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Positional Asphyxia: A Paramedic Responsibility to Protect

As the world ground to halt in the early months of 2020, pandemic fever literally swept the globe. However, whilst we watched from our home’s mid pandemic, an incident in Minneapolis redirected our attention to another silent killer, positional asphyxia. Paramedics are no stranger to positional asphyxia and have been championing awareness of such incidents since the early 2000s. But as I watched in despair as a human was choked to death on social media my colleagues and I reflected on similar cases that we had all responded to during our careers.

The Never-ending Rhetoric

An ambulance responding to the scene outside a night club find security guards managing an unruly patron. The offender was positioned face down, hands held behind his back with four guards holding him down with a knee in his back. The initial request to relieve the pressure on this patient’s chest by repositioning him on his side was met with some defiance however after persistence and gentle persuasion the security guards comply. The story went that he was found by security to be anxious and nervous and failed to follow some simple requests. Things had allegedly escalated, and the patient went from anxious to agitated and eventually combative requiring force to restrain him.

The patient was found to be not breathing and pulseless and immediate cardiopulmonary resuscitation commenced. He was ventilated and eventually intubated on the sidewalk as people moved casually passed with some taking selfie snaps. The crew had gained intravenous access to push adrenaline and after the fifth defibrillation was delivered, a heartbeat returned but the crew had to continue ventilations. While a small celebration was held around the crew by the bystanders with lots of people clapping, the paramedic team were not so celebratory. Although the patient’s heart rate maintained and his blood pressure stabilised, his brain had been starved of oxygen through positional asphyxia. Whilst the heart is fragile, the brain is more fragile and less responsive following a hypoxic injury. As the crew loaded the patient into the ambulance the security team were already back to their duty posts unaware of the damage that may have been caused. The patient was transferred to the hospital however he sadly died two days later.

What is Positional Asphyxia

In general terms, asphyxia refers to oxygen deprivation. Whereas positional asphyxia is a type of mechanical asphyxiation due to the positioning of an individual’s body.

Although mechanical and physical restraint may be used by health and security staff to manage the potential risk of violent people, some restraint techniques used by police, health care staff, prison officers, and the military may be a factor in sudden and preventable deaths. This includes the forceful restraint of a person in a prone position which can impede chest expansion in breathing. The more weight applied, the less capacity for ventilations to occur. This inadvertently leads to reduced ventilatory capacity, respiratory failure and hypoxia.

Whilst this pressure on the chest is of great concern, so too is the position of the neck. Hyperflexion, hyperextension and external pressure of the neck can cause airway obstruction which can also lead to hypoxia. This includes neck-hold, headlock and impactful pressure which can also reduce blood flow to the brain.

With these in mind, the possibility of physical harm occurring during forced restraint has real potential, and unfortunately it is not a new concept. The risk of positional asphyxia has been known for decades.

How can we prevent this?

Simply limiting physical restraint would reduce the physical distress forced on an individual, however this is an unlikely strategy in law enforcement. Where physical restraint is required, it should be utilised as a last resort following recurrent attempts at other de-escalation techniques. That said, as paramedics, we are unlikely to be in a situation where we are required to physically restrain someone. However, we are likely to be called to support law enforcement situations or indeed call for law enforcement support ourselves. Either way, regardless of the role, the reality of emergency service work is that exposure to physical restraint is a part of the job as much as the emotional response of exposure to such situations.

The limbic system, or specifically the amygdala is the part of the brain involved in our emotional responses, which is often activated during a physical altercation. This is important for paramedics to recognise. When the amygdala is activated it can reduce a person’s ability to think critically. A paramedic can impact an emotional scene by recognising this behaviour and work to advocate for the patient.

When restraint is applied it should not exceed a defined period, and the restrained person must be closely monitored. Clinicians can advise the restraining officers on better positioning of the patient / safer positions that encourages or supports respiratory function. Whilst the prone position should be avoided, the supine position not only relieves pressure on the chest, but it also permits airway monitoring. Similarly, the lateral position supports airway function and allows airway monitoring to occur.


Working towards a cohesive and collaborative approach to emergency scenes, paramedics are well positioned to support restraining officers avoid situations that may result in positional asphyxia. Whilst up to date and regular staff training programs exist, the ongoing rhetoric of preventable deaths from positional asphyxia have no place in todays society. It is up to the attending emergency service workers to ensure they protect themselves, and the patient. As paramedics we have a responsibility to continue doing what we do best, advocating for the patient.


  1. Barnett, R., Hanson, P., Stirling, C., & Pandyan, A. (2013). The physiological impact of upper limb position in prone restraint. Medicine, Science And The Law, 53(3), 161-165.
  2. Barnett, R., Stirling, C., & Pandyan, A. (2012). A review of the scientific literature related to the adverse impact of physical restraint: gaining a clearer understanding of the physiological factors involved in cases of restraint-related death. Medicine, Science And The Law, 52(3), 137-142.
  3. Chmieliauskas, S., Mundinas, E., Fomin, D., Andriuskeviciute, G., Laima, S., & Jurolaic, E. et al. (2018). Sudden deaths from positional asphyxia. Medicine, 97(24).
  4. Dijkhuizen, L., Kubat, B., & Duijst, W. (2020). Sudden death during physical restraint by the Dutch police. Journal Of Forensic And Legal Medicine, 72, 101966.
  5. Parkes, J., Thake, D., & Price, M. (2011). Effect of seated restraint and body size on lung function. Medicine, Science And The Law, 51(3), 177-181.
  6. Smethurst, L. (2016). Applying ethical principles to restraint practice. Learning Disability Practice, 19(1), 23-26.

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Steve Whitfield

Steve Whitfield

Steve Sunny Whitfield is a lecturer at Griffith University School of Medicine (paramedicine) with experience in humanitarian operations, high altitude expeditions, marine expeditions and flight and retrieval medicine. In 2015 Steve founded a platform that became the international collaboration Medics Beyond Borders to support health care in remote communities. Steve is also a keen geographer, surfer and climber. Updated 2021

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