Scenario — Suspected cervical spinal injury following a fall at the races

intermediate Trauma · Elderly · 75yr · male

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

Scenario Progression and Treatment Objectives

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 attempts to apply a semi-rigid cervical collar without Intermediate Care authorisation — remind the trainee that collar application is an Intermediate Care procedure; at EHS Primary Care level, a lanyard and head blocks are the appropriate tools, and manual in-line stabilisation should be maintained pending higher-scope backup.)
! (If the trainee does not apply the NEXUS Clinical Decision Rule — have the patient ask 'Is my neck okay?' prompting the trainee to formally assess NEXUS criteria: posterior midline tenderness is present, focal neurological deficit is present, mild intoxication is present — all three criteria fail NEXUS clearance.)
! (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. Apply NEXUS Clinical Decision Rule: identify posterior midline cervical spine tenderness (POSITIVE), focal neurological deficit — bilateral hand tingling and weakness (POSITIVE), evidence of mild intoxication — 2 beers (POSITIVE). NEXUS is FAILED — cervical spine cannot be cleared.
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 the positive NEXUS criteria.
10. Do NOT apply a semi-rigid cervical collar — collar application is Intermediate Care scope; at Primary Care EHS level use lanyard, manual in-line stabilisation, and 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. Note that pain relief administration is outside EHS scope — 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 State Operations Centre — request Priority 1 ambulance transport given: neurological deficit, failed NEXUS, age ≥65, anticoagulation (Warfarin increases bleeding risk in potential spinal cord haemorrhage).
16. Do NOT perform a SPEED assessment — SPEED assessment completion is Intermediate Care scope; document findings for handover.
17. Scenario ends on arrival of ambulance and IMISTAMBO handover — include: mechanism, NEXUS failure criteria, focal neurological deficit (bilateral hand tingling and weakness), medications (Warfarin, Metoprolol), spinal precautions applied, vital signs trend.
18. Attention to hand hygiene will be given throughout the scenario.

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

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Signs/Symptoms	Posterior midline neck pain, bilateral tingling and mild weakness in both hands since the fall.
Allergies	Nil known drug allergies.
Medications	Metoprolol (beta-blocker for hypertension), Warfarin (atrial fibrillation). Denies NSAID or aspirin use.
Pertinent History	Known hypertension and atrial fibrillation. No prior spinal conditions documented. No prior spinal surgery.
Last Oral Intake	Lunch approximately 2 hours ago. Two beers consumed over 3 hours.
Events Leading	Pt was descending a staircase between grandstands at the racecourse when he tripped on the top step and fell approximately 6 stairs, striking his head on the handrail. He was assisted by bystanders to a seat nearby.
Treatment Prior	Nil. Security kept him still in the chair until EHS arrived.

Onset	Immediately following the fall down 6 stairs, approximately 20 minutes ago.
Pain	Posterior midline cervical spine pain, worst at the base of the neck.
Quality	Dull, aching, constant. Worsens with any attempted head movement.
Radiates	Tingling radiating into both hands and fingers.
Severity	6/10