Clinical Imaging 79 (2021) 165–172
Available online 24 April 2021
0899-7071/© 2021 Elsevier Inc. All rights reserved.
Musculoskeletal and Emergency Imaging
Non-lethal weapon: Injury patterns and imaging correlates for
firearm alternatives
Navdeep Singh Manhas a,1
, Daniel Stahl b,d,1
, Morgan Schellenberg b,c,1
,
Ali Gholamrezanezhad b,d,*,1
a
California University of Science and Medicine, Colton, CA 92324, United States of America
b
Keck School of Medicine of University of Southern California, Los Angeles, CA 90033, United States of America
c
Department of Surgery, Los Angeles, CA 90033, United States of America
d
Department of Radiology, Los Angeles, CA 90033, United States of America
A R T I C L E I N F O
Keywords:
TASER
Beanbag(s)
Pepper spray
Tear gas
Flash-ball
Rubber bullet(s)
Firearms
Guns
Law enforcement
Police
Injury patterns
Imaging correlates +
A B S T R A C T
Law enforcement officers have adopted the use of non-lethal weapons to mitigate civilian casualties incurred by
firearm use over recent years and decades. These weapons include, but are not limited to, TASER, beanbag rifles,
pepper spray, tear gas, and Flash-ball guns. Nonetheless, severe injuries and even deaths do occur with use of
these weapons, in rare instances. This review aims to comprehensively discuss these cases and associated injuries,
as well as their according findings on imaging studies. It will also examine how often injuries occur in situations
with non-lethal weapons.
1. Introduction
Law enforcement officers have employed several types of non-lethal
weapons in altercations with civilians for decades, which include TASER
weapons, pepper spray, tear gas, beanbag-loaded rifles, and Flash-Ball
guns. All of these weapons have been manufactured and utilized as
relatively safe alternatives to firearms with the specific intent of subduing,
rather than killing, individuals. Nonetheless, these weapons have
been associated with serious injuries and even death [1]. For example,
conducted energy devices (CEDs) appear to be relatively safe when
tested on healthy individuals in clinically controlled settings [2–10].
However, CEDs can increase the risk of secondary head injuries from
falls [11–13]. Pepper spray-related deaths have even been recorded, but
they were usually due to “positional asphyxia, pre-existing health conditions,
or drug-related factors.” [14] Despite these rare occurrences,
these weapons prove to be non-lethal in most interactions with healthy
individuals. To that point, a review of police and medical records for
suspects detained with CEDs during a two-year period showed that <1%
experienced moderate injuries and only one individual (0.1%) sustained
a severe injury [15]. Nevertheless, as previously mentioned, exceptions
do occur. Imaging has been used to elucidate the extent of the damage
inflicted by these weapons. This review will discuss several cases,
focusing on the pattern of injuries associated with various non-lethal
weapons, as well as the associated imaging correlates. In particular,
this article will more closely examine CEDs and their related complications.
Furthermore, we aim to bolster medical knowledge about injuries
associated with non-firearm weapons, in order to improve clinical
management of these cases.
2. Conducted energy devices (CEDs) - TASER
Conceived in 1960 by an American physicist and commercialized in
* Corresponding author at: Department of Radiology Division of Emergency Radiology, Keck School of Medicine, University of Southern California, 1500 San Pablo
Street, Los Angeles, CA 90033, United States of America.
E-mail address: ali.gholamrezanezhad@med.usc.edu (A. Gholamrezanezhad).
