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PubMed2004

Blunt cardiac trauma caused by fatal falls from height: an autopsy-based assessment of the injury pattern.

BACKGROUND: Falls from height are contributing widely to population morbidity and mortality, especially in urban settings. The presence of blunt cardiac injuries can increase morbidity among these patients, leading even to death. Some clinical studies and case reports have been published on the subject, but a systematic autopsy-based approach to the subject is missing in the literature of recent decades. METHODS: This study reviewed 61 cases of fatal fall from height that were subjected to a full autopsy at the Institute of Legal Medicine, Hamburg, Germany, from 1998 to 2002. The autopsy protocols and available clinical information were evaluated for assessment of the cardiac injury pattern. RESULTS: Cardiac injuries were found in 33 cases (54%), all of which involved falls from heights exceeding 6 m. In 16 cases, the cardiac injuries were the cause of death or contributed to the fatal outcome. In five of these cases, the individuals possibly could have recovered from their trauma if their heart injury had been sufficiently diagnosed and adequately treated in time. The most frequent finding was pericardial tearing (45%). Tears caused by stretching of the epicardium in the area wherein the inferior vena cava leads into the right atrium and epicardial hematoma were present in 11 cases (33%). Endocardial tears of the atria were found in six cases (18%), and did not occur during falls from heights lower than 11 m. Transmural tears to the right atrium were present in 10 cases (39%), and to the left atrium in 6 cases (18%). These tears occurred with increasing frequency in relation to greater heights. When the heights were lower than 15 m, these tears were smaller than 1 cm in diameter, but when the heights exceeded 15 m, extensive irregular tears were observed. Sternal fractures were seen in 76% of all cases involving heart injuries. In 16% of these cases, the fractures were multiple. Only 18% of the cases without cardiac injuries had sternal fractures, and none of these was multiple. Thus, the presence of severe sternal fractures can be used as an indicator of possible cardiac trauma. CONCLUSIONS: A thorough cardiologic diagnosis should always be performed for patients who survive a fall from height. These patients should be transported to a unit capable of performing cardiopulmonary bypass, and explorative thoracotomy should be considered.

Accidental Falls↗
PubMed2004

[Victims of fall from height. Study of 287 patients and determination of clinical prognostic factors].

INTRODUCTION: Fall from height is a common cause of severe blunt urban trauma but this mechanism of trauma is poorly documented. OBJECTIVE: To describe initial clinical parameters, injuries and outcome in patients victims of falls from height and to determinate clinical prognostic factors. STUDY DESIGN: Retrospective study from January 1998 to May 1999 and prospective study from June 1999 to September 2000. Inclusions: patients older than 12 year-old victims of falls with height of more than 3 m. PATIENTS AND METHODS: Studied parameters: demographic data, fall circumstances, prehospital clinical evaluation (Glasgow coma scale (GCS), Arterial Blood Pressure (ABP), Heart Rhythm (ER) and revised trauma score (RTS) initial and patients outcome. RESULTS: Two hundred and eighty seven patients were included during 32.5 months; 33% were women and 67% men. Mean age: 37 +/- 16 years. Median height of fall: three stairs (3-4). Final mortality: 34% including 22% death on site with or without resuscitation, 5% before hospitalization, 8% during the first day and 2% later. Independent prognostic factors were GCS (OR = 0.40; IC: 0.25 - 0.65; P = 0.0002), initial ABP (OR = 0.94; IC: 0.90 - 0.98; P = 0.008) and RTS (OR = 2.93; 1.19-7.24; P = 0.02). CONCLUSION: Immediate mortality after fall from heights is high and remains low after day 3. GCS, ABP and RTS are independent prognostic factors.

Accidental Falls↗
PubMed1987

Peripheral vascular injuries associated with falls from heights.

Peripheral vascular injuries associated with falls from heights are uncommon. We report our 15-year experience with ten such injuries in 230 patients who jumped or fell from heights of at least 3 stories. These injuries occurred in seven patients and included four popliteal artery thromboses or disruptions, two popliteal vein disruptions, one traumatic tibial arteriovenous fistula, one subclavian artery pseudoaneurysm, one radial artery transection, and one lacerated medial circumflex artery. Although the mechanism of injury is multifactorial, all were associated with significant orthopedic trauma. Early recognition of vascular injuries, minimization of ischemic time, completion arteriography, venous repair, and liberal use of fasciotomy are emphasized to maximize limb salvage.

Accidental Falls↗
PubMed2000

Pediatric falls: is height a predictor of injury and outcome?

