POSITIONAL ASPHYXIA

by Dr Faiz Ahmad

DEFINITION Any body positions of ones own body

that obstructs the restrained persons

airway or interferes with the

muscular or mechanical components

of respiration and person can not get

enough oxygen(hypoxia) - result in

positional asphyxia.

• Deprived of Oxygen.

• Excess carbon dioxide.

• Hypoxia .

• Loss of consciousness.

Breathing is a mechanical process

involving the chest wall, rib cage,

diaphragm and abdominal

muscles, and if the movement of

all, or any of these are

significantly impaired for any

length of time, then death may

result as a consequence of hypoxia

which may disturb heart rhythm.

• Positional asphyxia has been associated with a number of deaths during physical restraint, mechanical restraint but also during ‘hands on’ techniques, which physically restrict the person’s freedom of movement.

What are Risk Factors?

 • Position During Restraint (particularly face down

prone but also hyper flexion).• Prolonged struggle/agitated delirium syndrome• Drug or alcohol intoxication, in particular cocaine

and methamphetamine intoxication or cocaine-induced psychosis

• Mania• Obesity• Sedation/Accidents/Organic diseases/quadriplegia

• Respiratory Syndromes including Asthma and Bronchitis.

• Cardio Vascular Disorder including an enlarged heart

(hypertrophic cardiomyopathy) and other cardiovascular

disorders

• Prescribed Drugs.

A combination of factors may place individuals at Risk

of Positional Asphyxia.

Prolonged violent physical agitation

Stage 1 – Development of an incident –

The individual exhibits irrational,

violent, aggressive behaviour and

paranoia. The person may be

physically active and aroused.

Stage 2 – Intervention –

One or more interveners' are

tempted to sit or lean on the subject

to maintain control.

• The subject may perceive

this hostile and fight even

harder in an attempt to get

relief.

• The person may also be

fighting harder because they

cannot breathe and what is

perceived to be increasing

violence may actually be

increasing desperation to

stay alive.

Stage 3 – Exhaustion

• While struggling with security

staff the person expends large

amounts of energy trying to

breathe.

• The individual becomes exhausted

with low blood oxygen and when

they are finally unable to struggle

any more, it may be too late.

Obesity

puts additional stress on

the body. In a prone

position inhibits the

person’s ability to properly

contract the diaphragm and

raise the ribs to enlarge the

chest and inhale.

Psychosis

stimulant drugs (amphetamines,

speed, ‘ICE’, ecstasy) can create an

“excited delirium” in which the

person is paranoid, over excited and

potentially violent. The stimulation

of the heart can produce cardiac

rhythm disturbances which can be

fatal. In this situation any difficulty

breathing can result in sudden

deterioration in condition and

death.

Pre-existing physical conditions – • Any disease condition that

impairs breathing under normal circumstances will put a person at a higher risk when they are physically restrained. Examples are heart disease, asthma, emphysema, bronchitis and other chronic lung diseases.

• On down in a prone position, the greater the risk that there will pressure on the person’s abdomen making it difficult to breathe.

Influence of drugs

profound effect on the respiratory

and cardiovascular system.

Excited Delirium Also known as

Agitated delirium

Cocaine induced psychosis

Acute exhaustive mania • It is characterised by purposeless, often violent activity coupled with

incoherent or often meaningless speech and hallucinations with paranoid delusions

o Bizarre or aggressive behaviour• Impaired thinking• Combativeness• Super-Human Strength• Disorientation • Hallucinations• Acute onset of paranoia• Shouting

Delirium Can Be Caused By

• Psychiatric illness

(combined with Drink and/or Drugs)

• Drug intoxication

(Cocaine is the best known cause of excited Delirium)

• Alcohol

Effects of Excite Delirium

• Hypothermia • High tolerance to pain • Quick to fatigue –

especially after a violent struggle

• Skin may be hot to touch • Abnormal Strength

Prader-Willi risk factors

Obesity

• more prone to obstructive

apnea, pulmonary

compromise, and diabetes. High pain threshold

• Someone with PWS has

high threshold and in

addition may have difficulty

localizing pain.

