UCI Medical Center
Base Hospital
Medical Director’s Newsletter
Objectives
· Identify a high risk EMS response with the potential for occult trauma or evolving medical complications.
· Identify historical elements contributing to death in custody.
· Identify specific medical complications of drug or alcohol abuse, violence, psychiatric illness and physical restraint.
· Discuss the elements and interpretation of the mental status exam.
· Discuss complications of sympathomimetic drug use.
· Discuss potential complications of physical restraint.
· Discuss medical consequences of electronic weaponry.
· Define and discuss the neuroleptic malignant syndrome.
Law enforcement,
EMS and the fire service interface on many levels.
One of the most potentially problematic is management of the intoxicated
or uncooperative custody patient. Law
enforcement has objectives and responsibilities, as does the fire service.
Sometimes these responsibilities appear to be in conflict.
Sometimes the patient is sufficiently unpleasant to entice us to play
down the medical implications of the call.
No matter what the cause, when a bad outcome occurs it’s a bad
situation for all involved. I’ve
reviewed some topics in the medical literature relating to custody patients to
give us some guidance in assessment of the patient, the overall situation, and
in identification of potentially serious medical problems.
This discussion will cover a number of quite varied topics.
However I’m sure you will recognize most of them from experience.
We’ll try to tie these topics together in a way that yields some useful
means of critically thinking about uncooperative or intoxicated patients. If they won’t or can’t talk to us, we have to rely on
other ways to assess the situation and make the right call. One place to start is to outline the elements of any call
that place us at risk for missing subtle but important observations.
Here is what I’ve come up with. I’m
sure you all could add a few of your own.
Late night or early morning calls (wake-up calls)
Alcohol
or drug intoxication
Communication
barriers (language, culture)
Elder
persons
Alcoholism
and chronic drug abuse
Violence
of unclear mechanism
Agitation
or agitated delirium
Unpleasant
or uncooperative patients
Police
custody
Head
and facial trauma
Psychiatric
history
Undirected
violence
Let’s take a look at a few of these before reviewing the literature. First, let’s distinguish alcohol or drug intoxication from alcoholism and chronic drug abuse. Even without acute intoxication the alcoholic or drug abuser can have significant medical problems. Chronic liver diseases like cirrhosis, hepatitis B or hepatitis C can occur in both types of patients. Intravenous drug users can have immunodeficiency from HIV or AIDS and have a wide variety of infectious diseases. Alcoholics in particular can have sufficient liver disease to impair synthesis of blood clotting factors. This coagulopathy can allow significant bleeding with otherwise minor trauma, especially head trauma. Withdrawal or abstinence syndromes can occur in both types of patient, but are more severe in alcohol, barbiturate and benzodiazepine (e.g. Valium) abuse. If the patient is anywhere from 1-3 days past their last drink and have tremors, tachycardia, anxiety or sweating this may progress to seizures. The patient may have had blackouts during periods of intoxication and now cannot give a reliable history or mechanism of injury. The more unanswered questions there are, the greater the risk involved with the call.
A confusing history can develop in the elderly
for several reasons; Alzheimer’s disease or other organic brain syndromes,
chronic medical problems, medication interactions, dehydration from inability
for self-care, fever from infections, falls and trauma.
The elder trauma victim is at greater risk of serious injury than their
younger counterparts experiencing a similar mechanism of injury.
Communication barriers are
common in our communities. Unless a
crew member is fluent in the language spoken by the patient we are left to rely
on family or friends of the patient. Although
this may be the only practical option there is a difference between translation
and interpretation. When a person
involved with the emergency is the interpreter we may hear what that person
wants us to hear rather than what the patient really has to say. A neutral interpreter is more likely to give an unbiased
translation.
So, if we transport them what will the hospital do differently?
After blood and urine tests to look for dehydration, acidosis and other
metabolic and toxicological problems and possibly a brain CT to look for
bleeding or other structural problems, observation and serial examination will
be the key thing. They may be
admitted outright based on test results or for convenience, but observation in
the emergency department will reduce the risk of undetected injury or illness
when the patient is discharged or returned to custody.
