OBJECTIVE: Assess characteristics of trauma patients who sustained falls from their own height, more specifically focusing on presence of severe injuries, diagnosis and treatment. METHODS: Retrospective study including all adult blunt trauma patients admitted in the emergency room in a period of 9 months. Lesions with AIS (Abbreviated Injury Scale)>3 were considered "severe". Variables were compared between victims of fall from their own height (group I) and other blunt trauma mechanisms (group II). Student's t, chi square and Fisher exact tests were used for statistical analysis, considering p<0.05 as significant. RESULTS: Of the 1993 trauma patients included, 305 (15%) were victims of falls from their own height. In group I, mean age was 52.2 ± 20.8 years and 64.8% were male. Injuries in the head segment were the most frequently observed (62.2%), followed by injuries in the extremities (22.3%), thorax (1.3%) and abdomen (0.7%). Severe injuries (AIS>3) were more frequent in the head (8.9%), followed by extremities (4,9%). In group I, craniotomies were needed in 2.3%. By comparing groups, we observed that victims of falls from their own height had significantly higher mean age, higher mean systolic blood pressure, and higher head AIS mean, as well as lower ISS mean, thorax AIS mean, abdomen AIS mean and extremities AIS mean. CONCLUSION: Importance of the trauma mechanism in victims of falls from own height should be emphasized due to a considerable possibility of occult severe injuries, mainly in the cephalic segment.
Closed head injuries; Multiple trauma; Trauma severity indices; wounds and injuries; Traumatology; Accidental falls
OBJETIVO: Avaliar as características das vítimas de queda da própria altura, principalmente a respeito da frequência de lesões graves, seu diagnóstico e tratamento. MÉTODOS: Estudo retrospectivo dos protocolos de trauma (coletados prospectivamente) de 10/06/2008 a 10/03/2009, incluindo as vítimas de trauma fechado com idade igual ou superior a 13 anos admitidas na sala de emergência. Consideraremos como "graves" as lesões com escore de AIS (Abbreviated Injury Scale) maior ou igual a três. As variáveis foram comparadas entre o grupo de vítimas de quedas da própria altura (Grupo I) e as demais vítimas de trauma fechado (Grupo II). Empregamos os testes T de Student, Qui quadrado e Fisher para a comparação entre os grupos, considerando o valor de p<0,05 como significante. RESULTADOS: Foram analisados 1993 casos de trauma fechado, sendo que 305 (15%) foram vítimas de quedas da própria altura (Grupo I). A média etária nas vítimas de quedas da própria altura foi 52,2 ± 20,9 anos, sendo 64,8% do sexo masculino. Noventa e oito (32,1%) tinham idade acima de 60 anos. No grupo I, as lesões em segmento cefálico foram as mais encontradas (62,2%), seguidas das lesões em extremidades (22,3%), torácicas (1,3%) e abdominais (0,7%). As lesões graves (AIS>3) foram mais frequentemente observadas em segmento cefálico (8,9%), seguidas pelas lesões em extremidades (4,9%). A craniotomia foi necessária em 2,3% das vítimas de quedas de própria altura. Observamos que, em comparação às vítimas de outros mecanismos de trauma fechado, as vítimas de quedas da própria altura apresentavam, significantemente (p<0,05), maior média etária, maior média de pressão arterial sistólica à admissão e maior média de AIS em segmento cefálico bem como menor média de ISS, de AIS em tórax, de AIS em abdome e AIS em extremidades. CONCLUSÃO: A valorização do mecanismo de trauma nas vítimas de quedas da própria altura é de extrema importância, visto a possibilidade de haver lesões graves e clinicamente ocultas, principalmente em segmento cefálico.
