• Rapid Reviews: Don’t leave me hanging! Suspension trauma management.

    by Alan Batt. Last modified: 15/04/14



    I was recently asked for a summary of the evidence available in management of suspension syncope (also commonly known as suspension trauma). On a quick glance through numerous textbooks in preparing this article including Emergency Care in the Streets, Emergency Care, PHTLS, ATLS, ATT and ITLS manuals, there were no specific references made to management of these patients. Usual disclaimers regarding scope of practice, guidelines etc. apply.

    Update: I’ve just discovered Jason van der Velde’s excellent chapter on Suspension and Trauma in the ABC of Prehospital Emergency Care (affiliate link). This chapter deals with the management of rescue cardioplegia, and makes for interesting reading. I’ve added some of Jason’s recommendations to the additional management section at the bottom.

    What is suspension syncope/trauma?

    Suspension syncope or suspension trauma (also known as harness hang syndrome (HHS)) occurs when the human body is held upright without any movement for a period of time (orthostasis). Pooling of blood in the gravitationally dependent legs leads to the clinical state described as orthostasis, which will eventually lead to a state of unconsciousness. Prior to unconsciousness, patients may describe symptoms of of presyncope such as:

    • dizziness
    • light-headedness
    • nausea
    • flushing sensations
    • tingling, numbness
    • anxiety
    • dyspnoea

    Who is at risk?

    Anyone who uses a harness during their activities, such as those working in industrial harnesses (working at height, lowered into confined spaces), abseiling, mountaineering, caving, bungee jumping, theatrical events etc.

    In essence, anyone who could faint, but cannot not fall over.

    Lie flat or sit up?

    One hypothesis to explain fatalities in suspension syncope is that of reflow syndrome (also known as rescue death) – toxin build-up in orthostasis that can be fatal on placing the patient supine when rescued.  Authors of several articles on suspension trauma hypothesise that if a person has been suspended in a vertical position motionless for longer than 30 min, then he or she should not be laid in a horizontal position on his or her rescue as this may cause ‘rescue death’ (Raynovich et al., 2009)

    • There is however, no scientific evidence of reflow syndrome/rescue death (Pasqiuer at al., 2011; Mortimer, 2011; Adisesh, Lee & Porter, 2011)
    • There is no international consensus on the correct positioning for patients rescued from suspension (Lee & Porter, 2007; Seddon, 2002).
    • There is no evidence to suggest that lying a patient down increases the risk of death after rescue from suspension (Thomassen et al., 2009)

    According to an evidence review by the Health & Safety Executive in the UK in 2009, rescue recovery of a semi-conscious or unconscious person should be in a horizontal position, even if they are the subject of prior harness suspension (Adisesh et al., 2009).

     So what’s the bottom line?

    • Rescue all suspended patients as soon as possible!
    • Lie them flat and follow standard resuscitation guidelines.
    • If you can’t rescue them immediately, lift their legs, or get them to lift them.
    • Be aware of the signs of pre-syncope in those in harnesses – as listed above.

    Additional Management Recommendations

    Rescue Cardioplegia

    Rescue cardioplegia is stunning of the myocardium that can occur on uncontrolled release of a compressing force, harness or tourniquet. Sudden release of pooled blood back into the circulation can cause a rapid increase in right-sided preload, which can cause atrial stretch, resulting in conduction abnormalities such as fibrillation.


    • Apply arterial tourniquets just proximal to a harness or entrapping force – these should remain in place until the patient is fully resuscitated, potential haemorrhage points have been addressed and the patient is in a safe environment
    • 20 mL/kg bolus (10 mL/kg in elderly people) of 0.9% saline should be administered prior to release in patients trapped for over 1 hour
    • Administration of potassium-containing solutions such as Hartmann’s must be strictly avoided to avoid hyperkalaemia
    • Judicious use of opiates and/or analgesic doses of ketamine (0.2 mg/kg) should be employed
    • Tourniquets should be released in a staged/staggered strategy, and immediately reapplied if clinical condition deteriorates.

    (van der Velde, 2013)

    Cast Your Vote!

