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• Suspension Trauma
  David S Whitmore
  Published on: 29 April 2016
• Suspension Trauma - Other places where the physiology may apply
  David A Halliwell
  Published on: 29 April 2016
• Suspension trauma can be unrelated to harness use
  Dave Merchant
  Published on: 29 April 2016
• Suspension Trauma - Case to prove.
  Patrick J Morgan
  Published on: 29 April 2016
• Suspension Trauma in UK Climbers?
  David Hillebrandt
  Published on: 29 April 2016

• Published on: 29 April 2016

  Suspension Trauma

  • David S Whitmore, Paramedic

  Dear Editor,

  Thank you for your article which I found very interesting. I have undertaken some work in this area with a colleague of mine from the, now, South Western Ambulance Service NHS Trust, (Mr. David Halliwell). I was also asked to advise the National Scaffolding and Access Confederation (UK)(NASC) on the formulation of a "Rescue Plan" as required under the Working at Height Regulations. Having researche...

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  Dear Editor,

  Thank you for your article which I found very interesting. I have undertaken some work in this area with a colleague of mine from the, now, South Western Ambulance Service NHS Trust, (Mr. David Halliwell). I was also asked to advise the National Scaffolding and Access Confederation (UK)(NASC) on the formulation of a "Rescue Plan" as required under the Working at Height Regulations. Having researched the HSE texts and advice that you cite, and also after discussing the anatomy and physiology with Professor Douglas Chamberlain, I came to a view that the sitting position being advocated for all casualties was flawed and did not take sufficient cognisance of the unconscious casualty. I therefore advocated that an unconscious casualty should be initially managed, if required, in a "head uppermost" inclined supine position. I further advised that "ABC" and "BLS" protocols should underpin any training given to staff working in these envirionments. This is now published as NASC Guideline SG19:06. I have also urged the HSE to look at producing a laminated "Action Card" to be used on all sites where such workers may be injured to inform pre- hospital care providers so that, given the nature of pre-hospital care, they can take this advice into account when actually on scene.

  From a Mountain Rescue Team (MRT) perspective the newly published 2nd Edition of the Casualty Care in Mountain Rescue manual (August 2006), uses the term Suspension Induced Shock Syndrome. The manual has a section on the management and treatment of such a casualty in the MRT envirionment. They also quote an interesting reference from the Alpine Club of Canada written by a Dr. Millar - (http://alpineclub- edm.org/accidents/SuspensionInducedShockSyndrome.htm).

  Like you I feel that there is a need for more research in this area. I also feel that the term Suspension Trauma is a misnomer as actual trauma may not be present. I prefer the terms Suspension Induced Shock Syndrome, or Orthostatic Incompetence. I also feel that the design and correct fitting of harnesses is a crucial factor in this scenario.

  I would also add a note of caution for those involved in any form of "Casualty Care" education / training etc... It is possible to induce these effects in "willing volunteers" who are acting as patients when they have been strapped immobile into various lifting & carrying devices, and not necessarily for long periods of time.

  Yours sincerely,

  David Whitmore, Senior Clinical Advisor to the Medical Director

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  Conflict of Interest:
  None declared.

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• Published on: 29 April 2016

  Suspension Trauma - Other places where the physiology may apply

  • David A Halliwell, Head of Education
  • Other Contributors:
    • Robert Clark, Jon Knight

  Sirs,

  Following on from the paper on suspension trauma from Caroline Lee and Keith M Porter Suspension trauma Emerg. Med. J., Apr 2007; 24: 237 - 238.

  I have previously worked with rope access teams using both front attachment and rear attachment harnesses and have personally seen some of the physiological changes associated with the concept of suspension trauma. These teams have recounted pre-syncopi...

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  Sirs,

  Following on from the paper on suspension trauma from Caroline Lee and Keith M Porter Suspension trauma Emerg. Med. J., Apr 2007; 24: 237 - 238.

  I have previously worked with rope access teams using both front attachment and rear attachment harnesses and have personally seen some of the physiological changes associated with the concept of suspension trauma. These teams have recounted pre-syncopial symptoms and have often taken some time before feeling "normal".

