- Case report
- Open Access
Survival following a vertical free fall from 300 feet: The crucial role of body position to impact surface
© Weckbach et al; licensee BioMed Central Ltd. 2011
- Received: 22 September 2011
- Accepted: 25 October 2011
- Published: 25 October 2011
We report the case of a 28-year old rock climber who survived an "unsurvivable" injury consisting of a vertical free fall from 300 feet onto a solid rock surface. The trauma mechanism and injury kinetics are analyzed, with a particular focus on the relevance of body positioning to ground surface at the time of impact. The role of early patient transfer to a level 1 trauma center, and "damage control" management protocols for avoiding delayed morbidity and mortality in this critically injured patient are discussed.
- Damage Control
- Mild Traumatic Brain Injury
- Femur Shaft Fracture
- Posterior Spinal Fusion
- Pelvic Ring Injury
Vertical deceleration injuries represent a significant cause of preventable deaths and long-term morbidity in survivors . The amount of energy absorbed by the falling body is dependent on the fall height and the characteristics of the contact surface. For example, a fall onto concrete results in an instantaneous loss of speed, whereas falling onto a soft surface will allow for a more gradual deceleration over time . In addition, the position of the body relative to the impact surface represents an important determinant of injury severity. The American College of Surgeons' Committee on Trauma (ACS-COT) defines a critical threshold for a fall height in adults as > 20 feet (6 meters), as part of the field triage decision scheme for transport to a designated trauma center . A retrospective analysis of 101 patients who survived vertical deceleration injuries revealed an average fall height of 23 feet and 7 inches (7.2 meters), confirming the notion that survivable injuries occur below the critical threshold of a falling height around 20-25 feet . A more recent study on 287 vertical fall victims revealed that falls from height of 8 stories (i.e. around 90-100 feet) and higher, are associated with a 100% mortality . Thus, a vertical falling height of more than 100 feet is generally considered to constitute a "non-survivable" injury.
The present case report describes the rare survival of a 28-year old rock climber who survived a free fall from 300 feet onto a solid rock surface. This report emphasizes the crucial relevance of body positioning at the time of impact, and the importance of standardized institutional "damage control" management protocols for survival.
A 28-year old woman was free climbing with her boyfriend near Gunnison, Colorado. Both were wearing a helmet and a harness for safety. The girl had 20 years of experience of rock climbing, being taught early tricks by her father at the age of 8 years. The ascent consisted of three pitches of 90-100 feet (ca. 30 m) each. The climbing distance was defined by the climbing rope which had been fixed at a defined length. The girl took the lead on the third pitch, to a total height of 300 feet (ca. 90 m). After securing the anchor at that height, the rope - which was lacking a security knot - slid through her harness. She then fell a total of 300 feet, with a first impact at 200 feet onto a flat rock surface, and a further fall for about 100 feet. Based on this falling height, the velocity at the time of impact is estimated around 75-80 mph. Her boyfriend witnessed the entire fall, climbed back down and provided first aid at the scene. The patient was awake and moaning, but not responsive to verbal or painful stimuli. She was intubated at the scene and transported to a local level IV trauma center, where she was resuscitated and transfused with 4 units of packed red blood cells (PRBC). Due to ongoing hypotension and transfusion requirements, a decision was made for transfer to our regional level 1 trauma center. On arrival, the patient was intubated and sedated. She was hypotensive, with systolic pressures in the 80s. She was successfully resuscitated with crystalloids and blood products, using a standardized institutional massive transfusion protocol with point-of-care thrombelastography-guided resuscitation [5, 6]. The patient was managed according to the ATLS guidelines for initial assessment and management, and by our institutional "damage control" protocols, including the initial spanning external fixation of femur shaft fractures [7, 8] and a proactive "spine damage control" approach .
The patient sustained the following combination of injuries:
Blunt chest trauma with sternal fracture, bilateral hemo-/pneumothoraces, bilateral pulmonary contusions, right 1 and 2 rib fractures, left 9-11 rib fractures.
Blunt abdominal trauma with grade 3 liver laceration, grade 2 splenic laceration, and a devascularized right kidney.
Mild traumatic brain injury.
Rotationally unstable flexion/distraction injury at T6 (AO/OTA type 52-C2.1) with traumatic spinal cord transsection and complete paraplegia ASIA grade A below T6.
Unstable L1 burst/split fracture (AO/OTA type 53-A3.2).
