Falls from height: A retrospective analysis

Abstract

BACKGROUND:

Emergency services manage trauma patients frequently and falls from height comprise the main cause of emergency service admissions. In this study, we aimed to analyse the demographic characteristics of falls from height and their relationship to the mortality.

METHODS:

A total of 460 patients, who admitted to the Emergency Department of Inonu University between November 2011 and November 2014 with a history of fall from height, were examined retrospectively. Demographic parameters, fall characteristics and their effect to mortality were evaluated statistically.

RESULTS:

The study comprised of 292 (63.5%) men and 168 (36.5%) women patients. The mean age of all patients was 27±24.99 years. Twenty-six (5.6%) patients died and the majority of them were in ≥62 years old group. The highest percentage of falls was at 0–5 years age group (28.3%). People fell mainly from 1.1–4 metres(m) level (46.1%). The causes of falls were ordered as unintentional (92.2%), workplace (8.1%) and suicidal (1.7%). Skin and soft tissue injuries (37.4%) were the main traumatic lesions.

CONCLUSION:

Age, fall height, fall place, lineer skull fracture, subarachnoidal hemorrhage, cervical fracture, thoracic vertebra fracture and trauma scores had statistically significant effect on mortality. The casualties died because of subarachnoid hemorrhage mostly.

INTRODUCTION

Falls are the second most common cause of injury-associated mortality after traffic accidents. They comprise a significant percentage of blunt trauma cases and emergency department (ED) admissions.[1] A fall is defined as an injury to a person that occurs after landing on the ground after falling from a higher place, such as a ladder, scaffold, building, roof, or other elevated place or work area.[2] Falls mostly affect males, and disproportionately affect the very young or very old. They cause more deaths in old people than in children.[3] Many factors affect the mortality and morbidity of falls, such as patient age, fall height, cause of fall, type of ground on which the patient fell, and body parts injured.[4] This study aimed to analyze the demographic characteristics of falls from height and their effects on morbidity and mortality.

METHODS

The study was approved by the Inonu University Ethics Committee (No: 2014/154). We retrospectively enrolled 460 patients of all ages presenting to the Inonu University Emergency Service between November 2011 and November 2014 with a history of falls from height. Patients with incomplete or missing data or those with trauma from simple falls were excluded. The patients were divided in two groups: those who died and survivors. The patient data were recorded on standard forms, which included the following parameters: age, gender, vital signs, cause of fall, fall height, fall location, type of ground on which the patient fell, season, time of day fall occurred, injured body part, and trauma scores [Revised Trauma Score (RTS), Circulation, Respiration, Abdomen, Motor, Speech (CRAMS), Abbreviated Injury Scale (AIS), Injury Severity Score (ISS), New Injury Severity Score (NISS), Trauma and Injury Severity Score (TRISS), Glasgow Coma Score (GCS)] on hospitalization and discharge.

Statistical analysis

The data were analyzed with IBM SPSS, ver. 22.00. The Shapiro-Wilk test was used to examine the fit of quantitative values to a normal distribution. The Mann-Whitney U-test and Kruskal-Wallis test were used for statistical analysis. Multiple comparisons were done with the Conover-Imam test. Yates’, Pearson’s, and Fischer’s chi-square tests were used for qualitative values. Continuous variables are presented as the mean±standard deviation (SD). A P-value <0.05 was considered statistically significant.

RESULTS

During the 3-year study period, 460 patients [292 (63.5%) men, 168 (36.5%) women; mean age 27±24.99 (range 1–88) years] were admitted to the ED after falling from a height. The overall mortality rate was 5.6% (26) and it was 6.9% for men and 3.6% for women. The highest number of casualties was in the 0–5-year age group (28.3%) followed by the 6–15-year age group (18.5%). Patients in all age groups died and the ≥62-year age group had the greatest number of deceased, 15 patients. There was a significant relationship between mortality and the 0–5- and ≥62-year age groups (P<0.05). The greatest number of falls was from 1.1–4 meters (m) (46.1%). The relationship between mortality and fall height was significant at 0–1, 4.1–9, and >9 m (P<0.001). The patients fell mostly on solid ground (83.7%), but the outcomes of patients falling on solid versus soft ground did not differ significantly (P>0.05). Of the falls, 92.2% were unintentional, 8.1% were workplace accidents, and 1.7% were related to suicide. The highest mortality rate was in the suicide group (12.5%). The causalities mostly fell from balconies, stairs, and domestic furniture in decreasing order. The highest mortality rate was in the group falling from balconies (30.8%). There was a significant relation between mortality and place of fall (P<0.05). Most falls were from 12:01 to 18:00 o’clock and the highest number of deaths occurred in the same period (Table 1). Most falls were in June or July (15.6% and 15.6%, respectively). Half of the patients were treated in the ED and discharged, while 27.8% were hospitalized in the neurosurgery service and 15.4% in the orthopedics service.

Table 1.

Population characteristics associated with fall from height (n, %)

Skin and soft tissue injuries were the most common traumatic lesions (37.4%). In the head injury group, linear fracture and subarachnoid hemorrhage had significant (P<0.05) effects on mortality. The most common thoracic injury was rib fracture (56.5%). The least common lesions involved the abdomen and pelvis. Upper extremity injuries were more common than lower extremity injuries. Abdominopelvic, thoracic, and extremity injuries had no significant effect on mortality. The most deadly spinal fractures were cervical fractures (33.3%). Spinal fractures had a significant (P<0.001) effect on mortality (Table 2). There were significant (P<0.05) relationships between fall height and the trauma scores. As fall height increased, AIS, ISS, and NISS increased, while GCS, RTS, CRAMS, and TRISS decreased (Table 3). All of the trauma scores (GCS, AIS, RTS, ISS, NISS, TRISS, and CRAMS) had significant (P<0.05) effects on mortality (Table 4).