What all of our discussion will really come down to is determining the mental
status of the patient and assessing the circumstantial risk of serious injury or illness.
Assessing circumstantial risk is dependent on having a knowledge base of
the possible things that can go wrong. That’s
what the literature review will try to accomplish.
First, let’s clarify a few terms that come up whenever mental status is
discussed: delirium, dementia, delusions, hallucinations and psychosis.
Delirium refers to abnormal
behavior with disorientation.
They will not be oriented to time, person, place and/or situation.
In other words a person with delirium will not be CAOx4.
One or more of these elements of orientation will be abnormal.
This also means their Glasgow Coma Scale (GCS) will be between 9 and 14
(15 being normal, 8 and below being coma), confused but still conscious with
stimulation. Agitated delirium is
confused mental state with aggressive or agitated behavior, still conscious but
agitated and confused. Here’s the key point: delirium is always due to toxic, metabolic or structural brain problems and is a
medical emergency. In contrast, dementia
is abnormal behavior with orientation to time, person, place and situation
retained. Organic brain syndromes
like Alzheimer’s disease and strokes can lead to dementia.
The person is still alert and oriented but may get lost when they leave
home, not recognize family or friends or be searching for a cat that ran away 10
years ago. To assess a person with
dementia you need some reference point, like a relative or friend who knows the
person’s typical behavior. Dementia
can be stable or can deteriorate over time.
If there is no reference point for their baseline mental status this
becomes a high-risk call. Abrupt
changes may be due to toxic, metabolic or new structural brain problems.
A high stress event, like getting lost and not recalling how to get home,
may also cause a transient change in the degree of dementia and reduction in
level of functioning.
Delusions are false beliefs. Once
again the person is alert and oriented, but having thoughts without foundation
in reality. They may think, for
example, that they are constantly being watched and followed by Martians.
Now if they say they see or hear those Martians (and assuming you
don’t) these are hallucinations.
There is an important but subtle distinction in the interpretation of
visual and auditory hallucinations. Hearing
voices or commands, auditory hallucinations, can be a symptom of psychiatric
disease like schizophrenia. However
visual hallucinations are more likely associated with a medical condition than
with a psychiatric one. The best
example is the visual hallucinations of alcohol withdrawal. As we said before, this can lead to seizures and is a medical
problem requiring treatment.
Psychosis also has to be
distinguished from delirium, or organic mental disorders.
Psychosis is thought disorder and impaired reality testing with delusions
or hallucinations. However the
person remains conscious and oriented. Psychosis
can occasionally have a structural, toxic or metabolic cause.
Non-psychiatric causes of psychosis should be suspected when orientation
is not normal, when vital signs are significantly abnormal especially
tachycardia associated with pallor and diaphoresis (autonomic instability), when
it first occurs in a person older than 40 years without prior known psychiatric
illness, when it is associated with visual hallucinations and when it has
fluctuating symptoms.
The formal mental status exam involves elements not particularly
practical in the field. We do
assess orientation to time, person, place and situation.
These elements are more sensitive than those of the Glasgow Coma Scale,
which assess eye opening, motor response and verbal response to stimulus.
Orientation to person seems to be the last thing to go as mental status
declines toward coma. Other components of the mental status exam include counting
backward by sevens (difficult on a good day), digit recall (memorizing numbers
forward and backward), object name recall, interpretation of sentences or
statements (like proverbs) and drawing figures. To assess these finer elements of mental status you need a
calmer, more controlled environment than can be expected in the field.
This also takes time. The
four elements of orientation can be determined simply by addressing the patient
and taking a history. In the spinal
immobilization curriculum we spent a fair amount of time discussing when a
patient’s history and physical exam is reliable.
That same strategy applies here too.
The big problem comes when a patient refuses to cooperate with the
history or when they are oriented by these four criteria but intoxicated with
impaired judgment. The issue of
patient rights collides head-on with patient safety.
