Health impacts of chemical irritants used for crowd control: a systematic review of the injuries and deaths caused by tear gas and pepper spray.

BACKGROUND: Chemical irritants used in crowd control, such as tear gases and pepper sprays, are generally considered to be safe and to cause only transient pain and lacrimation. However, there are numerous reports that use and misuse of these chemicals may cause serious injuries. We aimed to review documented injuries from chemical irritants to better understand the morbidity and mortality associated with these weapons. METHODS: We conducted a systematic review using PRISMA guidelines to identify injuries, permanent disabilities, and deaths from chemical irritants worldwide between January 1, 1990 and March 15, 2015. We reviewed injuries to different body systems, injury severity, and potential risk factors for injury severity. We also assessed region, context and quality of each included article. RESULTS: We identified 31 studies from 11 countries. These reported on 5131 people who suffered injuries, two of whom died and 58 of whom suffered permanent disabilities. Out of 9261 total injuries, 8.7% were severe and required professional medical management, while 17% were moderate and 74.3% were minor. Severe injuries occurred to all body systems, with the majority of injuries impacting the skin and eyes. Projectile munition trauma caused 231 projectile injuries, with 63 (27%) severe injuries, including major head injury and vision loss. Potentiating factors for more severe injury included environmental conditions, prolonged exposure time, and higher quantities of chemical agent in enclosed spaces. CONCLUSIONS: Although chemical weapons may have a limited role in crowd control, our findings demonstrate that they have significant potential for misuse, leading to unnecessary morbidity and mortality. A nuanced understanding of the health impacts of chemical weapons and mitigating factors is imperative to avoiding indiscriminate use of chemical weapons and associated health consequences.

Tear gas: an epidemiological and mechanistic reassessment.

Deployments of tear gas and pepper spray have rapidly increased worldwide. Large amounts of tear gas have been used in densely populated cities, including Cairo, Istanbul, Rio de Janeiro, Manama (Bahrain), and Hong Kong. In the United States, tear gas was used extensively during recent riots in Ferguson, Missouri. Whereas tear gas deployment systems have rapidly improved-with aerial drone systems tested and requested by law enforcement-epidemiological and mechanistic research have lagged behind and have received little attention. Case studies and recent epidemiological studies revealed that tear gas agents can cause lung, cutaneous, and ocular injuries, with individuals affected by chronic morbidities at high risk for complications. Mechanistic studies identified the ion channels TRPV1 and TRPA1 as targets of capsaicin in pepper spray, and of the tear gas agents chloroacetophenone, CS, and CR. TRPV1 and TRPA1 localize to pain-sensing peripheral sensory neurons and have been linked to acute and chronic pain, cough, asthma, lung injury, dermatitis, itch, and neurodegeneration. In animal models, transient receptor potential inhibitors show promising effects as potential countermeasures against tear gas injuries. On the basis of the available data, a reassessment of the health risks of tear gas exposures in the civilian population is advised, and development of new countermeasures is proposed.

Investigation of accidental secondary exposure to CS agent.

We report on an unusual exposure to o-chlorobenzylidene malononitrile (CS agent) following its use to detect unauthorized stowaways aboard a vehicle, and the subsequent handling of the cargo delivered to retail stores across Scotland. Twenty-one staff in 16 retail stores across Scotland experienced symptoms including itching and running eyes, rhinorhoea, a burning sensation on the face and hands, and a burning throat, following the furniture deliveries. A survey was conducted to assess the extent of exposure to the contaminated furniture and the scale of illness associated with exposure. Experiencing symptoms was significantly associated with having contact with the furniture or packaging (chi(2) = 10.5, p < 0.001). This incident demonstrates the risk of inadvertent secondary exposure and subsequent acute symptoms from contact with residual CS agent when sprayed in the confined spaces of haulage vehicles.

Prevention of CS "tear gas" eye and skin effects and active decontamination with Diphoterine: preliminary studies in 5 French Gendarmes.

