The injury pattern of a new law enforcement weapon: the police bean bag.

STUDY OBJECTIVE: This case series describes the injury pattern of the police bean bag, a new weapon adopted by US law enforcement agencies. METHODS: Retrospective chart review between 1996 and 2000 identified bean bag injuries. Autopsy data were gathered for 1 fatality. Circumstances of the shootings, toxicology results, and psychiatric diagnoses, if any, were recorded. RESULTS: Thirty-nine men and 1 woman between the ages of 16 and 77 years were shot by officers of either the Los Angeles Police Department or the Los Angeles Sheriff's Department. The fatality was caused by massive hemothorax after thoracic penetration. The locations of serious penetrating injuries included the thoracic cavity, eye, abdomen, arm, and leg. Blunt injuries included splenic rupture, pneumothorax, compartment syndrome, testicular fracture, subcapsular liver hematoma, and cardiac contusion. Complications included hemothorax, pneumopericardium, wound infection, compartment syndrome, and osteomyelitis. Psychiatric consultation was requested for 27 (69.2%) of 39 surviving patients. The Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) Axis I was used for diagnosis in all 27 patients. Psychosis was diagnosed in 16 (59.3%), suicidal ideation in 15 (55.6%), and major depression in 6 (22.2%) of the 27 cases. Schizophrenia had previously been diagnosed in 7 (25.9%) of the 27 cases. All but 1 of the patients had toxicology screenings performed, and the results of 29 (74.4%) of 39 were positive. Of these 29 positive results, 15 (51.7%) were positive for alcohol and 8 (27.6%) were positive for cocaine. CONCLUSION: Awareness of the broad scope of potential injuries mandates a thorough evaluation of both blunt and penetrating trauma in patients shot with police bean bags. The scope of these injuries raises significant public health considerations because use of this weapon has been adopted by law enforcement agencies in all 50 states and at least 10 countries.

The Flexible Baton TM-12: a case report involving a new police weapon.

The purpose of this case report is to describe a new type of police weapon and the injuries sustained by an individual after being shot with it. The Flexible Baton is a type of ammunition that consists of a fabric bag, filled with lead shot pellets, that is shot from a shotgun. It is predicted that this bag may cause bruising, abrasions, and blunt trauma. In our patient, the fabric bag burst and the pellets penetrated the skin of the elbow, resulting in cortical violation of the distal humerus. As more guns with this ammunition have been introduced throughout the United States, we conclude that injuries from this weapon will be seen with greater frequency.

Dapsone intoxication: two case reports.

Two patients with dapsone intoxication, an adult and a 16-month-old child, are reported. Both developed symptomatic methemoglobin concentrations, of 35% and 37%, respectively, and improved with intravenous methylene blue. Methemoglobin levels subsequently rose in both cases to 25% at 24 and 37 hours, respectively. The recurrence of elevated methemoglobin levels resulted from either continued absorption of dapsone or its toxic metabolite from the gastrointestinal tract. Both patients were begun on serial oral activated charcoal and the child received a second methylene blue treatment. During the intoxication, serum hemoglobin concentrations dropped 2 gm with an increase in the reticulocyte count. Review of 20 cases of dapsone overdose from the literature showed that the major toxic manifestations are methemoglobinemia and hemolysis. Delayed sulfhemoglobinemia, reported in only one case, resolved spontaneously. The treatment of dapsone intoxication is intravenous methylene blue for symptomatic methemoglobinemia, gastric decontamination, and early administration of serial oral activated charcoal. Hemolysis is mild but transfusions may be required for patients with a glucose-6-phosphate dehydrogenase deficiency.

Diphenoxylate-atropine (Lomotil) overdose in children: an update (report of eight cases and review of the literature)

Eight pediatric accidental overdoses of diphenoxylate-atropine (Lomotil) are reported, and 28 literature cases are reviewed. This overdose is primarily an opioid intoxication, occasionally associated with atropine toxicity. Only 6 of 36 children showed signs of atropine overdose (central nervous system excitement, hypertension, fever, flushed dry skin). Contrary to popular belief, atropine effects occur before, during, or after opioid effects. Opioid overdose (central nervous system and respiratory depression with miosis) predominated or occurred without any signs of atropine toxicity in 33 cases (92%). Diphenoxylate-induced hypoxia was the major problem and was associated with slow or fast respirations, hypotonia or rigidity, cardiac arrest, and in 3 cases cerebral edema and death. Respiratory depression recurred 13 to 24 hours after the ingestion in 7 cases and was probably due to accumulation of difenoxine, an active metabolite of diphenoxylate. Recommended treatment is intravenous naloxone for depressed or inadequate respirations, followed by continuous intravenous naloxone infusion, prompt gastric lavage, repeated administration of activated charcoal, and close monitoring for 24 hours.