Unstable pelvic ring injury with bilateral SI-joint disruption, bilateral L5 transverse process fractures, bilateral pubic rami fractures, and left-side transalar/transforaminal Denis type 2 sacral fracture (Young-Burgess type LC-3, AO/OTA type 61-B3.3).
Right femur shaft fracture (AO/OTA type 42-A3.2).
Right type IIIA open talar body fracture (AO/OTA type 81-C3) and associated posterior facet calcaneus fracture (AO/OTA type 82-C2)
Left comminuted joint-depression type calcaneus fracture (AO/OTA type 82-C3).
On day 2, she was taken back to the operating room for stabilization of the pelvic ring injury using bilateral "triangular osteosynthesis" with lumbo-pelvic fixation from L4 to the ilium, and placement of bilateral 7.3 mm cannulated sacro-iliac screws through a safe surgical corridor . On day 3, an IVC filter was placed due to the high risk constellation for a thromboembolic complication.
This is the first case report, to our knowledge, which documents survival from a free vertical fall of 300 feet onto a hard surface. The anecdotal threshold for sustaining critical injuries from a vertical fall has been defined by the American College of Surgeons' Committee on Trauma (ACS-COT) at >20 feet (6 meters) . This threshold is corroborated by the published literature on survivors from accidental and suicidal free falls . In general, a falling height of >100 feet is considered a "non-survivable" injury . The height of 300 feet is ascertained by the fact that in "lead climbing", the climbing rope is fixed at a defined length, corresponding to 150 feet in the present case. The patient's boyfriend took the lead on the first pitch of 150 feet, where after she took over the lead on the next 150 feet. After securing the anchor at 300 feet height, the rope slid through her harness and she sustained an undamped vertical free fall onto a flat rock surface.
Furthermore, the rapid intubation, early resuscitation, and timely transfer to a qualified level 1 trauma center likely contributed to this patient's survival. It is striking to note that, despite the critical overall injury pattern, the patient did not sustain significant complications which may have been expected as the sequelae of the traumatic impact, including posttraumatic/postoperative infections, and the development of remote organ insults, including acute respiratory distress syndrome (ARDS) and multiple organ failure, which represent the main cause of late deaths in patients who survive the initial injury [16–18].
Likely, the application of standardized resuscitation strategies, in conjunction with thrombelastography-guided administration of blood products, and the limited exposure to the interventional burden by "damage control" strategies applied in the first few days after trauma, contributed to the survival of this patient [5–7, 9, 11, 19, 20].
The impact of falling height, quality of impact surface, and the position of the body to the impact surface on injury severity and outcome require further investigation in ex-vivo experimental and biomechanical studies.
Written informed consent for publication of this case report and of all radiological images and pictures was obtained from the patient by the senior author. She agreed to publish the case report including all figures shown in this paper. Written consent by the patient is available to the journal's Editor-in-Chief upon request.
- Richter D, Hahn MP, Ostermann PA, Ekkernkamp A, Muhr G: Vertical deceleration injuries: a comparative study of the injury patterns of 101 patients after accidental and intentional high falls. Injury. 1996, 27 (9): 655-659. 10.1016/S0020-1383(96)00083-6.View ArticlePubMedGoogle Scholar
- Bragg S: Vertical deceleration: falls from height. J Emerg Nurs. 2007, 33 (4): 377-378. 10.1016/j.jen.2007.04.017.View ArticlePubMedGoogle Scholar
- American College of Surgeons Committee on Trauma: Resources for optimal care of the injured patient. 2006, Chicago, IL: American College of SurgeonsGoogle Scholar
- Lapostolle F, Gere C, Borron SW, Petrovic T, Dallemagne F, Beruben A, Lapandry C, Adnet F: Prognostic factors in victims of falls from height. Crit Care Med. 2005, 33 (6): 1239-1242. 10.1097/01.CCM.0000164564.11989.C3.View ArticlePubMedGoogle Scholar
