SUSPENSION TRAUMA Recognition, prevention and treatment for First Responders ©2005

© Introduction ‘Suspension Trauma’ –The medical effects of immobilisation in a vertical position –Medical term is ‘Orthostatic Incompetence’ The effects are nothing new –Crucifixion is death from suspension trauma It presents an immediate threat of death to anyone immobilised in a vertical position –Hanging still in an industrial, theatrical or sport harness –Stretcher patients, performers, stuntmen, confined space workers The onset and progress are rapid and unpredictable All those ‘working at height’ must be trained in how to recognise, manage and prevent suspension traumaAll those ‘working at height’ must be trained in how to recognise, manage and prevent suspension trauma

© Immobile is important! Suspension trauma can only affect someone who is immobile – specifically not using their leg muscles to any great extent It does not normally affect people who wear a harness but who are:- –Actively moving about (climbing, caving, etc) –Suspended for only a minute or two (parachutists) The danger is when someone is unable to move, or forgets to bother!

© Who may be at risk? The ‘classic group’ are people who wear harnesses –Sport climbers, cavers, parachutists, parascenders, etc –Industrial climbers –Confined space workers lowered using a harness and winch –Theatrical and circus performers, stuntmen and artists There are other ways to be ‘immobilised’ –Rescue stretchers, spine boards and splints –Personal pursuits involving bondage or confinement –Becoming stuck in a confined space

© So what happens? General feelings of unease –Dizzy, sweaty and other signs of shock –Increased pulse and breathing rates Then a sudden drop in pulse & BP Instant loss of consciousness If not rescued, death is certain –From suffocation due to a closed airway, or from lack of blood flow and oxygen to the brain.

© A little biology… Humans are not designed to stand upright –Our circulatory system was built for life on all fours –Volume of blood vessels is much greater than that of the blood So, when we stand upright we have a problem –Gravity pulls your blood into your legs –Your heart is a positive-pressure pump – it cannot suck! –The only way to get the blood back out of the legs is to pump it using another method. Luckily, we’ve evolved one!

© Muscular pumps The veins in your legs are entwined within the skeletal muscles, and when you move your legs, these muscles squeeze the veins, pushing the blood out of the way We have one-way valves in these veins, so each squeeze can pump the blood a short distance towards the heart Providing you are walking around, this process makes a ‘heart in each leg’ – and it’s very effective! –Try it – take your socks off and stand still – look at your feet and you’ll see the veins all standing out and the skin red. –Now walk around in a little circle and look again – the veins are empty and flat, and the skin goes pale. Pumping in action!

© But what if we’re not pumping? If the muscles are not pumping the blood upwards, it pools in your legs –You can ‘lose’ several pints and go into shock Your brain tries ‘shock’ for a while, but of course it doesn’t help – blood is still stuck in your legs. After a few minutes, it goes for the last-ditch method If I faint, I fall over. I get the blood back. It assumes you must fall over. If you stay upright:- –Your brain has no oxygen supply –Your airway is at risk –You will probably die within 10 minutes

© How long have you got? Uninjured volunteers felt dizzy in as little as 3 minutes –Typically 5 to 20 minutes Loss of consciousness in as little as 5 minutes –Typically 5 to 30 minutes It is difficult to put a timeline on deaths, however from research it is clear that death can result in as little as 10 minutes, more typically between 15 and 40 minutes post-suspension. Death is more rapid with existing injuries but can happen to anyone. Anyone immobilised in an upright posture is in immediate danger of death

© Feeling faint? John Doe on parade Blood pools in the legs Brain detects low O 2 Cardiac output increases Brain O 2 still falls Emergency response: –Pulse drops –Loss of consciousness –John falls over –Blood flows back to brain John wakes up. John Doe in suspension Blood pools in the legs Brain detects low O 2 Cardiac output increases Brain O 2 still falls Emergency response: –Pulse drops –Loss of consciousness –John CANNOT fall over –Brain cells start to die John never wakes up.

© What actually matters? Constrictive leg loops contribute but are NOT needed –Even stretcher patients are at risk. All makes of harness show almost identical results Patient age, weight, height, sex and fitness seem to make little difference to the time it takes before you faint Stress, panic, injury, smoking/drinking, extant cardiac conditions and illness increase the risks All that matters is that the legs are lower than the heart and the leg muscles are immobile. No other injury is needed.

