1. Recognition, prevention and treatment for First Aiders
SUSPENSION TRAUMA
Recognition, prevention and treatment for First Aiders
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©2005

2. Introduction ‘Suspension Trauma’ The effects are nothing new
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 of ST are rapid and unpredictable
All those ‘working at height’ must be trained in how to recognise, manage and prevent suspension trauma
Since the early 1970’s when people started wearing harnesses for climbing, caving and in industry, we believe that about 100 people have been killed directly from suspension trauma.
Several of these have been stretcher patients, people training with rescue teams, theatrical performers and almost all were healthy and uninjured.

3. 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!

4. Who may be at risk? The ‘classic group’ are people who wear harnesses
Sport climbers, cavers, parachutists, par ascenders, 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
Becoming stuck in a confined space

5. 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 & Blood Pressure
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.
Early effects are from distributative shock, and develop within a few minutes. Timings are given in a later slide.
The fainting process is instant – a test performed by the Suspensiontrauma.info medical staff asked fit and uninjured students to hang in a harness and count upwards, paying them money if they counted highest and remembered the number. They fainted almost between one number and the next, and of 50 volunteers only two remembered a number, but both were wrong.

6. 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!
Typical adult blood volume is 10 pints
Completely dilated, the intravascular space is about 15 pints

7. 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!
Brisk walking can lower the blood pressure at your ankles by a factor of five. When you stop moving, the blood pressure builds to normal within about 10 seconds.

8. 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, the brain goes for the last-ditch method
“If I faint, I fall over. I get the blood back”
Your Brain 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
The fainting process is called the Syncopal Response or Central Ischaemic Response, and is unavoidable.
In a typical industrial harness, the torso is within 45 degrees of vertical even when unconscious – so the airway can be compromised very easily.

9. 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

10. Feeling faint? Tommy Atkins on parade Tommy Atkins in suspension
Blood pools in the legs
Brain detects low O2
Cardiac output increases
Brain O2 still falls
Emergency response:
Pulse drops
Loss of consciousness
Tommy falls over
Blood flows back to brain
Tommy wakes up.
Tommy Atkins
in suspension
Blood pools in the legs
Brain detects low O2
Cardiac output increases
Brain O2 still falls
Emergency response:
Pulse drops
Loss of consciousness
Tommy CANNOT fall over
Brain cells start to die
Tommy never wakes up.
Remember that the conscious brain has no feeling as to what is going on. There is no realization of the need to use the legs or of blood being trapped in them. Any slight feelings of pulse pressure are overwhelmed by the other symptoms of shock and distress.
The very first sign of fainting is a loss of peripheral vision (dark tunnel effect) – but this happens only one or two seconds before loss of consciousness and once you feel your vision failing you cannot prevent the faint.

11. What actually matters? All that matters is that the legs are lower
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, existing 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.
Madsen (Aviation Space Journal) – performed tests using a simple tilting table and saw the same suspension trauma effects as for wearing a harness
1990 – German Federal Post Office – compared front and rear attachment points on fall arrest harnesses and found no difference in the onset of suspension trauma.
It is known that endurance athletes are MORE susceptible, as their anaerobic systems are over-developed and they react to changes in brain oxygen differently.

12. OK, so we rescue them!
Not 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 is NOT the same as crush syndrome. It has some similarities but is medically more complex. Remember that hanging in a harness doesn’t crush any tissues like having a bus parked on your knees will. Crush syndrome is caused by local tissue damage – reflow syndrome is caused by stale blood.
Reflow syndrome is only manageable in a hospital setting with full fluid therapy. It cannot be treated or controlled by ambulance staff or first responders as it requires complex drug programs.

13. Reflow Syndrome Pooled blood in the legs is ‘stale’ after 10-20 mins
Drained of oxygen, saturated with CO2
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
A sitting position with the torso upright and the legs either flat or bent at the knees will allow SOME blood to return, keeping brain oxygen levels high, but will keep MOST of the blood volume trapped in the legs.
If the person is unconscious, you STILL keep them sitting up but have to manage their airway. If they need CPR then this clearly needs them to be laying down – but it’s OK as without a heartbeat that blood will stay put anyways.

14. Preventing suspension trauma
If you’re in a a harness:
Keep your legs moving as much as you possibly can
If you’re not using your legs much, you need a work seat
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 most urgently needing rescue!
If you’re at work, your national occupational health and safety laws will require employers to protect their workers against risks, and suspension trauma is a recognized risk. Ignoring it can be fatal for the worker, and legally dangerous for the company!

15. 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!

16. 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
Rear attachment is common in all countries, but in the USA, the ISO standards for fall arrest harnesses require that ONLY a rear attachment is used.
In the EU and elsewhere, harnesses can have either front or back, or both.
Confined space or parachute harnesses with shoulder-mounted straps are fine, and behave the same as for front attachment.

17. 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

18. 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 work seat 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 Aiders and communications are vital
Never work alone! Who’s going to help you?

19. 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

20. 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 Directive is 2001/45/EC and is freely available on the Internet
In the United Kingdom, the national law is the Work at Height Regulations 2005.
All EU member countries have to create these national laws, but many are failing to properly implement them.

21. 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!
Please remember to advise your students that free information is available from our website along with links to their national standards and legislation.