Ferimentos e lesões; Ferimentos não penetrantes; Índices de gravidade do trauma; Traumatismos cranianos fechados; Traumatismos encefálicos; Acidentes por quedas
IDoutor em Cirurgia Geral - Médico Assistente. Serviço de Emergência na Irmandade da Santa Casa de Misericórdia de São Paulo, São Paulo, SP
IIResidentes em Cirurgia Geral - Médico na Irmandade da Santa Casa de Misericórdia de São Paulo, São Paulo, SP
IIIAluna - Curso de Medicina da Faculdade de Ciências Médicas da Santa Casa de São Paulo, São Paulo, SP
IVDoutor em Cirurgia Geral - Diretor do Serviço de Emergência na Irmandade da Santa Casa de Misericórdia de São Paulo, São Paulo, SP
OBJECTIVE: Assess characteristics of trauma patients who sustained falls from their own height, more specifically focusing on presence of severe injuries, their diagnosis and treatment.
METHODS: Retrospective study including all adult blunt trauma patients aged 13 or more admitted in the emergency room in a period of 9 months. Lesions with AIS (Abbreviated Injury Scale)>3 were considered "severe". Variables were compared between victims of fall from the same level (group I) and other blunt trauma mechanisms (group II). Student's t, chi square and Fisher exact tests were used for statistical analysis, considering p<0.05 as significant.
RESULTS: Of the 1993 trauma patients included, 305 (15%) were victims of falls from the same level. In group I, mean age was 52.2 ± 20.8 years and 64.8% were male. Injuries in the head segment were the most frequently observed (62.2%), followed by injuries in the extremities (22.3%), thorax (1.3%) and abdomen (0.7%). Severe injuries (AIS³3) were more frequent in the head (8.9%), followed by extremities (4,9%). In group I, craniotomies were needed in 2.3%. By comparing groups, we observed that victims of falls from the same level had significantly higher mean age, higher mean systolic blood pressure, and higher mean head AIS, as well as lower mean ISS, mean thorax AIS, mean abdomen AIS and mean extremities AIS.
CONCLUSION: Importance of the trauma mechanism in victims of falls from the same level should be emphasized due to a considerable possibility of hidden severe injuries, mainly in the cephalic segment.
Key Words: Closed head injuries. Multiple trauma. Trauma severity indices. wounds and injuries. Traumatology. Accidental falls.
Falls on the same level (FSL) are regarded as a public health problem, due to their high frequency and duo to their direct and indirect effects on the health of the population.1,2 Although they are most common among the elderly, FSL also affect the epilleptic, chronic alcoholics and drug addicts. They can cause severe and life-threatening injuries, in addition to deteriorating previous morbid states, thus leading to late mortality.3 Falls are often the result of several factors combined, and it is hard to narrow down the event of falling to one single risk factor or causing agent.4
Currently, about 15% of the patients admitted in specialized trauma centers suffered a FSL, thus consuming a significant portion of the resources allocated to health care. 4,5,6 It is estimated that, in 2000, approximately 19 billion dollard were spent in the USA treat FSL victims.1 The incidence of falls increases with age, ranging from 34% among patients aged 65-80, 45% among patients aged 80-89 and 50% over 90 years old.3 About half of these will fall again in the following 12 months.1
This type of trauma is often neglected by paramedics for being a low kinetic energy mechanism. However, severe and potentially lethal injuries may present. The large majority of the studies available assesses only accidental falls in the elderly, but there is no reference to the injuries found in victims of FSL in general.6,7,8 In spite of its importance, we have not found many studies that investigate the problem9,10,11.
Therefore, the objective of this study is to assess the characteristics of FSL victims as compared to the victims of other blunt trauma mechanisms, as well as to compare the frequency of severe injuries, their diagnosis and treatments in each group.
This study was approved by the Ethics Committee for Research of Irmandade da Santa Casa de Misericórdia de São Paulo (project 008/10).
In the Emergency Room of Irmandade da Santa Casa de Misericórdia de São Paulo (ISCMSP), a prospective data collection is carried out with all trauma patients admitted into the ER since June, 2008. This protocol is initially filled out by the surgery residents at patient admission, and, later, by follow-up service attendants until discharge. The information is stored into an Access 2007® database.
