, Mills TJ, et. al. “Indications for computed tomography in patients with minor head injury.” N Engl J Med. 2000;343(2): 100-5

6) Hoffman JR, Wolfson AB, Todd K, Mower WR. “Selective cervical spine radiography in blunt trauma: methodology of the National Emergency X-Radiography Utilization Study (NEXUS).” Ann Emerg Med. 1998;32(4): 461-9

7) Larsson SC, Drca N, Wolk A. “Alcohol consumption and risk of atrial fibrillation: A prospective study and dose-response meta analysis.” JACC. 2014;64(3): 281-289

8) Tonelo D, Providencia R, Goncalves L. “Holiday heart syndrome revisited after 34 years.” Arq Bras Cardiol. 2013;101(2): 183-189

9) George A, Figueredo VM. “Alcohol and arrhythmias: a comprehensive review.” JCM. 2010;11(4): 221-228

10) Dr. Smith’s ECG Blog, Wednesday, September 7, 2016 – An Alcoholic Patient with Syncope http://hqmeded-ecg.blogspot.com/2016/09/an-alcoholic-patient-with-syncope.html

11) Enevoldson TP. “Recreational drugs and their neurological consequences.” J Neurol Neurosurg Psychiatry. 2014;75(Suppl III): iii9-iii15

12) Lowenstein DH, Massa SM, Rowbotham MC, et. al. “Acute neurologic and psychiatric complications associated with cocaine abuse.” Am J Med. 1987;83(5); 841-6
13) Daras M, Tuchman AJ, Marks S. “Central nervous system infarction related to cocaine abuse.” Stroke. 1991;22: 1320-1325

14) Gamouras GA, Monir G, Plunkitt K, Gursoy S, Dreifus LS. “Cocaine abuse: Repolarization abnormalities and ventricular arrhythmias.” Am J Med Sci. 2000;320(1): 9-12

15) Martell BA, Arnsten JH, Krantz MJ, Gourevitch MN. “Impact of methadone treatment on cardiac repolarization and conduction in opioid users.” Am J Cardiol. 2005;(95): 915-918

16) Fanoe S, Hvidt C, Ege P, Jensen GB. “Syncope and QT prolongation among patients treated with methadone for heroin dependence in the city of Copenhagen.” Heart. 2007;(93): 1051-1055

17) Lamont P, Hunt SC. “A twist on torsade: a prolong QT interval on methadone.” J Gen Intern Med. 2006;(21): c9-c12

18) Thanavaro KL, Thanavaro JL. “Methadone-indued torsades de pointes: a twist of fate.” Heart & Lung. 2011;40(5): 448-453

19) Arch AE, Weisman DC, Coca S, et al. “Missed ischemic stroke diagnosis in the emergency department by emergency medicine and neurology services.” Stroke. 2015;47(00): 1-6

20) Rittenhouse KJ, To T, Rogers A, et. al. “Hyponatremia as a fall predictor in a geriatric trauma population.” Injury. 2015;46(1): 119-23

21) Blair AJ, Manian FA. “Coexisting systemic infections (CSIs) in patients presenting with a fall: tripped by objects or pathogens?” Abstract 813. Presented at IDWeek. San Diego. October 7-11, 2015.

22) Soliman Y, Meyer R, Baum N. “Falls in the elderly secondary to urinary symptoms.” Rev Urol. 2016;18(1): 28-32

23) Kamano S, Yonezawa, Aria Y, et. al. “Acute abdominal aortic aneurysm rupture presenting as transient paralysis of the lower legs: a case report.” JEM. 2005;29(1): 53-55

24) Joo JB, Cummings AJ. “Acute thoracoabdominal aortic dissection presenting as painless, transient paralysis of the lower extremities: a case report.” JEM. 2000;19(4): 333-337

25) Goyal P, Maurer MS. “Syncope in older adults.” J Geriatr Cardiol. 2016(13): 380-386

26) Bhat PK, Pantham G, Laskey S, Como JJ, Rosenbaum DS. “Recognizing cardiac syncope in patients presenting to the emergency department with trauma.” JEM. 2014;46(1): 1-8

27) Fries M, Bieckenback J, Beckers S. et. al. “Neurological emergencies as causes of accidents.” Eur J Emerg Med. 2005;12: 151-154

28) Lai HC, Chien WC, Chung CH, et. al. “Atrial fibrillation, CHA2DDS2-VASc score, antithrombotics and risk of traffic accidents: a population-based cohort study.” Int J Cardiol. 2015;197: 133-139

29) Nume A-K, Gislason G, Christiansen CB, et. al. “Syncope and motor vehicle crash risk: a Danish nationwide study.” JAMA Intern Med. 2016;176(4): 503-510