Legal and philosophical arguments never seem to come to any resolution.
Science isn’t a whole lot better, but if you can establish some degree
of patient rapport or enable cooperation through law enforcement then there are
a number of situational risk factors we can discuss to help determine what to do
next. First let’s survey some of
these risk factors, then we’ll discuss them.
Law enforcement, forensic scientists and plaintiff’s lawyers have sought causes for death in custody for a long time. Yet, specific cause-effect relationships have been elusive. Death in custody seems to be multi-factorial. There are however a variety of things associated with but not individually causing death in custody.
Cocaine, amphetamine, PCP and LSD use
Agitated
delirium
Positional
restraint
Psychiatric
history
Taser
use
Capsaicin
or Mace use
Underlying
heart disease
Body
packing
Head
injury
Sickle
Cell Disease
Although not comprehensive, the forensic medicine literature mentions two chronic diseases associated with cases of death in custody, valvular heart disease and sickle cell disease. Certainly you can imagine that significant underlying diseases like heart disease or hypertension can get markedly worse during violent behavior. Strokes, MI’s, dysrhythmias and bronchospasm are possible in persons who are struggling and who are predisposed to these conditions. Probably most forensic medicine studies had a patient population of younger individuals, and probably most were males. Since chronic disease is less likely in a younger population, MI’s and strokes will also be less likely. In older custody patients, the probability goes up. However, valvular heart disease can exist in younger people and, if normally asymptomatic, may be undiagnosed. Then when this individual uses alcohol or stimulant drugs and exhibits violent behavior, the defective heart valve will be stressed beyond everyday requirements and cardiac pumping efficiency can decline. The exact problem depends on which valve is affected, but valve failure can lead to sudden reduction in cardiac output and hypotension. Mitral valve prolapse is the most likely undiagnosed heart valve problem in young adults.
Sickle cell disease is a
hereditary disease of the hemoglobin. It
is encountered in African-American and Latino populations.
The hemoglobin has an abnormal structure so that when it becomes
unsaturated with oxygen it structurally deforms.
This molecular deformation leads to red blood cell deformation, taking on
a sickle shape. The abnormal red blood cell shape prevents it from moving
smoothly through capillaries leading to reduced blood flow and ischemia to
organs like the brain, heart, lungs and kidneys.
An adult with this disease will most likely know it since it manifests in
childhood. So if any history is
available it should not be a surprise. The
sickling of the red blood cells will occur anytime there is excessive oxygen
demand, so it is easy to see why this might become a problem in the intoxicated,
struggling person. The immediate
treatment is high flow oxygen, IV saline infusion (1-2 liters initially) and
morphine for pain control. The ischemia of tissue is what causes the pain crisis.
If the sickle cell crisis is bad enough it can lead to myocardial
infarction, pulmonary infarction, renal or bowel infarction and stroke.
There is a list of problems that seem to keep coming up whenever the subjects of violence, restraint, intoxication and psychiatric illness are discussed with or without law enforcement custody. These are medical conditions that may be anticipated and sought out.