  Reading the E letter from Whitmore D, April O7 I felt we should report that we have also experienced a similar phenomenon using a spinal board(in a training environment) for moving a simulated back injured patient down a steep flight of stairs...

  The patient was a student Paramedic and the scenario was testing the students ability to move the patient down a flight of stairs - assessing lifting ability etc.. The stairs are steep - approximately 60 degrees.. The patient was secured to the board, with legs immobile... transported head up...

  After a few minutes of indicision (20+)by his peers - mid transfer down the stairs the patient became - pre syncopial - pale, sweaty, complaining of tunnel vision, his Bp had dropped quite dramatically and he was complaining of nausea.

  We believe that this may be an occurance based on similar physiology - head higher than legs - legs imobile - strapped together, and concur with Morgan P in his e letter to the EMJ that this condition may present with varying symptoms and under varying conditions.We stress that the importance of teaching Paramedics the Physiology associated with being immobile and Having head higher than legs.

  We now encourage the students to wiggle their toes (as with soldiers on parade) when strapped on boards in head up position to minimise similar occurance...

  Regards

  David Halliwell - Head of Education

  References

  Morgan P, suspension Trauma case to prove, Emerg Med J, e letter 2007 20 NOV

  Caroline Lee and Keith M Porter Suspension trauma Emerg. Med. J., Apr 2007; 24: 237 - 238.

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  Conflict of Interest:
  None declared.

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• Published on: 29 April 2016

  Suspension trauma can be unrelated to harness use

  • Dave Merchant, Consultant, technical rescue

  Dear Editor,

  As a provider of instruction and advice on this subject to both commercial bodies and the emergency services I agree with the response by Dr Patrick Morgan[1] that the condition certainly exists beyond the theoretical level, but more significantly that it does not require that the patient is suspended in a harness - from the cases I have been informed of it seems that harness wearers are actually i...

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  Dear Editor,

  As a provider of instruction and advice on this subject to both commercial bodies and the emergency services I agree with the response by Dr Patrick Morgan[1] that the condition certainly exists beyond the theoretical level, but more significantly that it does not require that the patient is suspended in a harness - from the cases I have been informed of it seems that harness wearers are actually in the minority. I also support David Whitmore's response[2] in that the nomenclature can be restrictive - one of the most common misconceptions I see in delegates is that suspension trauma both requires "suspension" and "trauma" (which is not an unexpected assumption given the name). I tend to refer to it using the same phrase as it's most commonly used, but would prefer "orthostatic intolerance" if it wasn't so hard for people to remember. In the USA the term used is "harness hang syndrome".

  Two recent verbal reports made to me by UK fire officers demonstrated orthostatic intolerance in what I personally consider are more statistically-common events for the UK. In the first case OI developed un- noticed during a prolonged vehicle entrapment (pt reportedly suffered no significant compression, impact or decelerative pathologies but was entrapped between the steering wheel and seat of a goods vehicle in a semi -standing position for ~1h and suffered cardiac arrest when removed to a supine posture).

  The second case was entrapment in free-flowing solid (estuarine mud flats), with a similar loss of stasis at release but no details on outcome. This particular case is likely to be further complicated by hydrostatically-induced OI where vascular compensation for the external pressure on the legs is unable to react to the sudden removal of such pressure during rescue; an event commonly reported when lifting shipwreck survivors from the water.

  This is not to say that harness-induced cases are not happening - they appear in the references by Lee & Porter[3] and instructors I work with have seen presyncopal symptoms develop in a delegate on a training course (perfectly healthy adult male suspended intentionally indoors from a sternal full body harness for a few minutes), and I have experienced it myself at least twice over the years as a climber and caver.

