AAEM
Clinical Practice
EMERGENCY DEPARTMENT EVALUATION AFTER CONDUCTED ENERGY WEAPON
USE: REVIEW OF THE LITERATURE FOR THE CLINICIAN
Gary Vilke, MD,* Ted Chan, MD,* William P. Bozeman, MD,† and Richard Childers, MD*
*Department of Emergency Medicine, University of California, San Diego Health, San Diego, California and †Department of Emergency
Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina
Reprint Address: Richard Childers, MD, Department of Emergency Medicine, UC San Diego Medical Center, 200 West Arbor Drive, Mail Code
#8676, San Diego, CA 92103
, Abstract—Background: Conductive energy weapons
(CEWs) are used daily by law enforcement, and patients
are often brought to emergency departments (EDs) for medical
clearance. Objective: Our aim was to review the medical
literature on the topic of CEWs and to offer evidence-based
recommendations to emergency physicians for evaluation
and treatment of patients who have received a CEW exposure.
Methods: A MEDLINE literature search from 1988
to 2018 was performed and limited to human studies published
from January 1, 1988 to November 1, 2018 written
in English with the following keywords: TASER, conductive
energy device(s), electronic weapon(s), conductive energy
weapon(s), non-lethal weapon(s), conducted energy device(s),
conducted energy weapon(s), conductive electronic device(s),
and electronic control device(s). Studies identified then underwent
a structured review from which results could be
evaluated. Results: Two hundred and sixty-three articles
on CEWs were screened and 37 appropriate articles were
rigorously reviewed. Evaluation and treatment recommendations
are presented. These studies did not report any evidence
of dangerous laboratory abnormalities, physiologic
changes, or immediate or delayed cardiac ischemia or dysrhythmias
after exposure to CEW electrical discharges of
up to 15 s. Conclusions: The current medical literature
does not support routine performance of laboratory studies,
electrocardiography, or prolonged ED observation or
hospitalization for ongoing cardiac monitoring after CEW
exposure in an otherwise asymptomatic awake and alert
patient. Ó 2019 Elsevier Inc. All rights reserved.
, Keywords—conductive energy weapons; TASER; electronic
weapons; systematic review
INTRODUCTION
Use of conducted energy weapons (CEWs), such as the
TASER, includes delivery of a series of electrical pulses,
which result in pain and muscular contractions. The electrical
pulses can be delivered by a pair of metal probes
propelled from the device, commonly referred to as
‘‘probe mode,’’ or by direct contact with the end of the device,
commonly referred to as ‘‘drive stun’’ or ‘‘touch
stun’’ mode.
Clinical practice managing patients who present to the
ED after being exposed to a CEW are varied. This article
reviews the medical literature on the topic of CEWs and
offers evidenced-based recommendations to emergency
physicians for evaluation and treatment of patients who
have received a CEW exposure. The clinical question
is: Do patients who present to an ED after a CEW exposure
require any specific radiographic or laboratory evaluation
or any specific monitoring because of the use of a
CEW itself? This work was done at the request of and
published as a position statement by the American
Clinical Practice Paper approved by the American Academy
of Emergency Medicine Clinical Guidelines Committee.
740
The Journal of Emergency Medicine, Vol. 57, No. 5, pp. 740–746, 2019
Ó 2019 Elsevier Inc. All rights reserved.
0736-4679/$ - see front matter
Academy of Emergency Medicine (AAEM) Clinical
Guidelines Committee. The original AAEM Guidelines
on this topic were published in 2011 (1). This article
will update findings from that article to include more
contemporary literature.
MATERIALS AND METHODS
This study is a structured review of the literature on the
topic of CEWs. A literature search of the National
Library of Medicine’s MEDLINE database’s PubMed
system was performed and limited to studies published
from January 1, 1988 to November 1, 2018 written in
the English language. Keywords used in the search
were: TASER, conductive energy device(s), electronic
weapon(s), conductive energy weapon(s), non-lethal
weapon(s), conducted energy device(s), conducted energy
weapon(s), conductive electronic device(s), and
electronic control device(s). After searching the articles
found from these keyword parameters, the reference
sections were also reviewed for additional
articles.
Studies included for the final review were limited to
randomized controlled trials, clinical trials, prospective
and retrospective cohort studies, and meta-analyses in
human subjects. Case reports, case series, and general
review articles were not included for the selection
criteria for formal rigorous review. The final list of articles
was assessed independently by two emergency
physicians to determine the classification of the article,
and deem whether it was appropriate for formal review.