Hyperthermia
Rhabdomyolysis
Seizures
Tachydysrhythmias
Aspiration
Hypoxia
Sudden
death
Occult
trauma
Sympathomimetic drugs are drugs that stimulate the sympathetic nervous system. Common findings are dilated pupils (mydriasis), tachycardia (sometimes with dysrhythmias), vasoconstriction (pallor) and hypertension, as well as agitation or agitated delirium, intense paranoia, tremors and sweating (diaphoresis). Sometimes there will be involuntary movement of the eyes rapidly side to side or up and down (nystagmus). These are very common drugs of abuse. They may be over-the-counter medications like pseudoephedrine or phenylpropanolamine found in decongestants or cocaine, amphetamine and PCP (phenyl cyclohexyl piperidine, phencyclidine). PCP used to be the predominant stimulant used in urban cultures years ago and is the one that causes the most significant nystagmus. It’s still around. Stories of extraordinary human strength associated with PCP use reflect its initial purpose as an intravenous anesthetic. Strength is actually not affected but pain perception is. With reduced pain perception violence has fewer limits. Cocaine and amphetamines are a lot more common in our local communities. Sometimes designer amphetamines surface during underground parties and raves like MDA (methylenedioxyamphetamine) and MDMA (methylenedioxymethamphetamine, ecstasy). The power of sympathomimetic drugs is considerable. The degree of vasoconstriction of the coronary arteries or of hypertension and the degree of tachycardia can lead directly to myocardial infarction, aortic dissection and stroke. In fact it is safe to say that cocaine use in particular can be included in the usual risk factors for heart attack like age, hypertension, high cholesterol, smoking, diabetes and family history. So the message here is that anyone with chest pain symptoms of myocardial ischemia after cocaine use should be treated like any other probable angina or MI using oxygen, nitroglycerin, aspirin and morphine. But other things beside chest pain, MI and stroke are more common.
The sympathetic effects of cocaine result from both central effects on the brain as well as peripheral effects on nerve transmission. In the sympathetic nerves, cocaine blocks one pathway for removal of norepinephrine, one of the chemicals responsible for nerve transmission. Since norepinephrine is removed at a slower rate, its effects on blood pressure and heart rate persist longer. In the brain cocaine stimulates the area which regulates blood vessel tone and heart rate. Initially the effects of cocaine toxicity will be tachycardia and hypertension. Later, in high doses, cocaine has a direct toxic effect on the contractile force of cardiac muscle and can cause hypotension by reducing cardiac pumping capacity. The degree of hypertension is usually moderate but can be severe. The degree of tachycardia can be quite variable. There are a few important implications for us here.
Since both the tachycardia and hypertension are mediated by central (brain) as well as peripheral (nerve) effects, sedation can be a very effective means of controlling these problems. Sedation with intravenous diazepam (Valium)or midazolam (Versed) to control dangerous agitation will also reduce the brain-mediated sympathetic effects and lower blood pressure and heart rate. This is the best way to approach this problem. Other drugs we normally use may not work. If the person has typical angina chest pain then nitroglycerin is appropriate to use along with sedation. But nitro by itself just to treat hypertension will only have temporary effects and does not address the underlying reason for the high blood pressure. Likewise, adenosine for cocaine-induced narrow complex tachycardia will not work because the problem is overdrive stimulation of the heart and not a reentrant rhythm involving the atrioventricular node.
Here’s another interesting problem for us. Cocaine toxicity can cause ventricular dysrhythmias like PVC’s and unsustained or sustained VTach. Normally we us lidocaine for these rhythms. But, as the names suggest, cocaine and lidocaine have similar chemical structures and when used together, especially in serious cocaine toxicity, can cause additive effects on the myocardium to reduce pumping capacity and cause hypotension. The drug that has been advocated for serious cocaine toxicity with dangerous ventricular dysrhythmias is sodium bicarbonate. Just like in tricyclic antidepressant overdoses, bicarb (actually the sodium in the bicarb) stabilizes conduction across cell membranes in the heart muscle and can treat wide complex tachycardia from cocaine toxicity.
