We postulate that most atraumatic deaths during police restraint of subjects in the prone position are due to prone restraint cardiac arrest (PRCA), rather than from restraint asphyxia or a stress-induced cardiac condition, such as excited delirium. The prone position restricts ventilation and diminishes pulmonary perfusion. In the setting of a police encounter, metabolic demand will be high from anxiety, stress, excitement, physical struggle, and/or stimulant drugs, leading to metabolic acidosis and requiring significant hyperventilation.Although oxygen levels may be maintained, prolonged restraint in the prone position may result in an inability to adequately blow off CO 2 , causing blood pCO 2 levels to rise rapidly.The uncompensated metabolic acidosis (low pH) will eventually result in loss of myocyte contractility. The initial electrocardiogram rhythm will generally be either pulseless electrical activity (PEA) or asystole, indicating a noncardiac etiology, more consistent with PRCA and inconsistent with a primary role of any underlying cardiac pathology or stress-induced cardiac etiology. We point to two animal models: in one model rats unable to breathe deeply due to an external restraint die when their metabolic demand is increased, and in the other model, pressure on the chest of rats results in decreased venous return and cardiac arrest rather than death from asphyxia. We present two cases of subjects restrained in the prone position who went into cardiac arrest and had low pHs and initial PEA cardiac rhythms. Our cases demonstrate the danger of prone restraint and serve as examples of PRCA. K E Y W O R D Sprone restraint, in-custody deaths, arrest-related deaths (ARDs), police-involved deaths, restraint asphyxia, positional asphyxia, excited delirium, sudden cardiac death, metabolic acidosis, George Floyd, forensic pathology, autopsy Highlights• Prone restraint deaths result from metabolic acidosis, not hypoxic asphyxia.• Metabolic demand is increased by stimulant drugs, physical exertion, and stress.• Metabolic acidosis requires hyperventilation to "blow off" carbon dioxide (CO 2 ).• Prolonged restraint in the prone position may prevent adequate elimination of CO 2 .• An initial ECG rhythm of PEA or asystole after a cardiac arrest is generally inconsistent with a primary cardiac etiology.How to cite this article: Weedn V, Steinberg A, Speth P. Prone restraint cardiac arrest in in-custody and arrest-related deaths.
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