Table of Contents

 

About This Issue

Although less-lethal weapons and tactics used by law enforcement are intended to ensure the safety of all involved, these weapons can cause significant injuries and even death. As the prevalence of these weapons increases, emergency clinicians will continue to see more patients presenting to the emergency department (ED) with injuries caused by these weapons. Knowledge of these weapons and tactics can help direct the workup and management of patients with injuries from these methods and can protect clinicians from secondary exposure and injuries. This issue discusses injury patterns associated with common less-lethal weapons used by law enforcement and provides recommendations for evaluation and management of these injuries in the ED. You will learn:

The mechanism of incapacitation of conducted electrical weapons (CEWs), oleoresin capsaicin spray (pepper spray), tear gas, canine (K-9) bites, and kinetic impact projectiles

Specific injuries (including the most significant and most common injuries) associated with each of these weapons

When laboratory studies, electrocardiogram, prolonged ED observation periods, or inpatient cardiac monitoring is required for CEW patients

Techniques for removal of CEW darts

Strategies to prevent further injuries and contamination and ensure patient and staff safety while managing patients who were exposed to chemical irritants

Key aspects of the skin and ocular examinations of patients exposed to chemical irritants

Recommendations for eye irrigation for patients who have been exposed to chemical irritants, such as how long irrigation should continue and when a pH check is needed

When a monitoring period is required for patients who have been exposed to chemical irritants

Differences between a K-9 bite and a domestic dog bite, as well as how those differences result in different injuries

When advanced imaging is warranted for K-9 bite patients

Strategies to help prevent infection of K-9 bite wounds

To have a lower threshold for imaging patients struck by kinetic impact projectile weapons, since significant internal injuries can underlie seemingly superficial injuries

Which kinetic impact projectiles are associated with the highest risk for infection

Special considerations when managing patients who will be released into a carceral setting, including when observation/admission is warranted

1. About This Issue
2. Abstract
3. Case Presentations
4. Introduction
5. Critical Appraisal of the Literature
6. Differential Diagnosis
7. Prehospital Care
8. Trauma-Informed Care
9. Conducted Electrical Weapons
   1. Etiology and Pathophysiology
   2. Emergency Department Evaluation
   3. Diagnostic Evaluation
   4. Management
10. Chemical Irritants
    1. Oleoresin Capsaicin Spray
       1. Etiology and Pathophysiology
       2. Emergency Department Evaluation
       3. Diagnostic Evaluation
       4. Management
    2. Tear Gas
       1. Etiology and Pathophysiology
       2. Emergency Department Evaluation
       3. Diagnostic Evaluation
       4. Management
11. Law Enforcement K-9 Bites
    1. Etiology and Pathophysiology
    2. Emergency Department Evaluation
    3. Diagnostic Evaluation
    4. Management
12. Kinetic Impact Projectiles
    1. Etiology and Pathophysiology
       1. Rubber Bullets
       2. Beanbag Munition
       3. Stingball/Stinger Grenade
    2. Emergency Department Evaluation
    3. Diagnostic Evaluation
    4. Management
13. Special Circumstances
14. Controversies and Cutting Edge
    1. Antibiotic Prophylaxis for K-9 Bites
    2. Novel Less-Lethal Weapon Development
15. Disposition
16. Summary
17. Time- and Cost-Effective Strategies
18. Risk Management Pitfalls for Pediatric Patients With Less-Lethal Weapon Injuries
19. Case Conclusions
20. Clinical Pathway for Pediatric Patients With Less-Lethal Weapon Injuries
21. Tables and Figures
    1. Table 1. Injuries Associated With Conducted Electrical Weapons
    2. Table 2. Injuries Associated With Oleoresin Capsaicin
    3. Table 3. Injuries Associated With Tear Gas
    4. Table 4. Injuries Associated With K-9 Bites
    5. Table 5. Injuries Associated With Kinetic Impact Projectiles
    6. Figure 1. TASER Weapon
    7. Figure 2. Intraocular Penetration Injury by a TASER Dart
    8. Figure 3. Intracranial Penetration of Tear Gas Canister Seen on Computed Tomography
    9. Figure 4. Stingball Weapon
22. References

Abstract

Less-lethal weapons and tactics are being increasingly used by law enforcement to minimize the reliance on more-lethal force. While these methods are designated as “less-lethal,” they can cause morbidity and mortality when deployed. Knowledge of these weapons and tactics can help direct the workup and management of patients with injuries from these methods and can protect clinicians from secondary exposure and injuries. This issue reviews the most common less-lethal weapons and tactics used by law enforcement, describes their mechanism of action, and discusses associated common injury patterns. Recommendations are provided for the evaluation and management of these patients in the emergency department.

Case Presentations

A 10-year-old girl is brought to your ED with the chief complaint of eye burning and tearing...

• The girl was attending a peaceful march downtown when some protestors became violent and began shoving the attendees. Law enforcement responded and dispersed a “gas” into the crowd to clear the area. The girl and her mother remember seeing large cannon-like weapons and then being surrounded by thick smoke. The girl initially had some coughing that improved after they removed themselves from the crowd, but now she has persistent “burning” eye pain and constant eye watering.
• On examination, you note mild conjunctival injection bilaterally with persistent tearing. The girl’s pupils are round and reactive to light, and her extraocular movements are intact. You notice traces of powder on the child’s face. Her vital signs are within normal limits, her lungs are clear, and her heartbeat is regular.
• What was this patient most likely exposed to? How can you best decontaminate her? How can you protect your staff from secondary exposure? What additional findings should you be looking for on examination? What treatment is needed?

