The three main factors in determining outcome following a fall from a height are the distance fallen, the surface struck and the presence of neurological injury.1
In the literature, survival following falls of greater than 40 ft are rare as the energy transfer involved is massive.1
A fall greater than five storeys is usually considered fatal, although which body region collides with the ground first contributes to prognosis.1
We report an unusual case of a patient who fell over 100 ft, on to boggy ground, limbs first sustaining limb and pelvic trauma while, crucially, remaining neurologically intact.1
His New Injury Severity Score was 50 (chest 5, pelvis 3 and abdomen 4), Revised Trauma Score 6.817 and percentage predicted survival using Trauma and Injury Severity Score methodology 70.8%. His outcome is related to several factors: his physiological reserve and the prompt resuscitation.
Hindering the resuscitation of trauma patients is the derangement of physiology seen in major injury often referred to as ‘the lethal triad’—acidosis, hypothermia and coagulopathy.2
In this case, the patient presented with hydrogen ions 110, temperature 34.1 °C, and prothrombin time 1.11 (1.55 post massive transfusion). Successful management involves prompt restoration of circulating volume and controlling further haemorrhage; in this case, by the early application of his external pelvic fixator in the emergency department.
Focusing on blood product resuscitation, current opinion is undergoing a paradigm shift in what constitutes appropriate management. Administration of packed red cells is often prompt, but the slow use of non-red cell components to maintain a ‘normal’ clotting cascade has been lacking. Previous guidelines used a prothrombin ratio >1.5 to trigger the use of FFP.3
This has been found inadequate as laboratory testing can take 20 min and FFP defrosting 25 min.3
Thus, a trauma patient's clotting profile may differ from when a sample is taken to when FFP is finally administered.
There is now emerging evidence from several large retrospective series, using military resuscitation guidelines, that using increased FFP from the outset reduces mortality with additional benefit in using the ratio of 1:1 packed red cells:FFP.4
Civilian practice, as yet, cannot fully embrace such resuscitation practice as the system for issuing blood has yet to allow for the dynamic pace of trauma resuscitation; hence, our ratio is only 1.1.8. As the evidence base expands, this may change.
However, haemostatic resuscitation is not without risk and level I evidence is still lacking in identifying its exact benefit and use. Fundamentally, what is required is a better real time assessment of a patient's clotting profile enabling a more patient-specific approach.
- Survival from a high fall is rarely possible but in this case is helped by the patient landing on his lower limbs and boggy ground without sustaining a serious head injury (presenting GCS of 13: E3, M6, V4).
- A successful outcome was achieved by the use of aggressive blood product resuscitation and the early application of a pelvic fixator.
- The precise role of blood product resuscitation in blunt trauma is unclear and requires clarification.