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I Can’t Breathe - Positional Asphyxia, Excited delirium & Neck Restraints

I Can’t Breathe - Positional Asphyxia, Excited delirium & Neck Restraints

I am sure you have all hear the Black Lives Matter slogan of “I Can’t Breathe” that was adopted after several high-profile deaths of black males who were being detained by American law enforcement personnel.

What amazed me when watching the numerous videos of these incidents was the obvious lack of basic training of the law enforcement personnel in restraint techniques. And also, why they were not interested learning from the mistakes made from previous questionable, controversial and fatal incidents.

I have heard the arguments that those that died were “Career Criminals” and should not have resisted the police, so they got what they deserved. Maybe so in some people’s eyes, but I am not really comfortable with the idea that a police force can just kill or abuse someone because they view the person as being an undesirable. Remember, we are all an undesirable is someone’s eyes! A police force is a civil service and must work within the law and for law to maintain the respect of the people, if they do otherwise and break the law then they are just another street gang.

I also do not believe that these high-profile deaths were racially motivated as the mainstream media has overly promoted but were the result of untrained or wrongly trained police personnel. For a start they obviously had no understanding of the consequences of positional asphyxia and neck restraints.

It’s a basic fact that when you are physically restraining or controlling a person, they will try to resist to some extent, that’s basic human nature. If they have been drinking alcohol, taking illegal drugs or are on medications they can struggle a lot more as their thought process is confused. What can appear to be an aggressive response can be put down to the fact the person is scared, confused, panicking, in a state of excited delirium, having mental health issues or suffering from a medical emergency like diabetes. This is where all potentially hostile situations must be dealt with calmly and initially deescalated as much as possible before any reasonable legal force is used. I will explain more about excited delirium in the following paragraphs.

Now, the problems of positional asphyxia, excited delirium and the issues of using neck restraints has been common knowledge to me for many years. They are what I understand to be basic topics for use of force for security and police personnel. So, why are these highly trained and best of the best American police officers apparently so ignorant to such basics?

The technical notes for this article I compiled over 20 years ago when I was trying to put together a course program for running the door supervisor (bouncer) licensing courses in UK, when the industry was regulated at the local council level. I never got around to applying to run the courses as I relocated from London to Miami and at that time the idea of the UK SIA was being talked about, as was the fact the licensing requirements and courses would be changing completely in near future. Nevertheless, the draft of the training manual I put together has proved useful on many other occasions.

When I was in London, I worked freelance and also ran my own security and investigation company. I work in and provided security and close protection in all flavors of venues, some very colorful and some very shady. When I started providing door supervisors and guards all the new guys I employed were given a printout detailing the basic UK laws that were applicable and the basics of use of force such as positional asphyxia, excited delirium and the issues of using neck restraints. There is a citizen’s arrest law in UK and if detaining people you have to be extremely careful. If someone died while you were detaining them, I am sure it would be an immediate manslaughter charge to start with and if they were excessively injured an assault charge.

In the UK door supervisors and event staff working in venues where alcohol was being served have needed to be licensed since at least the early 1990’s. From what I understand the licenses were brought in to push organized criminals out of the business of running the security for bars and nightclubs. Another basic fact, if you control the security for a venue, you can control the drug dealing etc. etc. etc.

I was surprised when I reached the US that the security licensing regulations did not apply to the bar and club sectors. When I mentioned this to a member of Florida Department of Agriculture, the State Department the regulates the security industry in Florida he laughed at me dismissively and his response was something like “Why do bouncers need training and regulating”. I got very used to dealing with the arrogance, ignorance, and incompetence of such people while I was living in the U.S. for 18 years.

If any sector of security industry should be regulated it’s the bar, club and hospitality sector. Why? Because the guards are dealing with drunks, drugs and violence on a regular basis. But, I suppose in Miami such things as drug abuse, prostitution, sexual assaults, organized crime, drunks and violence in bars and clubs doesn’t happen. And if it did ever happen it would be best to ignore the problem, then you do not have to deal with it...

Meanwhile in Miami - Cannibal Attack

On May 26, 2012, Rudy Eugene attacked and maimed Ronald Poppo, a homeless man, on the MacArthur Causeway in Miami, Florida. During the 18-minute filmed encounter, Eugene accused Poppo of stealing his Bible, beat him unconscious, removed Poppo's pants, and bit off most of Poppo's face above the beard (including his left eye), leaving him blind in both eyes... @

Excited Delirium

On a basic level whenever approaching or being approached by someone where a physical confrontation could take place, in addition to assessing your surroundings you need to be checking their body language. You need to be assessing if they are agitated, armed, drunk, medicated or drugged as this will help you prepare your response to any aggression, and sometimes these assessments need to be done in a matter of seconds.

The following information is from British Police guidelines on assessing and dealing with excited delirium. Since these notes were taken over 20 years ago other drugs such as Bath Salts and Fentanyl have come onto the market and can cause excited delirium in those stupid enough to knowing take them, or unfortunate enough to given them without knowing.