In this study, we conducted a retrospective analysis of the protocols collected in the period from June 10, 2008 to March 10, 2009. All victims of blunt trauma aged 13 or more admitted into the Pronto Socorro Central Emergency Room whose trauma protocol had been correctly filled in were included in the study. Cases in which the trauma mechanism had not been described were excluded. Patients were divided into two groups: Group I: FSL victims; and Group II: victims of other blunt trauma mechanisms (automobile drivers and passengers, motorcycle riders and passengers, run over victims and victims of assault and level falls).
The groups were compared regarding the trauma mechanism, vital signs at admission, additional tests conducted, associated diseases, injuries diagnosed and their gravity, trauma rates and treatment. All variables listed in over 90% of the protocols were considered for analysis. The stratification of severity of the sample was carried out according to the trauma indexes Glasgow Coma Score (GCS)12, Revised Trauma Score (RTS)13, Abbreviated Injury Scale (AIS)14, Injury Severity Score (ISS)15 and computing the survival probability with the TRISS method.16 Lesions with AIS > 3 in the various body segments were considered to be "severe".17 For instance, severe lesions in blunt trauma extremities include hip fractures, femur fractures, luxations of the knee, hip, wrist or ankle, amputation or crushing of the knee, tear of knee ligaments, laceration of the sciatic nerve, lesions of the femoral artery, trombosis of the popliteal or axillary artery or of the popliteal, axillary or femoral vein, as well as association with 2nd or 3rd degree burns encompassing over 20% of the body surface14,17.
The statistical analysis was carried out using the Statistical Package for Social Sciences® (16.0). The numerical variables are presented as mean and standard deviation (when noted). We used the Student's t-test, the chi square test and the Fisher's test to compared the groups, considering the value of p<0.05 as statistically significant.
During this period, 2,059 trauma patients were admitted to the emergency room. From these, 66 had non-established trauma mechanisms, thus leaving 1993 for the analysis. The most frequently observed trauma mechanism involved motorcycle riders (28.2%) (Table 1). Three hundred and five patients (15.0%) had suffered FSL. In Group I, age ranged from 13 to 99 years (52.2 ± 20.8 years), and 198 patients were male (64.9%). Ninety-eight (32.1%) victims of FSL were aged 60 or more. In Group II, age ranged from 13 to 91 years (35.4 ± 14.9 years), and 1,271 patients were male (75.3%).
When comparing the groups, we observed that Group I presented significantly higher mean age (52.2 ± 20.8 years versus 35.4 ±14.9 years; p<0.001) and systolic blood pressure (134.0 ±21.2 mmHg versus 126.7 ± 23.4 mmHg; p<0.001)than those observed in Group II(Table 2). Mean AIS in cephalic segment was significantly higher in Group I (0.92 ±1.0 versus 0.55± 1.1; p<0.001) (Table 2). Mean severity rates in thorax (0.16± 0.2 versus 0.20 ±0.8; p<0.001), abdomen (0 versus 0.12± 0.6; p<0.001) and extremities (0.35± 0.8 versus 1.11± 1.3; p<0.001) were significantly higher in Group II. The ISS anatomical injury severity score was significantly lower in Group I (2.7 ±4.4 versus 5.4± 8.8; p<0.001). There was no significant difference in the comparison between the groups regarding the mean values for the RTS physiological score and the survival probability computed with the TRISS method (Table 2).
In victims of FSL (Group I), the cephalic segment injuries were most commonly found (62.2%), followed by extremity injuries (22.3%), thoracic injuries (1.3%) and abdominal injuries (0.7%). Cerebral contusions (5.6%) and extradural bruises (2.6%) were the most frequent severe injuries in cephalic region (Table 3). When compared to Group II, the patients of Group I presented a higher frequency cerebral contusions (5.6% versus 2.2%; p<0.001), as well as a lower frequency of hemothorax (0 versus 2.1%; p=0.005), pneumothorax (0 versus 2.5%; p=0,005), flail chest (0 versus 1.3 %; p=0.049), pulmonary contusion (0 versus 2.2%; p=0.009), pelvis fracture (0.3% versus 2.5%; p=0.018), fracture of the upper limb (0.7% versus 5.6%; p<0.001), fracture of the lower limb (2.3% versus 5.5%; p=0.017), exposed fracture of the upper limb (0 versus 1.4%; p=0.040) and exposed fracture of the lower limb (0 versus 4.1%; p<0.001) (Table 3).
