Less-lethal law enforcement weapons: clinical management of associated injuries in the emergency department.

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.

¿Cuál es el efecto en salud en las personas expuestas a gases lacrimógenos?: síntesis rápida de evidencia / What is the health effect on people exposed to tear gases?: rapid evidence synthesis

ANTECEDENTES Y OBJETIVO Desde el 18 de octubre de 2019, Chile se encuentra en una crisis social relacionada a demandas de la ciudadanía para mejorar la calidad de vida. Frente a esto es que Chile lleva más de 5 meses de manifestaciones y concentraciones masivas y en las cuales Carabineros de Chile ha utilizado gases lacrimógenos como medida de control de masas. En este contexto el Instituto Nacional de Derechos Humanos (INDH) ha solicitado al Ministerio de Salud, el desarrollo de una síntesis de evidencia con el objetivo de informar sobre los riesgos para la salud como consecuencia del uso de gases lacrimógenos, así informando a la toma de decisiones. METODOLOGÍA Se utilizaron estrategias de búsqueda en las bases de datos Health Systems Evidence, Epistemonikos, EMBASE, y PUBMED, con el objetivo de identificar revisiones sistemáticas que abordaran la pregunta formulada. Como las revisiones sistemáticas no siempre reportaron adecuadamente los resultados presentados, se extrajeron los datos de los estudios primarios contemplados en estas revisiones. Se incluyeron revisiones sistemáticas que evaluaran el efecto del gas CS o combinados de gas CS con otro tipo de sustancias sobre la salud de la población. Se excluyeron estudios que evaluaran los efectos de gases lacrimógenos diferentes a CS, como gas pimienta o cloroacetopheno. RESULTADOS -Los efectos en salud inmediatos reportados son la irritación de mucosas, a mediano y largo plazo son asma, disnea, estrés postraumático, depresión, alteración funcional, estado vegetativo y muerte como consecuencia de impactos de dispositivos lacrimógenos.

Direct head injury caused by a tear gas cartridge. Questions on safety: A case report from Iraq and review of the literature.

INTRODUCTION AND BACKGROUND: Primary injuries from tear gas weapons include injuries to the visual and respiratory systems and skin. However, few studies have reported direct mechanical brain injuries from tear gas weapons. CASE REPORT: A 27-year-old male presented to the emergency department of a neurosurgery teaching hospital in Baghdad, Iraq, with a penetrating head injury of unknown source. DISCUSSION: Tear gas weapons are considered safe, but tear gas exposure causes severe complications. Traumatic brain injuries as a direct effect of tear gas bombs are rarely reported in the literature. Tear gas cartridge injuries should be managed in the same manner as any penetrating brain injury, with appropriate neuromonitoring. This monitoring is crucial for the detection and prevention of secondary brain insults. CONCLUSION: Emergency medicine specialists and neurosurgeons should be aware that tear gas weapons are not always safe, and they should anticipate chemical, thermal and mechanical side effects of tear gas weapons. The literature and our results suggest that these weapons should not be considered civil and harmless.

Baby Shampoo to Relieve the Discomfort of Tear Gas and Pepper Spray Exposure: A Randomized Controlled Trial.

INTRODUCTION: Oleoresin capsicum (OC) or pepper spray, and tear gas (CS) are used by police and the military and produce severe discomfort. Some have proposed that washing with baby shampoo helps reduce this discomfort. METHODS: We conducted a prospective, randomized, controlled study to determine if baby shampoo is effective in reducing the severity and duration of these effects. Study subjects included volunteers undergoing OC or CS exposure as part of their police or military training. After standardized exposure to OC or CS all subjects were allowed to irrigate their eyes and skin ad lib with water. Those randomized to the intervention group were provided with baby shampoo for application to their head, neck, and face. Participants rated their subjective discomfort in two domains on a scale of 0-10 at 0, 3, 5, 10, and 15 minutes. We performed statistical analysis using a two-tailed Mann-Whitney Test. RESULTS: There were 58 participants. Of 40 subjects in the OC arm of the study, there were no significant differences in the ocular or respiratory discomfort at any of the time points between control (n=19) and intervention (n=21) groups. Of 18 subjects in the CS arm, there were no significant differences in the ocular or skin discomfort at any of the time points between control (n=8) and intervention (n=10) groups. CONCLUSION: Irrigation with water and baby shampoo provides no better relief from OC- or CS-induced discomfort than irrigation with water alone.

