Suspected cervical spinal injury following a fall at the races

Patient Information

Dispatch: A 75YO male who has been brought to the FAP by security after tripping on a staircase and falling down 6 steps at the racecourse. He is alert but complaining of neck pain. (Barry Hutchinson)
Patient: Barry Hutchinson — 75yr (75kg)
Incident History: Pt tripped on the top step of a staircase and fell approximately 6 steps, landing on his hands and knees. Bystanders report his head struck the handrail on the way down. He walked to a seat nearby with assistance before security brought him to the FAP.
Emergency Contact: Margaret Hutchinson (Wife) — 0412 774 903

Initial Rapid Assessment

Response: Alert
Airway: Patent. No airway obstruction, no stridor, no swelling. Speaking in full sentences.
Breathing: Adequate. Self-ventilating. Nil accessory muscle use. Nil abnormal breath sounds.
Circulation: Radial pulse strong and regular. Skin warm and dry. No active external bleeding noted.
Disability: GCS 15 (E4V5M6). Alert and oriented to time, place and person. Complaining of posterior midline neck pain and tingling sensation in both hands.
Exposure: Superficial abrasions to both palms. No visible head laceration. No obvious spinal deformity. Pt is seated in a chair.

Vitals

Time	SpO2	Resp Dist	RR	Pulse	BP	CRT	GCS	PERL	Temp	BGL	Pain
Initial	97% (RA)	Nil	16	78	148/88	<2s	15	4 4 ++	36.8	–	6
10 mins	97% (RA)	Nil	15	76	146/86	<2s	15	4 4 ++	36.8	–	5

History Taking

Treatment Response

Diagnosis

This patient is suffering from a suspected cervical spinal injury with neurological deficit (bilateral upper limb tingling and hand weakness) following a fall down 6 stairs with head strike, in a 75-year-old male on anticoagulation therapy.

Facilitator Triggers — if trainees miss a critical step

! (If the trainee does not identify the bilateral hand tingling and weakness as a focal neurological deficit — the patient volunteers: 'My hands feel really strange and heavy, is that normal?')
! (If the trainee does not identify clinical indicators requiring spinal precautions — have the patient ask 'Is my neck okay?' prompting the trainee to assess: posterior midline tenderness is present, focal neurological deficit is present (bilateral tingling/weakness), mild intoxication is present — C-spine cannot be cleared at EHS Primary Care level and spinal precautions are mandatory.)
! (If the trainee allows the patient to stand up or self-extricate without coaching — the patient begins to stand and reports 'My hands feel numb and my legs feel weak' — reinforce that self-extrication may aggravate injury and the patient should not be walked.)
! (If the trainee fails to ask about anticoagulation medication — facilitator states 'The patient's wife arrives and mentions he is on blood thinners for his heart.' This is a distracting injury risk factor and should inform urgency of transport.)
! (If oxygen is applied — remind the trainee that oxygen is not indicated for this patient as SpO2 is 97% on room air and the target is 94–98%; oxygen should not be administered to a normoxic patient.)

Treatment Objectives

1 Ensure scene safety and don appropriate PPE before approaching the patient.
2 Perform Primary Survey — confirm patent airway, adequate spontaneous breathing, strong radial pulse, GCS 15, and identify bilateral hand tingling as a focal neurological deficit.
3 Instruct the patient to remain still and NOT stand or walk — explain the need to keep head and neck in a neutral, still position.
4 Identify clinical indicators mandating spinal precautions — (1) posterior midline cervical spine tenderness (POSITIVE); (2) focal neurological deficit — bilateral hand tingling and weakness (POSITIVE); (3) mild intoxication — 2 beers (POSITIVE). C-spine CANNOT be cleared at EHS Primary Care level; spinal precautions are mandatory.
5 Recognise high-risk factors: age 75 years (≥65), dangerous mechanism of injury (fall ≥5 stairs with head strike), neurological deficit — all indicate spinal precautions are mandatory.
6 Place a lanyard around the patient's neck and instruct the patient clearly: 'We cannot clear your neck — please keep your head and neck as still as possible and do not move them.'
7 Maintain manual in-line stabilisation of the head and neck — assign one EHS officer to this role and do not release until appropriate packaging is achieved.
8 Perform Vital Sign Survey: GCS 15, HR 78, RR 16, BP 148/88, SpO2 97% (RA), pain 6/10, PERL 4 4 ++.
9 Conduct Secondary and CNS Survey: assess bilateral upper limb sensation, motor strength and grip strength; assess lower limb sensation and movement; palpate the posterior midline cervical spine for tenderness; document all findings including clinical indicators for spinal precautions.
10 Use lanyard, maintain manual in-line stabilisation, and apply head blocks once the patient is positioned appropriately.
11 Position the patient supine using a controlled technique with manual in-line stabilisation maintained throughout — do NOT allow the patient to lie down unassisted.
12 Apply head blocks to limit lateral movement once the patient is supine on the stretcher.
13 Perform pain assessment and record: 6/10. document and hand over to responding ambulance.
14 Record full observations every 10 minutes — monitor for any changes in GCS, limb sensation, limb motor function, or respiratory function (high cervical injuries can compromise breathing).
15 Escalate to CSP — request urgent ambulance given: neurological deficit, clinical indicators for mandatory spinal precautions, age ≥65, anticoagulation (Warfarin increases bleeding risk in potential spinal cord haemorrhage).
16 Scenario ends on arrival of ambulance and IMISTAMBO handover — include: mechanism, clinical indicators for spinal precautions (midline tenderness, focal neurological deficit, mild intoxication), bilateral hand tingling and weakness, medications (Warfarin, Metoprolol), spinal precautions applied, vital signs trend.
17 Attention to hand hygiene will be given throughout the scenario.

Clinical references: Spinal Trauma · Spinal assessment · Primary Survey · Secondary & CNS Survey · Pain Assessment · Glasgow Coma Scale (GCS)

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