Suspension Trauma

Suspension trauma treatment

Treating someone with suspension trauma is not standard First Aid. If you follow the normal advice for 'fainting' then you can easily kill your patient. If you haven't read our section on Reflow Syndrome then please do so now.

First Response

Anyone who has developed suspension trauma to any extent will have reduced blood flow to their brain. This initially causes symptoms of shock, and if untreated will lead to loss of consciousness. This in itself could kill by preventing the patient controlling their own airway, but eventually the reduced cerebral blood supply will lead to brain damage and death. The goal of the first responder is to return oxygen to the brain while preventing Reflow Syndrome. Never allow the patient to lie down, even for an instant, unless there is a life-critical need to perform CPR Normally, suspension trauma makes the legs feel numb. If the patient has no other injuries and yet complains of severe pain in their legs, especially when you try to move them, then they may have developed a severe condition called compartment syndrome. You should place them in a sitting position and summon an ambulance with great urgency. The patient may deteriorate rapidly. There is nothing you can do for compartment syndrome as a first responder.

If managed correctly, patients with suspension trauma - even severe cases - will make a full recovery and have no long-term complications. Normally patients who do not require hospital treatment will be well enough to return to normal duties within 24 hours.

If the patient is conscious

If removal from suspension is not going to happen instantly, and you can reach the casualty or they can follow your instructions, lift their knees into a sitting position using a rope, sling, hose, items of clothing etc.

Your first action when they are released from suspension should be to place them in a sitting position with their body upright and their legs flat, or bent at the knees. This will reduce the pooling effect of gravity, but will keep most of the pooled blood in the legs, preventing reflow. The patient must not be allowed to stand up, exercise, drink or eat. If possible keep them as calm and relaxed as you can, to reduce the effects of stress on the heart rate. There is no difference in the angle of the knees - the critical issue is that their body is upright, and their legs are no longer dangling.

Obviously they need to be removed from suspension, and kept in the same sitting position at all times. They may feel faint, and so you will have to stay with them and prevent them collapsing onto the floor. If you have oxygen available, administer it at 100%. Do not give the patient any other medication or fluids unless you have been trained to do so, and are aware of a pressing need. Summon medical help as soon as possible - a fully conscious and aware patient may be taken to hospital in a private vehicle, but remember that everyone suspended for more than 10-20 minutes should be sent to hospital for routine blood tests, even if they are not injured.

If you cannot reposition the patient or remove them from suspension, then you must expect them to faint at some point. Providing 100% oxygen will help a great deal, but your priority is maintaining their airway and arranging urgent rescue.

If the patient is not conscious

If removal from suspension is not going to happen instantly, and you can reach the casualty, lift their knees into a sitting position using a rope, sling, hose, item of clothing etc.

Loss of consciousness due to suspension trauma itself indicates that the pooling of blood has had time to develop, and that laying the patient flat will probably be counterproductive - maybe leading to death. You will have to manage the airway while keeping the patient in a sitting position. Suspension trauma rarely leads to cardiorespiratory arrest in the short term, but if the patient requires CPR then this overrules the posture policy, and you must of course lay them flat. This specific situation is allowable because without a heartbeat, the reflow effect cannot happen - and the circulation caused by normal CPR is not strong enough to kick-start any reflow issues.

A patient who has been rendered unconscious by another event (such as impact in a fall or electrocution) and who is reached within the first 10 to 20 minutes of suspension can be allowed to lay flat. If you are trained in the use of artificial airways then these may assist in supporting the airway even in a sitting position, but there is no need to use the sitting position unless the casualty has been suspended for a longer time.

EMT / Paramedical PHLS treatment

The following advice is aimed at trained medical and EMT staff

Note that suspension trauma (orthostatic incompetence) is not part of your standard training program. You should approach the incident as similar to a crush injury in terms of immediate management though there are critical differences in both pre-release and post-release therapy. If the condition is advanced or the patient has lost consciousness, urgent transport to a trauma center is required.

The patient will be cerebrally hypoxic due to gravitational pooling of venous blood in the legs, the majority being in the thighs. The initial presentation after 5 to 10 minutes of suspension will be of distributative shock leading to tachycardia and tachypnea. Local PP02 from fingertip sensors will be normal, but saturations from earlobe sensors will be reduced. There need be no other injuries. The patient may complain of general symptoms of shock, heat or absence of sensation in the legs. Patients reporting severe pain in the legs with the absence of othopedic insult are of great concern as it suggests formation of compartment syndrome.

