Positional asphyxia occurs when a restrained person's body position interferes with their ability to breathe. It can happen quickly, sometimes in under 6 minutes. Several factors increase the risk, such as obesity, drug use, agitation, being prone or face down which restricts chest movement and lung expansion. Those with Prader-Willi syndrome are at especially high risk due to obesity, weak chest muscles, and other anatomical and medical factors. Signs of distress during restraint require immediately ending the hold and seeking medical attention.

1. Positional Asphyxia DEFINITION: “THE POSITION OF ONE’S OWN BODY INTERFERES WITH THE RESTRAINED PERSON’S ABILITY TO BREATHE AND THE PERSON CANNOT GET ENOUGH OXYGEN”

2. Positional Asphyxia Oxygen is necessary for our muscles and organs to function Asphyxia is caused by depriving the muscles and organs of oxygen Oxygen enters the blood through the lungs and is pumped to the muscles and organs by the heart

3. Air can be prevented from entering the lungs by either obstructing the airway or stopping the chest wall from moving Positional Asphyxia AIRFLOW TO LUNGS CHEST EXPANDS TO BRING IN AIR

4. General risk factors Agitation Heart rate, blood pressure and rate of breathing increase As the physical struggle occurs, the student becomes out of breath Student has increased oxygen need to fuel the muscles Student is placed in a face down position on the floor causing sompresssion of the chest and limiting ability to expand the chest cavity and breathe Abdominal organs pushed up Restricts movement of the diaphragm, further limiting available space for lungs to expand

5. General risk factors 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. Influence of drugs profound effect on the respiratory and cardiovascular system. Prolonged violent physical agitation state of oxygen deficiency, In addition the chest wall muscles which help the process of breathing (diaphragm) are fatigued. Underlying natural disease asthma, enlarged heart, high blood pressure, diabetes, increases risk, poor muscle tone (PWS) Hot humid environment

6. General risk factors “ THE MORE AGITATED A PERSON IS THE LESS TIME IT WILL TAKE FOR SUFFOCATION TO OCCUR ”

7. 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 Hypotonia 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 easily Anatomic and physiologic differences such as : narrow airway, underdevelopment of the larynx, edema, hip dysplasia, and scoliosis

8. Prader-Willi risk factors “ THE AVERAGE TIME BETWEEN BEGINNING A PRONE RESTRAINT AND THE ONSET OF DEATH WAS ONLY 5.6 MINUTES”

9. Warning signs A student struggling to breath Complaining of being unable to breathe Evidence or report of feeling sick or vomiting Swelling, redness or bloodspots to the face or neck Marked expansion of the veins of the neck Individual becoming limp or unresponsive Change in behavior (both escalative and de escalative) Loss of or reduced levels of consciousness Respiratory or cardiac arrest

10. Common misconception If an individual can talk then they are able to breathe. An individual dying from positional asphyxia may well be able to speak or shout prior to collapse MISCONCEPTION TRUTH

11. Common misconception ALMOST ALL SUBJECTS WHO HAVE DIED DURING RESTRAINT HAVE ENGAGED IN EXTREME LEVELS OF PHYSICAL RESISTANCE AGAINST THE RESTRAINT FOR A PROLONGED PERIOD OF TIME.

12. Safety points Never place 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. If student says “you are hurting me’ or “I can’t breathe” adjust hold and make sure you are not putting pressure or weight on the student. If any signs of distress end restraint and seek medical attention. Never allow student to continue lying on the floor after restraint. Get the student up and checked by medical staff . Always keep the arms close to the floor . Do not raise them up as that might cause pain and decrease ability to breathe. In the small child, do not lean over or press forward on the back as this could critically restrict ability to breathe .

13. Distress signs If noted terminate restraint and seek medical attention!! 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

14. Check your ABCs AIRWAY: FREE OF OBSTRUCTION BREATHING: AIR FLOWS TO AND FROM LUNGS CIRCULATION: HEARTBEAT AND PULSE ARE PRESENT

15. Resources The Gathered View of PWSUSA “Advisory for Care Providers Exploring the Dangers of Positional Asphyxia,” Tina Didino, Mark K. Ziccardi Positional Asphyxia-pso.mhprisonservicd.gov.uk 7/7/2010 Positional Asphyxia-Wikipedia