Ortho-chlorobenzylidene malononitrile (CS) "tear gas" is a lacrimating riot control agent causing eye irritation, excessive lacrimation, and blepharospasm. Diphoterine has been efficacious for decontamination of a wide variety of eye and skin chemical splashes and was tested in CS exposure. Five French Gendarmes either entered a standard training CS exposure chamber, developed eye or skin signs and symptoms, and were post-exposure decontaminated with Diphoterine or used Diphoterine as pre-CS exposure prophylaxis in the eyes and on the face before entering the chamber. Gendarmes who entered the CS chamber without prior application of Diphoterine developed expected effects of excessive lacrimation, eye irritation, and blepharospasm. After post-exposure Diphoterine decontamination, in four Gendarmes these effects rapidly resolved and they were fully operational. When Diphoterine was applied to the eyes and face before entering the CS chamber, the expected effects did not occur and the single Gendarme remained fully operational on exiting the chamber. These results suggest that Diphoterine can prevent or rapidly ameliorate the ocular and dermal effects of CS and allow law enforcement personnel to remain fully operational or rapidly regain operational status after decontamination.

[The group intoxication by tear-gas]. / Zbiorowe zatrucie gazem drainiaco-lzawiacym.

The case of group intoxication of 52 pupils by tear CS gas (2-chlorobenzelidenemaloninitrile) at school is presented. The most often clinical signs observed at hospital admitted children, at 13-16 year old were detail described. The special attend was given for 4 cases, heavy clinical intoxication observed for young girls. The clinical symptoms, action of xenobiotics and clinical treatment compare with literature data, were discussed.

Brief report: exposure to tear gas from a theft-deterrent device on a safe--Wisconsin, December 2003.

On December 4, 2003, a hazardous materials (HazMat) release occurred at a jewelry store in Beloit, Wisconsin, when the store owner tightened a screw on the door of an old safe outfitted with a chemical theft-deterrent device. The device included a metal housing containing a glass vial of liquid, which cracked as the screw tightened, releasing approximately 4 ounces of tear gas. The store owner sustained eye and skin irritation and was treated at a hospital and released. Twelve persons in the building and persons in adjacent businesses were evacuated for 3 hours while a certified Level A HazMat team*, city firefighters, and emergency medical technicians responded to the release. This report summarizes the response to this event and underscores the need for persons who use old safes and vaults to know how to identify these devices and avoid tampering with them.

CS gas exposure in a crowded night club: the consequences for an accident and emergency department.

A case is reported of deliberate release of CS gas (O-chlorobenzylidene malononitrile) in an enclosed space and the consequences for an accident and emergency department.

Delayed pulmonary edema and bronchospasm after accidental lacrimator exposure.

Clinical manifestations of lacrimator exposure can be immediate or significantly delayed. In both phases, the sequelae can be severe and life-threatening. As personal protection devices, these agents have become readily available to the public in many areas of the country. Emergency physicians should gain a firm understanding of the presentation, management, and disposition of the lacrimator-exposed patient. A case of accidental prolonged lacrimator exposure inducing pulmonary edema and bronchospasm is presented.

Spectral differentiation and gas chromatographic/mass spectrometric analysis of the lacrimators 2-chloroacetophenone and o-chlorobenzylidene malononitrile.

2-Chloroacetophenone (CN) and o-chlorobenzylidene malononitrile (CS) are the most common chemical agents used as lacrimators in the United States. There is a lack of complete spectral data on these compounds in the literature. Spectral data (ultraviolet, fluorescence, proton nuclear magnetic resonance, and infrared) and a gas-liquid chromatographic/mass spectrometric method are presented that differentiate and identify CN and CS. These methods and data were used to identify a forensic science specimen from an accidental intoxication.

Chemical agents used in riot control and warfare.

The development of riot control agents is reviewed with emphasis on the major factors influencing the selection and deployment of those agents in current use. Typical agents, irrespective of their chemical nature, cause unpleasant symptoms involving the eyes, skin, mouth, nose and respiratory tract. Ideally, these symptoms cause the sufferer to seek escape from exposure and resolve within 15-30 minutes after exposure has ceased. The medical management of casualties is discussed, with particular consideration of the problems likely to be referred to a Poison Control Centre.

[Acute exposure to CS tear gas and clinical studies]. / Akute Exposition durch CS-Rauchgas und klinische Beobachtungen.

A case of serious intoxication with CS tear gas (o-chlorobenzylidene-malononitrile) is reported in a previously healthy male subject of 43 years involving pulmonary edema complicated by pneumonia, signs of heart failure and evidence of hepatocellular damage. Comparison with animal and human exposures supports the etiologic and pathogenetic role of CS tear gas in the present case. The pulmonary edema may have been the consequence of unusual conditions of exposure and/or increased individual susceptibility. The question of the "safety" of CS tear gas is discussed.