Effects of tear gases on the eye.

Chemical agents that target the eyes have been a popular choice for law enforcement during riots and for military training for nearly a century. The most commonly used agents are chloroacetophenone (formerly sold as Mace), o-chlorobenzylidene malononitrile, and oleoresin capsicum (OC or pepper spray, current ingredient for Mace). Initially, most severe ocular injuries were caused by the explosive force rather than the chemical itself. The development of sprays reduced the mechanical severity of ocular injuries, but resulted in a variety of chemical injuries. The effects on eyes include conjunctival injection, complete corneal epithelial defects, pseudopterygium, corneal neovascularization, persistent conjunctivalization, corneal opacities, and reduced visual acuity. Current management, based on limited human studies, emphasizes decontamination and symptomatic treatment. We review the literature related to clinical and histopathologic effects of tear gas agents on the eye and their management.

Rare and Severe Maxillofacial Injury Due to Tear Gas Capsules: Report of Three Cases.

Tear gases are used by police or armed forces for control of riots or social events or by the general population for private self-defense. These agents are used widely throughout the world, but some harmful effects have reported. In addition, despite well-defined chemical side effects documented in the literature, data are insufficient regarding mechanical injury due to tear gas capsules. We report three cases of severe maxillofacial injury in patients who had these capsules fired from tear gas guns directly to their faces. The capsules penetrated the patients' faces, causing potentially fatal injuries. To our knowledge, reports of this kind of injury related to tear gas capsules are very rare in the literature. In conclusion, tear gas guns may be very dangerous in terms of human health and they may cause severe injuries, especially when they are not used according to strict guidelines.

[Injuries from pepper spray used for self defense: analysis of 15 cases managed in an emergency chemical decontamination area]. / Agresiones realizadas con espráis de defensa personal atendidas en el área de descontaminación química de urgencias. A propósito de 15 casos.

EN: We analyzed epidemiologic and clinical characteristics, treatment received, and clinical course in cases of pepper spray injury treated in the chemical decontamination area of an emergency department over a 5-year period. A total of 15 patients with a mean (SD) age of 25 (8.3) years were included. Thirteen were men and 53% were foreign-born. All uses of pepper spray occurred during muggings that to place mainly in the early hours of the morning (66.7% between 4:30 and 6:30 AM). Two or more attackers were injured in 60% of the events. Seventy-three percent of the attacks took place on the street and the median delay in reaching the emergency department was 30 minutes. The face and eyes were usually injured, and symptoms included itching, irritation, burning, and pain. On arrival, the patients were treated immediately (mean delay, 3 minutes) with hypertonic saline, an amphoteric surfactant, and a chelating agent in 80% of the cases, in which improvement was substantial as mean pain scale scores changed from 7.2 on admission to 3 on discharge (P=.009). Patients spent an average of 40 minutes in the treatment area. Eleven patients required further care from an ophthalmologist and topical medication for symptoms. Outcomes were good and there were no complications in any of the cases. We conclude that pepper sprays are being used as an aid to self defense in muggings in our community. Decontamination measures have priority as they alleviate symptoms and prevent long-lasting effects.