1
These authors contributed equally to the work and should be considered as co-first authors
Contents lists available at ScienceDirect
Clinical Imaging
journal homepage: www.elsevier.com/locate/clinimag
https://doi.org/10.1016/j.clinimag.2021.03.007
Received 14 December 2020; Received in revised form 21 February 2021; Accepted 5 March 2021
Clinical Imaging 79 (2021) 165–172
166
1974, the TASER device was employed by law enforcement with the
intent to subdue individuals without causing significant harm. It is used
to incapacitate someone with an electrical discharge. The TASER X26 is
the most common variant of this non-lethal weapon that is favored by
law enforcement due to its small size, making it easy to carry on an
officer’s person. The TASER uses “compressed nitrogen to propel barbed
electrodes, which penetrate light clothing and skin.” These electrodes
remain attached to the TASER by copper wires, which deliver up to
50,000 V at 19-Hz. This results in extreme discomfort and skeletal
muscle tetany, as well as convulsions and other adverse effects, in some
cases [16,17]. In fact, many TASER encounters have resulted in visits to
emergency rooms and hospitalizations.
2.1. Penetrating Injury
In one case, a 16-year-old male presented to the Emergency Room
with a TASER electrode penetrating his right forehead, after resisting
arrest. He complained of a mild headache, but was otherwise grossly
neurologically intact upon physical examination. The lodged electrode
dart was immobile, so the patient underwent computed tomography
(CT) of the head, which showed intracranial penetration of the dart and
possible perforation of the dura mater. The patient was admitted for
surgery, to remove the electrode, which had indeed penetrated the dura
and brain parenchyma. Surgeons observed discoloration of the dura,
likely resulting from the electric current. The patient had an uneventful
post-operative course and was discharged without focal neurologic
deficits [18].
An inebriated 27-year-old male, resisting arrest, became incapacitated
after law enforcement struck him with a TASER X26. He was
allowed to return home, but decided to go to a hospital a few hours later
because of a headache. Upon arrival to the Emergency Department, he
was conscious. However, examination revealed a barbed electrode in his
right frontal skull along with a periorbital bruise. The patient’s GCS
(Glasgow Come Scale) was 15 and neurological examination was
normal. Head x-ray confirmed that the electrode was lodged in the
frontal bone. Subsequent CT Head studies revealed that the patient
sustained an encephalic injury to the right frontal lobe. More specifically,
the injury was localized to the squama frontalis, a smooth convex
surface of the lateral right frontal bone. Imaging revealed a squama
thickness of 5.6 mm and that the probe had penetrated a few millimeters
deeper, through the dura and into the right frontal cortex. The patient
was admitted to neurosurgery to remove the probe from the frontal
parenchyma, which revealed a “minor hemorrhage at the tip.” The patient
was eventually discharged without major complications. However,
he endorsed persistent, throbbing frontal headaches associated with
physical activity and head extension for more than five months after
surgery. In addition, the patient endorsed sleep disturbances, anxiety,
irritability, and difficulty with concentrating, although these symptoms
resolved after a few months [19].
2.2. Cerebrovascular accident
It is especially important to take note of the cases that involve
damage to extremely vital organs, such as the brain and heart. As
described by Bell et al. (2014), the TASER has the ability to reach very
high currents, which can induce spasms in vessels along with endothelial
lesions. This in turn can serve as a focal point for arterial ischemia and
can ultimately lead to catastrophic cerebrovascular accidents and
myocardial infarctions [20].
A 32-year-old male presented to the Emergency Department with
right-sided weakness, altered mental status, dysarthria, and forehead
abrasions after a confrontation with law enforcement officers, who fired
a TASER. CT Head revealed an acute, ischemic infarct involving the left
MCA (Middle Cerebral Artery) territory with surrounding edema and
mass effect. Subsequently, CTA (Computed Tomography Angiography)
and MRI/MRA (Magnetic Resonance Imaging/Magnetic Resonance
Angiogram) of the head and neck were performed. These studies
revealed filling defects in the distal M1 and proximal M2 segments of the
MCA, “with restricted diffusion in the MCA territory.” EKG, TTE (Transthoracic
echocardiogram), and TEE (Trans-esophageal echocardiogram)
were all performed to rule out a cardio-embolic etiology, but all studies
were negative [20].