Falls account for a significant proportion of pediatric injuries and deaths. A retrospective review of pediatric patients (age 0-14 years) was performed to determine whether patterns of injuries and outcomes could be predicted on the basis of the height of the fall. In addition we evaluated the triage criterion "fall greater than 15 feet" for transport of patients to a trauma center. Patients were stratified by the height of the fall: greater than or less than 15 feet. The end points for analysis were the associated injuries and survival. Patients who fell less than 15 feet had a higher incidence of intracranial injuries (and fewer extremity fractures than patients who fell more than 15 feet). Skull fractures were the most frequent injury and were associated with an increase in intracranial injuries in both subgroups. In conclusion low-level falls are associated with significant intracranial injuries. The evaluation of patients sustaining low-level falls should not be limited on the basis of the height of the fall. Using falls of greater than 15 feet as a triage criterion for transport to a trauma center needs to be prospectively evaluated to ensure that critically injured patients are triaged appropriately.

Accidental Falls↗
PubMed1978

[Mathematic-statistical discrimination between suicide and accident in falls from height (author's transl)].

On the basis of 185 deaths caused by falls from height we examined the probability to differentiate between suicide and accident. Variables about the person, about the course and the background of the action as well as about the injury-pattern were taken into consideration. Contingency table analysis, chilsqare tests and probportional reduction in error measure were used first to determine the significant differences in criminal classification: sex, job, domicile, hour of the day, locality and height of the fall and the injuries established by postmortem examination. To test the discriminative power of the identified characteristics discriminant function analysis was used. Utilizing only 11 characteristics 88,6 percent of the deaths could be classified correctly.

Accidents↗
PubMed2005

Can the height of fall predict long bone fracture in children under 24 months?

AIMS: It can be difficult to determine the exact mechanism of injury in infants and babies aged 24 months and under. Falls are the most common mechanism of injury in children. The purpose of this study is to identify the relationship between reported height of fall and long bone fracture. METHODS: All children aged under 24 months who sustained a fracture (in the year 2003) were identified prospectively on the departmental fracture database. These children were matched for age and sex with children identified as having fallen but not having sustained a fracture. RESULTS: Sixty-three children aged 24 months and under were studied. The median height of fall in this group was 48 cm and that in the control group was 20 cm, P<0.001. A significant correlation was observed between the height of fall (cm) and severity of injury (Pearson's correlation coefficient=0.255). Receiver operating characteristic analysis indicates that the likelihood of significant fracture requiring admission and/or manipulation under anaesthesia occurs with a fall from a height of 56 cm [sensitivity 80% (confidence interval 29-97%), specificity 79% (confidence interval 70-86%)]. It was not possible to identify a height at which the risk of any fracture injury became significantly more likely. CONCLUSION: Height of fall is only one factor that must be considered in dealing with fracture injury in children aged 24 months or under. However, significant injury presenting with falls from less than 50 cm should be critically evaluated.

Accidental Falls↗
PubMed2003

Fatal falls from heights in and around Diyarbakir, Turkey.

Falls from high places, such as from a building, are frequently encountered in suicides, in some accidents, and sometimes in homicides. In this study, we evaluated the demographic data, mortality rates, fall causes, and post-mortem findings of individuals who fell from heights. Our cases were collected retrospectively from the files of the Branch of the Council of Forensic Medicine in Diyarbakir between 1996 and 2001. There were 431 accidental and 53 suicidal deaths due to blunt injury resulting from falls. Of the victims, 188 were female and 296 were male. The average age of the 484 victims was 27.05 years (range: 4 months-100 years). For buildings, the height ranged from 3 to 8 stories for suicides and from 1 to 8 stories for accidents. We proceeded to analyse the characteristics of accidental falls as follows. The majority of falls were from balconies or rooftops due to the tendency of people to sit and sleep on these places during the hotter months of the year. Some 54.5% of all falls occurred in May-August. The 53 suicidal jumps all occurred off buildings. The victims ranged in age from 15 to 70 years, and comprised 29 women and 24 men. One of the deceased jumped from the roof of a school in which he was boarding, and another from the seventh story of a hospital in which he was receiving treatment. The remaining 51 jumped from heights ranging from 3 to 8 stories. Psychiatric illness was reported in 18 (33.9%) of the suicide deaths, while 10 (18.8%) of the 53 suicides were single women. The results of this study were at variance with literature data with respect to the following: falls from heights were most common in the 0-5 year age group, females had a higher suicide rate than males, and the majority of accidental falls occurred at home rather than in the workplace.

Accidental Falls↗
PubMed1986

Free falls from heights: a persistent urban problem.