Severe cephalic segment injuries were more frequent in Group I, but were not statistically significant (8.9% versus 7.6%; p=0.467). Both in the thoracic segment and in the extremities, severe lesions were significantly more frequent in Group II (0.3% versus 4.3%; p<0.001 and 4.9%; versus 17.0% p<0.001, respectively) (Table 3). Craniotomy was required in 2.3% of FSL victims and in 1.3% of remaining patients.
Most studies about falls are focused on the elderly1,18-24. Data from the Centers of Disease Control report an investment of about US$ 24,900,000 in only 20 years to study and prevent falls among the elderly in the United States of America19 . Several studies assess the risk of falling among the elderly, as well as its prevention20-24 . Most falls among the elderly take place at home and relapse is a problem23.
The greatest risk group are the elderly who make continued use of four or more medications and have had a previous fall20,25. The mortality rate due to falling after age 85 can reach 136.5/100,000, which corresponds to three times the rate observed in elderly patients aged 75 to 8418. In spite of some debate, prevention programs seem to have positive effect, but their application is difficult.19,21,26-30
However, we have observed, in our date, that only 32.1% of FSL victims are aged over 60. In spite of its severity among the elderly, this trauma mechanism involves a greater number of patients with their own characteristics. The problem seems to be much more far-reaching, as suggested by the severe and life-threatening injuries observed. There are probably other risk factors involved, such as drug and alcohol use, as well as the presence of seizures and lipothymia, although such data has not been analyzed in our study. This information points to the importance of prevention and education programs for the population and to the need for further research on the topic.
Our motivation to conduct this study was the observation of the large number of victims of this trauma mechanism, the real possibility of severe injuries associated to it, and the lack of research on the topic in the literature. In a period of nine months, 305 victims of FSL were admitted in our service; from these, about 8.9% presented severe cranial injuries and 4.9% presented severe extremity injuries. We underscore that this frequency of injuries is characteristic of this group, in which only adult trauma patients admitted to the emergency room were included. Most of these patients are brought to the hospital with some kind of pre-hospital care. In 2006, Schwendimann et al. observed more severe injuries in 3.9% of FSL victims in a intrahospital environment.31 The falls are also frequent in children, corresponding to 45% of emergency room visits (under five years old), although only 3% lead to admissions.18
Although severe injuries have been identified, most FSL victims presented with mild injuries. Mean RTS and ISS showed trauma without compromise of the physiological state and with little anatomical involvement. The mean survival probability (TRISS) of 98% also showed that, in most cases, FSL victims present with mild trauma.
The definition of severe injuries in this study (AIS>3) involves those that require specific treatment and which could definitely influence the prognosis unless they are identified and treated.17 There were also other patients with identified lesions, but lower AIS (Table 3). Although extremities were frequently involved, the largest number of severe injuries was identified in the cranial segment. This is extremely important, once some potentially lethal intracranial injuries could present with minimum symptoms at admission, and computerized tomography is the only way to obtain an early diagnosis. Less experienced physicians, when faced with an FSL victim, may underestimate minor signs and eventually miss the opportunity of diagnosing severe injuries.
The low frequency of these injuries could be a problem. In our study, about 2.6% of patients presented with extradural bruises and 5.6% presented with cerebral contusions. These injuries could go unnoticed initially, with the possibility of deteriorating hours later. If this occurs after discharge from the hospital, it could result in grim consequences for the patient and the medical team. This problem could also occur with orthopedic injuries, especially when the patient presents with impaired consciousness or lacks orientation to express their complaints. In our study involving general FSL victims, fractures were diagnosed in 3% of the cases.
We observed important differences in the comparison between Groups I and II, which points to characteristics that are specific of FSL victims. The greater number of elderly patients among FSL victims was accountable for the difference in mean age between the groups. This might also explain the greater frequency of females in this group. The comparison between the anatomical trauma scores (ISS) shows that FSL victims present less severe injuries. However, we observed a greater mean AIS in cephalic segment among the patients in Group I, which, again, points to the problem of cranioencephalic trauma among victims of this type of trauma. An interesting observation is that the need for craniotomy was approximately doubled in Group I, although there was no statistically significant difference.