2.3. Myocardial infarction
A 20-year-old male presented to the Emergency Department with
TASER probes lodged in his posterior upper right thorax following an
altercation with police. Thirty minutes after arrival, the patient
endorsed burning, retrosternal chest pain, described as “5/10 in intensity,”
along with associated dyspnea. His symptoms resolved after
receiving aspirin and nitroglycerin. EKG showed ST segment elevation
in the inferior leads and troponin levels were elevated, consistent with
evolution of an acute, inferior wall infarct. The patient was admitted for
emergent coronary angiography, which revealed patent coronary arteries
that were “angiographically normal.” Finally, left ventriculography
showed “hypokinesis of the distal inferior wall, with an ejection
fraction of 60%.” The remainder of the patient’s admission was unremarkable,
except for some instances of elevated blood pressure. The
patient was discharged with aspirin, an ACE inhibitor, a statin, and a
beta-blocker [21].
2.4. Limb injuries
An 18-year-old male presented to the Emergency Department with a
finger injury following an attempt to evade French law enforcement. In
order to detain the subject, an officer discharged a TASER, penetrating
the middle phalanx of his left index finger. Physical examination
revealed no sensory or motor deficits in the left upper extremity. AP
(anterior & posterior) and lateral radiographs confirmed penetration of
the dart at the base of the left middle phalanx. Physical examination
revealed that active flexion of the distal phalanx was compromised.
Surgery was performed to remove the dart and address the injuries. The
patient was given a course of antibiotics after surgery and discharged.
On post-operative day 15, the patient was re-evaluated and found to
have recovered all range of motion, with no motor or sensory deficits
[22].
2.5. Vertebral compression fractures
A 38-year-old law enforcement officer was participating in CED-use
training when he volunteered to be shocked in the shoulder and hip.
Following this incident, he experienced persistent, severe, thoracic
muscle spasms, so he went to the Emergency Room for medical evaluation.
Physical examination revealed diffuse tenderness over the
thoracic spine, but no point tenderness. Thoracic and lumbar x-rays
showed compression fractures at T6 and T8 (with “30% loss of vertebral
body stature”) and anterior wedging at L2. CT imaging confirmed these
findings along with several posterior disc bulges of the lumbar spine.
The patient endorsed no risk factors for pathological fracture. He was
admitted to the hospital for fitting of a Jewett hyperextension orthosis
for comfort and was discharged the next day. At a 9-week follow-up, he
was still experiencing significant pain and was not able ambulate
properly [23].
A 23-year-old employee at the Department of Corrections volunteered
as a test subject for a CED demonstration. TASER leads were
placed on his right shoulder and ankle and the device was discharged.
The patient began complaining of muscle contractions in his bilateral
flanks along with severe mid-back pain. He then presented to the
Emergency Department for medical evaluation. On physical examination,
he appeared in severe distress with elevated blood pressure of 168/
100. The patient had diffuse thoracic midline and bilateral paravertebral
tenderness, as well as limited range of motion due to the pain. CT Chest
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with contrast showed acute compression fractures of the “superior
endplates of the sixth, seventh, and eighth thoracic vertebrae without
retropulsion of any of the spinal fragments.” He was transferred to a
Level I trauma center where a neurosurgeon consulted on the case. Ultimately,
non-operative management was pursued, using a thoracolumbar-sacral
orthosis device, physical therapy, and pain medication.
After five days, the patient was discharged with a plan for outpatient
follow-up [24].
3. Tear gas
Tear gas contains chemicals such as oleoresin capsicum (OC), orthochlorobenzylidene
malononitrile (CS), or chloro-acetophenone (CN),
which induce acute irritation of mucus membranes, leading to irritation
of the eyes, rhinorrhea, skin inflammation, and respiratory distress. It is
used by law enforcement to quell riots and can be fired in the form of
canisters from tear gas guns. In addition to the aforementioned chemical
effects, tear gas capsules can cause blunt force trauma, if fired incorrectly.
[25]
3.1. Multisystem hypersensitivity reaction
An incarcerated 30-year-old man presented to the Emergency
Department with moderate respiratory distress, eight days after an
altercation with prison guards, who sprayed the individual with tear gas.
