This report has focused on answering three questions of relevance for the trial phase with CEW in the Danish Police:

A. What adverse events (injuries and/or illnesses) could arise in individuals shot by CEW?
Cardiac dysrhythmias, including fatal cardiac dysrhythmias, are observed after shock from CEW. Animal studies and computational/theoretical models produces somewhat contradictory results in the risk of eliciting cardiac dysrhythmias with the use of CEW. The risk for fatal cardiac dysrhythmias cannot size wise be estimated but seems to be low in a population of healthy individuals without complicating factors such as severe physical agitation, drugs, illness, cardiac disease, pacemaker/ICD or other implantable electrical devices and possible gross obesity. Other groups in which the knowledge of CEW effects is low is children, elderly, and pregnant women.

The electrical stimulation has also been described to cause such forceful muscle contractions that fractures in the spine has occurred. The prevalence of these adverse events cannot be size wise evaluated, but the risk seems to be low and dependent on the location of the darts. Also, if a dart hits a sensitive area of the body serious injury with risks for life-long debilitation, such as blindness, can occur. Sensitive body parts identified in case reports are the eye, throat/neck, and testis but to some extent also the head and torso.

There is a risk of injuries in falls following the muscle incapacitation caused by shock from a CEW. Observed injuries range from abrasions and hematomas to life-threatening intracranial injuries. The muscle incapacitation gives rise to tactical considerations such as the risk of drowning if the subject is in proximity of water or the risk of falling down stairs, of ledges or out in traffic. CEW has also been described to being able to ignite flammable substances giving rise to burn injuries.

B. How can adverse events be prevented (tactical considerations)?
To minimize risks with CEW it is advised against general use of CEW on children, pregnant women, and elderly as well as persons with complicating factors such as cardiac disease, having pacemaker/ICD or another electrical implantable device. Furthermore, the use of CEW on subjects with severe agitation, being under the influence of drugs, having other illnesses as well as possibly gross obesity, requires tactically aware decisions. It is advised against giving shocks if the darts is placed in such a way on the torso that the heart is in-between, as well as if a dart is placed in close proximity of the heart. Moreover, the number of shocks should be as few and as short as possible. It could be considered to deploy cardiac defibrillators with each patrol car carrying a CEW, in the case that a potentially fatal cardiac dysrhythmia ensues after shock with a CEW.

To avoid injuries caused by the dart it should be avoided to hit sensitive parts of the body such as the eye, throat/neck, and testis but to some extent also the head and torso. If a dart is lodged in a sensitive body part, it is recommended, if possible, not to use electric shock as this might worsen the tissue damage due to heat effects. If darts are not easily removed or lodged in a sensitive body area, it is recommended that they are removed by professional medical personnel.

We recommend tactical guidelines on when and how to use the CEW. Tactical considerations should include assessments of health-related risks using other forcible means as well as contextual risks. In producing such guidelines, the expertise at the Department of Forensic Medicine is available for expert advice in health-related issues.

C. What medical follow up is advised for subjects shot by a CEW?
Based on the observed health-related consequences of CEW it is advisable that a subject shot by a CEW is offered a medical check-up at an emergency department as soon as possible. The examination should focus on the cardiovascular system, acid-base disturbances, muscle cell integrity, blunt force trauma after a fall and wounds caused by the darts. If darts are left in the body these should be removed. We recommend that for each case an electrocardiogram is taken, a blood sample is drawn and analyzed for lactate, troponin, and myoglobin. Any injuries should be documented. The cardiovascular and respiratory system should be examined. Other investigations should be performed according to the discretion of the medical professional.To strengthen the knowledge on of the use of CEW in the Danish Police the Department for Forensic Medicine have previously recommended an evaluation of the trial phase to gain further knowledge on short- and long-term health effects.