© OK, so we rescue them! No so fast! There’s something important to deal with:- The blood that is trapped in the legs may not be in very good condition, and may even kill the person if we let it all pour back into their brain! This is called the ‘reflow syndrome’ and is medically very complicated – you will not be able to control it once it starts, and the patient will die. Luckily you can prevent it from happening if you handle them with care!

© Reflow Syndrome Pooled blood in the legs is ‘stale’ after mins –Drained of oxygen, saturated with CO 2 –Loaded with toxic wastes (from the fat burning process) Re-elevating the legs returns this to the rest of the body in a massive flood –Heart can be stopped –Internal organs (especially the kidneys) can be damaged You have to stop this flood of stale blood – but still keep enough tricking to the brain to keep the person alive! Anyone released from immobile suspension should be kept in a sitting position for at least 30 minutes

© Preventing suspension trauma If you’re in a a harness by CHOICE: –Keep your legs moving as much as you possibly can –If you’re not using your legs much, you need a workseat –Take regular rest breaks, eat and drink normally If you fall accidentally and are suspended: –AVOID using your legs. You don’t want blood sent there. –Lift your knees into a sitting position –Relax as much as possible. Panic makes things worse –If you can, every few minutes swing yourself upside down If you’re trapped and cannot move –Strain your leg muscles as hard as you can every 5 seconds –Breathe slowly and deeply –You’re going to be needing rescue!

© Lifting those knees All you need is to get your knees level or higher than your hips – the position you’d be in if you were sitting on a chair You can either sit ON something (a ledge, a plank of wood, etc) or put something under your knees (rope, strap, hose, wire.. Anything!) Behind your knees there’s no fat, so padding is very helpful if you’re going to be there a while! Carrying something as simple as an 8ft length of webbing or thin rope is all you need – but being able to DO this depends on how your harness was attached!

© Rear attachment points Using a knee-loop is possible but only with a separate anchor point The head drops forwards and so the airway is at risk Many people can’t even reach their attachment points after a fall

© Front attachment points For sport climbing or caving harnesses, or fall arrest with a front attachment point, access and knee-lifting is easy! Everyone can reach what they’re hanging from The airway is still at risk, but not quite as much

© Emergency action If at all possible, climb out of suspension –Using self-rescue equipment, improvised or otherwise Get into a sitting position straight after the fall –Use a loop under the knees (rope, wire, clothing, etc) –Pass the casualty a workseat or improvised platform All casualties must be ‘immediately rescued’ –Abseil rescue kits, winches, hydraulic platforms, cranes, ladders –Suspension trauma is more important than other injuries – remember life over limb. Don’t be afraid of hurting someone to rescue them! On-site first responders and communications are vital Never work alone! Who’s going to help you?

© Hitting the ground Lowering systems must be controlled to prevent the patient’s body being laid flat as it reaches the ground –Keep them sitting up for 30 minutes Normal first-response and paramedic rules are WRONG –This is not ‘fainting’ ! –You need to stop ‘professionals’ doing the wrong thing and laying your patient flat on a trolley or hospital bed

© The Law - EU In the European Union, ‘work at height’ is controlled by national laws, based on the Temporary Work at Height Directive. This requires certain things to be done:- –Workers must have on-site rescue equipment and training –They must be rescued ‘immediately’ from suspension This usually means within ten minutes of an incident –Workers must be aware of the risks of suspension trauma –Any First Responders must know how to treat it safely –Work in suspension must be minimised whenever possible Work seats, rest periods, etc. must be used when needed

© The Law - USA The Occupational Safety & Health Act requires employers to comply with hazard-specific health & safety standards In Section 5(a)1 it requires employers to provide a workplace free from recognized hazards likely to cause death or serious harm –Suspension trauma is one of those hazards and so MUST be managed safely – preventing, educating and minimising risk. –Equipment user training must include suspension trauma –‘Prompt rescue in the event of a fall… or self-rescue’ must be provided for in terms of equipment and training Front-attachment points for fall arrest harnesses are still illegal, though this will hopefully change very soon.

© And finally… Remember although suspension trauma is rare, it can happen to anyone. If you’re at work, your employer needs to manage the risks – if not, think twice about working! If you’re doing a leisure activity, think about what would happen if you fell, or got stuck. Would anyone help? It’s true what you’ve known all along – sitting down all the time is the best way to survive the day!