On physical exam, diffuse bilateral rhonchi were auscultated and
bilateral conjunctival injection and icterus were present. The patient’s
abdominal exam was also significant for guarding. Chest x-ray showed
“inhomogeneous ground glass and linear opacities in the left lower lobe
and lingula, as well as increased reticulonodular markings in the right
base.” Abdominal ultrasound was unremarkable.
The patient was diagnosed with “bronchoconstriction and pneumonitis”
secondary to a tear gas-mediated hypersensitivity reaction. A
repeat chest x-ray showed improvement four days after the first radiograph.
The patient was discharged with prednisone; however, after he
finished his course, his dyspnea and cough recurred, so he returned to
the Emergency Department. He was subsequently admitted to the ICU
for severe asthma exacerbation. He also complained of severe pruritis.
After improvement of his symptoms, he was again discharged and followed
up after six months in the outpatient setting. Results of allergy
skin testing showed “marked sensitization to CS,” the chemical ultimately
determined to be the culprit of his illness [26].
3.2. Maxillofacial trauma
Three men (32, 38, and 41 years of age) all presented to the hospital
with gun shot wounds sustained in the Syrian Civil War. All three men
had irregular maxillofacial wounds, including ecchymoses ranging from
2 to 4 cm in diameter. The 32 and 41-year-old both had unremarkable
brain CT scans. CT scans of the maxillofacial region in the 32-year-old
showed “severe soft tissue damage” and multiple fractures with a
foreign body lodged inside, which was deemed to be a tear gas capsule
fragment. He underwent reconstructive surgery and was ultimately
discharged. Maxillofacial CT of the 41-year-old was essentially the same
as that of the 32 year old. Unfortunately, he developed septic shock and
died on his 10th day of admission. The 38-year-old man deteriorated
into cardiopulmonary arrest and was intubated after successful CPR and
ROSC (Return of Spontaneous Circulation). Brain CT was performed,
which showed “a foreign body in the deep maxillofacial region.” Unfortunately,
the patient’s condition continued to deteriorate into cardiac
arrest, again, and he ultimately expired despite ACLS (Advanced Cardiac
Life Support) measures [25].
4. Flash-ball
The Flash-Ball is an alternative, non-lethal weapon that fires large
rubber balls, rubber bullets, rubber buckshot, and pellets containing
“coloring or irritating chemicals.” These projectiles fire with up to 200 J
of kinetic energy. In comparison, a major league fast ball reaches up to
50 J [27,28]. Although the gun is not designed to penetrate skin, it can
cause significant damage to it, as well as severely damage internal organs,
rarely. For this reason, it is not surprising that the use of flash-ball
is the ultimate step before the use of deadly force [29].
4.1. Soft tissue contusions
A 22-year-old man presented to the Emergency Department with
multiple bruises after losing consciousness during a political demonstration,
where riot police fired rubber bullets. Physical examination
revealed ten contusions on the abdominal wall and thighs. CT Abdomen,
EKG, and labs were unremarkable. The patient rejected analgesic
treatment and was discharged [28].
4.2. Cardiac and pulmonary contusions
A 25-year-old man was mutilating himself with a knife when police
subdued him, using a Flash-Ball gun. Upon arrival to the Emergency
Department, he complained of severe lower thoracic pain. The patient
was mildly hypoxic with oxygen saturation of 91% and his chest x-ray
was unremarkable. CT of the head, neck, and chest revealed a pulmonary
contusion. Although an EKG was unremarkable, troponin was
slightly elevated, indicative of cardiac contusion, as well. The patient’s
cardiac enzymes and blood gases normalized over the day and he was
discharged the following morning with analgesics [28].
