Fall from height

Question 1

A 25 year old painter falls 2 metres off a ladder. He is in pain with a deformed leg, a painful back and states the side of his leg feels numb. Discuss his initial management and pain relief.

Answer 1

Impression
Fall from a height, concerned about Red flag Ddx of herniated disc, spinal cord compression/transection, cauda equina. Provisionally concerned about spinal fractures/femur/pelvic fractures. Want to ensure neurovascularly intact

Would also like to rule out other MSK injuries, in particular head and C-Spine fractures, intracranial bleeds, or TBIs, other long-bone fractures.

Goals
- Primary survey approach, call for senior assistance
- Trauma work-up including eFAST, trauma series X-Ray +/- CT Brain/Spine.
- Appropriate analgesia: step it up according to WHO pain ladder

Question 2

Fall from height - Assessment

Answer 2

Assessment
- Trauma call, primary survey
- MIST AMPLE handover from ambo’s
- C-Spine immobilisation initially before clinically/radiologically clearing.
- Assess and clear C-spine, look for evidence of base of skull fractures of otherwise, screen for raised ICP.

A - patent, maintaining, consider support/manoeuvres and intubate pending GCS
B - RR/SP02, supplemental as required - trauma series including
C - BP/ECG/HR. IV access for pre-op bloods: VBG, G+H, UEC, FBC.
D - GCS, PEARL, Full neuro screen/assessment, trauma series X-Ray
E - Log roll, secondary survey for other injuries.

Question 3

Fall from height - History

Answer 3

History
- MOI
- ?medical reason for fall (preceding events, syncope, LOC)
- MIST AMPLE

Question 4

Falls from height - Examination

Answer 4

Examination
- General appearance + repeat vitals
- Neurovascularly intact in lower limbs, neuro screen otherwise
- log roll for ?spinal fracture, deformity
- secondary survey for other injuries sustained

Question 5

Fall from height - Investigations

Answer 5

Investigations
Key
- X-ray of affected limb
- CT spine
+/- MRI spine for spinal cord involvement\

other; pre-op bloods
- FBC, UEC, LFT, Coags, G+H

Question 6

Fall from height - Management

Answer 6

Management
Supportive
- NBM
- VTE prophylaxis
- Immobilise leg with splint
- Analgesia
Pharm;
o Paracetamol
o NSAIDS
o IV opioids - morphine
o consider regional anaesthesia depending on location/nature of injury - involve anaesthetics
Non-pharm;
o ice packs
o elevation

Definitive
- involve ortho +/- spine surg. for?spinal fractures
o refer for urgent reduction and fixation
o ?need for spinal fusion