Positional Asphyxia
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Positional asphyxia, also known as postural asphyxia, is a form of
asphyxia Asphyxia or asphyxiation is a condition of deficient supply of oxygen to the body which arises from abnormal breathing. Asphyxia causes generalized hypoxia, which affects primarily the tissues and organs. There are many circumstances that ca ...
which occurs when someone's
position Position often refers to: * Position (geometry), the spatial location (rather than orientation) of an entity * Position, a job or occupation Position may also refer to: Games and recreation * Position (poker), location relative to the dealer * ...
prevents the person from
breath Breathing (or ventilation) is the process of moving air into and from the lungs to facilitate gas exchange with the internal environment, mostly to flush out carbon dioxide and bring in oxygen. All aerobic creatures need oxygen for cell ...
ing adequately. People may die from positional asphyxia accidentally, when the mouth and nose are blocked, or where the chest may be unable to fully expand.


Background

A 1992 article in ''The American Journal of Forensic Medicine and Pathology'' and a 2000 article in ''The American Journal of Forensic Medicine and Pathology'' said that multiple cases have been associated with the hogtie or hobble prone restraint position. The New York Police Department’s guidelines, explaining protocols for mitigating in-custody deaths, were published in a 1995
Department of Justice A justice ministry, ministry of justice, or department of justice is a ministry or other government agency in charge of the administration of justice. The ministry or department is often headed by a minister of justice (minister for justice in a ...
bulletin on "positional asphyxia." The NYPD recommended that, “ soon as the subject is handcuffed, get him off his stomach. Turn him on his side or place him in a seated position." A 1996 FBI bulletin said that many law enforcement and health personnel were being taught to avoid restraining people face-down or to do so only for a very short period of time. via Federal Bureau of Investigation Resuscitation of persons who exhibit cardiac arrest following restraint has proven to be difficult, according to a 1995 article in ''
Annals of Emergency Medicine The ''Annals of Emergency Medicine'' is a monthly peer-reviewed medical journal covering all aspects of emergency medicine care. It is the official journal of the American College of Emergency Physicians (ACEP) and is published on their behalf by ...
''. Even in cases where the subject was in the immediate care of paramedics, resuscitation has failed and the subject has died. A March 1999 article in the ''Academic Emergency Medicine'' journal reported that one group of doctors had presented a method of resuscitation, correcting
acidosis Acidosis is a process causing increased acidity in the blood and other body tissues (i.e., an increase in hydrogen ion concentration). If not further qualified, it usually refers to acidity of the blood plasma. The term ''acidemia'' describes ...
in the blood of the victim, which proved effective in their small scale study. A 2010 article in the ''Journal of the Tennessee Medical Association'' reported a single case of successful resuscitation using "aggressive sedation", "ventilatory assistance" among other interventions but added that "avoiding hobble and prone restraint positions may eliminate some of the problems". In 1997 ''
Annals of Emergency Medicine The ''Annals of Emergency Medicine'' is a monthly peer-reviewed medical journal covering all aspects of emergency medicine care. It is the official journal of the American College of Emergency Physicians (ACEP) and is published on their behalf by ...
'' article reported on a single small laboratory study in which "15 healthy men ages 18 through 40 years" were placed in the "hobble" or "hog-tie" restraint position. Researchers found that the effects of restraint on the breathing and oxygen levels these 15 healthy men, was limited. A 2002 review of the literature published in the '' British Journal of Forensic Practice'' said that restraining a person in a face-down position is likely to cause greater restriction of breathing than restraining a person face-up. A 2008 article in '' Medicine, Science and the Law'' said that the way the subject is restrained can also increase the risk of death, for example kneeling or otherwise placing weight on the subject and particularly any type of restraint hold around the subject's neck. Research measuring the effect of restraint positions on lung function suggests that restraint which involves bending the restrained person or placing body weight on them has more effect on their breathing than face-down positioning alone. In the United States, there were 16 cases reported deaths in police custody between 1998 and 2009 in which restraint was a "direct or contributory factor to the death." The investigation into the deaths resulted in a 2010 report tabled by the Independent Police Complaints Commission (IPCC). Prolonged (particularly resisted) restraint, obesity, prior cardiac or respiratory problems, and the use of illicit drugs such as cocaine can increase the risk of death by restraint, according to a 2001 article in ''American Journal of Emergency Medicine''. Positional asphyxia is not limited to restraint in a face down position according to a 2011 article in ''Medicine, Science, and the Law''. Restraining a person in a seated position may also reduce the ability to breathe, if the person is pushed forwards with the chest on or close to the knees. The risk will be higher in cases where the restrained person has a high
body mass index Body mass index (BMI) is a value derived from the mass (weight) and height of a person. The BMI is defined as the body mass divided by the square of the body height, and is expressed in units of kg/m2, resulting from mass in kilograms and he ...
(BMI) and/or large waist girth. A 2012 series by the
Bureau of Investigative Journalism The Bureau of Investigative Journalism (typically abbreviated to TBIJ or "the Bureau") is a nonprofit news organisation based in London. It was founded in 2010 to pursue "public interest" investigations. excited delirium Excited delirium (ExDS), also known as agitated delirium (AgDS), is a controversial diagnosis sometimes characterized as a potentially fatal state of extreme agitation and delirium. It is typically diagnosed postmortem in young adult males, dispr ...
", to explain restraint-related deaths involving police officers. A May 1997 article in ''Wiener klinische Wochenschrift'' said that deaths in real life situations occur after
excited delirium Excited delirium (ExDS), also known as agitated delirium (AgDS), is a controversial diagnosis sometimes characterized as a potentially fatal state of extreme agitation and delirium. It is typically diagnosed postmortem in young adult males, dispr ...
, which had not been studied in laboratory simulations at that time.


