Journal of Forensic and Legal Medicine 73 (2020) 101990
Available online 29 May 2020
1752-928X/© 2020 Published by Elsevier Ltd.
Electrical weapons, hematocytes, and ischemic cardiovascular accidents
Mark W. Kroll a,*
, Klaus K. Witte b
, Sebastian N. Kunz c
, Richard M. Luceri d
, John C. Criscione e
a
University of Minnesota, Box 23, Crystal Bay, MN, 55323, USA
b
Leeds Inst. of Cardiovascular and Metabolic Medicine, Univ. of Leeds, LS2 9JT, UK
c
Institute of Forensic Medicine, University Hospital Ulm and Ulm University, Germany
d
Holy Cross Hospital, 4725 N. Federal Hwy, Ft. Lauderdale, FL, 33308, USA
e
Biomedical Engineering, Texas A&M University, USA
A R T I C L E I N F O
Keywords:
CEW
Electrical weapon
Myocardial infarction
Stroke
Hematocyte
TASER®
A B S T R A C T
Background: There have been case reports following the use of a conducted electrical weapon (CEW) suggesting
that these devices might affect coagulation or thrombosis in at-risk individuals. The aim of this manuscript
therefore is firstly to explore this hypothesis by reviewing each of these cases and secondly to report the results of
a prospective study exploring a priori the effects of electrical weapons on hematocytes in a group of human
volunteers.
Methods: First, we systematically reviewed all cases of adverse outcomes following CEW discharge that could be
due to an effect on coagulation or thrombosis, with particular focus on the clinical scenario and its relationship
with the weapon discharge. Second, we assessed hematocyte levels in venous blood from 29 volunteers before, 5
min after, and 24 h after receiving a full-trunk 5-s TASER® X26(E) CEW exposure.
Results: Following extensive review of the literature, we found 3 relevant case reports of possible vascular
thromboembolic clinical events after CEW exposure, specifically a case of ischemic stroke, and 2 cases of STsegment
elevation myocardial infarctions. Review of these published cases failed to establish a plausible linkage
to the CEW beyond a temporal association with significant emotional and physiological stress from a violent
struggle.
Our prospective study of biomarker change following CEW discharge revealed acutely increased values for WBC
(white blood cells), specifically lymphocytes and monocytes, and a raised platelet count. Neutrophil levels
decreased as a percentage of WBC. While these changes were statistically significant at 5 min, all results
remained within established reference ranges. At 24 h, all values had returned to baseline except total WBC
which decreased to slightly below baseline but was still within the normal reference range.
Conclusions: A review of clinical cases, of ischemic or thrombotic events revealed no direct association with the
CEW discharge. A full-trunk electrical weapon exposure did not lead to hematocyte changes beyond normal
clinically expected variations in similar acute response scenarios. The case report and biomarker data do not
support the hypothesis that a CEW discharge is associated with changes likely to promote coagulation or
thrombus formation.
1. Introduction
The handheld conducted electrical weapon (CEW) deploys small
probes to deliver short-duration (50–100 μs) electrical pulses to control
skeletal muscle contractions. This typically leads to a loss of regional
muscle control and a fall to the ground to end a violent confrontation or
suicide attempt. The benefits and primary complications of the CEW are
well established in numerous large studies and papers as summarized in
Table 1. The aim of the present report is to review and summarize
reported cases of thrombotic or ischemic vascular events in people
receiving a CEW discharge. There is substantial literature describing the
possibility of electrocution (CEW-induced ventricular fibrillation) and
this will not be reviewed in this paper.1–4
We also present the results of a
biomarker study that explored whether changes in hematocytes might
underlie any temporal relationship between a CEW discharge and
ischemic or thrombotic events occurring in the field.
* Corresponding author. Box 23, Crystal Bay, MN, USA, 55323,
E-mail address: mark@kroll.name (M.W. Kroll).
