Client found with a ligature: the rescue sequence before anything else

First action: call for help and release the neck

A ligature compresses the neck, and every second it stays in place threatens oxygen delivery to the brain. The nurse shouts for help or activates the emergency alarm while staying with the client, then removes or cuts the ligature straight away, using the unit's safety cutters where they are available. If the client is suspended, support the body weight while it is released so the client is not dropped.

Leaving the room to find help, waiting for a provider, or trying to untie a tight knot slowly are all wrong. Help comes to the nurse; the nurse does not go to it. Once the ligature is off, lower the client to the floor on their back so the airway and chest can be assessed and compressions given if they are needed.

Then airway, breathing and circulation

Check responsiveness and look for normal breathing for no more than about ten seconds. If the client is unresponsive and not breathing normally, or is only gasping, begin chest compressions at 100 to 120 per minute and ask another staff member to bring the defibrillator and emergency equipment. Continue until the response team takes over or the client shows clear signs of life.

If the client was hanging or fell, a neck injury is possible. Where trained responders open the airway in suspected cervical injury, a jaw thrust rather than head tilt and chin lift is advised. A client who is breathing still needs close monitoring: record level of consciousness, respiratory effort, oxygen saturation and vital signs, note any voice change, noisy breathing, difficulty swallowing or neck marks, and report them for urgent medical evaluation.

What waits, and what can be delegated

Physical injury is treated before psychiatric evaluation, so documentation, an incident report, a room search, calling the family and asking the client why all come after the rescue. They matter, but none of them restores breathing. A careful search for further means and a review of how the ligature was obtained follow once the client is stable and observed.

In the moment, the nurse leads the airway and breathing assessment. Other staff can call the emergency team, bring the defibrillator and suction, guide other clients away and stay with them. After stabilisation, the client needs continuous observation at the level set by the team and protocol, and the nurse documents what was found, the time, actions taken and the response in factual terms.

After the rescue: monitoring, observation and follow-up

Once breathing and circulation are supported, the client usually needs medical assessment before any psychiatric review, because a neck that has been compressed may show problems that are not obvious at first. The nurse continues to recheck consciousness, breathing, oxygen saturation and the voice, and passes concerns straight to the medical team rather than waiting for scheduled observations.

Continuous observation is maintained at the level ordered by the team, and the environment is checked for further means once the client is safe. Staff who were involved and other clients who witnessed the event may need support and debriefing. These steps come after the physical rescue, but they are part of the nurse's responsibility to prevent a repeat attempt.

Working a hypothetical rescue question

Imagine a hypothetical inpatient found in the bathroom with a strip of sheet tied tightly around the neck. The client is breathing but drowsy. The options are completing an incident report, cutting the ligature and assessing airway and breathing, searching the room for other items, or asking the client what happened. Cutting the ligature and assessing the airway is first because it removes the ongoing threat.

Change the scenario so the client is unresponsive with no normal breathing after release. Now the answer moves to starting CPR and getting the defibrillator while help arrives. The room search is tempting because ligature safety is a familiar topic, but it belongs to prevention and follow-up. Exam questions reward the action that addresses the immediate physical threat first.

Sources and further reading

MSD Manual Professional: Suicidal behavior. Treating physical injury first after a suicide attempt, followed by psychiatric evaluation; hanging as a major method.

MSD Manual Professional: Cardiopulmonary resuscitation in adults. Recognising absent or gasping breathing, calling for help and a defibrillator, compression rate, and jaw thrust in suspected cervical injury.

St John Ambulance: CPR. Calling for help without leaving the casualty, compressions and continuing until help arrives.