What's new in emergencies, trauma and shock? Pellets, rubber bullets, and shotguns: Less lethal or not?

The article entitled, “Pattern, presentation and management of vascular injuries due to pellet and rubber bullets in a conflict zone”[1] published in this issue of the journal illustrates an interesting and less common group of vascular injuries, at least in terms of mechanism of injury. The article does require some clarification to ensure that the reader is not in any quandary about the topic under discussion.

There are four distinct sets of weapon that may be included in the group of “police arms for civil unrest,” and in particular there appears to be some measure of uncertainty in the description of the pellet injuries in particular. The one group of “weapons” used by police utilize electronic or chemical methods and are not for discussion at this time. The traditional sharp-point ammunition standard gun (hand-gun or rifle) is obviously used for self-defence and apprehension of violent perpetrators and is designed for lethal force. What does require comment is the different types of “nonlethal” weapons used in riot situations.

Pellet guns are most often air-driven rifles that utilize compressed air to rapidly discharge a single pellet at fairly low energy and velocity toward the intended target. Many are sold as “toys” and as such are thought of as “less lethal.” Injuries due to these weapons are not uncommon, may damage individual organs (especially the eyes) and the injuries have been well described in the literature.[2,3] These guns are seldom used by police today and are not the type of pellet referred to in this article, but the point is made for completeness sake. In similar, vein are the “toy” BB guns that fire plastic pellets. These are also not used by law enforcement for police action, but also have the potential to cause injury, with the additional challenge of not being radioopaque, thus making detection of the pellets more challenging.

The other type of pellet is the type most commonly used in police shotgun cartridges, which are discharged with the use of gunpowder detonation and vary from buck-shot (usually about 12 pellets of a larger size per round) and bird-shot (up to 150 small metal pellets around 1-2 mm in diameter per round). The latter is more commonly used in control of civil disobedience by police services, by shooting these pellets into the ground in front of protesters aiming for ricochet effect and dispersing the crowd. The pellet injuries from these weapons include a spectrum from superficial peppering of the soft-tissue to contusion of vessels, when used at close range, to perforation of bowel or other organs, transection of blood vessels, and even cases of embolization to distant organs being described.[4,5] While considered “less lethal” when used as described above, the risk of serious injury from shotgun wounds is well-known when used at close range.

Thirdly, the most common projectile used in police crowd control is the rubber bullet, usually a solid round or cylindrical projectile of a heavy plastic or rubber, without a sharpened tip, although a number of different types exist – something which is not clearly stipulated in the article under discussion is the type of projectile used in Kashmir. Commonly two rounds are combined with a cartridge fired from a 12-bore shotgun. These weapons are very effective in causing pain and the projectile may penetrate, but more often causes blunt injury, which may include vascular contusions or intimal injuries. Severe injury is far more common when the weapon is fired from closer than 20 m and without the use of indirect action (ricochet). These injuries have been previously described, and it is therefore not surprising that the most common injury in the 35 patients in this series are from these rounds.[6,7]

Modern trauma vascular surgery includes the use of “novel” approaches, in addition to traditional procedures such as fasciotomy, including early vascular shunting and temporary external fixation, to reduce the amputation or stroke rate and stabilize fractured bones prior to intricate vascular repair. The shunts that are used could be available commercially procured items, or be fashioned by making use of items readily available locally, such as the use of pieces of either drip tubing, nasogastric tubes or chest tubes, depending on the vessel diameter. Temporary external fixation has become well established as a form of either initial, or even definitive, orthopedic fracture care and the use thereof with early shunting is associated with improved limb survival. While not specifically mentioned in this study, these techniques are promoted as forms of vascular “Damage control.”[8]

In conclusion, less “lethal” weapons do cause serious injury, thus a high index of suspicion and low threshold for intervention, including early fasciotomy when required, remain the key to early and successful limb and life-salvage.