Each of the articles selected underwent a Grade of Evidence
Review (grades A, B, C, or D). Each of the
selected articles was subjected to detailed review by all
three authors. The level of the evidence was assigned a
grade using the definitions as noted in Table 1 and were
based on reference focus, specific research design, and
methodology.
Each of the selected articles was also subjected to
detailed review and assigned a Quality Ranking
(Outstanding, Good, Adequate, Poor, or Unsatisfactory)
based on a critical assessment with regard to quality of
the design and methodology. This includes Design
Consideration (eg, focus, model structure, and presence
of controls) and Methodology Consideration (ie, actual
methodology utilized). The definitions of the quality
ranking scores are included in Table 2.
Independent review of the articles as well as discussion
and joint review by the authors was undertaken to
answer the clinical question. Finally, recommendations
were made based on the review of the literature and
assigned a level of recommendation (class A, B, C, or
indeterminant), which are defined in Table 3.
RESULTS
The findings of the original keyword search in MEDLINE
are noted in Table 4. Combining these references resulted
in 263 unique articles on CEWs. From these original 263
articles, the reference sections were also reviewed, and no
further novel articles were identified. The numbers of references
yielded by the various search parameters are
included in Table 4. There were a total of 37 articles
deemed appropriate for intensive critical review based
on their suspected relevance to the clinical question.
These 37 articles are briefly described in Table 5 and
include: randomized controlled trials (n = 2), prospective
controlled trials (n = 2), prospective cohort studies
(n = 28 ), and retrospective cohort studies (n = 5).
The vast majority of studies (n = 30) received an
evidence grade of C (prospective, controlled, nonrandomized,
cohort studies); 5 studies were grade D,
and 2 studies were grade B. No studies were determined
to reach the A grade level (randomized clinical trial or
meta-analysis directly addressing the review issue). All
but three of the studies were determined to be Good or
Outstanding in terms of quality, as determined by the re-
viewers.
Based on this analysis, the following recommendations
were formulated as classified by level of recommendation/evidence
(A, B, C).
Recommendation 1: Cardiac Monitoring and
Electrocardiography Screening after CEW Use
Level of recommendation: class A. The current human
literature has not found evidence of immediate or delayed
cardiac ischemia or dysrhythmias after CEW exposures
of up to 15 s. Therefore, the medical literature does not
support routine performance of electrocardiograms
(ECGs), prolonged ED observation, or hospitalization
for ongoing cardiac monitoring after CEW exposure in
an otherwise asymptomatic awake and alert patient with
a short duration (< 15 s) of CEW exposure.
Table 1. The Definitions of the Grades of Evidence of the
Articles
Grade Definition
A Randomized clinical trials or meta-analyses
(multiple clinical trials) or randomized clinical
trials (smaller trials), directly addressing the
review issue
B Randomized clinical trials or meta-analyses
(multiple clinical trials) or randomized clinical
trials (smaller trials), indirectly addressing the
review issue
C Prospective, controlled, non-randomized, cohort
studies
D Retrospective, non-randomized, cohort or case–
control studies
ED Evaluation after CEW Use 741
Studies have looked for dysrhythmias during and
immediately after CEW use (2–10). There have been no
reports of ectopy, dysrhythmia, QT prolongation,
interval changes, or other ECG changes immediately
following CEW use. Additionally, studies have looked
at delayed monitoring findings and there have been no
changes in ECGs up to 60 min or longer post CEW use
(3,7,11).
Studies have also looked at serial troponin levels as
a marker of cardiac injury or ischemia. A number of
studies have looked at troponin levels at 6 h post
CEW activation, and all levels except one troponin
level have been normal (3,4,7,12). The one study that
showed elevated troponin was on a healthy young
male subject who received a 5-s TASER activation
(3). The troponin I values were all < 0.3 ng/mL, except
a single value of 0.6 ng/mL at the 24-h draw, which
had been normal at the 16-h draw, and returned to
normal within 8 h of the reported elevation. The subject
was evaluated at the hospital by a cardiologist
and showed no evidence of myocardial infarction or
cardiac disability. More recent studies have measured
troponin initially and at 24 h; no clinically significant
elevations were found (9,10,13–15).