In order to determine the significance and implications of falls from heights in the North Central Bronx Hospital (NCBH) patient population area, the records of 203 patients who fell from heights of 5 to 72 feet and who died or were admitted to NCBH over a five-year-period were reviewed. Demographic and clinical data were collected and analyzed for 192 of those patients. The findings show a male-to-female ratio of two to one, an age range of four months to 86 years, and a disproportionately high incidence of falls among minority group children.Seventy-six percent of patients had skeletal, 12 percent abdominal, and 10 percent skull fractures and cerebral edema. Twenty-two percent of juveniles (0 to 17 years) and 5 percent of adults had craniocerebral trauma. Thirty-one percent required surgery. Ten percent of the admitted patients had permanent disabilities. A trauma scoring system, the Injury Severity Score, correlated directly with height fallen. Overall mortality was 28 percent but only 6.6 percent in the juvenile group. Most of the falls were accidental (45 percent) or suicide attempts (22 percent).Although recognized as a health problem at least since 1965, falls from heights continue to be a cause of morbidity and mortality in urban people 20 years later. Renewed efforts at education and the passage and enforcement of public health laws are needed if their numbers are to be decreased.

Accidents↗
PubMed2003

Suicides by fall from height in Geneva, Switzerland, from 1991 to 2000.

Suicides due to fall from height in Geneva from 1991 to 2000 were reviewed. Scene investigations, autopsy findings, psychiatric histories, and toxicology results were examined. There were 197 of these suicides, an incidence of five cases per 100,000 inhabitants per year or one fourth of all suicides in Geneva per year. Autopsies were performed on 33%, the rest had external examinations. Of the victims, 56% were female and 44% were male. The age distribution peaked at 20-29 years in men and 60-69 years in women. Most of the victims jumped from their home, the range of 2 to 7 stories being the most frequent height. Major injury sites, in decreasing frequency, were the thorax, abdomen, skull, vertebrae, pelvis and limbs. Psychiatric illness was reported in 38% of the cases. Toxicological analysis was performed in 25% of the cases and showed that the main drugs present were benzodiazepines, cannabis and antidepressant.

Adolescent↗
PubMed2003

Case studies of occupational falls from heights: cognition and behavior in context.

PROBLEM: The aim of this study was to examine individual workers' cognitive, behavioral, and motivational processes leading up to occupational falls from heights. METHOD: The study is based on 26 semistructured personal interviews and on-site investigations with male workers who reported to an emergency department for treatment of injuries due to falls from heights. RESULTS: A greater number of workers carrying out nonroutine compared to routine tasks perceived, identified, interpreted, and attempted to control a fall hazard. Two cases are presented illustrating how cognition and behavior in context progresses from a lesser to a greater active role in the incident processes. SUMMARY AND IMPACT ON INDUSTRY: The addition of full-scale investigations of how and why workers thought and behaved the way they did in a particular situation can give important clues as to whether preventive measures will be effective in a similar situation in the future.

Accidental Falls↗
PubMed2005

Preference for fall from height as a method of suicide by elderly residents of New York City.

We studied all medical examiner-certified suicides in New York City from 1990 to 1998 to compare suicide methods used by elderly and younger adults. Associations between age and suicide method and place of occurrence were examined. Fall from height was more likely to have been used by individuals 65 or older than by those who were younger. Among persons who died by fall from height, those 65 or older were more likely than others to have fallen from buildings where they lived.

Adolescent↗
PubMed1982

Blunt force lesions related to the heights of a fall.

Patterns of traumatic injuries due to fall from height certainly have an association with the amount of impact involved. A study of 63 medicolegal autopsies with the history of falls has been carried out during the period January 1974-July 1980. The injuries found were caused either by the direct impact, i.e., at the site of impact, or in a region distant from the site of impact of force as a result of transmitted force or indirect force. An attempt has been made to evaluate, generalize and correlate the characteristic pattern of the injuries to the various parts of the body with respect to various heights of fall. Stress has also been laid on the mechanism of production of these injuries in order to create a composite picture to help determine the most likely traumatic force in falls from height.

Abdominal Injuries↗
PubMed2006

Review of morbidity and mortality associated with falls from heights among patients presenting to a major trauma centre.

OBJECTIVE: To compare differences in demographics and injuries of patients presenting after falls from heights at home and at work. METHOD: A retrospective case series review of patients treated by the Royal Adelaide Hospital (RAH) Trauma Service following a fall from a ladder, scaffold, building, or tree between July 2000 and December 2003. RESULTS: Two hundred and eighty-two patients fulfilled study criteria. The 162 (57.4%, 95% confidence interval [CI] 48.9-60.5) injured at home were significantly (P < 0.001) older (mean age 53.9 years, 95% CI 51.3-56.7) than those injured at work (mean age 41.2 years, 95% CI 38.6-43.8). Injury severity score (ISS) was similar in the two groups. Those injured at home were more likely to be admitted to hospital and have significantly longer hospital stays (P = 0.003). Thirteen deaths were recorded, eight (61.5%) from home, all over 49 years old. Ladders were implicated in seven (53.8%, 95% CI 26.7-80.9) of the deaths. A 67% (95% CI 55.4-79.0) increase in the number of presentations following falls at home over the study period was significantly greater than the 12.2% (95% CI 10.7-13.7) increase in total trauma presentations during this time (P = 0.0007). CONCLUSIONS: Injuries resulting from falls at home are increasing. This group tends to be elderly and at risk of significant injury and prolonged hospital stays. Causes are multifactorial and might be related to increased popularity of home renovations. Ladders are implicated in many of these accidents. As emergency physicians we should target this population to educate them in safe ladder use.

