A case report of pediatric rubber bullet injury.
Rubber bullet injuries are considered to be relatively rare in the United States. However, recent widespread protests combined with crowd control tactics used by police have increased the incidence of these injuries. We present a case report of a pediatric patient, who to our surprise, suffered serious internal injuries secondary to a rubber bullet.
Although rubber bullet injuries often appear superficial, these powerful projectiles can inflict significant blunt trauma and in rare cases death. We are sharing this case report to help physicians better understand and care for these injuries in the future
Rubber bullets are one example of a kinetic impact projectile (KIP), a high energy projectile fired from riot guns or standard firearms for crowd control.
These were initially introduced in 1970 to deter protestors in Northern Ireland and are now used worldwide. Until recently, KIPs have rarely been used in the United States and as a result, physicians are relatively unfamiliar with these injuries.
Manufactures produce more than 75 different types of bullets and launchers. These projectiles are composed of various materials including rubber-coated metal bullets, bean bag rounds filled with tiny lead pellets, rubber bullets, metal/PVC composite, plastic bullets, sponge rounds with stiff foam, pepper spray balls and many more variations.
KIPs travel anywhere from 240 feet per second (163 miles per hour (mph) to 330 feet per second (225 mph.)[1,3] The latter is similar to three times the kinetic energy of a professional baseball pitch. Some have been found to travel 600 feet per second (410 mph). One bean bag clocked in at 900 feet per second (610 mph), about the same speed as a .45-caliber bullet.
All projectiles function by transferring kinetic energy from a weapon into the body of an individual. KIPs have a wide range of variables that can impact injury patterns and severity including material composition, muzzle velocity, flight path, firing distance and the location of impact on the body. It is important to note that many KIPs have muzzle velocity equal to those of live ammunition.
Haar et al performed a systematic review of the available literature regarding rubber bullet injury in 2017 (1990-2017). They classified injury into minor and severe. Minor injuries were classified as those that are present on physical examination, but do not require professional medical care, such as contusions, abrasions and sprains. Severe injuries required professional medical management and included lacerations that needed suturing, penetrating injuries that required surgery or any care in an intensive care unit.
KIPs injuries can be severe, result in death and permanent disability.[4, 5] They do not always require surgical intervention, but have the potential to cause significant morbidity and mortality. Thus similarly to high energy blunt force trauma, (falls, handlebar injury, motor vehicle accidents), they often require evaluation(imaging, labs), observation, serial clinical exams and laboratory trending, before safely discharging home.
A 17-year-old male presents to the Children’s Pediatric Emergency Department from protests in Salt Lake City, Utah after being hit by two projectiles fired by police — one to his right chest and another to his left abdomen. On arrival, he is mildly short of breath and screaming of pain in his right chest and abdomen. He was quickly evaluated for potential penetrating trauma. We determined there were no entry or exit wounds and external injuries were consistent with a rubber bullet. Vitals showed elevated blood pressure.
Patient was given morphine for pain control. On visual inspection, his right lateral chest showed a large indurated bruise measuring 8 x 8cm (Fig. 1). Abdomen was tender near the right rib border and in the left upper quadrant where the patient sustained a small abrasion. Trauma EFAST demonstrated small right-sided peritoneal fluid, presumably blood, around the right kidney and paracolic gutter. Left chest showed equivocal trace pleural effusion, which prompted ordering a CT chest and abdomen/pelvis for further evaluation. (Fig. 1).
Trauma labs demonstrated elevated AST and ALT at 486 and 341 unit/L respectively. CT chest and abdomen with IV contrast revealed grade 2 hepatic contusion with moderate amount of blood in the pelvis and pulmonary contusion of the right lung.
Patient admitted to trauma surgery overnight for serial hematocrits and hemodynamic monitoring. Hematocrit remained stable for 18 hours, AST and ALT measurements remained unchanged at 12 hours, and the patient was discharged the following day. Fortunately, it appears he has recovered well without permanent disability.
With the recent increase in protests and use of certain crowd control methods, we are seeing patients present to Emergency Departments with kinetic impact projectile related trauma. Physicians for Human Rights and Scott Reynhout have collected data on at least 115 individuals in the United States who sustained head injuries from these projectiles since May 2020.
Injuries include a facial fracture, traumatic brain injuries and blindness. According to the American Academy of Ophthalmology, at least 20 people have suffered severe eye injuries, including seven people who lost an eye.[2,6]
This case and literature review strongly suggest that kinetic impact projectiles, such as rubber bullets, can cause major blunt injury due to the focused delivery of substantial kinetic energy, and rarely even cause penetrating trauma. It is essential to maintain a high index of suspicion for significant internal injury, even if only superficial wounds are apparent.
We recommend evaluating blunt force trauma injuries from KIPs meticulously with a low threshold for advanced imaging and laboratory evaluation, just as one would with other mechanisms of considerable blunt force or penetrating trauma.
- Miller R, Rutherford EH, Johnson S, Malhotra VJ. Injuries Caused by Rubber Bullets: A Report on 90 Patients. Br J Surg. 1975 Jun;62(6):480-6. doi: 10.1002/bjs.1800620613
- Szabo L, Hancock J, McCoy K, Donovan S, Wagner D, Kaiser Health News. (2020, Sept 11). Fractured skulls, lost eyes: Police break their own rules when shooting protesters with ‘rubber bullets’. Retrieved from https://www.usatoday.com/in-depth/news/nation/2020/06/19/police-break-rules-shooting-protesters-rubber-bullets-less-lethal-projectiles/3211421001/
- Hambling D. (2020, Jun 8). The Deadly Truth About Rubber Bullets. Retrieved from
- Haar, Rohini et al. Death, Injury and Disability From Kinetic Impact Projectiles in Crowd-Control Settings: A Systematic Review. BMJ Open. 2017 Dec
- Mahajna et al. Blunt and Penetrating Injuries Caused by Rubber Bullets During Israeli-Arab Conflict in October 2000. A Retrospective Study. Lancet. 2002 May 25;359(9320):1795-800. doi: 10.1016/S0140-6736(02)08708-1. 5;7(12):e01815. doi: 10.1136/bmjopen-2017-018154.6/C.
- Physicians for Human Rights. (2020, Sept 14). Shot in the Head. Retrieved from https://storymaps.arcgis.com/stories/29cbf2e87b914dbaabdec2f3d350839e