Table 2.

Distribution of injuries sustained (n, %)

Table 3.

The relation between trauma scores and fall height

Table 4.

Trauma scores of survivor and died patient

DISCUSSION

Falls from height are a common cause of blunt trauma.[1] Age, fall height, cause of fall, ground type struck, injured body part, and organ injuries are the main factors that affect the morbidity and mortality of falls from height.[5,6] In agreement with the literature, we found that age, fall height, fall location, head injury, linear skull fracture, subarachnoid hemorrhage, cervical fracture, thoracic vertebra fracture, and GCS, AIS, ISS, NISS, RTS, TRISS, and CRAMS had significant effects on mortality.

In this study, the majority of falls involved males (63.5%), in agreement with the literature.[5,7-9] Generally, men are exposed to trauma and falls more often than women because boys are more active than girls at early ages and more men are physical laborers than women. The highest number of falls in our study was in the 0–5-year group (28.3%). In other studies, the greatest number was in the 0–4- and 0–10-year groups.[9,10] The high number of falls in these age groups is related to the very active nature of children and lack of protection. Overall, 74.3% of the patients were ≤45 years old, indicating that people of active ages are more frequently involved in trauma. Older individuals, especially those over 60 years old, lose their ability to balance, which causes more falls.[11] According to the National Trauma Data Bank, falls are the most common cause of death at older ages.[12] İcer et al[5] found that the highest proportion of deaths (19.2%) from falls was in individuals ≥55 years old. In our study, it was in individuals over 61 years old and the mean age of all deaths was 55.27±26.46 years.

Generally, the mortality rate is greater with falls from higher places compared with lower places.[5] The reported mortality rates of falls from ≥12 meters and ≥18 meters were 50% and 100%, respectively.[13] However, a survivor who fell from 19 stories (57 meters) has also been reported.[14] Liu et al[15] found that the mortality rate due to falls from >6 meters was 22.7% and while Velmohos et al[16] found that it was 9.6% for falls from >9 meters. In our series, the mortality rate from falls from >9 meters was 23.5%, which is compatible with the literature. Al et al[17] found that the mean fall height was 3.2±2.4 meters and Yagmur et al[18] found that it was 4.5±2.6 meters. In our series, the mean fall height was 2.51±3.7 meters for all patients and 6.79±9.87 meters for those who died.

The main causes of falls from height are suicide, workplace accidents, and unintentional accidents.[11] In our series, 90.2% of the falls resulted from unintentional accidents. In an Indian study, falls from height comprised the highest number of deaths among workplace accidents and the majority of these falls were from construction sites.[19] In our series, 8.1% of the workplace accidents were falls and 32.4% of them were from construction sites. In the construction sector and other workplaces, sufficient measures must be taken to prevent falls, competent workers should be employed, and adequate training must be given to reduce the number of workplace accidents.

In many studies of falls, the greatest number of falls occurred in summer.[3,9,20,21] In our series, 45.9% of the falls and 30.8% of the deaths occurred during summer. Al et al[17] and Gulatı et al[3] found that the highest number of falls occurred from 00:00 to 06:00 o’clock. That was because people sleep on rooftops in summer because of the warm weather in the regions where those studies were conducted. The weather in our region is cool in the summer and people do not sleep on the rooftops. In our series, the majority of falls and deaths occurred from 12:01 to 18:00 o’clock (46.1%), which coincides with the active work hours. In descending order, the patients in our series underwent definitive treatment in the emergency, neurosurgery, orthopedics, and general surgery departments. Other studies of falls obtained similar results, i.e., the majority of falls were treated in the emergency department.[1,9]

In falls from height, the first body part that hits the ground and the lesions resulting from fall impact affect the morbidity and mortality. The majority of injuries are to the skin and subcutaneous tissues and head.[5,7,9,17] In our series, similar to the literature, skin and subcutaneous tissue (37.4%) and head (25.4%) injuries were most frequent. Of those who died, 73.1%[19] had head injuries and 50% also had subarachnoid hemorrhages.

We calculated the trauma scores of those who died and the survivors. The results accorded with the literature and there were significant relationships between mortality and the trauma scores.[5,17,22] There were also significant relationships between the trauma scores and fall height.

In the present study, we evaluated the mortality factors of patients that admitted to hospital. We determined brain injury as the main cause of death. But, the majority of traumatic deaths occurred in prehospital setting; on-scene or during transport and the leading cause of death is polytrauma.[23] The incidence of pre-hospital mortality is great among overall trauma related deaths. So, pre-hospital medicine and trauma prevention programs are significant factors to reduce traumatic deaths.[24] All countries should take measures for prehospital medicine and physician based rescue systems may reduce traumatic deaths.

In this study, the data on the falls were obtained from the patients or their relatives. Consequently, the fall heights of some patients might be inaccurate. We collected data from the hospital records of the ED doctors. These records often lack data because the ED doctors have limited time to complete their charts. Therefore, we were obliged to exclude many patients. Neither of these limitations can be avoided easily.

CONCLUSION

In conclusion, age, fall height, fall location, head and spinal system injuries, and trauma scores related to mortality. The main causes of death were subarachnoid hemorrhage and subdural hematoma. The emergency services have an important role in treating victims of falls from height and other forms of trauma. Consequently, emergency services staff should be trained to use a systematic approach to trauma patients. Triage must be done accurately at the accident location and critical patients should be referred to trauma centers quickly. This should reduce the mortality and morbidity due to falls from height.