Management of a Patient Who Fell and Hurt Her Back
Immediately suspect spinal injury and manually stabilize the head to minimize motion of the head, neck, and spine until you can determine if the patient meets high-risk criteria for spinal injury. 1
Initial Assessment and Spinal Precautions
Do not move the patient from the position found unless the area is unsafe or the airway is blocked. 1 If the patient has a suspected neck, back, hip, or pelvic injury, she should remain still and await EMS arrival rather than being rolled onto her side. 1
High-Risk Criteria for Spinal Injury
Suspect spinal injury if your patient has ANY of the following risk factors: 1
- Age ≥65 years
- Fall from greater than standing height
- Pain or tenderness in the neck or back
- Tingling in the extremities
- Sensory deficit or muscle weakness involving the torso or upper extremities
- Not fully alert or is intoxicated
- Other painful injuries, especially of the head and neck
Manual Stabilization Technique
Maintain spinal motion restriction by manually stabilizing the head so that motion of the head, neck, and spine is minimized. 1 Do NOT use immobilization devices (cervical collars, backboards) as a first aid provider because their benefit has not been proven and they may be harmful. 1
When to Activate Emergency Medical Services
Call 911 immediately if: 1
- The patient meets any high-risk criteria listed above
- There is loss of consciousness or altered mental status
- The patient cannot rise from the bed, turn, and steadily ambulate (failed "get up and go test")
- Any neurological symptoms are present (weakness, numbness, tingling)
- The patient is age ≥65 years (this alone warrants medical evaluation) 1
Assessment for Elderly Patients
If your patient is elderly (≥65 years), conduct a comprehensive fall assessment even if the injury seems minor: 1
Key historical elements to obtain: 1
- Exact location and mechanism of fall
- Time spent on floor or ground
- Any loss of consciousness or near-syncope
- Current medications (especially vasodilators, diuretics, antipsychotics, sedative/hypnotics)
- History of previous falls
- Visual impairments or neurological conditions
- Alcohol use
Physical examination priorities: 1
- Complete head-to-toe evaluation for ALL patients, even with seemingly isolated injuries
- Orthostatic blood pressure assessment
- Neurologic assessment with attention to neuropathies and proximal motor strength
- Gait evaluation and "get up and go test" before allowing discharge
Management of Soft Tissue Injuries (If No Spinal Injury Suspected)
If the patient has only soft tissue injury without high-risk features for spinal injury: 1
Apply cold therapy: 1
- Use a plastic bag or damp cloth filled with ice and water mixture (superior to ice alone)
- Place a thin towel barrier between the cold container and skin
- Apply for 10-20 minutes maximum to prevent cold injury
- Refreezable gel packs are less effective than ice-water mixture
Do NOT apply heat to acute injuries - cold application is superior for initial treatment. 1
Critical Pitfalls to Avoid
- Never attempt to straighten an injured extremity - this may cause further injury and does not improve outcomes. 1
- Never use cervical collars or immobilization devices as a first aid provider - evidence shows potential harm without proven benefit. 1
- Never assume an elderly patient's fall is "simple" - ground-level falls in patients ≥65 can result in serious injuries including cervical spine fractures, rib fractures, and hip fractures with mortality rates up to 7%. 1
- Never delay calling EMS if any high-risk criteria are present - secondary spinal cord injury from improper movement can result in permanent quadriplegia. 1