Positional Asphyxia and Excited Delirium: Recommendations for Police, Prison and Security Operatives

Guest Article by Daz Norton from https://www.fendo.uk/

The purpose of this article is to draw attention to the conditions known as Positional Asphyxia and Excited Delirium.

To start, let us imagine a scene:

You hear a call over the radio where a member of the public has reported a naked man in the street who is screaming and smashing car windows with a baseball bat. You respond and make your way to the location along with other officers who have also responded.

Upon arrival, you see a large overweight man who is wielding a baseball bat and screaming “make them stop”.

There are officers yelling for him to put down the bat. The man occasionally lets out a scream but ignores the commands. One officer with a taser takes aim and yells “taser” before firing the device, which hits the man in the chest. The man then falls to the ground.

The officer approaches but when the taser stops firing the man immediately begins to flail his arms and strikes the officer. The officer threatens to use the taser again, but the man continues to violently resist. By now you have moved in with other officers to restrain the man and attempt to move him onto his stomach. You continue to restrain him and after 10 minutes struggle the man is finally subdued face down on the pavement with handcuffs behind his back.

Suddenly the man becomes quiet. You notice that the man has stopped breathing. You roll the man onto his back and check for a pulse to find there isn’t one. You decide to start CPR but no matter how many times you try there is no response from the man. You call for an Ambulance but when they arrive, they check his vitals but inform you that the man has died.


Excited delirium has provoked some controversy, with some critics even claiming the term was “invented” to defend the excessive use of force by police officers, Prison Officers and Security Personnel. In fact, excited delirium is nothing new. Descriptions of cases bearing this phenomenon date back 150 years with events that look much like what we call excited delirium today to what was then called Bell’s Mania.

Excited delirium is a widely accepted entity in forensic pathology and is cited by medical professionals to explain the sudden in-custody death of individuals who are combative and in a highly agitated state. Excited delirium is broadly defined as a state of agitation, excitability, paranoia, aggression, and apparent immunity to pain, often associated with stimulant use and certain psychiatric disorders. … Speculation about triggering factors include sudden and intense activation of the sympathetic nervous system, with hyperthermia, and/or acidosis, which could trigger life-threatening arrhythmias in susceptible individuals.

The exact pathophysiology of Excited delirium remains unidentified, although theories on contributing factors include dopamine transporter abnormalities, genetic susceptibility, excessive enzyme deficiency, an overdose or withdrawal state, or some other multifactorial trigger. There is no definitive, diagnostic test for Excited delirium, meaning Police, Prison and Security officers must use identification by clinical features.

In layman’s terms, this is when a person exhibits violent behaviour in a bizarre and manic way rather than just being simply violent.


Positional asphyxia, also known as postural asphyxia, is a form of asphyxia which occurs when one’s position prevents them from breathing adequately. Positional asphyxia also may be a result of the a technique known as “The prone restraint”, used by police, Prison Officers, military, Security or Healthcare staff. People can and do die from positional asphyxia accidentally, when the mouth and nose are blocked, or where the chest may be unable to fully expand due to the position they have been put in (i.e. asphyxiated). which interferes with their ability to breath, and they cannot escape from that position.

It has been discovered that people with Excited delirium are far more violent than drunken individuals.

Additional findings include:

With individuals displaying probable Excited delirium, 89% of the time there was a struggle between that person and the officer that went to the ground.

82% of individuals in a state of EDS displayed assaultive behaviour or presented a threat of grievous bodily harm or death. The more the EDS features displayed by a person, the greater chance of assaultive behaviour. This greater physical risk comes from the individuals lack of remorse, normal fear or understanding of surroundings and rational thoughts of safety. The usual tactics to detain an individual often does not work and the potential exists for the struggle to be elongated.

De-escalation tactics are not likely to be effective, as people with EDS are usually either not paying attention or are unable to follow commands. If the person does not present imminent danger to themselves or others, officers should wait until additional personnel arrive for a tactical approach to stabilise that individual. Additionally, pain compliance techniques are unlikely to be effective as people with EDS are often impervious to pain. Because prolonged struggle increases the chance of sudden death, officers should focus on the quickest possible restraint followed by sedation by medical personnel. When a person does not respond to stimuli, officers should concentrate on restraint without using large muscle groups, which minimises the build-up of lactic acid, decreasing the risk of potential cardiac arrest. Using repeated distraction strikes or a Taser device will likely not produce much impact or benefit. Clinically, the use of a Taser is not likely to subdue and should the individual experience sudden cardiac arrest during the struggle, the use of multiple energy cycles will likely come under scrutiny.

Officers should treat these conditions as a Medical Emergency. If a restrained person suddenly becomes quiet and suddenly stops resisting, their vital signs should be monitored carefully. If, on the way to hospital, or awaiting the arrival of medical personnel, Officers should prepare for the possible use of Cardiopulmonary Resuscitation (CPR).

Positional Asphyxia is likely to occur:

· When a person is prone causing their stomach to press up to their ribs.

· When a person is sitting (possibly in a vehicle) and their head drops between their knees compressing their chest and abdomen.

· When a person’s head falls forward, restricting their windpipe.

Positional Asphyxia can occur rapidly, and post-mortems have been known to fail in identifying any other anatomical or toxicological findings sufficient to explain the death.

The Risk Factors

The following are factors that have been shown to contribute to this phenomenon:

· Subject’s body position results in partial or complete airway constriction.

· Alcohol or drug intoxication (the major risk factor).

· Person’s inability to escape from a particular position.

· The person is prone.

· Obesity (particularly those with large stomachs/abdomens).

· Restraints.

· Stress.

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

· Pressure applied to the back of the neck, torso or abdomen of a person held in the prone position.

