What is the immediate management for a patient who fell from a height, got stuck midway with their neck in extension, suggesting a high risk for cervical spine trauma?

Immediate Management of Fall from Height with Neck in Extension

Apply a rigid cervical collar immediately with manual in-line stabilization (MILS) to prevent secondary spinal cord injury, maintain systolic blood pressure >110 mmHg, and transport directly to a Level 1 trauma center. 1, 2

Initial Stabilization (First Priority)

The mechanism described—fall from height with neck stuck in extension—represents extremely high risk for cervical spine injury and requires immediate action:

• Apply rigid cervical collar with head-neck-chest stabilization immediately upon patient contact to limit onset or worsening of neurological deficit. 3, 1, 2 This is the single most critical intervention despite limited evidence quality, as the consequences of secondary spinal cord injury (permanent quadriplegia) are catastrophic. 3

• Use manual in-line stabilization (MILS) in conjunction with the rigid collar, as this combination significantly reduces complications. 3, 1, 4 Do not use immobilization devices beyond basic collar and MILS unless specifically trained, as improper use may cause harm. 3

• Maintain the patient in a neutral position and avoid any manipulation of the neck. The extended position during the fall creates high suspicion for hyperextension injury with potential ligamentous disruption or fracture-dislocation. 5, 6

Hemodynamic Management (Critical for Outcomes)

Blood pressure management is equally important as mechanical stabilization:

• Maintain systolic blood pressure >110 mmHg continuously before and during injury assessment to reduce mortality. 3, 1, 2, 4 This threshold is specifically evidence-based for spinal cord injury patients.

• Target mean arterial pressure ≥70 mmHg during the first week post-injury to limit neurological deterioration. 2

• Place an arterial line for continuous accurate blood pressure monitoring as soon as feasible. 2, 4

Risk Factor Assessment

This patient meets multiple high-risk criteria for cervical spine injury:

• Fall from greater than standing height is a specific risk factor requiring spinal immobilization. 3
• Age considerations: If patient is ≥65 years, risk is substantially elevated. 3
• Assess for: tingling in extremities, neck/back pain or tenderness, sensory deficits, muscle weakness involving torso or upper extremities, altered mental status. 3

Transport and Definitive Care

• Transport directly to Level 1 trauma center within the first hours, as this reduces morbidity, mortality, and improves neurological outcomes through earlier surgical intervention. 1

• Remove patient from hard backboard as soon as safely possible (once in controlled environment with proper support) to avoid tissue ischemia, but maintain cervical immobilization. 7

Temperature Management During Transport

• Prevent hypothermia aggressively with target core temperature 36-37°C, as each 1°C drop reduces coagulation factor function by 10%, and temperatures <34°C are associated with >80% mortality. 1, 2

• Remove all wet clothing immediately and cover the patient. 1

• Increase ambient temperature in ambulance/treatment area. 1

Airway Management (If Required)

If airway intervention becomes necessary during transport or initial management:

• Remove the anterior portion of the cervical collar during intubation attempts while maintaining MILS to improve mouth opening and glottic exposure. 3, 1, 2, 4 Never leave the collar fully in place during intubation, as this significantly worsens glottic visualization and increases failure rates. 2, 4

• Use rapid sequence induction with direct laryngoscopy and gum elastic bougie without Sellick maneuver. 3, 1 Sellick maneuver increases cervical spine movement and should be avoided. 3, 1, 2, 4

Critical Pitfalls to Avoid

• Do not allow systolic blood pressure to drop below 110 mmHg, as this increases mortality risk. 3, 1, 2, 4

• Do not apply traction to the cervical spine, as this causes clinically significant distraction and should be avoided. 8

• Do not delay transport to obtain imaging at a non-trauma center, as definitive management timing is critical. 1, 2

• Do not overlook life-threatening injuries while focusing on spine immobilization—assess for airway compromise, breathing difficulties, and circulatory shock. 5