Danger at every rung: Epidemiology and outcomes of ICU-admitted ladder-related trauma

The incidence of ladder-related falls is increasing, and this represents a disturbing trend, particularly in the context of increased life expectancy and the impending retirement of the populous 'baby-boomer' generation. To date, there have been no critical illness-focused studies reporting on the incidence, severity and outcomes of severe ladder-related injuries requiring ICU management.

Major trauma patients admitted to ICU over a 5year period to June 2011 after ladder falls >1m were identified from prospectively collected trauma data at a Level 1 trauma service. Demographic and ICU clinical management data were collected and non-parametric statistical analyses were used to explore the relationships between variables in hospital mortality/survival.

There were 584 ladder fall admissions, including 194 major trauma cases, of whom 29.9% (n=58) fell >1m and were admitted to ICU. Hospital mortality was 26%, and fatal cases were almost entirely older males in domestic falls of ≤3m who died as a result of traumatic brain injury. Non-survivors had lower GCS at the scene (p=0.02), higher AIS head code (p=0.01), higher heart rate and lower mean arterial pressure (p<0.01) in the initial 24h period in ICU, and were ≥55years of age (p=0.05). Only 46% of patients available for follow-up were living at home at 12months without requiring additional care.

The incidence of ladder falls requiring ICU management is increasing, and severe traumatic brain injury was responsible for the majority of deaths and for poor outcomes in survivors. In-hospital costs attributable to the care of these patients are high, and fewer than half were living independently at home at 12months post-fall. A concerted public health campaign is required to alert the community to the potential consequences of this mechanism of injury. The use of helmets for ladder users in domestic settings, where occupational health and safety regulations are less likely to be applied, is strongly recommended to mitigate the risk of severe brain injury. The benefits of this simple strategy far outweigh any mild inconvenience for the wearer, and may prevent catastrophic injury.