· Pressure applied restricting the shoulder girdle or accessory muscles of respiration while the person is lying down in any position.

· Persons in an excitable condition or exhibiting bizarre behaviour. PLEASE NOTE Officers should be mindful of the risks involved in using their bodyweight on the upper body of a subject during restraint. The prone position should be avoided if at all possible, or the period for which it is used minimised. 

Police officers should pay close attention when they recognise the following signs and symptoms, taking immediate action to remedy them, and apply emergency first aid:

· Body position restricted to prone, face down.

· Cyanosis (face has turned blue due to lack of oxygen).

· Gurgling, gasping sounds.

· A subject’s behaviour suddenly changes from ‘active’ to ‘passive’ i.e., from loud and violent to quiet and tranquil.

· Panic.

· Subject tells the Officer that they cannot breathe. (such as we saw in the case of George Floyd)

Transporting a Person 

When transporting a person:

· The condition of the subject should be checked prior to transportation.

· Where possible, the subject should be monitored during the journey.

· The subject should not be transported in a prone, face down position. In cases where transportation in a face down position is unavoidable, constant supervision of that person is of paramount importance.

· The condition of the person should be checked at the conclusion of the journey.

Procedure and Guidance – Excited Delirium

The known causes of Excited Delirium are:

· Psychiatric illness.

· Drugs, of which cocaine is the best-known cause.

· Alcohol.

· A combination of drugs, alcohol, and psychiatric illness.

Signs and Symptoms of Excited Delirium

A person may exhibit the following signs and symptoms:

· Bizarre and/or aggressive behaviour.

· Impaired thinking.

· Disorientation.

· Hallucinations.

· Acute onset of paranoia.

· Panic.

· Shouting.

· Violence towards others.

· Extraordinary physical strength. •

· Significantly diminished sense of pain.

· Sweating, fever, heat intolerance.

· Sudden tranquillity after frenzied activity.

· Apparent ineffectiveness of incapacitant sprays (e.g., CS or PAVA).

It should be noted that many of the signs indicating Excited Delirium are common to anyone behaving violently.

Why a Person in a State of Excited Delirium is of Particular Concern

Persons suffering from Excited Delirium can die suddenly. This may occur during, or shortly after a violent struggle, and either at hospital or in custody. Death can occur…. During a struggle, During restraint or after a struggle.

Death is most likely to occur in two ways:

1. The state of Excited Delirium causes the person to have a cardiac arrest.
2. The efforts to avoid being restrained make a person exhibiting Excited Delirium a greater risk from Positional Asphyxia.

Dealing with a Case of Excited Delirium

It is important to recognise the difference between Excited Delirium and a violent outburst. Once identified, there then lies the problem of how a person in an Excited Delirium state should be handled without endangering the public, the Officer/s, medical Personnel as well as the person in question.

Controlling a Person in a State of Excited Delirium 

This will always be very difficult. officers may have to place them face down on the ground in order to handcuff them safely. The risk of Positional Asphyxia affecting a person who is in a state of Excited Delirium is far greater than that for a normal violent person. They will continue to struggle beyond their point of exhaustion, and it will be very difficult to prevent this, regardless of whether or not they are handcuffed (hands to rear).

Once they are handcuffed, do not hold them face down. They should be moved onto their side or into a sitting, kneeling, or standing position as soon as it is safe to do so. They may continue to kick out. However, officers must get them off their stomach in some way or other as soon as they can.

officers should consider the impact of heat and humidity and try to cool the person. Once Control has been achieved.

If Officers believe or suspect that they are dealing with a case of Excited Delirium, the person should be examined at hospital as a priority, regardless of any subsequent signs of apparent recovery. Subjects may collapse very suddenly and attempts to resuscitate them usually fail. The person may continue to be extremely violent in spite of the use of CS Spray, handcuffs or batons. Such bizarre, exhaustive, and persistent violent resistance is a classic indication of a case of Excited Delirium. Officers must monitor subjects carefully, treating them as a medical emergency. The person should be examined at hospital, even if they suddenly calm down before the arrival of police at the scene. Certain Restraint Positions of Persons Exhibiting Excited Delirium Increase the Risk of Death. Restraining a subject in a prone, stomach down position is particularly hazardous. This is increased if the person’s hands are handcuffed behind their back or to their feet. It should be remembered that obesity, alcohol, and drugs increase the hazard still further by restricting diaphragm and lung function.

Reducing the Risk

The following actions may reduce the risk of death to a restrained person who is displaying signs of excited delirium:

· Get the person onto their side, into a kneeling or seated position as soon as possible.

· Never transport in prone position if at all possible.

· Pay close attention to the life signs of the person and monitor closely, especially if they should suddenly become very passive.

The following mnemonic ‘A MEDICAL CRISIS’ will help as an aide – memoire:

· Acute onset.

· Mental Health issues.

· Excited, extreme agitation, emotional changes.

· Delusional, disoriented, distracted.

· Insensitive to pain, invisible people.

· Call emergency medical support, back-up officers, and supervisor to scene.

· Aggression towards objects (e.g. glass, mirrors).

· Loud, incoherent speech, screaming. Confused, disoriented about self. Resists violently. I can’t breathe (may indicate respiratory issues). Strips off clothing, naked, sweating profusely. Intense paranoia. Superhuman strength, struggles.


It’s advisable for Officers to document the event in detail, including any action taken.

Records could include:  

· Describe the subject and their behaviour.

· How did their behaviour make you feel?

· Force used or attempted by Officers (describe in detail).

· Reactions of subject to force used (i.e. effective or ineffective?).

· How the person was restrained.

· The person’s resistance to being restrained.

· How the person was transported.

· How the person was monitored.

Hear more from Daz Norton in the interview above.