Increased risk of respiratory difficulties• Hypotonic and weak chest muscles

Thick saliva• complicates airway management

Chronic stomach reflux and aspiration

Temperature instability

• Idiopathic hyper and hypothermia have been reported. Fever may be

present despite serious infection.

Bruise easilyAnatomic and physiologic differences

• such as : narrow airway, underdevelopment of the larynx, edema, hip

dysplasia, and scoliosis

Hogtie bondage

• Hogtie bondage requires the

tying of all four limbs

together behind a person's

back. It typically involves

connecting a person's wrists

and ankles behind their back

whilst lying face down using

some form of physical

restraints.

Ball tie• The ball tie is a bondage position in

which a person is bound tightly into

a ball position. A ball position (also

called a fetal position) is one where

the legs are bent double so the heels

press against the bottom; the legs

should also be brought up so that

the thighs are pressed against the

chest. Pressing the thighs against

the abdomen may restrict

breathing .

Newborns at risk

• In newborns the airway is

kinked due to baby’s heavy

head resting with his chin

on his little chest.

However, it can also

happen in all directions

your little one’s head can

be turn.

• Who is at risk?

Newborns from 0-4 month old are the greatest risk group.

Babies under 4 months old Newborns with low birth

weight Premature babies Babies with hypotonia

(low muscle tone) Babies placed in reclined

baby holding devices

Where can positional asphyxia happen?

Car seats

Swings

Strollers

Activity saucers

Ill designed or incorrectly used baby carriers

Crib

Playpen

Bike trailer

Incident

of

Restraint

Vicious cycleViolent muscle activity

Respiratory muscle energy deficit

Muscle weakness

Hypercatabolic state

Increased oxygen demand

Stress on heart

• Extreme physical energy expenditure generates excessive production of adrenalin and

noradrenalin. • A progressively increasing amount of these body

chemicals in the individuals system can occur creating a

• “hyper- catabolic state”.

• A hyper-catabolic state can weaken all the body's muscles especially the

• Respiratory muscles.

• The hyper-catabolic state also puts “stress” on the heart by increasing its workload

(requiring faster and stronger contractions). • Thus the heart needs more than normal

amounts of oxygen in order to keep it functioning.

• If an individual with severe respiratory muscle fatigue is restrained in a position that

impairs or prevents breathing it is easy to understand why asphyxia can occur so

quickly!

General signs and symptoms

• Noisy, laboured breathing

• Grey-blue skin (cyanosis/excess deoxygenated haemoglobin in blood )

• congestion of the face• facial oedema• Flaring of the nostrils

• Reversed movement of the chest while breathing; the chest wall will suck in as the casualty breathes in.

• Drawing in of the chest wall between the ribs and of the soft spaces above the collarbones and breastbone.

How to asphyxiate

• Compression to neck• Compression to chest/back/torso• Obstructed airways/vomiting• Chemical/environmental• Postural position

Distress signs

• Gurgling gasping sounds.

• Extremities cold to touch

• Face becomes flush or ashy

• Bleeding or bruising

• Seizures

• Unconsciousness

• Complaints of “I can’t breathe” or “I have chest pain”

• Limpness of the arms and legs

• A violent and loud individual suddenly changes to a passive, quiet, tranquil.

Safety points

Avoid putting direct weight or pressure on chest, stomach or back

Never put pressure on the neck or put the head in a position that compresses the neck

 

Never restrain on a soft surface (mattress) or place a pillow, towel under the head or

over the mouth.

Achieve a kneeling, sitting or standing position as soon as practical.

  Monitor the individual’s vital signs.

 

Get medical assistance immediately if you have any concerns about the condition of

the individual under restraint. 

Staff made aware of basic warning signs and of respiratory distress.

 

Must be able to recognise factors that contribute to Positional Asphyxia (medical

history, use of drugs, etc).

 

Vigilant monitoring of the person’s condition must be stressed.

Recent history i.e. past 24 hours – drug taking, alcohol use etc.

Medical history – establish any heart complaint, breathing problems etc.

thanks