Contents lists available at ScienceDirect
Journal of Forensic and Legal Medicine
journal homepage: http://www.elsevier.com/locate/yjflm
https://doi.org/10.1016/j.jflm.2020.101990
Received 5 September 2019; Received in revised form 17 May 2020; Accepted 23 May 2020
Journal of Forensic and Legal Medicine 73 (2020) 101990
2
1.1. Clinical cases
We have reviewed each of the 3 case reports of unexpected vascular
sequelae temporally related to the use of a CEW and summarized them:
Case 1: Bell reported on a 32-year-old male who developed an
ischemic stroke following electronic control.5
He presented to the
emergency department following a CEW discharge to the forehead
during an altercation with the police. The patient became briefly
nonresponsive during the incident. Upon arrival to the emergency
department, the patient had a persistent change in mental status with
speech difficulty. Physical examination revealed abrasions on the forehead
from the probe and generalized right-sided weakness. The past
medical history was significant only for bipolar and schizoaffective
disorder. The initial work-up included normal electrolytes and normal
sinus rhythm on electrocardiogram (EKG). Upon further evaluation, a
computed tomogram (CT) of the head demonstrated a non-hemorrhagic
acute infarct along the left middle cerebral artery (MCA) territory with
surrounding edema and associated mass effect. CTA and MRI/MRA of
the head and neck were subsequently performed which demonstrated
filling defects in the distal M1 and proximal M2 segments of the left
middle cerebral artery with restricted diffusion in the MCA territory.
There were no other intracranial or cervical vessel abnormalities. Subsequent
work-up including tests for infections, inflammatory states, drug
screening and coagulation abnormalities were normal except for mildly
decreased protein S levels. Transesophageal echocardiogram was
normal and HbA1c and lipid studies were negative. History of tobacco
use was the only relevant cardiovascular risk factor. Heart rhythm
monitoring during the hospitalization was normal. Bell suggested that
the temporal relationship of the development of a stroke and probe
discharge on the head in an otherwise young healthy individual presented
the possibility of electrical injury-induced stroke from a combination
of vasospasm and endothelial thermal injury.
Case #2: Belen reported a 37-year-old male patient with no prior
cardiac history who, after an altercation with the security personnel of a
hotel, collapsed after application of a CEW in probe mode to the anterior
thoracic wall with pain in all parts of the body and spasms.6
One CEW
probe entrance wound was 1 cm left of the left midclavicular line on the
6th intercostal space, and the other was 2 cm right of the anterior
axillary line near the nipple level. While the patient was able to stand up
with support, a crushing-like pain in the chest lasted for approximately
30 s following CEW application. The patient was admitted to the
emergency service. EKG showed elevated ST segment in leads II, III and
AVF, and reciprocal ST depression in leads I and AVL. The patient was
conscious and had no past medical history or family history of relevance
for ischemic heart disease. Physical examination showed no signs of
traumatic injury or bleeding. The patient was transferred to coronary
intensive care. Early laboratory tests were all normal including a drug
screen. The patient was treated with aspirin, clopidogrel, isosorbide
dinitrate, metoprolol, and diazepam (for sedation), and transferred for
coronary angiography. Coronary angiography, 3 h after the CEW
discharge, was normal and his further recovery was uncomplicated. The
chest pain lasted for a total of 5 h, and the EKG normalized completely,
while echocardiography showed minimal levels of inferior wall hypokinesia.
The patient’s cardiac markers peaked at 12 h: CK (1250 U/L),
CK-MB (150 U/L), and troponin I (9 ng/mL). The patient was discharged
on medication for secondary prevention and remained without symptoms
at follow-up. In this case, it is possible that the effects of extreme
stress could have led to a form of stress-related cardiomyopathy (similar
to Takutsubo syndrome).7
Case # 3: Baldwin reported a case of a 20-year-old man involved in a
brawl who received a TASER® X26 discharge to the upper right posterior
part of the thorax and in the right buttock consisting of two 5-s
activations of the device.8
The man did not sustain a significant fall,
but was brought to the hospital in custody an hour later to have the
probes removed whereupon, having initially been pain free, he developed
burning retrosternal pain accompanied by dyspnea. He was treated
with aspirin and nitroglycerin paste, and his symptoms subsided. The
initial EKG showed ST elevation in the inferior leads. Urgent coronary
arteriography revealed normal coronary arteries but left ventriculography
showed hypokinesis of the distal inferior wall, and a normal
ejection fraction. Four hours after the onset of chest pain, the EKG
showed evolution of an inferior infarct. The initial serum troponin was
0.66 ng/mL and peaked at 10.73 (reference < 0.04); serum creatine
kinase (CK) was 373 U/L and peaked at 1016 (reference < 230); and
CK-MB was 7.3 ng/mL and peaked at 52.5 (reference < 7.7). The patient
was taking no prescribed medications, and a drug screen was normal,
but he reported regular use of Finaflex (Redefine Nutrition), an
over-the-counter anabolic steroid supplement for muscle building.