Although we found few severe injuries in the thorax and abdomen, we understand that these can happen, even if not as frequently, in FSL victims. The fact that these lesions were not observed in our study is probably due to the size of our sample.
A general assessment of our data points to the frequency of FSL and to the possibility of complications associated with injuries that are not initially diagnosed. The underestimation of this trauma mechanism and the possibility of clinically hidden severe injuries could result in worse prognosis. The problem is considerable in the elderly, but not exclusive of this age group. There is a need for specific prevention projects, as well as new, focused studies on the topic.
Awareness of the trauma mechanism in FSL victims is of the utmost importance, given the possibility of clinically hidden severe injuries, especially in the cephalic segment.
- 1. Berry SD, Miller R. Falls: Epidemiology, pathophysiology and relashionship to fracture. Curr Osteoporos Rep. 2008; 6: 149-54.
- 2. Barbosa MLJ, Nascimento EFA. Incidências de internações de idosos por motivos de queda em um Hospital Geral de Taubaté. Rev. Biocienc 2001; 1(7): 35-42.
- 3. Jahana KO, Diogo MJDI. Quedas em idosos: principais causas e conseqüências. Saúde Coletiva 2007; 04(17): 148-153.
- 4. Gawryszewski V P. Importância das quedas no mesmo nível entre idosos no estado de São Paulo. Rev. Assoc. Med. Bras. [online]. 2010. 56: 162-167.
- 5. Melo JRT, Junior L, Laudenos P, Teixeira LM. Principais causas de trauma craniencefálico na cidade de Salvador, Bahia, Brasil. Arq. Bras. Neurocir. 2005, 24 (3): 93-97.
- 6. Braga FM, Netto AA, Santos LR, Braga PB. Avaliação de 76 casos de trauma crânio-encefálico por queda da própria altura atendidos na emergência de um hospital geral. Arq. Catarinense de Medicina. 2008, 37 (4): 35-39.
- 7. Fabricio SCC, Rodrigues RAP, Costa MR. Causas e consequências de quedas de idosos atendidos em hospital publico. Rev. Saúde publica. 2004, 38(1):93-99.
- 8. Perracini MR, Ramos RL. Fatores associados à queda em uma coorte de idosos residentes na comunidade. Rev. Saúde publica. 2002, 36(6):709-16 .
- 9. Batigália F, Carvalho FR, Delgado AS, Vencio PRC, Casagrande MR, Cury FA. Evoluçäo espontânea favorável de lesão tráqueo-brônquica traumática. HB cient. 1997;4:66-73.
- 10. Piton DA. Análise dos fatores de risco de quedas em idosos: estudo exploratório em instituição de longa permanência no município de Campinas. Dissertação de Mestrado. 2004, UNICAMP.
- 11. Paiva AW, Oliveira RL, Ferreira AA, Marino RJ. Contusões cerebrais devido a trauma crânio-encefálico: princípios fisiológicos e conduta. J. Brás. Med. 2006, 91(2):11-18.
- 12. Teasdale G, Jennet B. Assessment of coma and impaired consciuosness: a pratical scale. Lancet 1974, 2: 81-84.
- 13. Champion HR, Sacco WJ, Copes WS, Gann DS, Gennarelli TA, Flanagan ME. A revision of the trauma score. J Trauma. 1989; 29: 623 - 629.
- 14. Association for Advancement of Automotive Medicine.The Abbreviated Injury Scale. 1990 Revision. 1990, Des Plaines, IL 60018, USA.
- 15. Baker S, O'Neil B, Haddon W, Long WB. The Injury Severity Score: A method for describing patients with multiple injuries and evaluating emergency care. J Trauma, 1974, 14: 187-196.
- 16. Boyd CR, Tolson MA, Copes W. Evaluating trauma care: the TRISS method. J Trauma. 1987, 27: 370-8.