Excited delirium is when someone displays violent, bizarre, and manic behavior rather than only being violent. Excited delirium, or delirious mania, is a form of severe mania sometimes considered part of the spectrum of manic-depressive psychosis and chronic schizophrenia.

Excited Delirium Can Be Caused By

  • Psychiatric illness

  • Drugs, of which cocaine is the best-known cause

  • Alcohol

  • A combination of drugs, alcohol, and psychiatric illness

Excited Delirium Symptoms

  • Bizarre and/or violent behavior

  • Impaired thinking

  • Confusion

  • Hallucinations

  • Acute onset of paranoia

  • Panic

  • Shouting

  • Violence towards others

  • Unexpected physical strength

  • Significantly diminished sense of pain

  • Sweating, fever, heat intolerance

  • Sudden calm after frantic activity

These signs can be common to anyone behaving violently. People suffering from excited delirium can die suddenly, during, or after a violent struggle. Death is most likely to occur in two ways:

  • The state of excited delirium causes the suspect to have cardiac pains.

  • The efforts to avoid being restrained makes an 'excited delirium' suspect at greater risk from positional asphyxia.

Dealing With A Case Of Excited Delirium

It’s imperative that you recognize the difference between excited delirium and an ordinary violent flare-up. If you believe that someone is suffering from excited delirium, your next problem is of how to handle them without endangering themselves and others. This will be very challenging. The police must be called immediately. You will almost certainly have to place the person face down on the ground, in order for them restrained safely before the police arrive.

The risk of positional asphyxia far greater than for a normal violent person. They will struggle beyond their point of exhaustion. When they are under your control do not hold them face down, move them onto their side, sifting, kneeling, or standing position as soon as it is possible to do so. It can be expected that they will continue to struggle violently. You must get them off their stomach in some way or other as soon as you can. Such behavior is a typical indication that someone is suffering from excited delirium.

You must supervise them carefully and treat them as a medical emergency. Be aware they could collapse and die at any time. They can collapse very suddenly and attempts to resuscitate them usually prove to be unsuccessful. If you think you are dealing with an excited delirium case inform the police as soon as they arrive. The police will then get them to a hospital…

So, these were the basic guidelines in UK in the mid 1990’s for door supervisors etc. I take it such information never made it across the Atlantic…

Neck Restraints

Another issue in at least one these high-profile deaths of black males in the U.S. while the police were restraining him was the use neck restraints. More specifically kneeling on the persons neck… Personally, I think whatever idiot came up with this restraint technique and all the idiots teaching it need to be held accountable for any injuries those they have taught this blatantly stupid technique have caused.

I teach one pain compliance technique for high-risk situations when you place a knee on the skull of person you’re trying to control, not neck. If this technique is used the body of the person you are trying to control needs to be controlled to prevent damage to the neck. This is old technique and preventing injury to the neck has always been a major consideration to my knowledge.

I have never taught wrist or joint locks for close protection or security personnel because if you’re dealing with someone who is struggling its easy to break their wrist or joint. On a basic level when people are under the influence of drugs or alcohol, they have a higher tolerance for pain and a lot of the pressure point and pain compliance techniques will not work and can lead to them being injured and you ending up in court.

On my courses I tell my clients that strikes to the neck or any neck restraints are a last resort and only to be used in a high-risk situation as it’s very easy for the strike or technique to become lethal. I have heard many “experts” defending the restraint technique of kneeling on someone’s neck. Well, in my personal and professional opinion these “experts” are obviously retarded or just need to lay off what ever medications they are taking.

I understand that those in law enforcement like to protect each other and in the U.S. I have heard it being called the “Blue Line of Silence” etc. Street gangs and adolescent fraternities have similar codes and values… To me, blind unquestioning loyalty to anyone, cause or country is a pathetic slave mentality. Such mentalities do nothing for progress and just continually sweep under the carpet and gloss over issues that need to be addressed while protecting incompetent fools. If you don’t the courage to acknowledge you have a problem, then you will never rectify it…

Now, the facts are there are significant dangers in the use of any neck restraint or strike. There is a risk of injury or fatality when a neck restraint or strike is applied in a confrontation. Any form of pressure to the neck is highly dangerous and can easily be lethal, especially if the person whom you are trying to control continues to struggle.

The Following Facts Are Based On Medical And British Police Advice

Although the neck column provides mobility for the head, it is not, in itself, mobile and within it are structures which are highly vulnerable to attack. When a person breathes, the air passes in through the nose and continues back into the throat, where it enters the windpipe (trachea). The windpipe is a tube that is approximately four and a half inches in length. It is located in the front of the neck and it leads directly into the chest. In the chest, it divides into two branches, one leading into each lung. The voice box (larynx) is located high up in the front of the neck and leads to the windpipe from the back of the throat. It contains the vocal cords and allows the individual to speak. The 'Adam's Apple' (thyroid cartilage) forms the front wall of the voice box.