Abdominal Injuries↗
PubMed1991

[The fall from height of king Ocozhyia of Israel].

An historic and literary analysis was performed to evaluate the clinical characteristics of the fall from height experienced by Israeli King Ocozhyia (book of kings 2: 2-17). We conclude that the clinical course was brief, there was no brain injury and it is likely that he developed a fracture but no retroperitoneal, soft tissue or vascular injury. Most likely hypovolemia and respiratory insufficiency derived from thoraco-abdominal injury caused his death. The biblical writer apparently was close to the action.

Accidental Falls↗
PubMed2005

Out on a limb: risk factors for arm fracture in playground equipment falls.

OBJECTIVES: To investigate and quantify fall height, surface depth, and surface impact attenuation as risk factors for arm fracture in children who fall from playground equipment. DESIGN: Unmatched case control study. SETTING: Five case hospitals and 78 randomly selected control schools. PARTICIPANTS: Children aged less than 13 years in Victoria, Australia who fell from school playground equipment and landed on their arm. Cases sustained an upper limb fracture and controls had minor or no injury. A total of 402 cases and 283 controls were included. INTERVENTIONS: Children were interviewed in the playground as soon as possible after their fall. MAIN OUTCOME MEASURES: Falls were recreated on site using two validated impact test devices: a headform (measuring peak G and HIC) and a novel anthropometric arm load dummy. Equipment and fall heights, as well as surface depth and substrate were measured. RESULTS: Arm fracture risk was greatest for critical equipment heights above 1.5 m (OR 2.39, 95% CI 1.49 to 3.84, p<0.01), and critical fall heights above 1.0 m (OR 2.96, 95% CI 1.71 to 5.15, p<0.01). Peak headform deceleration below 100G was protective (OR 0.67, 95% CI 0.45 to 0.99, p = 0.04). Compliance with 20 cm surface depth recommendation was poor for both cases and controls. CONCLUSIONS: Arm fracture-specific criteria should be considered for future standards. These include surface and height conditions where critical headform deceleration is less than 100G. Consideration should also be given to reducing maximum equipment height to 1.5 m. Improved surface depth compliance and, in particular, guidelines for surface maintenance are required.

Accidental Falls↗
PubMed1997

Axonal injury in falls.

Amyloid precursor protein (APP) immunocytochemistry was used as a marker for axonal injury (AI) in a series of 16 cases of head trauma associated with fatal falls. Nine cases were falls from not more than the person's own height (falls from < or = own height) and seven cases were falls from a distance greater than the person's own height (falls from > own height). AI was recorded on a series of line diagrams of standard brain sections divided into 116 sectors. AI around focal lesions (infarcts, hemorrhages, contusions) was distinguished from nonfocal axonal injury that was distant from any focal area of damage. The percentage of sectors showing focal AI provided the Focal Axonal Injury Score (FAIS) and the percentage showing nonfocal AI the Non-Focal Axonal Injury Score (NFAIS). The FAIS is a measure of secondary AI and the NFAIS of diffuse axonal injury (DAI). The percentage of sectors involved with AI (focal and nonfocal) provided the cumulative Axonal Injury Score (AIS). A semiquantitative grading system was also used to assess the severity of axonal injury in each sector and the sum of the grades from all sectors was expressed as a percentage to provide the Axonal Injury Severity Score (AISS). Widespread AI was present in all cases irrespective of the height of the fall. AI was present in the midbrain (94%), pons (94%), corpus callosum (100%), central grey matter (100%), and cerebral hemispheric white matter (94%). AIS ranged from 10 to 94 in falls from < or = own height (mean 73) and from 38 to 92 in falls from > own height (mean 82). AISS ranged from 6 to 95 in falls from < or = own height (mean 65) and 28 to 95 in falls from > own height (mean 72). There was no statistically significant difference in AIS or AISS between the two groups. The extent and severity of AI cannot be predicted from biomechanical data, such as the height of the fall, as the total AI in a given case is a variable mixture of Nonfocal AI (DAI) and Focal AI arising by secondary mechanisms, and APP immunostaining is unable to distinguish primary from secondary AI. However, the combination of the Hypoxic-Ischemic Score (HIS) defined as the percentage of sectors showing any hypoxic-ischemic damage ranging from neuronal "red cell change" to infarction in conjunction with the FAIS and NFAIS provided a measure of the relative contribution of primary and secondary AI in a given brain.

Accidental Falls↗