- 17. Fraga GP, Ordonez CA, Hirano ES. Cálculo de índices de trauma. In: Ferrada R, Rodriguez A. Trauma. Sociedade Panamericana de Trauma. 2a Ed. Atheneu. São Paulo. 2010. Pp 43-61.
- 18. MacKenzie EJ, Fowler CJ. Epidemiology. In: Feliciano DV, Mattox KL, Moore EE. Trauma.Mc Graw Hill Medical. New York. 6th ed. 2008. 25-38.
- 19. Sleet DA, Moffett DB, Stevens J. CDCs research portfolio in older adult fall prevention: a review of progress, 1985-2005, and future research directions. J Safety Res. 2008;39:259-67. Epub 2008 Jun 6.
- 20. Ferreri S, Roth MT, Casteel C, Demby KB, Blalock SJ.Methodology of an ongoing, randomized controlled trial to prevent falls through enhanced pharmaceutical care. Am J Geriatr Pharmacother. 2008;6:61-81.
- 21. Hendriks MR, Evers SM, Bleijlevens MH, van Haastregt JC, Crebolder HF, van EijkJT. Cost-effectiveness of a multidisciplinary fall prevention program incommunity-dwelling elderly people: a randomized controlled trial (ISRCTN64716113). Int J Technol Assess Health Care. 2008;24:193-202.
- 22. Hakim RM, Roginski A, Walker J. Comparison of fall risk education methods for primary prevention with community-dwelling older adults in a senior center setting. J Geriatr Phys Ther. 2007;30:60-8.
- 23. Gillespie LD, Gillespie WJ, Robertson MC, Lamb SE, Cumming RG, Rowe BH. Interventions for preventing falls in elderly people. Cochrane Database Syst Rev. 2003;(4):CD000340.
- 24. Roe B, Howell F, Riniotis K, Beech R, Crome P, Ong BN. Older people and falls: health status, quality of life, lifestyle, care networks, prevention and views on service use following a recent fall. J Clin Nurs. 2009 Aug;18(16):2261-72.
- 25. Ganz DA, Bao Y, Shekelle PG, Rubenstein LZ. Will my patient fall? JAMA. 2007;297:77-86.
- 26. Milisen K, Geeraerts A, Dejaeger E; Scientific Working Party, Uniform Approach for Fall Prevention in Flanders. Use of a fall prevention practice guideline for community-dwelling older persons at risk for falling: a feasibility study. Gerontology. 2009;55:169-78. Epub 2008 Oct 16.
- 27. Ganz DA, Alkema GE, Wu S. It takes a village to prevent falls: reconceptualizing fall prevention and management for older adults. Inj Prev. 2008;14:266-71.
- 28. Hendriks MR, Bleijlevens MH, van Haastregt JC, Crebolder HF, Diederiks JP, Evers SM, Mulder WJ, Kempen GI, van Rossum E, Ruijgrok JM, Stalenhoef PA, van Eijk JT. Lack of effectiveness of a multidisciplinary fall-prevention program in elderly people at risk: a randomized, controlled trial. J Am Geriatr Soc. 2008;56:1390-7. Epub 2008 Jul 24.
- 29. Bonner A, MacCulloch P, Gardner T, Chase CW. A student-led demonstration project on fall prevention in a long-term care facility. Geriatr Nurs. 2007 Sep-Oct;28(5):312-8.
- 30. Banez C, Tully S, Amaral L, Kwan D, Kung A, Mak K, Moghabghab R, Alibhai SM. Development, implementation, and evaluation of an Interprofessional Falls Prevention Program for older adults. J Am Geriatr Soc. 2008;56:1549-55. Epub 2008 Jun 28.
- 31. Schwendimann R, Bühler H, De Geest S, Milisen K. Falls and consequent injuries in hospitalized patients: effects of an interdisciplinary falls prevention program. BMC Health Serv Res. 2006 Jun 7;6:69.
Severe injuries from falls on the same level
Publication in this collection
26 Jan 2011
Date of issue
18 Jan 2010
26 June 2010