There were no other risk factors for ischemic heart disease although
throughout his hospitalization, his blood pressure was elevated in the
range of 146/90–190/98 mmHg. He had no further symptoms, and he
was discharged with secondary prevention medications and was advised
to stop taking the anabolic steroid supplement.
This subject had been engaged in a physical altercation prior to his
myocardial infarction.9
Although a 10-s TASER exposure can lead to
nominal cardiovascular response, this is much less than simulated
combat and fleeing.9
Furthermore, anabolic steroid use and other
fat-burning supplements are associated with premature cardiovascular
complications including acute myocardial infarctions or coronary
vasospasm.10
Nevertheless, the latter 2 reports hint at the possibility of
acute myocardial injury due to coronary vasospasm in the presence of
normal coronary arteries.
In addition to a case review, we also wanted to establish whether
there are any effects on blood contents, specifically hematocytes, as a
result of a CEW discharge that might predispose at-risk individuals to
sustain coagulation or thrombotic-related sequelae.
2. Methods
2.1. Study design
Participants were cadets from the Austin (Texas) Police Academy
who had previously volunteered to undergo CEW exposure. The CEW
exposure was performed by Academy staff as part of their normal
training methods to ensure that cadets were aware of the effects of the
device. Thus, a primary inclusion criterion was that the subject was
participating in police-officer use-of-force training which implied that
they were capable of physical exertion. The study was approved by the
Institutional Review Board of Texas A&M University. Written, informed
consent was obtained from all volunteers confirming their ability to
withstand physical exertion. Exclusion criteria were: recent illness,
musculoskeletal injury, pregnancy, lactation, or any known cardiovascular,
pulmonary, or hematologic condition. A 12-lead EKG was
administered as part of the baseline evaluation before the CEW
exposure.
2.2. CEW application
Each subject was positioned prone on a padded mat. The 2 alligator
clips were connected to clothing at the subject’s shoulder area and waist.
Electrical current delivery, from an X26(E), lasted for a duration of a
Table 1
Known benefits and complications of electrical weapons.
Benefits & Complications n Effect Size
Reduction in any suspect injury32
24 380 65%
Reduction in injury requiring medical attention33
16 918 78%
All-cause mortality reduction4
59–66%
Fatal shooting reduction34
67%
Fatal brain or neck injury from fall4,35
18 4.6/million
Fatal burn injury4,36,37
8 2.1/million
Blinding from probe injury38,39
20 5.1/million
M.W. Kroll et al.
Journal of Forensic and Legal Medicine 73 (2020) 101990
3
standard 5 s cycle (single pull of the trigger), as used in training and in
the field.
2.3. Serum biomarker protocol
A 20 mL venous blood sample was taken before, 5 min after, and at
24 h following the CEW exposure. All phlebotomies were performed by
certified emergency medical technicians using routine venipuncture
practices, wherein a sterilized intravenous catheter was placed in the
vein of the anterior forearm for ease and repeatability. All drawn blood
specimens were labelled, collected, and transported to an off-site facility
by an independent laboratory (Laboratory Corporation of America,
Austin, TX).
2.4. Statistical analysis
Comparisons were done by a paired Student’s t-test for both baseline
to post and baseline to 24-h. Post-hoc analysis demonstrated that the
study was powered to detect p ¼ .05 difference with a 90% likelihood for
each biomarker. Because of the many comparisons, we used the HolmBonferroni
correction for significance testing. For baseline-to-post this
only affected the MCHC and MCV comparisons as seen in Table 2. The
Holm-Bonferroni correction affected the RBC and hemoglobin 24-h
comparisons as also seen in Table 2.
3. Results
A total of 29 subjects (26 male) participated and provided blood
samples before, 5 min after and 24 h after the CEW exposure. Subject
ages ranged from 21 to 55 years.
At 5 min following the discharge, there were increases in total WBC,
platelets, lymphocytes (% and absolute), and monocytes as shown in
Table 2. The absolute neutrophil count was increased but the proportion
of neutrophils decreased to due greater relative increases in lymphocytes
(Table 3). At 24 h, the only change was a slight decrease in the total
WBC from baseline (6.35 � 1.26/nL vs 5.93 � 1.41/nL, p ¼ .002)
whereas all other blood cell values had returned to pre-test values.
Importantly, although these changes were statistically significant, the
magnitude of change did not lead to a shift beyond normal values for any
of the hematocyte subfractions.
The 7 biomarkers with post-exposure shifts are detailed in Table 3.