Echocardiograms during CEW use have also shown no
abnormalities during activation that suggest structural
cardiac damage (5,9,10,14–17). Due to the proximity to
the myocardium, probes inserted in the anterior chest
are at highest risk of inducing cardiac capture. There
have been 66 human subjects who have had continuous
monitoring during anterior chest wall probe placement;
no cases of ventricular fibrillation (VF) were induced
and one case of capture was recorded (18). This case
occurred with an experimental CEW device model,
which was never manufactured or released for commercial
use (9).
Recommendation 2: Laboratory Testing after CEW Use
Level of recommendation: class A. The current human
literature has not found evidence of dangerous laboratory
abnormalities or physiologic changes after CEW exposures
of up to 15 s. Therefore, the medical literature
does not support routine performance of laboratory
studies, prolonged ED observation, or hospitalization
for ongoing laboratory monitoring after a short duration
of CEW exposure (< 15 s) in an otherwise asymptomatic
awake and alert patient.
Studies have not shown any clinically significant
changes in electrolyte levels or renal function in subjects
with up to 15-s CEW activations (3,7,10,13,19–21).
There have been mild, but clinically insignificant
elevations in lactate levels with CEW activations.
However, these have been demonstrated to be of a
smaller magnitude relative to other forms of physical
exertion with a similar duration (3,4,7,10,13–15,20–28).
Table 2. The Definitions of the Quality Ranking Scores of the Articles
Ranking Design Consideration Present Methodology Consideration Present Both Considerations Present
Outstanding Appropriate Appropriate Yes, both present
Good Appropriate Appropriate No, either present
Adequate Adequate with possible bias Adequate No, either present
Poor Limited or biased Limited No, either present
Unsatisfactory Questionable/none Questionable/none No, either present
Table 3. Definitions for Recommendations
Level of Recommendation Criteria for Level of Recommendation Mandatory Evidence
Class A: recommended with outstanding
evidence
Acceptable
Safe
Useful
Established/definitive
Level A/B grade
Outstanding quality
Robust
All positive
Class B: acceptable and appropriate with
good evidence
Acceptable
Safe
Useful
Not yet definitive
Level A/B grade lacking
Adequate to good quality
Most evidence positive
No evidence of harm
Class B1 Standard approach Higher grades of evidence
Consistently positive
Class B 2 Optional or alternative approach Lower grades of evidence
Generally, but not consistently, positive
Class C: not acceptable or not
appropriate
Unacceptable
Unsafe
Not useful
No positive evidence
Evidence of harm
Class indeterminate unknown Minimal to no evidence Minimal to no evidence
742 G. Vilke et al.
There have been three studies of humans, with a total
of 241 patients, examining the rise of creatine kinase
(CK) levels with CEW use (10,11,29). While there were
small rises in CK, none were clinically significant. Of
note, those subjects that were found to have a rise in
CK were often found to have broken study protocol and
performed strenuous exercise immediately after CEW
exposure and prior to blood sampling 24 h after exposure.
Acid–base status has been evaluated and has not
shown any significant pH shifts for a 5-s CEW activation
(3,7,20,25). Similar findings with mild transient pH shifts
were noted in CEW use for longer durations of
application up to 15 s (10,13–15,19,21,28).
Recommendation 3: Evaluation after Use of CEW in
Drive Stun or Touch Stun Mode
Level of recommendation: class B.For patients who have
undergone drive stun or touch stun CEW exposure, medical
screening should focus on local skin effects at the
exposure site, which may include local skin irritation or
minor contact burns. This recommendation is based on
a literature review in which thousands of volunteers and
individuals in police custody have had drive stun CEWs
used with no untoward effects beyond local skin effects.