Castor bean intoxication.

We report the cases of a child who ingested two or more castor beans and two adults who each ingested four beans. All three patients developed severe gastroenteritis and recovered without sequelae after receiving IV fluids. The literature contains reports of 424 cases of castor bean intoxication. Symptoms of intoxication include acute gastroenteritis, fluid and electrolyte depletion, gastrointestinal bleeding, hemolysis, and hypoglycemia. Delayed cytotoxicity has not been reported. Of the 424 patients, 14 died (mortality rates: 8.1% of untreated and 0.4% of treated). Deaths were due to hypovolemic shock. Recommended treatment for asymptomatic patients who have chewed one or more raw beans is emergency department evaluation, gastric decontamination, administration of activated charcoal, observation until four to six hours after ingestion, and discharge instructions to return if symptoms develop. After decontamination and activated charcoal, symptomatic patients require hospitalization for treatment with IV fluids, supportive care, and monitoring for hypoglycemia, hemolysis, and complications of hypovolemia. Monitoring for delayed cytotoxicity is unnecessary. Castor beans and their dust are highly allergenic and may cause anaphylaxis.

Pentazocine (Talwin) intoxication: report of 57 cases.

Overdose of pentazocine (Talwin), an agonist/antagonist opioid analgesic, is relatively uncommon. Fifty-seven cases occurring over ten years are reported. Twenty-three patients (40%) had ingested only pentazocine and did not have the classic opioid toxidrome of CNS and respiratory depression with miosis. Most patients were awake, and no patient had a respiratory rate below 12/minute. Other findings included: grand mal seizures, hypertension, hypotonia, dysphoria, hallucinations, delusions, and agitation. Eleven of 23 patients received IV naloxone (0.4-2.4 mg), but only two showed improvement. Thirty-four patients (60%) had coingested pentazocine with one to five additional substances. Patients who had ingested pentazocine with alcohol, a sedative/hypnotic drug, or an antihistamine, showed increased toxicity, including apnea, deep coma, and recurrent seizures. One patient developed opioid pulmonary edema. One patient died. Three of five patients with coma and inadequate respirations responded to IV naloxone in doses of 0.4 to 1.2 mg.

Brucella meningitis.

A 36-year-old Hispanic man came into the emergency department with nonspecific symptoms (headache, myalgias, low-grade temperature, and low white blood cell count) and was diagnosed with brucella meningitis. The patient said he had consumed unpasteurized goat's milk and cheese in Mexico, and had been treated 3 months previously for a febrile illness diagnosed as Malta fever (brucellosis). Cultures of both the blood and cerebrospinal fluid yielded Brucella melitensis. Blood agglutinin results for B abortus were positive at greater than 1:160. Unpasteurized milk and cheese are consumed in many countries where brucellosis is endemic. Emergency physicians are occasionally confronted with patients from developing countries with diseases that require rapid and specific diagnosis for optimal treatment.

Ammonium nitrate cold pack ingestion.

Disposable ammonium nitrate cold packs are widely used in emergency departments instead of ice bags. Five confused or suicidal patients who tore open a pack and ingested from 64 to 234 grams of ammonium nitrate in a single dose, and another patient who attempted to do so, are reported. It is known that chronic ingestion of 6 to 12 grams/day of ammonium nitrate may cause gastritis, acidosis, isosmotic diuresis, and nitrite toxicity manifesting as methemoglobinemia or vasodilatation. None of these patients developed severe toxicity, although three had symptoms of gastritis, three had slight methemoglobinemia, and two had mild hypotension. The product was removed from the stomach promptly in three of the five patients. None had pre-existing renal or intestinal dysfunction, which are known to enhance ammonium nitrate toxicity.