Fall on Ice with a Possible Spinal Injury
At 08:15 on a cold morning you respond to a 68-year-old woman who slipped on an icy sidewalk and fell backward, striking the back of her head on the curb. She is awake and talking. She complains of neck pain and a headache, and says her right hand feels 'tingly and numb.' She takes a blood thinner for a heart condition. She is lying on her back on the ice with her head slightly turned. Her breathing is 20 and unlaboured, pulse 88 and regular, blood pressure 142/86, SpO2 96% on room air. There is a small amount of blood in her hair at the back of her head. Her pupils are equal and reactive. She wants to sit up because the ground is cold. The sidewalk is sloped and icy, and a crowd is gathering.
1. Decide how to manage her spine and position, and justify your choice against her request to sit up.
Read the worked answer
Treat this as a possible spinal injury and keep her still until you have assessed and stabilized her. The mechanism is significant: a backward fall with a head strike on a curb, neck pain, and numbness and tingling in one hand. Those findings suggest possible cervical injury with nerve involvement. She is also on a blood thinner, which raises the risk of serious bleeding after head trauma.
Her request to sit up is understandable but should not be granted yet. Movement could worsen a spinal injury. Explain calmly why you need her to stay still, and address the cold by insulating her with blankets rather than repositioning her. Manually stabilize her head in a neutral, in-line position; if her head is turned and cannot be brought to neutral without pain or resistance, support it in the position found. Do not force it.
Assess and document: level of consciousness, pupils, motor and sensory function in all four limbs, and the exact area of numbness. Reassess frequently. If she must be moved because the scene is unsafe, use a coordinated move with manual stabilization maintained. Once a collar and backboard or other device per your protocol are applied, transport. Do not let the crowd or the cold rush a decision that could cause permanent harm.
2. She becomes drowsy and vomits once. Explain your reassessment, your airway plan, and how the blood thinner changes your concern.
Read the worked answer
Drowsiness and vomiting after a head strike are red flags for a worsening brain injury, possibly bleeding. Her blood thinner makes intracranial bleeding more likely and more dangerous. Reassess immediately: level of consciousness using a consistent scale, pupils and their response, breathing pattern, pulse, blood pressure, and SpO2. Recheck motor and sensory function. A falling level of consciousness or an unequal pupil is an emergency.
Airway plan: vomiting with a reduced level of consciousness threatens the airway. Turn her as a unit while maintaining manual spinal stabilization, clear the mouth, and suction if available. Keep her positioned to protect the airway; if she cannot protect it, support ventilation with a bag-mask and request paramedic intercept. Do not insert anything blindly into the mouth. Provide oxygen per protocol and monitor continuously.
Transport: this is now a time-critical transfer to a facility capable of managing head trauma. Pre-notify the hospital with the mechanism, blood thinner use, initial and current level of consciousness, vomiting, and neurologic findings. En route, keep her warm, reassess vitals and neurologic status every few minutes, and be ready for deterioration. The key judgment is that drowsiness and vomiting after head trauma in an anticoagulated patient convert a 'possible spine' call into a 'possible intracranial bleed' priority.