  In terms of the expected numbers of cases where ST results from harness suspension, it is not unusual to see little or no results in a database search as the number of cases of workplace *accidental* suspension are equally very low - and the majority of these do not involve more than a few minutes of suspension. Cases are statistically more common in confined spaces (industrial and caving) where intentional vertical suspension is seen, but less so for industrial rope access simply because of the methods of work adopted (workers suspended for prolonged periods normally sit on a work-seat, otherwise will be actively climbing and so causing normal return flow). It may therefore be misleading to concentrate pre-hospital education and research solely on "people working with harnesses", as whilst they certainly can be placed in a high-risk position they probably won't be during their working lives. Expanding the risk groups to the more general issues of "persons immobilized in a vertical or semi-vertical position" brings in many sectors of operation that personally I believe are more significant in terms of total hours-at-risk (RTA/USAR entrapment, stretcher rescue, geriatric falls into awkward positions etc.)

  Finally I'd like to clarify point (1) in Dr Patrick Morgan's response[1] - the term "full body harness" in an industrial setting refers to one with an attachment point above the center of gravity (dorsal or sternal) and therefore a vertical post-fall posture. Point (1)'s statement that full-body harnesses are "low risk" would not apply to an industrial full-body harness, which would instead be high risk.

  Dr Dave Merchant UVSAR

  References

  1. Morgan, P. Suspension Trauma - Case to prove. Emerg Med J, eLetters 20 Nov 2007. 2. Whitmore, DS. Suspension Trauma. Emerg Med J, eLetters 27 Apr 2007. 3. Lee C, Porter KM. Suspension Trauma, Review. Emerg Med J 24(4) Apr 2007.

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  Conflict of Interest:
  None declared.

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• Published on: 29 April 2016

  Suspension Trauma - Case to prove.

  • Patrick J Morgan, ST2 ACCS

  Dear editor

  I have read with interest the replies to Lee and Porter’s article on suspension trauma. As a mountain rescue doctor I have been involved in the care of an individual with suspected suspension trauma. The patient fell 10 metres vertically onto a 40 degree scree slope, with feet facing down the slope and reluctant to place the pelvis on the ground as it caused an increase in pain in both legs. Paramedi...

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  Dear editor

  I have read with interest the replies to Lee and Porter’s article on suspension trauma. As a mountain rescue doctor I have been involved in the care of an individual with suspected suspension trauma. The patient fell 10 metres vertically onto a 40 degree scree slope, with feet facing down the slope and reluctant to place the pelvis on the ground as it caused an increase in pain in both legs. Paramedics immobilised in a vacuum mattress with legs outstretched – still facing downhill, (Morphine Sulphate being used to relieve pain). The team attended to assist in extraction, the patient had been immobile in excess of two hours.

  The patient was not suspended vertically but was immobilised at a significant angle for a period of time. This prevented leg movement and recirculation of the pooled venous blood – alerting us to possible suspension trauma and hence raising the casualty’s feet. The side effects of morphine, (hypotension, nausea, dizziness, and bradycardia), are similar to the effects of suspension trauma, except for the narrow pulse pressure and dilated pupils present in this patient. It could be argued that a significant sympathetic drive would occur from the pain and fear of sliding, which prevented further onset. The absence of a tachycardia does not support this. The non specific bilateral leg pain may indicate suspension trauma associated paraesthesia, rather than mechanical injury. No hypovolaemia, back, pelvic or lower limb injury were confirmed in hospital and the patient denied further pain.

  It must be noted that if a casualty becomes unconscious whilst in suspension their airway will be become obstructed, either by neck flexion or hyperextension, masking any signs of suspension trauma. In training risk of suspension trauma is grouped as follows:

  1. Full body harness with posterior attachment point - low risk.

  2. Sit harness with anterior attachment – low risk. Casualty will hang almost horizontal, but additional weight can alter their centre of gravity changing the angle of suspension1. If still conscious they will attempt to recommence climbing or be lowered by the second climber to a better position.

  3. Full body harness with chest and waist attachment points – high risk. Used in caving and industrial rope access as it allows rapid ascent and descent of the rope. The unconscious casualty will remain in a vertical position; reducing the time to brain hypoxia secondary to reduced cerebral perfusion pressure from venous pooling and concomitant reduction in cardiac output. Consequently rope access technicians must be able to rescue and descend to safety in less than ten minutes2.