There are other problems besides these cardiovascular problems. Brain stimulation by cocaine can lead to seizures that may be hard to control. Intravenous diazepam (Valium) or midazolam (Versed) and airway control are the solutions. Severe agitation or seizures can lead to marked elevation in body temperature. The degree of hyperthermia can be above that expected for fever. Temperatures of 105, 106 or 107 and higher are possible. Temperatures this high, if untreated, can lead to prolonged seizures and irreversible brain injury. Aggressive cooling measures may be necessary in seizures unresponsive to diazepam or midazolam. The single most effective way to cool the body is to wet the skin with water and allow it to evaporate. A water mist with fans is ideal but impractical in the field, so wetting the person down with wet towels, removing the towels and manually fanning will work. Cold packs to the carotid, axillary (armpit) and groin areas are marginally effective. Evaporative cooling is much more effective. All of this agitation and seizing can lead to another problem too; rhabdomyolysis. Just like in crush syndrome, rhabdomyolysis is the breakdown of skeletal muscle cells releasing their contents into the blood. Cocaine toxicity can also directly cause muscle cell breakdown leading to rhabdomyolysis. The products of muscle cell breakdown that are the most dangerous are potassium, metabolic acids and myoglobin (the oxygen-carrying pigment in muscle). There are others but this is what will get you in trouble early. The only practical thing we can detect in the field is potassium by the presence of tall peaked T-waves on the ECG. Once again sodium bicarbonate can be given to shift the potassium back into cells and reduce the risk of ventricular dysrhythmias. These extremes of symptoms and signs can occur in recreational cocaine use. They are more likely to occur in body packers, who transport drugs wrapped in materials like condoms placed in the rectum, vagina or swallowed in large numbers. It can also occur when people try to conceal their stash by swallowing cocaine.
Positional
Retraint
A controversial area, physical restraint is sometimes necessary for scene and rescuer safety as well as protection of the individual from further violence. Some time ago the chokehold was used as a method of inducing brief loss of consciousness to obtain control of an individual. Those of you who have been around a while will probably have encountered it. When done correctly arm pressure is applied across the neck to transiently obstruct carotid blood flow to the brain causing unconsciousness. Upon release of arm pressure, perfusion is restored and consciousness regained. When done incorrectly or in a struggling person the trachea can collapse causing hypoxia and, if held long enough, hypoxic brain injury. This technique of control has been abandoned by law enforcement. However the hog-tie or hobble restraint is still occasionally used in the individual most difficult to control. The hog-tie restraint is hands cuffed behind the back, prone position and ankles cuffed and tied to the wrists.
The hog-tie has long been debated as a significant contributor to death in custody. But exact causes of death have been elusive. Intuitively it seems that lying on one’s abdomen with the arms and legs tied behind the back would compromise respiration by placing the body’s weight on the chest and diaphragm. It has been assumed that death is by asphyxia. Interestingly, throughout the forensic medicine literature deaths from physical restraint consistently seem to occur within the first ten minutes or so of restraint application. This would be long enough for a hypoxic death to occur only if there was marked respiratory or airway compromise. People with mild to moderate respiratory compromise can usually compensate longer than ten minutes. Recently a study was done looking at the mechanics of respiration in the hog-tie position. Normal volunteers were restrained and pulmonary function tests and arterial blood gases were measured. As you would expect there was a restrictive effect on pulmonary function by hog-tying but not enough to cause hypoxia or hypercapnia (accumulation of carbon dioxide in the blood). Effects on pulmonary function and blood gases were not sufficient to cause asphyxia. Now these were normal volunteers. There was no prior violence, drug use, trauma, intoxication, hyperthermia or psychiatric illness. So once again death in custody seem to be multifactorial.
These observations have several implications for us in the fire service and EMS. The first question to ask is: Why was restraint necessary? Remember that agitated delirium is due to medical causes and that cause has to be sought out. Another way to look at this is the nature of the violence. Undirected violence, lashing out at anything, may be due to psychiatric illness, uncontrollable rage or delirium. Directed violence focused on a specific situation should somewhat resolve once the individual is separated from the inciting stimulus. Someone who continues to rage despite isolation requires further evaluation. Another consideration is that an individual cannot be adequately evaluated while prone and hog-tied. If the person is still demonstrating violent behavior and the safety of rescuers is uncertain, then the best way to get control of this situation and safely allow adequate assessment of the individual is intravenous sedation. This of course requires a base hospital order and, as they say in advertising, results my vary. But a clear understanding of the degree of violent behavior and the need for further assessment should lead to an order for intravenous diazepam (Valium)or midazolam (Versed). Now, this is not without risk either since you may have to try to hit a vein on a moving target. With some help this can be done. In the worst case intramuscular midazolam can be tried realizing it will take a little longer to be effective. This option is being added to the treatment guidelines on December 15, 1999. Once chemical restraint has been accomplished the person can be placed supine in four-point restraint and further assessment begun.