4.3. Craniocerebral trauma
A 34-year-old man in France presented to the Emergency Department
with a severe left-sided headache after being shot in the side of the
head by police using a Flash-ball gun at a riot. The patient endorsed a
loss of consciousness immediately after being shot. He was admitted to
the hospital under the care of neurosurgery. Physical examination
demonstrated a large left frontotemporal hematoma with a “severe
contusion mark 60 mm in diameter with an abrased ring 10 mm wide.”
CT Head confirmed the hematoma, as well as a left temporal bone
fracture extending towards the left temporomandibular joint. Imaging
also showed “a moderate cerebral edema” and “a pneumocephalus
associated with a left fronto-temporal hemorrhagic contusion accompanied
by extra-axial and subarachnoid hemorrhage.” [29] The right
side of the head was unremarkable. The patient’s hospital course was
non-operative, primarily consisting of rehabilitation. One week after
admission, the patient had a generalized tonic-clonic seizure, which was
treated with Levetiracetam. After two months, the patient had sustained
significant complications, including circular alopecia scarring in the
frontotemporal area, left destructive vestibular syndrome, and subjective
syndrome of brain injury (a neuropsychological disorder). He also
experienced dysarthria and right-handed weakness secondary to left
motor cortex damage [29].
CT Head imaging is the standard of care in such cases of craniocerebral
trauma, in order to rapidly and efficiently evaluate for soft tissue
and bone damage, as shown in another case involving globe rupture and
orbital bone fracture secondary to a rubber bullet injury (Fig. 1).
5. Beanbag
A shotgun is typically used to fire a beanbag – a synthetic bag that
contains 40 g of lead pellets. It is similar to the Flash-ball gun and it is
designed to inflict painful, superficial injuries [30]. It is recommended
for an individual to stand 3 to 10 m away from his or her intended target
when firing this weapon, which can discharge projectiles up to 90 m/s.
In 2004, the National Institute of Justice reviewed 373 injuries caused
by “less lethal weapons.” Among the less lethal munitions, the beanbag
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Clinical Imaging 79 (2021) 165–172
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was most commonly used and was responsible for 65% of injuries. This
same study noted eight beanbag-related deaths, mostly due to thoracic
injury, with one death caused by a penetrating neck wound [31].
As discussed in the following sections, beanbags can become
embedded in the body, in rare instances. Two examples include an individual
involved in an altercation with law enforcement, with an
embedded beanbag in the left elbow on x-ray (Fig. 2) and another individual
who sustained cranial fractures and pneumocephalus secondary
to a beanbag rifle while resisting arrest (Fig. 3).
6. Penetrating thoracoabdominal injury
A 46-year-old male presented to the Emergency Department with
severe right-sided chest pain and dyspnea after an altercation with the
police. After verbal resolution failed, the police shot the individual in the
chest with a beanbag. On physical exam, the patient was tachypneic and
there was a 3.0 × 3.5 cm entry wound on the right parasternal border. A
chest x-ray showed a right hemopneumothorax and a radiopaque
foreign body. The patient underwent a right thoracotomy, which
revealed a beanbag pellet in the right lung with a surrounding hematoma
of the middle lung. The foreign body was extracted and the surrounding
area was irrigated and debrided. The patient’s postoperative
course was uneventful and he was discharged after five days [30].
Police escorted another male of unknown age to an Emergency
Department after an altercation. Law enforcement had shot him twice
with a TASER and once in the left lateral chest with a beanbag, from
approximately 6 ft away. The patient’s blood pressure was elevated at
159/99 mmHg and he was tachycardic at 106 bpm (beats per minute).
Physical examination showed a 2 cm wound of the chest wall anterior
and medial to the left axilla with crepitus. The patient was admitted for
cardiac evaluation and possible surgery. CT Chest with contrast revealed
a 3.6 × 1.4 cm foreign body bordering the pericardium with a small left
pulmonary contusion. Imaging also showed a left apical pneumothorax
and hemothorax. The patient underwent surgery to remove the beanbag.
There were no postoperative complications [32].