  4. Third party induced. This group are placed in suspension by other individuals and are at high risk. This includes rescue personnel immobilising casualties.

  This case demonstrates that suspension trauma is not hypothetical and may present with varying symptoms and under varying conditions. It has a small incidence following changes in harness design and education of those at risk, but must be considered during rescue and in hospital if a history of prolonged suspension at any angle is mentioned.

  Regards

  Dr Patrick Morgan

  Avon and Somerset Cliff Rescue Team

  References

  1. Hillebrandt, D. Suspension Trauma in UK Climbers? Emerg Med J, e- letter. 2007, 12 June.

  2. Guidance on rescue during work at height. Technical Guidance Note 5. The Work at Height Safety Association. www.wahsa.org.uk. 2006.

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  Conflict of Interest:
  None declared.

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• Published on: 29 April 2016

  Suspension Trauma in UK Climbers?

  • David Hillebrandt, General Medical Practitioner

  Dear Editor,

  Although I do not have any experience of the industrial rope access industry I do have considerable personal experience of rock climbing, general mountaineering and ski mountaineering and a long term interest in mountain medicine over the last 35 years, so it was with interest that I read the paper by Lee and Porter (1) in the EMJ. They suggest that they have never seen a case of suspension trauma...

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  Dear Editor,

  Although I do not have any experience of the industrial rope access industry I do have considerable personal experience of rock climbing, general mountaineering and ski mountaineering and a long term interest in mountain medicine over the last 35 years, so it was with interest that I read the paper by Lee and Porter (1) in the EMJ. They suggest that they have never seen a case of suspension trauma or heard of one by personal communication. In their conclusions they postulate that this may be a hypothetical risk.

  I suspect that this postulation is totally correct when applied to climbers in the UK using modern harness and rope systems. In the UK it would be very rare for an unconscious climber to hang in a situation where they could not be lowered. At a recent (28th April 2007) mountain rescue conference held at Ambleside in the UK Dr Xanvier Ledoux (France ICAR) presented a paper on this subject and was able to quote probable cases in industrial access workers, cavers and canyoners but no confirmed cases in mountaineers. Research was limited to harnesses that had not been designed for climbing. Nobody in the audience could quote specific cases since 1970 in climbers in the UK.

  Lee and Porter quote results Patsheider’s 1972 study of mountaineering deaths between 1957 and 1968 (2) and it is interesting to note that this coincides with the development of modern harness design by the UK climber Don Whillans for the 1970 Annapurna South Face Expedition. Initially climbers attached themselves to the rope by a direct tie to the waist, they then used multiple hemp waist loops which evolved into waist belts in the late 1960s. The Moac/Irvine and Troll chest harnesses also appeared on the market in the late 60s but the Whillans harness was such a revolution that it went into commercial production by Troll soon after the Annapurna expedition and all modern harnesses have evolved from it.

  These modern combination, waist, hip and thigh harnesses ensure that any unconscious climber falling free of the rock will hang almost horizontally. The exact angle will depend on the attachment point and whether or not a ruscac is being carried. In addition developments in methods of tying onto the rope for glacier travel ensure that the level of the anchor point can be varied for loads carried, terrain and position on the rope. The only time a modern climber is likely to hang in the vertical position is if they fall into a narrowing crevasse and get stuck at the constriction. In these circumstances hypothermia is likely to complicate any identification of possible Suspension Syndrome.

  Yours sincerely,

  Dr David Hillebrandt Hon Medical Advisor to the British Mountaineering Council, Vice President of the UIAA Medical committee

  References:

  1. Lee C, Porter KM. Suspension Trauma, Review. EMJ Vol 24, No 4 April 2007. 2.Patsheilder H. Pathologico-anatomical examination results in cases of death caused by hanging on the rope. Papers of the Second International Conference of Mountain Rescue Doctors. Austria 1972.

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  Conflict of Interest:
  None declared.

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