Medical emergencies while in physical restraint are a complex interplay of catecholamines from rage and violence, underlying medical or psychiatric conditions, drug or alcohol intoxication, trauma, hyperthermia and rhabdomyolysis. There may be sudden changes in mental status, seizures, lethal dysrhythmias or undetected serious trauma that may lead to sudden death.
Electronic
Weaponry
This category includes a new group of devices developed in the ongoing search for non-lethal weapons to gain control of violent individuals. Electronic weapons have the common goal of producing a current and voltage that are not lethal but that cause tetanic contraction of skeletal muscle. As long as the current is applied the skeletal muscle contracts involuntarily and the person is incapacitated. Once the current is turned off muscle function quickly returns. The two devices are the Stun Gun and the Taser. The stun gun is not a stand-off weapon. It requires contact with the aggressor and as such is not as good a defensive weapon as the Taser. The stun gun is more likely to be encountered in non-law enforcement confrontations. It generates a train of damped sinusoidal waves with a voltage of about 100,000 volts at a peak current of 3-8 amps at a rate of 5-20 Hertz (cycles per second). Although not truly alternating current (actually damped pulses) this is approximately equivalent to a 120VAC, 60Hz shock of 10mA. This is not enough to consistently cause tetany (sustained involuntary skeletal muscle contraction) in every person shocked. It can cause skin burns and has caused periods of asystole in animal models while the current is applied. Its safety and effectiveness are questionable and it is not widely used by law enforcement but may be encountered by people seeking personal protection or by security forces.
The Taser, however, is a law enforcement weapon. The Taser (Thomas A. Swift Electric Rifle) is a device that shoots 2-4 darts from a shotgun charge up to 15 feet. The darts are connected to the weapon by wires through which 50,000 volts at 3 milliamperes at 10-15 cycles/second are delivered (about 0.8 Joules of energy). When the trigger is pulled and the current applied tetanic skeletal muscle contraction occurs. It stops when the trigger is released. The barbs on the darts do not have to penetrate the skin to be effective. They are reported to be effective through up to 2 inches of clothing. Current is applied intermittently to achieve immobilization. Continuous application of current causes tetany of the intercostal muscles and leads to respiratory arrest. The debate over the contribution of the Taser to death in custody continues. Most reports suggest that the Taser alone is not a cause of death. Rather it seems it is the combination of tetany with extreme violence or struggling before immobilization, rhabdomyolysis, cocaine, amphetamine or PCP use, hypoxia, hyperthermia and/or underlying undiagnosed heart disease that lead to medical emergencies or death in custody. Dart removal, like fishhook removal, might be a medical problem. Little is known about the interaction of the stun gun or Taser with medical devices like pacemakers or AICD's (automatic implantable cardioverter-defibrillators). Based on electrical charge transfer estimations the literature suggests the stun gun has the higher risk of interacting with an indwelling cardiac pacemaker leading to dysrhythmias.
Managing emergencies involving electronic weaponry is the same as managing the suspected underlying problems of trauma, dysrhythmias, rhabdomyolysis, hyperthermia and seizures.
Neuroleptic
Malignant Syndrome
The neuroleptic malignant syndrome (NMS) is not common but is an emergency when you find it. It is a syndrome with some similarity to rhabdomyolysis that occurs in people taking antipsychotic (or neuroleptic) drugs. The syndrome is characterized by autonomic instability like variable tachycardia and hypertension, sweating (diaphoresis), pallor (from vasoconstriction), hyperthermia and occasionally pulmonary edema. There is also muscle rigidity which may be noticed in the extremities but is most dangerous in the chest because is limits respiration leading to hypoxia and hypercapnia (increasing blood carbon dioxide content). Muscle rigidity also contributes to the hyperthermia. This is distinguishable from a seizure because there is no shaking of the muscles, just rigidity, and there is no loss of consciousness (unless the syndrome has progressed too far). The person’s mental status will be abnormal, best described as delirium (disoriented to time, person, place and/or situation). As things progress there can be metabolic acidosis, hyperkalemia (high blood potassium), hypoxia, dehydration, marked hyperthermia, dysrhythmias, renal failure, coma and death.