Deaths in police custody

Three prominent cases of in-custody deaths involve David Smith in 2010,
Eric Garner On July 17, 2014, Eric Garner was killed in the New York City borough of Staten Island after Daniel Pantaleo, a New York City Police Department (NYPD) officer, put him in a prohibited chokehold while arresting him. Video footage of the incide ...
in 2014, and George Floyd in 2020. In 2013, the family of 28-year-old David Smith successfully sued Minneapolis, Minnesota for $3.075 million, the "second-largest for police misconduct" in the city's history, when the Smith family's legal team—cited evidence from a Minneapolis police officer's body-worn camera (BWC) showing that the officers had used the "controversial" police technique called prone restraint to subdue Smith. According to a June 1, 2013 ''Star Tribune'' article, MPD officers had "forced Smith onto his stomach, then placed a knee in his back and held him down for about four minutes, which the family attorneys said made it impossible for him to breathe." The July 17, 2014, killing of Eric Garner has been linked to positional asphyxia. On May 25, 2020, according to a private autopsy contradicting the official autopsy, George Floyd
died Death is the irreversible cessation of all biological functions that sustain an organism. For organisms with a brain, death can also be defined as the irreversible cessation of functioning of the whole brain, including brainstem, and brain ...
by
asphyxia Asphyxia or asphyxiation is a condition of deficient supply of oxygen to the body which arises from abnormal breathing. Asphyxia causes generalized hypoxia, which affects primarily the tissues and organs. There are many circumstances that ca ...
when Minneapolis Police officer Derek Chauvin knelt on Floyd's neck and another officer, J. Alexander Kueng, knelt on his back for almost ten minutes as Floyd lay on his stomach on the pavement.


Accident or illness

Positional asphyxia may also occur as a result of accident or illness, according to a 2008 article in the ''
Journal of Forensic and Legal Medicine The ''Journal of Forensic and Legal Medicine'' is a peer-reviewed medical journal covering forensic and legal medicine. It was established in 1972 as the ''Police Surgeon'', obtaining its current name in 2007. It is published by Elsevier on behalf ...
''. This can include bed rail strangulation. A 2008 ''EMBO Reports'' article on
sudden infant death syndrome Sudden infant death syndrome (SIDS) is the sudden unexplained death of a child of less than one year of age. Diagnosis requires that the death remain unexplained even after a thorough autopsy and detailed death scene investigation. SIDS usuall ...
, said that the number of diagnoses of 'accidental suffocation', 'wedging' or 'positional asphyxia' had increased." Olympic track athlete
Florence Griffith-Joyner Florence Delorez Griffith Joyner (born Florence Delorez Griffith; December 21, 1959 – September 21, 1998), also known as Flo-Jo, was an American track and field athlete. She set world records in 1988 for the 100 m and 200 m. During the late 1 ...
and ex-Major League Baseball player
John Marzano John Robert Marzano (February 14, 1963 – April 19, 2008), commonly referred to as "Johnny Marz", was an American professional baseball catcher, who played in Major League Baseball (MLB) for the Boston Red Sox, Texas Rangers, and Seattle Marine ...
both died due to positional asphyxia, the former following an epileptic seizure and the latter following a fall down a flight of stairs.


References

{{reflist, 30em Medical emergencies Law enforcement Causes of death