Positional asphyxiation is a fatal disorder occurring when the body is placed into a position that interferes with the mechanics of pulmonary ventilation or breathing. Postural asphyxia can occur in a variety of situations, although positional asphyxia is most common in situations where a violent or physically aggressive person is physically or mechanically restrained. These situations most commonly occur in settings where law enforcement officers or medical personnel must physically or mechanically restrain an agitated person to keep that person or others safe from harm.
There are many names for this condition, including postural asphyxia, restraint asphyxiation, and sudden in-custody death. Restraint or positional asphyxiation most commonly occurs in situations when someone is restrained on their stomach, face down or in a prone position. The risk of injury or death increases when the person is physically restrained by other people. A mechanical restraint includes handcuffs, ankle shackles, sheets, straps, leather restraints, towels, Velcro, ropes, or even tape used to keep the person from moving.
Preventing Restraint Deaths
There are certain factors that increase the risk of a positional asphyxiation death when someone is restrained in a prone position. These risks factors have been known to increase the risk of death in people who are obese, have certain medical conditions (like an enlarged heart) and use of drugs or alcohol prior to being restrained, especially cocaine. People who use cocaine can lapse into a condition known as cocaine-induced excited delirium. This is a condition which can result in disorientation, confusion, paranoia, hallucinations, and an increased heart rate.
How restraint or in-custody deaths happen seems simple, but in reality it is a complex situation resulting in s a vicious cycle. Although the actual cause of death varies when someone dies during a restraint, the situation begins the same way. Someone becomes physically and verbally agitated, escalating to the point he or she is no longer safe without a physical intervention. During the initial restraint, a person is typically placed face down in a prone position in a therapeutic hold. A therapeutic hold is designed to prevent someone from hurting themselves or someone else. When someone is placed in a therapeutic hold in a prone position, it can make it hard for one to breathe, especially if the person is obese or has a large abdominal girth. The pressure from the person’s own weight being placed on the stomach can cause the person to have difficulty breathing.
Try lying on the floor face down to see how it feels. Next imagine being physically restrained by numerous people holding you down so you cannot move. The increased pressure placed on the body by other hands and bodies can result in a decrease in the ability to oxygenate the lungs. Now the agitated person feels as if he or she cannot breathe. This may cause them to panic. Often they begin yelling, struggling to free themselves.
A Vicious Cycle to Breathe
When the person being held begins to panic by yelling and struggling to free themselves, the people applying the physical restraint will usually respond to the increased physical agitation with more pressure onto the body. Many people mistakenly believe if you can talk or yell then you can breathe without any difficulty, and this may be where the vicious cycle begins. As the person begins to struggle frantically because they cannot breathe, the pressure from the people retraining the person is increased to subdue the increased physical movement, which results in additional pressure being placed on the person who cannot take in additional air.
Often the vicious cycle ends only when the person suddenly stops moving. This is often when the person may have lapsed into an unconscious state, yet often the people restraining the person mistakenly believe the person is now listening to their commands to stop struggling and to lay calm, so they do not immediately loosen their physical hold for fear the person may be faking, just waiting for them to loosen their grip to renew their struggle. This process is compounded when someone is handcuffed or has their hands retrained behind their back or is hog tied, which means their wrists and ankles are tied to each other to prevent them from kicking. When possible, handcuff the person in the front, or use an extension or second set of cuffs to allow more room and less constriction. As soon as possible, sit the person upright or place them on their side.
Supine is Superior When Restraining Someone
When mechanically restraining someone, place them in a face-up (supine) position. Place a wedge pillow or blanket behind their head and back, elevating their head and torso. Never place physical force on the upper torso, back or neck, and do not use a sheet across the person’s legs or place anything over the person’s head or face, including towels or masks, even if the person is spitting. Although spitting is nasty, the reality is there is very little risk of contagious diseases being spread from saliva unless there is a great deal of blood in the saliva, and it is safer to have the personnel restraining the person wear a medical face mask.
Learn and practice proper restraint techniques, and always pay attention to the person who is being restrained, especially if the person is yelling that he or she cannot breathe. If someone goes limp, do not assume he or she is suddenly complying. Check that the person is still breathing and not in any obvious distress. Most restraint or sudden in-custody deaths can be prevented by knowing the risks and using proper restraint procedure during a physical or mechanical restraint.
Determining the cause in a possible positional or postural asphyxiation situation is difficult. “The main difference is in the way the event occurred”, according to the American Journal of Forensic Medicine and Pathology. “The diagnosis of positional asphyxia is essentially based on 3 criteria: the body position must obstruct normal gas exchange, it must be impossible to move to another position, and other causes of natural or violent death must be excluded”. It is never safe to leave anyone in a mechanical restraint unattended as they have no way to ask for help. Preventing restraint or in-custody deaths is possible by using proper techniques in physical and mechanical restraints and watching the person closely for any signs of obvious distress.
Sources:
- American Journal of Forensic Medicine and Pathology “Positional asphyxia: reflection on 2 cases” (accessed on May 10, 2011).
- Charly Miller “Restraint Asphyxia – Silent Killer” (accessed on May 8, 2011).
Erika Lyn Smith - Erika Lyn Smith - is a Psych RN, who has completed the UMSL Medicolegal Death Investigator Training Course, and is finishing a BS in ...