CT Thorax or Abdomen are first-line diagnostic modalities in
Fig. 1. A (axial), 1B, 1C, 1D (coronal) show the non-contrast CT Maxillofacial of a 35-year-old male who shot in the right eye by law enforcement with a rubber
bullet. Imaging reveals, rupture of the right globe (white), right orbital floor fracture extending to the orbital rim (black), and right zygomaticomaxillary complex
comminuted fracture (blue) [33]. (For interpretation of the references to color in this figure legend, the reader is referred to the web version of this article.)
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Clinical Imaging 79 (2021) 165–172
169
evaluating for penetrating body injuries, such as in the case of a 50-yearold
male involved in an altercation with law enforcement, who sustained
pulmonary injuries due to a beanbag (Fig. 4).
De Brito et al. (2001) discuss several cases of anterior injuries to
patients by law enforcement using beanbag weapons. One such case
involves a 45-year-old man who was struck in the right chest with a
beanbag. Physical examination revealed a 4 cm laceration just below the
right nipple. CT Chest showed a large pulmonary contusion with the
beanbag lodged in the right posterior chest cavity. He underwent surgery,
which revealed that the beanbag had ruptured into approximately
100 pieces, requiring removal from the pleural cavity. Another case
involves a 32-year-old male who was struck by a beanbag in the right
upper quadrant and genitals. CT Abdomen/Pelvis revealed a subcapsular
hematoma of his left liver lobe and contrast extravasation
within the scrotum. The patient sustained right testicular hemorrhage
and fracture, requiring surgical removal [27].
Of note, penetrating injuries often require CT Angiography to assess
the patency of vasculature, to rule out traumatic hemorrhage or occlusion
of vessels, such as in compartment syndrome (Fig. 5).
6.1. Penetrating ocular trauma
Another patient of unknown age, involved in an altercation during
civil unrest, presented to the Emergency Department after being shot in
the eye with a beanbag. He endorsed right facial pain and vision loss. A
head CT showed a “3 cm hyperintense mass” in the nasopharynx “lodged
against the anterior skull base.” Due to the proximity of the object to the
cavernous carotid artery, an angiogram was performed, which showed
no damage to the arterial system. The patient was admitted for surgery
to extract the foreign body. Complications included a tattered right
eyelid, which was ultimately not viable [31].
While the TASER uses electromagnetic energy, the Flash-ball and
beanbag deliver kinetic energy. As such, the resulting injury profiles can
be quite different. In some cases, the TASER can cause thromboembolic
and vasospastic ischemic events due to the electric current it generates.
In contrast, the Flash-ball and beanbag inflict more blunt trauma due to
fired projectiles. Therefore, it is logical that weapons predicated on kinetic
energy have caused more serious structural injuries, such as
various types of contusions and fractured bones. Cranio-cerebral blunt
trauma secondary to a Flash-ball weapon (discussed above) produced a
fracture and devastating, lasting neurological side effects that the patient
endured well beyond the hospital stay. If they strike a precise
location, kinetic energy-driven weapons can potentially be fatal, as
demonstrated by a case of commotio cordis-related death after chest
trauma from a Flash-ball gun, in an otherwise healthy middle-aged male
[29]. Commotio cordis describes a fatal ventricular fibrillation secondary
to blunt force trauma to the anterior precordium directly overlying the
heart, at a specific time of the cardiac cycle (i.e. early T wave) [32].
6.2. Subject resistance and police use of force (UOF)
Aforementioned cases describe different types of injuries using nonlethal
weaponry that usually involved altercations with law enforcement
(Table 1). It is also relevant to discus how often officers use particular
types of weapons, as well as the frequency of significant injuries.
Mesloh et al. (2008) analyzed information from two law enforcement
agencies in Florida over a five-year period (2000–2005). During this
time period, there were 4303 “first altercations” with suspects where
law enforcement pursued a particular UOF before escalating or deescalating
UOF (“second altercation”). 2775 of these encounters involved
aforementioned modalities (i.e. CED, tear gas, and beanbag), as well as
non-physical (i.e. verbal) intervention. 49.11% of this cohort involved
use of CED, 11.88% involved use of chemical agents (i.e. tear gas and
pepper spray), 3.35% involved use of verbal intervention, and 0.16%
involved use of beanbag [33]. (Table 2).