NMS in the early stages may look somewhat like the much more common dystonic or extrapyramidal side effect (EPS) reaction to antipsychotic and various other drugs. Dystonic or EPS reactions are characterized by mild muscle rigidity causing difficulty with speech (dysarthria), difficulty swallowing (dysphagia) and neck stiffness (torticollis). Other small muscle groups may also be effected but most importantly the person remains fully conscious and oriented.
Some things seem to predispose a person taking antipsychotic medication to NMS. They seem to most often be young males with chronic psychiatric disorders, be dehydrated or malnourished and have been agitated, violent or restrained. The syndrome can occur at any time during the course of taking antipsychotic medication but recent increases in dose may contribute to the onset of NMS.
Management of NMS is primarily aimed at temperature and airway control. Aggressive cooling measures as described earlier, IV fluid resuscitation, oxygenation and ventilation are the key elements. Seizures are not a part of NMS but if other problems contribute to seizure activity then seizure control with diazepam or midazolam is essential since this will worsen hyperthermia and respiratory compromise. The only specific therapy that has had some success is the skeletal muscle relaxant dantrolene which is helpful when muscle rigidity is a major presenting symptom.
Mace and Capsaicin
Oleoresin
Riot control agents like CS, CN (Mace), CR and capsaicin (pepper spray) have also been associated with but not direct causes of medical emergencies and death in custody. Mace, chloroacetophenone, is a lacrimator agent. It causes eye irritation and tearing, skin and mucous membrane irritation and pain. Capsaicin oleoresin is derived from chili peppers and causes pain, redness and irritation of skin, eyes and mucous membranes. Neither agent causes tissue destruction. The eyelid spasm (blepharospasm), tearing (lacrimation), runny nose (rhinorrhea) and coughing pass relatively quickly. The painful contact dermatitis can last for several hours. There have been a few reports of people with asthma and COPD experiencing bronchospasm after exposure to these agents. Albuterol aerosols and oxygen will work to treat this.
Decontamination of skin and eyes with cold water or saline is the first intervention. Mild soap and water on skin may help with skin discomfort but usually not much. There is an interesting solution to the skin pain from capsaicin. Since pepper spray is thought to work through a specific receptor in pain fibers that is sensitive to ions, magnesium and aluminum-containing liquid antacids like Maalox have been quite effective in controlling the skin pain.
Summary
Probably the single most important skill we have in EMS is that of patient assessment. Airway management is a close second. Patient assessment is a combination of communication skills and knowledge base. This discussion focused on a wide variety of medical issues influencing our decision-making about custody patients. As with so much in EMS and medicine actual interventions are a lot less common than rendering a judgment on the stability of the patient at the moment. By the very nature of our work the one thing we do not have on our side is time. Many of these stability questions can be answered by observation over time. Whenever uncertainty exists over the stability of a patient the solution frequently is transport to the emergency department where they can be observed for a reasonable amount of time then discharged or returned to custody.
We’ve identified some of the elements of high risk responses as well as some common medical problems encountered in persons in law enforcement custody. We’ve also reviewed the mental status exam and defined which elements favor a complicating medical problem. The forensic medicine literature has identified several conditions which contribute, but not directly cause, death in custody. There are also several medical conditions which may follow physical violence, drug or alcohol use and physical restraint. Some conditions may require field interventions like hyperthermia, hypoxia, seizures, hyperkalemia, marked agitation and tachydysrhythmias. Others may not be correctable in the field but may put the person at added risk for complications over time.
References
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