The greatest shift was in the lymphocyte level which was 0.83 sigma
(standard deviations of baseline) or 21%. Platelets were increased 0.16
sigma or 2%. All levels were within typical clinical reference levels.
4. Discussion
We believe that this is the first publication of the effects of modern
electrical weapons on hematocyte concentrations in humans. Our study
demonstrates that exist transient changes in hematocyte levels which
were not of a magnitude for any of the cellular subfractions to take them
beyond the normal range.
There are previous human reports of changes with hematocytes
following CEW discharge. Dawes collated hematocrit levels taken from 4
studies of 133 volunteer subjects including some intoxicated and exercising
subjects following TASER X26(E) discharges,11
and reported a
statistically significant, but clinically insignificant decrease in hematocrit.
Another human study used the Condor® Spark, a much
higher-powered weapon (~7 W vs modern CEWs < 2 W) than that used
in Dawes’ study and ours, and reported a rise in hematocrit in 71
volunteers.12
Our prospective human data confirm previous swine studies, all of
which have shown no consistent changes on RBC, platelets, neutrophils,
lymphocytes, hematocrit, and hemoglobin following X26(E) dis­
charges.13–16
The minor increases in platelets and lack of changes in RBC
or hematocrit seen in our volunteers suggest that thrombus generation
from a CEW exposure is unlikely, making an embolic event highly unlikely.
Our previous meta-analysis of 10 studies with a total of 421
subjects found an increase in troponin levels in only a single subject (at
24 h linked to a rigorous off-protocol workout).17,18
Vilke found no
changes in the 12-lead EKG at 1-h post-CEW exposure and no troponin I
levels above 0.2 ng/mL at 6 h suggesting that there is no direct deleterious
cardiac effect.19
In the present study, we did see a shift in the neutrophil/lymphocyte
ratio. A shift of the ratio in this direction, but of much greater magnitude
has prognostic significance in ischemic heart disease, heart failure and
patients with arrhythmias.20
The changes we saw may be due to the
effects of increased cortisol and catecholamines following physiological
stress on lymphocyte number and function, although the magnitude of
the changes suggests minimal stress from the CEW exposure.21,22
This is
supported by our data from a related study in volunteers (n ¼ 31) where
we reported mild increases in adrenergic and metabolic stress markers:
serotonin, cortisol, and lactic acid after a CEW exposure.23
The lack of stress-related changes in these data and our previous
work could be due to the fact that all currently available TASER brand
CEWs deliver less than 2 W, which is considerably less than the 5–7 W
allowed by the Underwriters Laboratories (UL) electric fence standard.24
Modern CEWs also satisfy the conservative IEC (International Electrotechnical
Commission) 2.5 W limit.25–27
Moreover, there is also an
Table 2
Statistical significance by Holm-Bonferroni test.
Parameter Units Baseline Post T-test HB Limit SS? 24 Hour T-test* HB Limit SS?
WBC /nL 6.35 � 1.26 7.02 � 1.35 0.0000 0.0028 Y 5.93 � 1.41 0.002 0.0026 Y
RBC /pL 4.47 � 0.45 4.47 � 0.42 0.91 0.03 4.40 � 0.45 0.022 0.0029
Hemoglobin g/dL 13.8 � 1.1 13.8 � 1.1 0.45 0.01 13.6 � 1.0 0.045 0.0033
Hematocrit % 40.2 � 3.3 40.3 � 3.0 0.70 0.01 39.6 � 3.3 0.10 0.004
MCV fL 90.1 � 3.8 90.5 � 3.8 0.032 0.0045 90.5 � 3.3 0.13 0.004
MCH pg 31.0 � 1.2 30.9 � 1.2 0.12 0.01 31.1 � 1.4 0.27 0.006
MCHC g/dL 34.4 � 0.5 34.2 � 0.6 0.007 0.0042 34.4 � 0.7 1.00 0.05
RDW % 13.5 � 0.7 13.5 � 0.7 0.88 0.02 13.5 � 0.7 0.85 0.025
Platelets /nL 226 � 34 231 � 35 0.002 0.0038 Y 227 � 32 0.67 0.013
Neutrophils % 60.7 � 8.7 58.4 � 9.0 0.0001 0.0031 Y 59.6 � 7.2 0.39 0.007
Lymphs % 28.8 � 8.1 31.2 � 8.9 0.0000 0.0029 Y 29.1 � 6.5 0.73 0.017
Monocytes % 7.69 � 1.97 7.69 � 2.00 1.00 0.05 8.03 � 2.57 0.22 0.005
Eos % 2.28 � 2.02 2.14 � 1.79 0.29 0.01 2.59 � 2.24 0.017 0.0028
Basos % 0.52 � 0.51 0.55 � 0.51 0.75 0.01 0.62 � 0.49 0.41 0.008
Neutrophils (Absolute) /pL 3.91 � 1.07 4.17 � 1.13 0.0003 0.0033 Y 3.60 � 1.28 0.031 0.0031
Lymphs (Abs) /pL 1.78 � 0.44 2.14 � 0.51 0.0000 0.0026 Y 1.69 � 0.37 0.058 0.0036
Monocytes (Abs) /pL 0.48 � 0.11 0.54 � 0.16 0.002 0.0036 Y 0.46 � 0.13 0.16 0.005
Eos (Abs) /pL 0.16 � 0.14 0.17 � 0.15 0.33 0.01 0.15 � 0.14 0.33 0.006
Baso (Abs) /pL 0.04 � 0.05 0.05 � 0.05 0.49 0.01 0.05 � 0.05 0.57 0.010
HB¼ Holm-Bonferonni. *From Baseline.