The windpipe and voice box are critically vulnerable to any forceful inward pressure. If steady and heavy pressure is applied, then breathing is cut off. If heavy, sudden force is applied, the windpipe can be crushed, and the voice box ruptured. This disruption can quickly lead to a blockage of the windpipe and death can occur very shortly afterwards. The carotid arteries run down each side of the neck slightly behind the ears. When pressure is brought to bear on this area of the neck, it has the effect of slowing down blood flow to the brain, reducing the amount of oxygen reaching it. It also restricts blood flowing away from the brain and stimulates that vagus nerve that runs down alongside the carotid arteries. This nerve affects the heart rate and its stimulation slows the heart rate down.

By understanding the anatomy of the neck, you will appreciate why any neck restraint or strike can result in serious injury or death to the person being restrained. When a person is in a neck restraint, pressure is applied to the front or the sides of the neck. Pressure to the front of the neck restricts the ability to breathe and can lead to damage to the trachea, hyoid bone or thyroid cartilage, which can result in an obstruction of the airway and death can follow very quickly. Pressure to the front of the neck can be extremely painful and restrict breathing; this can cause the person being restrained to struggle harder. The more the person struggles, the greater the risk of damage to the throat. Pressure to the sides of the neck restricts the blood flow to the brain and can result in unconsciousness. Blood flow is affected by pressure on the carotid arteries and by stimulation of the carotid sinus and the vagus nerve, the result of which is to slow down the heart rate. This slowing of the heart can lead to heart failure.

When in a violent struggle, it may be impossible to avoid applying pressure on someone’s neck. You must be aware of the dangers involved with neck restraints. Any neck holds or strikes of any sort should be avoided whenever possible unless your life or others’ lives are at risk.

Positional Asphyxia

When someone is restrained, there is a risk of injury to all involved. There is additional risk to restrained people known as positional asphyxia. Again, the below information are British Police guidelines.

What Is Positional Asphyxia

A person can stop breathing because of the position they are in and they become 'asphyxiated.' Positional asphyxia occurs when someone is in a position which impedes their inhalation and/or exhalation and they cannot escape that position.

When Is Positional Asphyxia Most Likely?

  • When a person is prone causing the stomach to press up to the ribs.

  • When a person is in a sitting position and their head drops between the knees compressing the chest and abdomen.

  • When a person’s head falls forward restricting the windpipe.

This can occur extremely rapidly. There are documented cases of this happening within 4 to 7 minutes. In these cases, the postmortems have failed to identify any other anatomical or toxicological findings to explain the death.

Positional Asphyxia Risk Factors

The following are factors that have been shown to add to the potential for positional asphyxia:

  • Subject's body position results in partial or complete airway constriction

  • Alcohol or drug intoxication (the major risk factor)

  • Inability to escape position

  • The subject is prone

  • Obesity (particularly large "beer bellies")

  • Restraints

  • Stress

  • Respiratory muscle fatigue, following violent muscular activity (such as fighting or running away)

Positional Asphyxia Signs and Symptoms

When you see the following symptoms in someone, take immediate action to remedy them and apply first aid if required:

  • Body position restricted to prone, face-down

  • Cyanosis (face is discolored blue due to lack of oxygen)

  • Gurgling/gasping sounds

  • An active subject suddenly changes to passive – from loud/violent to quiet/tranquil

  • Panic

  • Telling you he/she cannot breathe

You must be able recognize the risks and symptoms associated with positional asphyxia, especially where alcohol and obesity are factors. If you believe a person is suffering from positional asphyxia, call an ambulance immediately. Early recognition of signs and symptoms should help to significantly reduce the chance of these fatalities from occurring.

In any violent confrontation, it may be impossible to avoid placing someone in a prone position to gain control. As soon as you have control and the person is no longer at risk of causing injury to themselves or others, they should be moved onto one side or placed in a kneeling, sitting or standing position to avoid positional asphyxia.


As I said previously in this article, the technical notes here are from over 20 years ago. I remember teaching one class to a police force in the Middle East and the students wanted to know why the same mistakes with use of force are made again and again in the U.S. and why obvious issues were not addressed and rectified. Well, I could not answer the question as it’s beyond my comprehension why the same mistakes are made over and over again. But, the U.S. is a different culture to the rest of the world so, if they do not think they are making mistakes, there is nothing to rectify, everyone else is wrong, not them.

Sadly, in these days of the all-powerful and rabble-rousing social media and news platforms, it only takes the stupidity of one cop in America can cause protests, social divisions and inflame racial issues internationally. Of course, if there are justified racial or police brutality issues anywhere, they need to be responsibly addressed, but these days the only ones with a voice seem to the extremists on all sides who seem intent on fracturing society and communities as much as they can.

I hope this article has put a few things into perspective and not just the issues of positional asphyxia, excited delirium, and neck restraints. In my opinion were the high-profile deaths of black males in the U.S. due to racism and police brutality? No! The deaths happened because the cops involved lacked common sense, disciple and were not properly trained, if trained at all, in the basics of use of force and restraint techniques.

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