A 14-year-old girl is brought in by law enforcement for medical clearance for booking at a juvenile detention facility...

• The girl and her friends were arrested for stealing a car, and during the arrest, the girl was combative. In an attempt to subdue the girl, law enforcement officers deployed a beanbag gun. The patient was struck in the right leg and the right upper quadrant by beanbag projectiles. She complains of pain in the locations where she was struck. Otherwise, the history is limited.
• On examination, you note a contusion to the abdominal right upper quadrant, with surrounding erythema and tenderness. The girl’s breath sounds are equal bilaterally, and her heartbeat is regular. Her right anterior thigh has a small contusion with tenderness, but compartments are soft, and the patient is otherwise neurovascularly intact in that extremity. The girl’s vital signs are remarkable for mild tachycardia but are otherwise within normal limits.
• What types of injuries are associated with beanbag deployment? What internal injuries should be considered in this patient? What is the appropriate imaging for this patient?

A 17-year-old boy is brought in from a juvenile detention facility in law enforcement custody for evaluation of a TASER injury sustained during a riot in the facility...

• The boy complains of pain to his left mid-abdominal area as well as some pain in his low back and feeling “sore all over.” He presents without a shirt on and has cut wires protruding from his left mid-abdominal area and a TASER dart embedded in the skin with a small amount of dried blood surrounding the puncture site.
• On examination, he has some mild tenderness at the site of the lodged dart, but otherwise his abdomen is soft and nontender. On back examination, he has midline tenderness at L1 but is neurologically intact in the lower extremities, and there is no gross evidence of trauma to the back. His vital signs are otherwise unremarkable except for some mild tachycardia.
• How should you remove the dart? Is there any further electrical risk to the patient or staff? What laboratory studies or other tests should you order for this patient? What could be causing the patient’s back pain?

Clinical Pathway for Pediatric Patients With Less-Lethal Weapon Injuries

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Tables and Figures

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Key References

Following are the most informative references cited in this paper, as determined by the authors.

17. * Vilke G, Chan T, Bozeman WP, et al. Emergency department evaluation after conducted energy weapon use: review of the literature for the clinician. J Emerg Med. 2019;57(5):740-746. (Literature review) DOI: 10.1016/j.jemermed.2019.06.037

19. * Gardner AR, Hauda WE, Bozeman WP. Conducted electrical weapon (TASER) use against minors: a shocking analysis. Pediatr Emerg Care. 2012;28(9):873-877. (Retrospective review; 2026 patients) DOI: 10.1097/PEC.0b013e31826763d1

21. * Gapsis BC, Hoang A, Nazari K, et al. Ocular manifestations of TASER-induced trauma. Trauma Case Rep. 2017;12:4-7. (Case report) DOI: 10.1016/j.tcr.2017.10.001

35. * Olajos EJ, Salem H. Riot control agents: pharmacology, toxicology, biochemistry and chemistry. J Appl Toxicol. 2001;21(5):355-391. (Review article) DOI: 10.1002/jat.767

56. * Schep LJ, Slaughter RJ, McBride DI. Riot control agents: the tear gases CN, CS and OC—a medical review. J R Army Med Corps. 2015;161(2):94-99. (Review article) DOI: 10.1136/jramc-2013-000165

65. * Pineda GV, Hutson HR, Anglin D, et al. Managing law enforcement (K-9) dog bites in the emergency department. Acad Emerg Med. 1996;3(4):352-358. (Retrospective review; 4 patients) DOI: 10.1111/j.1553-2712.1996.tb03449.x

68. * Ifantides C, Deitz GA, Christopher KL, et al. Less-lethal weapons resulting in ophthalmic injuries: a review and recent example of eye trauma. Ophthalmol Ther. 2020;9(3):1-7. (Case report and review) DOI: 10.1007/s40123-020-00271-9

69. * Dhar SA, Dar TA, Wani SA, et al. Pattern of rubber bullet injuries in the lower limbs: a report from Kashmir. Chin J Traumatol. 2016;19(3):129-133. (Case series)  DOI: 10.1016/j.cjtee.2015.05.005

75. * Feier CC, Mallon W. Injury pattern of the stingball. J Emerg Med. 2010;38(4):444-448. (Case report) DOI: 10.1016/j.jemermed.2007.09.063

77. * Haar RJ, Iacopino V, Ranadive N, et al. Death, injury and disability from kinetic impact projectiles in crowd-control settings: a systematic review. BMJ Open. 2017;7(12):e018154. (Systematic review; 26 articles) DOI: 10.1136/bmjopen-2017-018154

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Keywords: less-lethal weapon injuries, less-lethal law enforcement weapon injuries, conducted electrical weapon, conducted energy weapon, TASER, pepper spray, oleoresin capsaicin spray, tear gas, CS, CN, chemical irritants, police dog bite, canine bite, K-9 bite, law enforcement dog bite, kinetic impact projectiles, stingball, flashball, beanbag gun, rubber bullets, secondary exposure, secondary contamination, trauma-informed care