Table 4. Search Parameters for All English Language
Papers Found
Search Parameter
All
References, n
Final
Review, n
Conductive electronic devices 1608 0
Taser 327 13
Conductive energy devices 994 2
Conductive electronic device 965 0
Conductive energy device 649 2
Electronic weapon 1169 5
Electronic weapons 955 5
Conducted energy weapons 102 4
Non-lethal weapons 55 2
Non-lethal weapon 52 0
Electronic control devices 20,296 0
Electronic control device 16,365 0
Conducted energy weapon 128 1
Conductive energy weapon 10 2
Conductive energy weapons 9 2
Conducted energy device 1140 0
Conducted energy devices 1463 0
Table 5. Details of the 37 Reviewed Articles
List No. First Author, Year (Reference) Grade Quality Design
1 Bozeman, 2009 (2) C Good Prospective cohort (n = 28)
2 Bozeman, 2009 (30) D Good Retrospective cohort (field use) (n = 1201)
3 Bozeman, 2012 (40) D Good Retrospective cohort (field use) (n = 178)
4 Criscione, 2014 (41) C Adequate Prospective cohort (n = 32)
5 Dawes, 2010 (16) C Good Prospective cohort (n = 10)
6 Dawes, 2010 (42) C Good Prospective cohort (n = 9)
7 Dawes, 2010 (14) C Outstanding Prospective cohort (n = 30)
8 Dawes, 2010 (15) C Outstanding Prospective cohort (n = 16)
9 Dawes, 2008 (24) C Good Prospective controlled trial (n = 32)
10 Dawes, 2009 (43) B Good Prospective randomized controlled trial (n = 52)
11 Dawes, 2011 (21) C Outstanding Prospective cohort (n = 53)
12 Eastman, 2008 (44) D Adequate Retrospective cohort (field use) (n = 426)
13 Gardner, 2012 (45) D Good Retrospective cohort (field use) (n = 100)
14 Havranek, 2015 (17) C Good Prospective cohort (n = 26)
15 Ho, 2012 (46) C Good Prospective cohort (n = 31)
16 Ho, 2010 (13) C Good Prospective cohort (n = 66)
17 Ho, 2011 (9) C Good Prospective cohort (n = 53)
18 Ho, 2009 (22) C Good Prospective cohort (n = 38)
19 Ho, 2009 (19) B Good Prospective randomized controlled trial (n = 40)
20 Ho, 2011 (23) C Good Prospective cohort (n = 25)
21 Ho, 2008 (5) C Good Prospective cohort (n = 34)
22 Ho, 2007 (4) C Outstanding Prospective cohort (n = 52)
23 Ho, 2006 (3) C Outstanding Prospective cohort (n = 66)
24 Ho, 2013 (25) C Good Prospective cohort (n = 37)
25 Ho, 2014 (10) C Good Prospective cohort. (n = 10)
26 Kroll, 2018 (27) C Good Prospective cohort (n = 31)
27 Levine, 2007 (6) C Good Prospective cohort (n = 105)
28 Moscati, 2010 (28) C Good Prospective cohort (n = 22)
29 Scherr, 2016 (47) C Good Prospective cohort (n = 71)
30 Sloane, 2008 (12) C Good Prospective cohort (n = 66)
31 Stopyra, 2017 (48) C Good Prospective cohort (n = 4)
32 Strote, 2010 (31) D Adequate Retrospective cohort (field use) (n = 1101)
33 Vanmeenen, 2013 (49) C Good Prospective cohort (n = 23)
34 Vanmeenen, 2010 (11) C Good Prospective cohort (n = 118)
35 Vilke, 2009 (20) C Outstanding Prospective controlled trial (n = 25)
36 Vilke, 2008 (8) C Good Prospective cohort (n = 32)
37 Vilke, 2007 (7) C Outstanding Prospective cohort (n = 32)
ED Evaluation after CEW Use 743
As mentioned, routine ECG, cardiac monitoring, laboratory
testing, or other forms of evaluation specific to
the electrical component of short duration CEW use are
generally unnecessary.
Recommendation 4: Evaluation after Use of CEW in
Probe Mode
Level of recommendation: class B.For patients who have
undergone probe-mode CEW exposure, medical
screening should focus on probe penetration sites, potential
injuries due to muscle contractions, and potential
trauma due to falls. CEW probes may strike the eyes
and penetrate skin and nearby superficial structures,
such as vessels, nerves, and bones. Muscle contractions
due to the CEW may produce spinal compression fractures
and other soft tissue injuries. Falls may occur
from loss of muscular control and protective reflexes, resulting
in blunt trauma. Literature review indicates that
significant injuries due to this mechanism are rare, occurring
in < 0.5% of real-world deployment in subjects
(30,31).
As mentioned, routine ECG, cardiac monitoring, laboratory
testing, or other forms of evaluation specific to
the electrical component of short-duration CEW use are
generally unnecessary.
DISCUSSION
CEWs are commonly used by police as a force option.
Civilian models of CEWs are also available to the public.
Patients may be brought to the ED for medical evaluation
after CEW exposure. The primary goal in conducting this
literature search was to identify whether routine monitoring,
ECG, with or without laboratory tests, are necessary
for a patient who presents after receiving an
electrical discharge from a CEW.