As soon as possible after suspension has begun, the patient should have been repositioned into a sitting posture with the thighs horizontal or slightly elevated with respect to the pelvis, and the spinal column vertical. If this was done within a few minutes, then it is unlikely that a sufficient volume of blood has pooled to cause loss of consciousness, however it can still present a hazard if permitted to return to the core in bulk. A patient who has not been repositioned in time is likely to have progressed beyond distributative shock and lost consciousness via the central ischaemic response. Barometric trigger pathways will produce enforced syncope via bradycardia, leading to decreased cerebral perfusion and an instant LOC. If the patient falls into a prone position at LOC then blood returns to the brain and they recover without artifact, however in suspension the patient is usually unable to fall over, and remains held upright. In this position the LOC persists, as does bradycardia and almost negligable cerebral perfusion. This is in itself fatal within a matter of minutes, but of course the patient is also unable to maintain a patent airway and so primary cause of death is often suffocation.

Stabilisation is possible on scene, but great care should be taken to monitor PP02 and ECG during release and transport, as the patient will be electrocardially fragile.

Do NOT allow the patient to lie flat (unless CPR is required) or to stand up
Provide oxygen at 100% for all patients
Prior to release, manually stabilise the airway via all possible means
During release, be particularly cautious of the patient entering a prone position by accident, for example when transferring between stretchers or being passed across an obstruction
Minimise fluids to those required for unrelated trauma. The patient is not hypovolemic and adding IV will lead to hypervolemia when the patient is repositioned. You may start a keep-open line for future access but operate on minimal flow
The patient may also be hypothermic if suspended outdoors, and external rewarming may be necessary. Do NOT give warmed IV fluids at this stage.
Monitor ECG carefully - peaked T waves, prolonged QRS or HTN indicates hyperkalemia and the onset of crush syndrome. If detected, direct and agressive action is needed. This is beyond current PHTLS training but via direction will require IV bicarbonate, calcium chloride, albuterol or insulin via large-bore IVs running normal saline. This contradicts the earlier fluid restriction policy but is only to be initiated under direction if compatible ECG artifacts are identified.
Transport the patient, in the sitting position, to the nearest hospital

Hospital ER treatment

If the patient has been in suspension for a prolonged period (variable, but between 5 and 40 minutes is the typical point at which symptoms develop) then venous pooling in the legs will have lead to cerebral hypoperfusion and hypoxia. This may have been treated on scene with O2 or by repositioning into a sitting posture. DO NOT ALLOW THE PATIENT TO LAY FLAT for at least 30 minutes unless there is a priority need for life support. Pooled venous blood in the lower extremities has been static for some time, and will be entirely hypoxic. Anaerobic metabolism within the legs will result in toxic levels of metabolytes in the pooled volume, and on release into core circulation, it can result in cardiac arrest, dramatic ETCO2 and PP02 fluctuations and transient hypercarbia. Cytochrome-C release and transient renal hypoxia will result in renal artery spasm, tubular necrosis and potential acute renal failure within 60 to 80 hours of the incident. Increased serum certainine with reduced output, uremia and acidosis are diagnostic. Dialysis would be required in such cases to prevent mortality.

In most cases of suspension in a purpose-designed harness, confined space or litter then the patient will not have experienced soft tissue insult sufficient to cause crush syndrome, however extended suspensions (in excess of 2 hours) or those with thin ropes or straps may initiate the syndrome. It manifests as release of potassium and myoglobin, and can contribute to renal insult. Serum K should be monitored, as hyperkalemia is diagnostic in these cases. Treatment of crush syndrome is based on volumetric support, renal protection and serum K management. Once local reflow has been corrected then IV support may be required to manage hypovolemia, bicarbonate and mannitol are indicated to control acidosis and hyperkalemia. Monitor ECG and regular urine myoglobin, CPK and full chem panel.

In severe cases of vertical immobile suspension where pooled blood has become cytotoxic, a split-form full blood transfusion is possible and effective, with surgical interruption of the femoral arteries and veins placing the lower limbs on bypass, enabling a localised transfusion and management regime for reflow and crush syndrome to be applied while the remainder of the body is managed in isolation. If successful this can remove the need for amputation, though the procedure is complex.

Patients are considered equally susceptible to suspension trauma in terms of gender, age, fitness, body mass or race. Those taking tricyclic antidepressants will have increased susceptibility as they contribute to orthostatic hypotension. There is no difference in treatment or medication required for patients on TcaDs.

Patients involved in enforced vertical posture but not caused by a harness can also present with suspension trauma. Potential candidates include those entrapped in vehicles, buried in snow, sand or grain, etc.

Suspension Trauma