Positional asphyxia

dfdgfhfh

1. POSITIONAL ASPHYXIA by Dr Faiz Ahmad

2. 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.

3. 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.

4. 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.

5. What are Risk Factors?   Position During Restraint (particularly face down prone but also hyper flexion). Prolonged struggle/ agitated delirium syndrome D rug or alcohol intoxication, in particular cocaine and methamphetamine intoxication or cocaine-induced psychosis Mania Obesity Sedation/Accidents/Organic diseases/quadriplegia

6. 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.

7. 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.

8. 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.

9. 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.

10. 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.

11. 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.

12. 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.

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

14. 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

15. 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.

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

17. 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.

18. 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 .

19. 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.

20. 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

21. Where can positional asphyxia happen?  Car seats  Swings  Strollers  Activity saucers  Ill designed or incorrectly used baby carriers  Crib  Playpen  Bike trailer

22. Incident of Restraint Vicious cycle Violent muscle activity Respiratory muscle energy deficit Muscle weakness Hypercatabolic state Increased oxygen demand Stress on heart

23. 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.

24. 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!

25. 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

26. 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.

27. How to asphyxiate Compression to neck Compression to chest/back/torso Obstructed airways/vomiting Chemical/environmental Postural position

28. 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 .

29. 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.  

30. 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.

31. thanks