Scenario — Neck pain and upper limb tingling following fall from horse

intermediate Trauma · Adult · 35yr · female

Patient Information

Dispatch	You are called to the Equestrian Ring at the Perth Royal Show. A 35YO female has fallen from her horse during a dressage event and is complaining of neck pain and tingling in both hands. (Megan Hartley)
Patient	Megan Hartley — 35yr (65kg)
Incident History	Pt was competing in dressage when her horse shied and she was thrown, landing on her right shoulder and head. Bystanders report she did not lose consciousness. She is sitting upright on the ground holding her neck.
Emergency Contact	David Hartley (Husband) — 0412 783 291

Initial Rapid Assessment

Response	Alert
Airway	Patent. Nil obstruction. No stridor. Speaking in full sentences.
Breathing	RR 18, adequate depth, nil accessory muscle use, chest rise equal bilaterally.
Circulation	Radial pulse strong and regular. Skin warm and dry. No visible external haemorrhage. Abrasion to right shoulder.
Disability	GCS 15 (E4V5M6). Alert and orientated to time, place and person. Reporting bilateral hand tingling since the fall.
Exposure	Abrasion to right shoulder and upper arm. Wearing riding helmet — intact, no visible cracking. Nil other obvious injuries on inspection. Pt is holding her neck manually and reports pain on posterior midline cervical spine.

Vitals

Time	SpO2	Resp Dist	RR	Pulse	BP	CRT	GCS	PERL	Temp	BGL	Pain
Initial	98% (RA)	Nil	18	96	118/76	<2s	15	4 4 ++	–	–	6
10 mins	99% (RA)	Nil	16	88	116/74	<2s	15	4 4 ++	–	–	5

History Taking

Scenario Progression and Treatment Objectives

Diagnosis

This patient is suffering from a suspected cervical spinal injury with bilateral upper limb neurological symptoms (bilateral hand tingling — focal neurological deficit) following a high-risk mechanism of injury (fall from horse — high axial loading, equivalent to fall ≥1 metre).

Facilitator Triggers — if trainees miss a critical step

! (If the trainee attempts to walk the patient or allows her to stand and walk to the stretcher — patient states her hands feel more tingly when she tries to stand. Prompt: 'She says it got worse when she tried to move.')
! (If the trainee does not ask about or identify the bilateral hand tingling — patient volunteers: 'My fingers feel really strange, like pins and needles in both hands — is that normal?')
! (If the trainee does not perform a posterior midline cervical spine palpation — patient states: 'Can you check my neck? It really hurts right in the middle at the back.')
! (If the trainee attempts to clear the spine using NEXUS without identifying the focal neurological deficit — facilitator reminds: 'Have you checked sensory and motor function in all four limbs?')
! (If the trainee removes the riding helmet without maintaining inline immobilisation — facilitator prompts: 'What is your plan to maintain cervical spine alignment during helmet removal?')
! (If spinal precautions are not applied and the patient is left unsupported — patient's pain score escalates to 8/10 and she reports increased tingling.)

Treatment Objectives

1. Ensure scene safety — confirm horse is secured by event staff before approaching patient.
2. Perform Primary Survey with C-spine consideration — do NOT move patient until assessed.
3. Apply manual inline cervical spine immobilisation immediately upon patient contact — maintain throughout.
4. Perform Vital Sign Survey — GCS, SpO2, RR, BP, HR, CRT, pain score.
5. Perform focused neurological assessment — assess sensation and motor strength in all four limbs; identify bilateral hand tingling as focal neurological deficit.
6. Perform posterior midline cervical spine palpation — identify midline tenderness from nuchal ridge to T1.
7. Apply NEXUS Clinical Decision Rule — NEXUS CANNOT clear this patient: posterior midline cervical tenderness IS present AND focal neurological deficit IS present (bilateral upper limb tingling). Spinal precautions are REQUIRED.
8. Do NOT attempt to clear the cervical spine — do NOT allow patient to self-extricate.
9. Perform Helmet Removal as per clinical skill — maintain inline immobilisation throughout; one officer stabilises head via mandible, assistant expands helmet laterally, tilts backwards to clear nose, removes helmet; reassume head control post-removal.
10. Perform Secondary/CNS Survey — systematic head-to-toe assessment; assess and document colour, warmth, movement and sensation (CWMS) to all distal extremities; assess right shoulder abrasion.
11. Apply appropriate sized cervical collar as per C-Spine Collar clinical skill — measure using finger-breadth technique; apply snug, ensure mouth can open.
12. Dress right shoulder abrasion with non-adherent dressing and crepe bandage as per Minor Wound Management skill.
13. Position patient supine — do NOT sit, stand or walk. Utilise log roll with three-person technique to achieve supine position on scoop stretcher/extrication board maintaining spinal alignment.
14. Apply head blocks once patient is on stretcher — secure with T.H.E. principle (Thorax, Head, Extremities).
15. Apply oxygen only if SpO2 drops below 94% — current SpO2 98% RA, oxygen not indicated at this time.
16. Monitor patient persistently — record full observations every 10 minutes; reassess neurological status for any deterioration.
17. Reassess pain — current 6/10; EHS are not authorised to administer analgesia. Note pain score and document. Analgesia is Intermediate Care scope.
18. Pre-notify receiving facility — this is a time-critical spinal injury patient with neurological deficit. Transport Priority 1 to nearest receiving hospital (State Trauma Centre if available — RPH for adults).
19. Scenario ends on arrival of ambulance and IMISTAMBO handover.
20. Attention to hand hygiene will be given throughout the scenario.

Clinical references: Spinal Trauma · Spinal assessment · C-Spine Collar · Helmet Removal · Log Roll · Spinal Immobilisation · Secondary & CNS Survey · Minor Wound Management · Primary Survey

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Signs/Symptoms	Posterior midline cervical spine pain, bilateral tingling in both hands (fingers and palms), right shoulder pain and abrasion. No headache, no visual disturbance, no weakness in limbs.
Allergies	Nil known drug allergies.
Medications	Oral contraceptive pill. Nil other regular medications.
Pertinent History	No prior spinal injuries or conditions. No pre-existing neck problems. Generally fit and healthy.
Last Oral Intake	Ate a sandwich and water approximately 2 hours ago.
Events Leading	Competing in dressage at the Perth Royal Show. Horse shied suddenly, throwing her forward and to the right. She landed on her right shoulder and the right side of her helmeted head, then rolled. Did not lose consciousness.
Treatment Prior	No treatment prior to EHS arrival. Bystanders kept her still and told her not to move.

Onset	Immediately following fall from horse approximately 10 minutes ago.
Pain	Posterior midline cervical spine pain, sharp, constant. Right shoulder aching pain.
Quality	Sharp and constant in the neck. Aching in right shoulder.
Radiates	Tingling radiates down both forearms to hands — reported as pins and needles in all fingers.
Severity	Neck pain 6/10. Right shoulder 4/10.