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Emergency Radiology

E2651. Neuroimaging Answers to the Patient Found Down

Short T1,  Knaus C2,  Smirniotopoulos J.3 1. Uniformed Services University of Health Sciences,, Bethesda, MD; 2. Walter Reed National Military Medical Center,, Bethesda, MD; 3. National Institutes of Health, , Bethesda, MD

Address correspondence to T. Short (

Background Information: Patients who are found down present to health care providers without being able to communicate important information about the events leading up to their current state, their current symptoms, or their past medical history. These patients can present a diagnostic quandary, leaving many distinct and life-threatening diagnoses in the differential. Further, traumatic injuries (blunt trauma to the head, drowning, etc.) can present as isolated etiologies or can overlap with medical causes, such as intoxication, endocrinopathy, seizure disorder, or even the initial presentation of a brain tumor. A patient’s chronic medical conditions can cloud the diagnostic picture. Imaging, therefore, provides great value when an unresponsive patient presents to health care providers.

Educational Goals/Teaching Points: The goal of this exhibit is to first, delineate the scope of the problem. Up to one-third of unresponsive patients (medical, traumatic, and combined causes) can be triaged incorrectly, and at best can lead to a delay in proper treatment and at worse can lead to frank mismanagement. Second, we consider all details in the differential diagnosis with appropriate imaging and a checklist of items to review. We present pertinent imaging and give a case presentation of common deadly, treatable causes of being found down known as the “4 Hs”: hemorrhage, herniation, hydrocephalus, and hypoxia or ischemia.

Key Anatomic/Physiologic Issues and Imaging Findings/Techniques: We review acute changes on imaging (primarily unenhanced head CT) that correlate with the patient found down.

Conclusion: Patients who are found down can have medical, traumatic, or a combination of causes leading to their stupor. In this patient population, history and physical examinations are extremely limited and imaging is key for diagnosis. Timely recognition of deadly, potentially reversible conditions (the 4 Hs) is critical for physicians to provide appropriate, lifesaving care.