Bozeman et al. (2018) examined three-midsized police agencies over
two years and concluded that police UOF rarely results in significant
injuries. Out of 914 suspects, 898 (98.2%) did not experience significant
injury from UOF. Moderate to severe injuries, most of which were
associated with canines and firearm use, occurred in the remaining 16
suspects (1.8%). In this study, use of CED caused no significant injuries
[34].
7. Discussion
Over several decades, law enforcement has used non-lethal weapons
to subdue individuals, in order to reduce mortality and morbidity in
altercations with the public. Most altercations result in minimal injury.
Ordog et al. (1987) compared CED injuries by the police to firearm injuries
by police using 0.38 Smith & Wesson Special handguns. The authors
reviewed 218 patients who were shot by TASER and 22 who were
shot by the 0.38 Special. The long-term morbidity of the TASER cohort
was 0% compared to 50% (p < 0.05) in the 0.38 Special group. Therefore,
TASERs appear to be relatively safe in terms of potential morbidities
when compared to conventional firearms [35]. This same
conclusion for other non-lethal weapon is supported by the aforementioned
study by Bozeman et al. [34] Thus, these aforementioned
weapons provide effective and safer alternatives than firearms for law
enforcement.
Fig. 2. A (lateral), 2B (oblique), and 2C (AP) show the complete left elbow xray
of a 27-year-old male presenting after an altercation with law enforcement.
A 3.0 × 2.3 cm lobular well circumscribed metallic density is visualized.
Additionally, a 2.1 cm skin laceration with soft tissue swelling and subcutaneous
emphysema in the lateral soft tissues at the level of the distal humerus
reveals the entry wound.
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Clinical Imaging 79 (2021) 165–172
170
However, this does not negate the fact that non-lethal weapons can
indeed cause moderate or severe injuries in some instances, such as with
previously discussed cases of CED-triggered vertebral fractures or fatal
injuries associated with tear gas canisters. Tyagi et al. (2017) state there
have only been two reported cases of vertebral fractures secondary to
CED use over a ten-year period [24]. Interestingly, in both aforementioned
cases, each volunteer had two leads: one on the shoulder and
another on the lower half of the body [24]. Theoretically, this balanced
placement across the spine could have stimulated the paraspinal muscles
enough to elicit a contraction intense enough to cause compression
fractures, even in patients that are not at risk of pathologic fractures (i.e.
osteoporotic patients).
Although the only two fatalities discussed in prior cases both
occurred with tear gas, these injuries were sustained in the Syrian Civil
War. As such, it’s possible they did not receive the standard of care
patients in the other cases received. One of the patients succumbed to
septic shock, an indirect outcome. Additionally, both patients had
already sustained gunshot wounds, so it’s likely firearms contributed
significantly to their deaths (e.g. via hemorrhagic or hypovolemic
shock). Thus, these cases are statistical outliers and not representative of
the most likely outcomes with non-lethal weapons.
It can be difficult to ascertain the extent of non-lethal weapon injuries
by clinical examination alone, as physical damage is often not
externally visible. Thus, imaging is invaluable in diagnosing inconspicuous,
yet significant injuries, which could otherwise remain undetected
on clinical examination, such as electrical damage to the superficial
brain parenchyma by TASER. Moreover, imaging is pivotal in dictating
medical decision-making, as well. For example, in an aforementioned
case of a suspect who presented with a beanbag lodged in his nasopharynx,
an angiogram was performed to rule out an arterial bleed. A
positive study would have required an immediate embolization; however,
since the angiogram was negative, the patient was admitted to
surgery for removal of the foreign body. Therefore, appropriate use of
imaging facilitates timely recognition, diagnosis, and treatment of lifethreatening
injuries.
