Applied Force During Prone Restraint

Kroll, Mark W.; Brave, Michael A.; Kleist, Scott R; Ritter, Mollie B.; Ross, Darrell L.; Karch, Steven B.

doi:10.1097/paf.0000000000000457

Cited by 10 publications

(7 citation statements)

References 36 publications

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“…We discuss here a subset of police arrest-related deaths with no obvious cause of death and involving prone restraint. It has been reported that the rate of arrest-related deaths is approximately one death per every 1000 arrests [28]. Prone restraint related deaths have been observed to occur two to three times per year in Ontario, England and Wales, Los Angeles and the Netherlands [49][50][51][52], each with populations exceeding 10 million.…”

Section: Discussionmentioning

confidence: 99%

“…[17,[25][26][27]. Kroll has pointed out that the entire weight of an officer is not necessarily applied to the back of the chest [28] and that there is a difference between static and dynamic compressional forces; he developed a biomechanical model suggesting that an adult male can tolerate up to 572 lb. of static pressure for a short period before developing rib fractures and a flail chest [29].…”

Section: Backg Rou N Dmentioning

confidence: 99%

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Prone restraint cardiac arrest in in‐custody and arrest‐related deaths

Weedn

Steinberg²,

Speth³

2022

Journal of Forensic Sciences

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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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Section: Discussionmentioning

confidence: 99%

Section: Backg Rou N Dmentioning

confidence: 99%

Prone restraint cardiac arrest in in‐custody and arrest‐related deaths

Weedn

Steinberg²,

Speth³

2022

Journal of Forensic Sciences

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“…36 This initial observation was followed by an evaluation of WF applied to prone mannequins by an LEO with three different single-knee techniques and one double-knee technique. 37 This group reported that the application of a single knee creates an average WF of 23.7–32.9 kg, independent of the weight of the LEO. The double-knee technique created a WF that was 23.3 kg plus 24% of the weight of the LEO.…”

Section: Ventilationmentioning

confidence: 96%

Prone restraint cardiac arrest: A comprehensive review of the scientific literature and an explanation of the physiology

Steinberg

2021

Med Sci Law

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Deaths occurring among agitated or violent individuals subjected to physical restraint have been attributed to positional asphyxia. Restraint in the prone position has been shown to alter respiratory and cardiac physiology, although this is thought not to be to the degree that would cause asphyxia in a healthy, adult individual. This comprehensive review identifies and summarizes the current scientific literature on prone position and restraint, including experiments that assess physiology on individuals restrained in a prone position. Some of these experimental approaches have attempted to replicate situations in which prone restraint would be used. Overall, most findings revealed that individuals subjected to physical prone restraint experienced a decrease in ventilation and/or cardiac output (CO) in prone restraint. Metabolic acidosis is noted with increased physical activity, in restraint-associated cardiac arrest and simulated encounters. A decrease in ventilation and CO can significantly worsen acidosis and hemodynamics. Given these findings, deaths associated with prone physical restraint are not the direct result of asphyxia but are due to cardiac arrest secondary to metabolic acidosis compounded by inadequate ventilation and reduced CO. As such, the cause of death in these circumstances would be more aptly referred to as “prone restraint cardiac arrest” as opposed to “restraint asphyxia” or “positional asphyxia.”

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“…Additionally, Kroll, Brave, Kliest, Ritter, Ross, & Karch measured the weight force of placing one or two knees on a Simulaids Rescue Randy training mannequin placed in the prone position, which replicated the prone restraint process. 31 Respondents placed either one knee on the shoulder blade area of the mannequin or placed one knee on the shoulder blade area and the other knee on the lower back. It was determined that the two-knee method applied slightly more weight than the one knee method.…”

Section: Scientific Research and Prone Restraintmentioning

confidence: 99%

Untitled

2019

FRCIJ

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During a period of confinement in a detention facility, it is not uncommon for detention officers to confront a violent and combative detainee. While rare, a detainee may unexpectedly die during or after the control and restraint process and from being restrained in the prone position. Following a custodial death, a lawsuit will most likely be filed claiming that the responding officers used excessive force and that it contributed to the positional asphyxia death of the detainee. Further, the lawsuit may assert that the administrator failed to train and supervise the officers and failed to implement constitutional policies and procedures. The medical issues associated with prone restraint and the excessive force litigation theories have emerged as a high profile subject in detention liability. This assessment examines the current status of the scientific research performed on prone restraint and provides an assessment of the outcomes and trends in the lower court's decisions regarding a custodial death after the use of the prone restraint position. Recommendations for detention administrators are also discussed.

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Applied Force During Prone Restraint

Cited by 10 publications

References 36 publications

Prone restraint cardiac arrest in in‐custody and arrest‐related deaths

Prone restraint cardiac arrest in in‐custody and arrest‐related deaths

Prone restraint cardiac arrest: A comprehensive review of the scientific literature and an explanation of the physiology

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