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    Your local protocols/guidelines for post-rescue suspension trauma management state:

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    Pre-Hospital Emergency Care Council (Ireland) CPG – Harness Induced Suspension Trauma – Responders

    Download from: http://www.phecit.ie/Images/PHECC/Clinical%20Practice%20Guidelines/3rd%20Edition%20CPGs/CPG%20Suspension%20Trauma%202.pdf

    Pre-Hospital Emergency Care Council (Ireland) CPG – Harness Induced Suspension Trauma – Practitioners

    Download from: http://www.phecit.ie/Images/PHECC/Clinical%20Practice%20Guidelines/3rd%20Edition%20CPGs/CPG%20Suspension%20Trauma%201.pdf

    Australian Resuscitation Council – Harness Suspension Trauma – First Aid Management

    Download from: http://www.resus.org.au/policy/guidelines/section_9/guideline-9-1-5july2009.pdf

    References (non-PubMed)

    Adisesh A., Robinson L., Codling A., Harris-Roberts J., Lee C., Porter K. (2009) Evidence based review of the current guidance on first aid measures for suspension trauma. Health & Safety Executive Research Report RR708. Health Safety Executive Books, HMSO: Norwich, 2009.

    Seddon, P. (2002) Harness suspension: Review and evaluation of existing information. CRR 451/2002 Health Safety Executive Books, HMSO: Norwich, 2002.

    van der Velde, J. (2013) Chapter 19: Trauma: Suspension and Crush in: Nutbeam, T. & Boylan, M. (eds) (2013) ABC of Prehospital Emergency Care. Oxford: Wiley Blackwell



    Pasquier M1, Yersin B, Vallotton L, Carron PN. Clinical update: suspension trauma. Wilderness Environ Med. 2011 Jun;22(2):167-71. PMID: 21420883.


    Lee C1, Porter KM. Suspension trauma. Emerg Med J. 2007 Apr;24(4):237-8. PMID: 17384373.


    Mortimer RB. Risks and management of prolonged suspension in an Alpine harness. Wilderness Environ Med. 2011 Mar;22(1):77-86. PMID: 21377125.


    Thomassen O1, Skaiaa SC, Brattebo G, Heltne JK, Dahlberg T, Sunde GA. Does the horizontal position increase risk of rescue death following suspension trauma? Emerg Med J. 2009 Dec;26(12):896-8. PMID: 19934143.


    Raynovich B1, Rwaili FT, Bishop P. Dangerous suspension. Understanding suspension syndrome & prehospital treatment for those at risk. JEMS. 2009 Aug;34(8):44-51, 53; quiz 53. PMID: 19665660.


    Adisesh A1, Lee C, Porter K. Harness suspension and first aid management: development of an evidence-based guideline. Emerg Med J. 2011 Apr;28(4):265-8. PMID: 20961926.

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    Alan Batt

    Alan Batt

    Paramedic, educator, researcher
    Alan is a critical care paramedic, paramedic educator and prehospital researcher, currently working around the world as an educator and researcher. He has previously worked and studied across Europe, North America and the Middle East. He holds a Graduate Certificate in Intensive Care Paramedic Studies, and an MSc in Critical Care. His main interests are in care of the elderly, end-of-life care, patient safety, professionalism (including role and identity), and paramedic education.

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    5 thoughts on “Rapid Reviews: Don’t leave me hanging! Suspension trauma management.

    • We don’t have a specific one for Suspension trauma, but in the past it has been treated under the Compression from MVC protocol. Virtually the same, TQ’s, Pain-relief, fluid boluses. Not suspension Specific though.

      • Alan Batt Alan Batt says:

        Seems to be a severe lack of suspension specific guidance out there, and mostly based on crush and compression research. Would you have your Compression from MVC protocol anywhere we could link to or upload?

    • Chris Leggett says:

      Hi guys. It seems the lack of evidence may be down to the definition of time the casualty is suspended, cause of suspension (possibly fall or collapse) and injuries that occur pre and/or post suspension. It’s a tricky one. But i think rescue time is the most pressing issue.

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