ACUTE MEDICAL EMERGENCIES
Prison medical emergencies should be managed according to standard treatment guidelines and protocols. If the prisoner requires admission after treatment, the prison authorities must make the necessary security arrangements at the facility of presentation or the referral location (Table 301-2).3
TABLE 301-2Common Clinical Conditions Seen in the ED3 ||Download (.pdf) TABLE 301-2 Common Clinical Conditions Seen in the ED3
Acute coronary syndrome
Exacerbation of chronic obstructive pulmonary disease
Alcohol liver disease
Deep venous thrombosis
Prison is a violent place. Violence among inmates is common. Minor injuries may be treated at the prison medical center. In one study, 18% of prison-related visits to the ED were due to violence.3 Penetrating stab wounds, head injuries, fractures, soft tissue injuries, and wounds may result from violence. In severe cases, trauma resuscitation, emergency surgery, and admission may be required.
Injuries Associated with Police Restraint
Persons in police custody often attempt to resist arrest; the police then may deploy tactics and equipment to aide in restraint and control. As a result, a variety of injuries may occur, including skin wounds, minor head injury, and joint dislocation.13 Injuries secondary to a handcuff application include neuropathy (in particular, the superficial branch of the radial nerve), and fractures of the ulna styloid. The use of a baton commonly results in soft tissue bruising; however, lacerations and fractures may occur.
Conducted electrical weapons (TASER®) have two methods of application: "drive-stun," whereby direct contact to the skin by the device is used, and "shooting," whereby two small darts attached to wires are fired into the skin to deliver the electric current. Complications associated with the use of such devices relate primarily to dart penetration (e.g., the trachea,14 brain,15 eye,16 and chest wall), resulting in pneumothorax.17 The proarrhythmogenicity of a conducted energy weapon is subject to debate18,19; however, there has been a report of atrial fibrillation following its use.20 Clinical management of individuals subjected to such devices is aimed at treating any complications secondary to penetrating injury. Electrocardiograms are advised, and for patients with pacemakers or internal defibrillators, device interrogation is warranted. Finally, the predisposing condition necessitating the requirement for the use of a conducted energy weapon should be assessed and, if necessary, treated.
It is estimated that 70% to 80% of prison inmates have been involved in some form of drug abuse before detention, with one-fifth being injecting opiate abusers.3,21 Many inmates are on drug rehabilitation programs and maintained on regular doses of methadone or a similar opiate substitute. The main problem for emergency care is the provision of adequate analgesia. Due to the high level of opiate tolerance, standard doses of opiates (morphine, hydromorphone) may produce no analgesic effect. This can lead to high doses of opiate being given before producing an adequate analgesic effect.22 If a prisoner is placed on a controlled opiate detoxification program sustained by the use of naltrexone, a long-acting opiate receptor blocker, opiate analgesia will have no effect regardless of the dose given.23 An alternative form of analgesia will be required (e.g., nonsteroidal anti-inflammatory drugs, which may or may not be effective). Ketamine is another option for pain relief.
A person detained in custody may be suspected of concealing drugs in the rectum or vagina. Within the United Kingdom, unless the patient consents to the examination and removal of any such substances, any action is against the policy of the British Medical Association, even if the practitioner is protected legally by a warrant issued from the appropriate jurisdiction.24 Legal practice may differ between countries. If the patient's ability to make an informed decision regarding their health care is compromised, then removal of drugs from the body is warranted should signs of drug toxicity be evident.
Within the prison population, there is a high prevalence of psychiatric illness. The most common is a personality disorder, found in 65% of men and 42% of women.6 The main ED contact with psychiatric problems will be related to deliberate self-harm and personality disorders, manifesting as manipulative behavior, fictitious illness, and Munchausen-type behavior. Other presentations include deliberate insertion of foreign bodies or alleged ingestion of objects or substances.
EXCITED DELIRIUM SYNDROME
Excited delirium is a condition that has been formally recognized by the American College of Emergency Physicians as "a unique syndrome which may be identified by the presence of a distinctive group of clinical and behavioral characteristics that can be recognised in the pre-mortem state."25 Once the domain of the forensic literature, recognition of excited delirium in the premorbid state is increasing.
Attempts to apply strict diagnostic criteria are hampered by a lack of quality research. By the very nature of the presentation, patients are in extremis both mentally and physically. Table 301-325 reports the frequencies of the presenting signs and symptoms.
TABLE 301-3Features of Excited Delirium ||Download (.pdf) TABLE 301-3 Features of Excited Delirium
|Features ||Frequency, % (95% Confidence Interval) |
|Increased pain tolerance ||100% (83–100) |
|Tachypnea ||100% (83–100) |
|Sweating ||95% (75–100) |
|Agitation ||95% (75–100) |
|Tactile hyperthermia ||95% (75–100) |
|Police noncompliance ||90% (68–99) |
|Lack of tiring ||90% (68–90) |
|Unusual strength ||90% (68–90) |
|Inappropriately clothed ||70% (45–78) |
The pathophysiology underlying excited delirium has yet to be fully elucidated; a background of stimulant drug use (predominantly cocaine) or, rarely, psychiatric illness is a consistent feature. Individuals exhibit confusion and agitation. Attempts to reason with patients and transport to medical facilities are met with resistance and aggression, often necessitating physical restraint. It is then observed that the detainee has pronounced tactile hyperthermia, struggles violently, and suffers cardiac arrest, from which successful resuscitation is rare. Severe metabolic acidosis, bradycardia, asystole, and pulseless electrical activity are the predominant preterminal findings.26
Treatment of excited delirium syndrome is predominantly aimed at reducing agitation. This can prove problematic, with issues regarding the safety of medical and law enforcement personnel, administration of parental medications, and the relative urgency necessary to reduce mortality. Physical restraint should be for as short duration as possible to reduce agitation and muscle activity–driven heat production. Intravenous access may prove difficult, and the intramuscular route for sedation is a viable, although slower onset, alternative.
Pharmacologic sedation is recommended: benzodiazepines (first line), antipsychotics (should not be used if long QT syndrome is suspected), and the dissociative anesthetic ketamine.27 The choice of drug used will depend on user experience and route available; combination therapy allows reduced doses of each class of drug, minimizing the side effect profile.
As with any sedation, the ability to manage sudden loss of the patient's airway and facilities for resuscitation must be available. In some cases, rapid sequence induction of anesthesia may be necessary due to the large doses of sedation required and for definitive airway protection.
Supportive treatment is vital for patients with excited delirium, including cooled IV fluids, whole-body cooling (antipyretics are ineffective), and treatment of any electrolyte disturbance. Hypoglycemia, hyperkalemia, and rhabdomyolysis may be encountered. Metabolic acidosis is invariably present and may improve with fluid administration and cooling.
Hepatitis C prevalence in prisoners is higher than in the general population, with studies demonstrating a prevalence of 25% to 39%.6,28,29 Contrasting the range of values for hepatitis C prevalence within the community against the prevalence of hepatitis C in prisons, there is a theoretical risk of a several hundred–fold greater chance that a prisoner may be a hepatitis C carrier compared with a member of the general public. This raises issues regarding possible needlestick injuries or contamination with infected body fluids. All emergency personnel must be aware of the increased risk of contracting hepatitis C infection when dealing with prisoners and exert extreme vigilance in their clinical procedures.