- Stahel PF, Moore EE, Schreier SL, Flierl MA, Kashuk JL: Transfusion strategies in postinjury coagulopathy. Curr Opin Anaesthesiol. 2009, 22 (2): 289-298. 10.1097/ACO.0b013e32832678ed.View ArticlePubMedGoogle Scholar
- Kashuk JL, Moore EE, Sawyer M, Le T, Johnson J, Biffl WL, Barnett C, Stahel PF, Silliman CC, Sauaia A, Banerjee A: Postinjury coagulopathy management: goal directed resuscitation via POC thrombelastography. Ann Surg. 2010, 251 (4): 604-614. 10.1097/SLA.0b013e3181d3599c.View ArticlePubMedGoogle Scholar
- Stahel PF, Smith WR, Moore EE: Current trends in resuscitation strategy for the multiply injured patient. Injury. 2009, 40 (Suppl 4): S27-35.View ArticlePubMedGoogle Scholar
- Flierl MA, Stoneback JW, Beauchamp KM, Hak DJ, Morgan SJ, Smith WR, Stahel PF: Femur shaft fracture fixation in head-injured patients - when is the right time?. J Orthop Trauma. 2010, 24: 107-114. 10.1097/BOT.0b013e3181b6bdfc.View ArticlePubMedGoogle Scholar
- Stahel PF, Flierl MA, Moore EE, Smith WR, Beauchamp KM, Dwyer A: Advocating "spine damage control" as a safe and effective treatment modality for unstable thoracolumbar fractures in polytrauma patients: a hypothesis. J Trauma Manag Outcomes. 2009, 3: 6-10.1186/1752-2897-3-6.PubMed CentralView ArticlePubMedGoogle Scholar
- Hasenboehler EA, Stahel PF, Williams A, Smith WR, Newman JT, Symonds DL, Morgan SJ: Prevalence of sacral dysmorphia in a prospective trauma population: Implications for a "safe" surgical corridor for sacro-iliac screw placement. Patient Saf Surg. 2011, 5: 8-10.1186/1754-9493-5-8.PubMed CentralView ArticlePubMedGoogle Scholar
- Haschtmann D, Stahel PF, Heyde CE: Management of a multiple trauma patient with extensive instability of the lumbar spine as a result of a bilateral facet dislocation and multiple complete vertebral burst fractures. J Trauma. 2009, 66 (3): 922-930. 10.1097/01.ta.0000215415.87801.fc.View ArticlePubMedGoogle Scholar
- Kossmann T, Payne B, Stahel PF, Trentz O: Traumatic paraplegia: surgical measures [German]. Swiss Med Wkly. 2000, 130: 816-828.Google Scholar
- Kossmann T, Jacobi D, Trentz O: The use of a retractor system for open, minimal invasive reconstruction of the anterior column of the thoracic and lumbar spine. Eur Spine J. 2001, 10 (5): 396-402. 10.1007/s005860100330.PubMed CentralView ArticlePubMedGoogle Scholar
- Gerdes EM, Hafner JW, Aldag JC: Injury patterns and safety practices of rock climbers. J Trauma. 2006, 61 (6): 1517-1525. 10.1097/01.ta.0000209402.40864.b2.View ArticlePubMedGoogle Scholar
- Stahel PF, Heyde CE, Flierl MA, Wilkerson JA: Head and neck injuries. Medicine for Mountaneering. Edited by: Wilkerson JA, Moore EE, Zafren K. 2010, Seattle, WA: The Mountaneers Books, 86-95. Volume 6Google Scholar
- Sauaia A, Moore EE, Johnson JL, Ciesla DJ, Biffl WL, Banerjee A: Validation of postinjury multiple organ failure scores. Shock. 2009, 31 (5): 438-447. 10.1097/SHK.0b013e31818ba4c6.PubMed CentralView ArticlePubMedGoogle Scholar
- Keel M, Trentz O: Pathophysiology of polytrauma. Injury. 2005, 36 (6): 691-709. 10.1016/j.injury.2004.12.037.View ArticlePubMedGoogle Scholar
- Stahel PF, Smith WR, Moore EE: Role of biological modifiers regulating the immune response after trauma. Injury. 2007, 38 (12): 1409-1422. 10.1016/j.injury.2007.09.023.View ArticlePubMedGoogle Scholar
- Burlew Cothren C, Moore EE, Smith WR, Johnson JL, Biffl WL, Barnett CC, Stahel PF: Preperitoneal pelvic packing/external fixation with secondary angioembolization: optimal care for life-threatening hemorrhage from unstable pelvic fractures. J Am Coll Surg. 2011, 212: 628-637. 10.1016/j.jamcollsurg.2010.12.020.View ArticleGoogle Scholar
- Osborn PM, Smith WR, Moore EE, Cothren CC, Morgan SJ, Williams AE, Stahel PF: Direct retroperitoneal pelvic packing vs. pelvic angiography: a comparison of two management protocols for hemodynamically unstable pelvic fractures. Injury. 2009, 40: 54-60. 10.1016/j.injury.2008.08.038.View ArticlePubMedGoogle Scholar
This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.