ES: Evalúan las características epidemiológicas, clínicas, terapéuticas y evolutivas, de las asistencias realizadas en el área de descontaminación química (ADQ) del servicio de urgencias, a consecuencia de un ataque con espráis de defensa personal durante un período de 5 años. Se han incluido 15 pacientes con una edad media de 25 años. Trece fueron hombres y el 53% eran personas no nacidas en España. En todos los casos la agresión con el espray se produjo en el curso de una pelea o con ánimo de robo, sobre todo de madrugada (66,7% de los casos entre las 4:30 y las 6:30 h). En el 60% de las atenciones hubo dos o más personas afectadas de forma simultánea. El ataque se produjo en la vía pública en el 73% de las ocasiones y tardaron una mediana de 30 min en llegar a urgencias. Cara y ojos fueron las zonas más afectadas y los síntomas referidos con mayor frecuencia fueron el picor, irritación, quemazón o dolor. El tratamiento aplicado en el hospital fue inmediato (media de demora: 3 min) y se empleó una solución hipertónica, anfótera y quelante en el 80% de los casos, con notable mejoría sintomática, pasando en la escala visual analógica (EVA) del dolor de una puntuación media de 7,2 al ingreso a 3 a la salida (p = 0,009). El tiempo medio de permanencia en el ADQ fue de 40 min. Once de los casos precisaron además asistencia oftalmológica y tratamiento tópico sintomático. La evolución fue favorable y sin secuelas en todos los casos. Concluimos que el uso de espráis de defensa personal con ánimo de robo o agresión es una realidad en nuestro medio. Las medidas de descontaminación son prioritarias y contribuyen a aliviar los síntomas y evitar secuelas.

Long term effects of tear gases on respiratory system: analysis of 93 cases.

AIM: This study aimed to assess the long-term respiratory effects of tear gases among the subjects with history of frequent exposure. MATERIALS AND METHODS: A questionnaire by NIOSH and pulmonary function tests was performed in 93 males exposed to the tear gases frequently and 55 nonexposed subjects. RESULTS: The mean numbers of total exposure and last 2 years exposure were 8.4 ± 6.4 times, 5.6 ± 5.8 times, respectively. Tear gas exposed subjects were presented with a higher rate for cough and phlegm more than 3 months (24.7% versus 11.3%, P > 0.05). Mean FEV1/FVC and % predicted MMFR in smoker exposed subjects are significantly lower than those in smoker controls (81.7% versus 84.1%, P = 0.046 and 89.9% versus 109.6%, P = 0.0004, resp.). % predicted MMFR in nonsmoker exposed subjects is significantly lower than that in nonsmoker controls (99.4% versus 113.1%, P = 0.05). Odds ratios for chest tightness, exercise dyspnea, dyspnea on level ground, winter morning cough, phlegm, and daily phlegm were increased almost 2 to 2.5 folds among tear gas exposed subjects. CONCLUSION: The rates for respiratory complaints were high in the case of the exposure to the tear gases previously. Tears gas exposed subjects were found to be under the risk for chronic bronchitis.

Exposición a gas CS: a propósito de un caso peculiar / Exposure to CS gas: Case study

El gas CS (o-clorobenzolideno malononitrilo) se incluye dentro del grupo de los gases lacrimógenos. La exposición a dicho gas ocurre durante su empleo como gas de defensa o antidisturbios, así como durante el entrenamiento rutinario de las fuerzas de choque especializadas. Su acción tóxica es ejercida a través de un efecto irritante sobre piel y mucosas, así como por mecanismos inmunoalérgicos. Presentamos el caso de un paciente de 24 años, perteneciente a una fuerza de choque, que consultó por lesiones cutáneas luego de una exposición a humo y dispersión de polvo de una granada de gas CS durante ejercicios de entrenamiento. Clínicamente se presentó características peculiares, referidas a sus manifestaciones cutáneas, localización y severidad de las mismas. Se analiza la etiopatogenia de las lesiones y los posibles mecanismos involucrados, diagnósticos diferenciales, así como los pilares del tratamiento frente a una exposición a gas CS...

Effects of pepper grenade explosions on non-combatant bystanders.

Pepper gas is used for riot control in many parts of the world. Yet, its effects on bystanders are largely unreported. We fielded a questionnaire-based survey of 500 bystanders exposed to gas when police used pepper grenades against belligerent 'stone-pelters' in the northern Indian state of Jammu & Kashmir. Of 294 non-combatants who consented to participate in our survey, 97 per cent developed cough and irritation of the throat within few seconds of breathing the pungent smelling gas. They reported respiratory problems, dermatologic symptoms, sleep disturbances, and mood changes with varying frequency. Sixteen reported exacerbations of underlying respiratory disorders, with one temporally related to death. Symptoms led 51 to get medical attention. Nearly all respondents reported that symptoms recurred on re-exposure. We conclude that use of pepper grenades can cause serious acute symptoms in non-combatants accidentally exposed. We recommend alternate methods of riot control - water cannons, baton charges, tasers, plastic or rubber bullets, and so on - that have no collateral side effects on non-combatants be considered for routine use.