M.W. Kroll et al.
Journal of Forensic and Legal Medicine 73 (2020) 101990
4
electrical standard designed specifically for the CEW: ANSI CPLSO-17,
requiring minimum outputs for effectiveness and maximum limits for
safety which are satisfied by all current TASER® models. Our work was
partly stimulated by the fact that these safety limits are based on the risk
of VF and do not explicitly speak to coagulation or thrombosis.
Cardiac damage is sometimes seen with high-power electrical injury,
and ST elevation has been reported with a lightning strike.28–31
Although the low-power 2-W CEW effect on skeletal muscle activation
appears dramatic, in the way a lightning strike might be imagined, the
electrical power of the latter and power line injuries is much higher (1
kW–100 kW).
4.1. Limitations
It is possible that our search for vascular spasm or thrombotic events
was incomplete and that we missed unpublished cases. We consider it
unlikely however, that our approach would miss large numbers of these
events, which are usually high-profile.
We only tested 29 individuals and because of the small sample of
females, we were not able to make a baseline comparison between
genders. Our prospective study did not measure fibrinogen or thrombin
levels. We consider it unlikely that these humoral factors would be
elevated — in isolation — in the absence of changes in cellular contents
since changes in both are usual during and following spontaneous cardiovascular
events. Our study was also unable to exclude stress-related
vascular spasm as a result of the CEW discharge in susceptible individuals
and although swine data have given no indication of this as a
phenomenon, this could form the subject of a future study.
5. Conclusions
We have identified 2 cases in the literature of possible stress-related
coronary artery vasospasm and although we could not exclude the
TASER discharge as a contributory factor, the events leading up to each
discharge were more likely to have played a dominant role. Our prospective
data do not support the hypothesis that a CEW discharge is
associated with changes likely to promote coagulation or thrombus
formation.
Declaration of competing interest
MWK is a member of Axon’s Scientific and Medical Advisory Board
(SMAB) and corporate board. RML is a SMAB member and consultant to
Axon. SNK is a SMAB member. KKW and JCC declare no conflicts. MWK
and RML have served as litigation or inquest experts in multiple
countries.
Acknowledgements
Funding provided by the Joint Non- Lethal Weapons Program Contract/PR
No. W911QY-08-C-0023.
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Table 3
Statistically significant changes from baseline to post-exposure by level and compared to reference limits.
Parameter Units Baseline Post Reference Limits Delta Z-score (Delta � sigma) Delta (%)
WBC /nL 6.35 � 1.26 7.02 � 1.35 6–18 0.67 0.53 11%
Platelets /nL 226 � 34 231 � 35 140–400 5.38 0.16 2%
Neutrophils % 60.7 � 8.7 58.4 � 9.0 45-70% À 2.31 À 0.27 À 4%
Lymphs % 28.8 � 8.1 31.2 � 8.9 20-45% 2.41 0.30 8%
Neutrophils (Absolute) /pL 3.91 � 1.07 4.17 � 1.13 1.8–7 0.26 0.24 7%
Lymphs (Absolute) /pL 1.78 � 0.44 2.14 � 0.51 1–4 0.37 0.83 21%
Monocytes (Absolute) /pL 0.48 � 0.11 0.54 � 0.16 0.2–0.8 0.06 0.54 13%
M.W. Kroll et al.
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