Our evaluation considered both techniques in which a
CEW can be used. They are the drive or touch stun mode
and the probe mode. In the drive stun mode, the end of the
device is placed in contact with the subject and locally
conducts energy across the two probes that are present
on the tip of the device. This mode typically causes local
painful stimuli. The other technique is the ‘‘probe mode,’’
which uses two metal probes that are propelled from a
distance into the subject or the subject’s clothing, causing
energy to arc a greater distance across the two probes. If
there is enough of a probe spread, generalized muscle
contraction, termed as neuromuscular incapacitation, is
produced. This may result in the subject falling if he or
she is in a standing position. Traumatic brain injuries
are probably the most serious result of these falls (32).
Rarely, direct traumatic injuries occur, including ocular,
skull, or genital penetration (33–35). Other case reports
of spinal compression fractures, presumably from
intense muscle contractions of the back musculature in
subjects with osteopenia, have been documented
(36,37). Very rarely, patients will be injured by serious
burns associated with CEW use; these will be obvious
and examination will guide treatment (38). There are no
rigorous studies demonstrating the effects on pregnant
women, so physicians will need to make clinical decisions
on the need for fetal assessment and monitoring
based on the type of CEW use, location, and patient pre-
sentation.
There has not been a documented case of CEWinduced
lethal VF that has withstood close scrutiny;
whether it is theoretically possible is controversial and
beyond the scope of this review (18,39). For the case of
this review, one should note that if a dysrhythmia is
going to be induced, the dysrhythmia should happen at
the time of the CEW discharge, not in delayed fashion
(39). Thus, providers evaluating a patient exposed to a
CEW who now has a reassuring examination can be
confident that the patient will not develop a delayed
dysrhythmia; and testing and monitoring specifically for
this possibility is unnecessary.
As noted, the literature review for this clinical guideline
focused on studies that involved rigorous methodologies
to evaluate the physiologic effects of CEWs in
humans. We did not include specific case reports or
case series, which in and of themselves cannot support
any causal connection between CEWs and physiologic
changes. We also did not include animal studies, which
are often more limited in scope and have questionable
applicability to clinical human findings.
Recommendations in this review are limited to CEW
exposure durations of # 15 s. This reflects the exposure
durations commonly used in the existing human literature
and applies to the large majority of subjects against whom
CEWs are used by police officers. While several reports
have included exposure durations of 20–45 s and have
not demonstrated concerning cardiac or physiologic effects,
collectively, this small body of literature is inadequate
to support guidelines on medical screening after
longer duration exposures. Therefore, clinicians should
use their own judgment regarding the need for screening
tests in this population.
It is important to point out that these recommendations
focus solely on the issue of CEWs and their physiologic
effects on humans. Clinical evaluation and testing may
very well be warranted when evaluating patients after
CEW application, not because of the CEW exposure,
but as a result of the patient’s underlying condition,
such as alcohol or drug intoxication, excited delirium
syndrome, altered mental status, physical exhaustion, or
psychiatric conditions that precipitated the application
of the CEW in the first place.
744 G. Vilke et al.
CONCLUSIONS
The current human literature has not found evidence of
dangerous or concerning laboratory abnormalities,
physiologic changes, or immediate or delayed cardiac
ischemia or dysrhythmias after exposure to CEW electrical
discharges of up to 15 s. Therefore, the current medical
literature does not support routine performance of
laboratory studies, ECGs, or prolonged ED observation
or hospitalization for ongoing cardiac monitoring after
CEW exposure in an otherwise asymptomatic awake
and alert patient.
Testing for cardiac abnormalities or injuries may be
appropriate in individual cases based on clinical presentation,
such as a history of cardiac disease or suggestive
symptoms like chest discomfort, shortness of breath, or
palpitations. Similarly, penetrating and blunt trauma as
a consequence of CEW exposure should prompt further
evaluation for traumatic and musculoskeletal injuries as
warranted. For CEW activations in the probe mode, patients
should be screened for injuries related to the dart
penetration or surface burns due to CEW use, as well as
injuries associated with falls and muscle contractions.
Among patients who had a CEW activation in drive
stun or touch stun mode, evaluation should focus on
skin manifestations, which are typically limited to surface
burns.
Coexisting conditions like intoxication, prolonged
struggling, altered mental status, or symptoms of excited
delirium syndrome may also be present in patients
exposed to CEWs, although the CEW does not appear
to be the precipitating factor. Presence of these findings
should prompt additional evaluation or treatment of the
underlying condition as clinically warranted.
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