[Medical aspects of common non-lethal weapons]. / Medizinische Aspekte gängiger nicht-letaler Wirkmittel.

The development and provision of non-lethal weapons (NLW) allow military and law enforcement personnel to exploit gradual engagement in countering potentially hazardous threats. Chemical, kinetic and electrical weapons systems are used to curb violence in civilian crowds. With inappropriate usage, these technologies can cause potentially fatal injuries that are not only of clinical, but also of legal relevance. In this context, the practicing physician is faced with treatment as well as assessment issues of new forms of injuries. In order to assure medical care and to be able to draw competent expert's conclusions, a detailed knowledge of the medical effects of these NLW is necessary. The review at hand presents today's most popular NLW and gives an overview of their possible injury potential and required treatments.

Demonstration control agents: evaluation of 64 cases after massive use in Istanbul.

An uncontrolled use of "demonstration control agents" commonly known as "teargas agents" has recently been a common practice in Turkey. One of the first massive uses of these agents had been during a meeting of the North Atlantic Council and NATO in 2004, in Istanbul. After the demonstrations, 64 patients were evaluated and treated by the Human Rights Foundation of Turkey. Their files have been reviewed retrospectively and were classified regarding age, sex, physical findings related of chemical agents, and other injuries.The patients were received 1 to 9 days after the chemical gas exposure. The maximum referral was 35 patients on the day of the gas exposure. The last application was 9 days after the exposure. Complaints and physical findings/symptoms were highest during the first 3 days.This study has been carried out to reveal the short- and long-term aftereffects of "demonstration control agents." The safety and effects of these agents are discussed in this article, based on our findings and existing references.

Usos y abusos de los gases lacrimógenos y la salud: prevención y manejo / Uses and abuses of teargas and health: prevention and management

Los gases lacrimógenos (GL) son métodos de control de manifestaciones públicas por los órganos represivos, muy utilizados y efectivos globalmente. El objetivo de esta revisión es actualizar información técnica sobre los gases lacrimógenos, añadiendo aspectos más recientes legales, éticos, médicos y preventivos del uso y abuso de estos agentes químicos durante las acciones de las fuerzas policiales y represivas. Las fuentes de información secundarias seleccionadas son portales generales con el buscador Google, académicos (Google académico), PubMed y de las organizaciones gubernamentales y no gubernamentales, también se incluyen hemerotecas de artículos periodísticos sobre su uso desde 2000 hasta 2014. La exposición aguda a (GL) se expresa con manifestaciones clínicas de afección respiratoria, irritación de los ojos y de la piel, requiriendo en la mayoría de los casos medidas generales de atención fuera del hospital. Sin embargo, en casos de personas con co-morbilidades respiratorias, alérgicas, glaucoma y del corazón, acarrean mayores consecuencias que requieren atención médica y hospitalaria. Se han reportado fatalidades relacionadas al uso y abuso de los agentes químicos. Desde el punto de vista de salud pública existe controversia sobre su uso, y definitivamente causan consternación en los afectados y los abusos de su utilización en manifestaciones pacíficas. Se hace un listado de recomendaciones ante exposiciones durante manifestaciones, como prevenir intoxicaciones severas y dar los primeros auxilios...

Tear gases (TG) are methods for public control used by police forces. The objective of this review is to update technical information about tear gas, adding more recent legal, ethical, medical and preventive aspects of the use and abuse of these chemicals during the actions of the police and repressive forces. Selected secondary sources of information are Google, Academic Google, PubMed and of governmental and non-governmental organizations, also included are newspaper archives about its use from 2000 to 2014. Acute exposure to (GL) is expressed with clinical manifestations of respiratory conditions, irritation of the eyes and skin, requiring in most cases general ambulatory measures of care. However, in persons with respiratory, allergic, glaucoma and heart comorbidities, they carry greater consequences requiring hospital care. Fatalities have been reported related to the use and abuse of chemical agents. From the viewpoint of public health there is a controversy about its use, and definitely cause consternation in the affected in peaceful demonstrations. A list of recommendations is made about how to prevent severe intoxications and give first aid...