Why the fall?

Author: Catriona J Thompson / Editor: Yasmin Sultan / Reviewer: Ahmad Alabood / Codes:  ELP3, SLO1, SLO4 / Published: 29/05/2023

A 72-year-old lady presents to a Minor Injuries Unit following head injury. On examination, evidence of suspected skull base fracture is found and she is, therefore, referred to the Emergency Department (ED) for radiological investigation.

On arrival at ED, she gives a history of having had a brief collapse leading to the head injury. The only feature of potential brain injury is vomiting, and there is blood evident in the right ear canal.

She appears slightly short of breath with saturations of 92% on low-flow oxygen. Systemically, she gives a history of dyspnoea on exertion for two weeks, and her accompanying friend has noticed a worsening cough over the preceding six weeks.

She has a background history of significant, but controlled Rheumatoid Arthritis for which she has been started on Methotrexate ten weeks previously.

Chest examination reveales bibasal fine, dry-sounding crackles, and some mild anterior pleuritic-type pain. Arterial blood gas shows hypoxia (PO2 <9 with FiO₂ of around 24%). A CTPA is therefore performed to exclude pulmonary embolism, (see image shown). Subsequently she required invasive ventilation for hypoxia, and died ten days later.