8. Conclusion
Non-lethal weapons rarely cause significant injuries; however, exceptions
do occur and changes can still be implemented to improve
outcomes. For example, officers using kinetic-energy devices (e.g.
beanbag and flash ball weapons), as well as TASERs, could aim to avoid
vital organs (e.g. brain, heart, and lungs), if possible, which portend
more severe injuries and potential surgeries. Aiming for the abdomen or
extremities would likely result in less severe injuries and outcomes.
Moreover, certain modalities appear to be more effective in resolving
altercations than others. Mesloh et al. found that 69.1% of CED encounters
were resolved (30.9% of CED cases required additional interventions),
64.4% of chemical agent encounters were resolved, 0.7%
of verbal encounters were resolved, and 28.6% of beanbag encounters
were resolved. Therefore, an officer might consider using a TASER
instead of a beanbag rifle in certain situations, as it appears to be 40.5%
more effective in resolving altercations [33].
However, research on injuries due to non-lethal UOF is limited and
requires further investigation [36]. Future studies should accrue more
clinical data and imaging correlates in order to better understand the
Fig. 3. A (coronal), 3B, 3C, 3D, 3E (axial), and 3F (sagittal) show the CT Head without contrast of a 21 year-old-male who was evading the police and shot in the
head with a beanbag. Finding shows comminuted frontal calvarial fractures with metallic fragments extending into the right and left orbits, as well as lamina
papyracea and bilateral nasal bones. Small pockets of pneumocephalus are also visible.
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171
extent of harm and injury patterns non-lethal weapons can cause, which
will in turn decrease the necessity for firearms. Imaging provides a
crucial link between sustained injuries and injury patterns, in order to
more effectively evaluate and manage such patients upon initial presentation.
Additionally, radiology studies can guide which areas of the
body law enforcement targets and avoids, as well as which non-lethal
weapons are employed, in order to effectively and safely subdue suspects
in various situations.
Author contributions
NSM conducted the case literature review and drafted the manuscript,
with support from AG, who conceived the concept. DS contributed
to the case literature review and revised the manuscript. MS
collaborated in conceiving the concept and contributed to the case
literature review. AG also provided feedback, guidance, and supervised.
IRB
N/A
Funding
N/A
Declaration of competing interest
None.
References
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Fig. 4. A (axial) and 4B (coronal) show CT thorax w/ contrast of a 50-year-old
male with history of schizophrenia brought in by the police after he was found
swinging large pipes in public. After law enforcement attempted verbal resolution,
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pulmonary laceration and contusion (white arrow), as well as a small right
pneumothorax (black arrow).
Fig. 5. CT Angiography left upper extremity (A, axial, and B, sagittal) for a 31year-old
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brachial artery.
Table 1
Law enforcement UOF modality and type of injuries
UOF modality Injuries inflicted (x Number of cases)
Conducted Energy
Devices (CED)
Intracranial Dart Penetration (x2), Cerebrovascular
Accident (x1), Myocardial Infarction (x1), Left Middle
Phalanx Penetration (x1), Vertebral Compression Fracture
(x1)
Tear Gas
Hypersensitivity Reaction (x1), Maxillofacial Capsular
Penetration (x3)
Flash Ball
Abdominal and Thigh Contusions (x1), Cardiac and
Pulmonary Contusions (x1), Left Sided Hematoma &
Temporal Bone Fracture (x1)
Bean Bag
Hemopneumothorax (x2), Pulmonary Contusions (x2),
Subscapular Injury of Liver & Scrotal Hemorrhage (x1),
Penetrating Ocular Trauma (x1)
Table 2
Florida police department UOF modalities for “first altercation incidents”
adapted from Mesloh et al. (2008).
UOF modality Incidents Percent
Bean bag 7 0.16%
CED 2113 49.11%
Tear gas & pepper spray 511 11.88%
Non-Physical (i.e. verbal intervention) 144 3.35%
N.S. Manhas et al.
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