Matthew D. Sztajnkrycer, MD, PhD
Department of Emergency Medicine
Mayo Clinic, Rochester, MN

On Wednesday 20 October 2004, Boston police officers attempting to contain a crowd of approximately 80,000 fans celebrating a Red Sox victory deployed less-lethal munitions. A 21-year-old fan was struck in the eye by a pepperball round reportedly intended for another individual, and died several hours later. As a result of this tragic event, increased awareness has been raised regarding this form of less-lethal munition.

Deployment of the pepperball less lethal munition may result in two distinct forms of medical injury, one related to the impact nature of the munition and one related to the chemical nature of the munition. Pepperball rounds are typically deployed from "paintball guns", which in turn are classified as non-powder guns. Additional weapons in the same general class include BB guns, pellet guns, and air rifles ^[1].

In the Boston incident, the weapon was identified in the lay press as the FN303, produced by FN Herstal (Table 1). According the FN website, the system has approximately 3 times the energy of a typical paintball weapon, and its predominant effect is an impact knock-down ^[2]. In the wake of the Boston incident, the Boston Police Department reportedly switched to the "less powerful" PepperBall Technologies, Inc (formerly Jaycor) system ^[3,4].

According to the CDC and the Consumer Product Safety Commission (CPSC), the overall non-fatal age-adjusted injury rate for all non-powder guns was 7.71 per 100,000 population ^[1]. The CPSC reported 21,840 injuries requiring emergency department visits in 2000; 12% of injuries were ocular, 24% involved the head and neck, 63% involved the extremities, and 1% involved other body areas. The case fatality rate in one study ^[5] was reported to be 30% for intracranial injuries. However, this study primarily examined air-gun pellet injuries.

Very little information currently exists regarding the medical consequences of paintball-type munitions. Due to the size of the paintball round, penetrating injuries have not been reported in the literature. Additionally, no deaths directly due to recreational paintball weapons have been reported. However, on 24 March 2004, the CPSC issued a warning involving the deaths of a 15-year-old boy and a female bystander, each of whom was killed after being struck by a CO2 canister ^[6].

Ocular trauma is the predominant injury noted with paintball weapon use. Since 1985, approximately 185 cases of ocular injury have been reported in the English-language literature, including drive-by paintball weapon shootings ^[7,8]. The size of the paintball projectile is such that it is able to avoid the protection afforded by the bones of the orbit and directly strike the globe.

In case series, specific injuries have ranged from hyphema (77.2%), to retinal detachment (27.5%) to ruptured globe (4.7%) ^[7]. After treatment, 43.1% of patients had documented visual acuities of 20/200 or worse.

In addition to direct impact injuries, the oleoresin capsicum (OC) component of the pepperball has the potential to cause medical issues. OC, derived from extracts of the peppers Capsicum annum and Capsicum frutescence, is the most commonly used sensory incapacitant in the United States. OC exposure results in release of substance P, which causes prolonged inflammatory pain response through slow-acting c-fibers ^[9]. Ocular effects of OC exposure occur rapidly after exposure, and include intense pain and blepharospasm capable of incapacitating the intended target. Similarly, rapid development of upper airway irritation results in rhinorrhea and increased secretions. Bronchospasm may occur, and several deaths have been reported secondary to severe bronchospasm ^[10].

An increasing number of law enforcement agencies are turning towards less-lethal technologies for crowd control during episodes of civil unrest. TEMS providers and those involved in medical support operations during periods of civil unrest should be aware of the potential medical consequences of pepperball deployments, especially as the majority of individuals being struck during these events will not be wearing appropriate eye protection.

References

1. Laraque D and the Committee on Injury, Violence, and Poison Prevention. Injru Risk of Nonpowder Guns. Pediatr 2004; 114; 1357 - 1361.
2. Anonymous. FN303: A Viable Option to Lethal Force. www.pol-tec.de/fn303.htm. Last accessed 12/6/2004.
3. Donald B. (AP) Boston Police to Use Different Pepper-Spray Gun After Fan's Death. Boston Globe 10/24/04.
4. Anonymous. PepperBall Technologies, Inc Systems http://www.pepperball.com/law/index.html. Last accessed 12/06/2004.
5. Friedman D, Hammond J, Cardone J, et al. The Air Gun: Toy or Weapon? South Med J 1996; 89: 475 - 478.
6. Anonymous: CPSC Issues New Safety Warning for Paintball Guns. US Consumer Product Safety Commission Release 04-105. 24 March, 2004. http://www.cpsc.gov/cpscpub/prerel/prhtml04/04105.html. Last accessed 12/06/2004.
7. Listman DA. Paintball Injuries in Children: More than Meets the Eye. Pediatr 2004; 113: e15 - e18.
8. Fineman MS, Fischer DH, Jeffers JB, et al. Changing Trends in Paintball Sport-Related Ocular Injuries. Arch Ophthalmol 1990; 22: 416 - 418.
9. Olajos EJ and Salem H. Riot Control Agents: Pharmacology, Toxicology, Biochesmity, and Chemisty. J Appl Toxicol 2001; 21: 355 - 391.
10. Steffee CH, Lantz PE, Flannagan LM, et al. Oleoresin Capsicum and "In Custody Deaths." Am J Forensic Med Pathol. 1995; 16: 185 - 192.

Table 1: Comparison of the FN303 and PepperBall Industries, Inc. Systems

*: Not for use against humans.

Data from references 2,4.