Taser Announces Research Disproves the Acidosis Theory of Liability Used in Heston Case, Taser Intl, 2009
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New Medical M Research R h Disproves the Ac cidosis Theory T of Liability Used in the e Heston Case TA ASER ECD Does not Cause C Dange erous Levels s of Acidos sis Backgrou und. TASER R International periodically provides upd dates on medical research findings rega arding the physiologic effects of electronic e con ntrol devices (ECDs) ( on hu uman and animal subjects.. This Trainin ng Bulletin contains the t most rece ent research findings as of the date of re elease. S Synopsis s onnel are freq quently called d upon to dea al with individu uals in crisis who w are physiologically Law enforrcement perso compromised and are e at a heighte ened risk of serious injuryy or death, regardless r off actions take en by law enforceme ent. In addition, the restraint and arrest process ca an introduce additional physiologic cha anges that may worssen a person’s s baseline ph hysiology. Th hese changess may include e significant acidosis, cardiiac arrest, or other medical m condittions. Acidosis: R human n medical ressearch determ mined that mu uscle contracctions from TA ASER ECD exposures e • Recent fo or up to 10 an nd 15 second ds in rested human h subjeccts resulted in n minimal increases in acidosis that diid not approach a dangero ous level and was clinicallyy not noticed by b the test su ubjects. • d that applicattion of a TAS SER device fo or up to 15 seconds s to an n exerted, This research also showed he acidosis th hat was alread dy present. allready acidotiic person did not worsen th • esearch disprroves the “strraw that broke e the camel’ss back theory”” of worsening g acidosis This medical re hat theorizes that the phyysiologic effe ect from a TA ASER device e discharge on o an alreadyy acidotic th pe erson was an n added acido osis “straw” that t contribute ed to death from f acidosis. This was essentially e th he theory of liiability used in i the Betty Lou L Heston, et e al. v. City of o Salinas, ett al. (CA) lawssuit. This ne ew research reveals the flaws f in this ju ury verdict since applicatio on of a TASE ER device forr up to 15 se econds to an exerted, already acidotic person p did no ot worsen the acidosis thatt was already present. • n comparing volitional v actio ons by the ind dividual, the to op two worst things that a criminal susp pect could In do o with regard d to acidosis are resist an nd flee – in th hat order. Th hese two voliitional actionss produce prrofound meta abolic acidosis that can make m the susspect very ill (in addition to any otherr volitional be ehaviors thatt they may ha ave undertakken such as abuse a of illicit drugs or co onsuming a significant s am mount of alco ohol). When compared with w a TASER R device application, this re esearch data indicates th hat a continue ed, prolonged resistive stru uggle or a foo ot chase is mo ore dangerouss. • d with a good probe e spread mayy represent th he best optio on that will alllow quick The TASER device, estraint and EMS E care. re Cardiac: H researrch has shown n that the imm mediate inducction of ventriicular fibrillatio on, an arrhytthmia that • Human ca an be fatal wiithout interven ntion, by the direct d electriccal effects of the t TASER X26 X on the normal adult he eart is unlike ely and that the t induction n of delayed cardiac arresst by this me echanism is extremely un nlikely. • Researchers have R h concluded that the a close distan nce between the ECD dart and the he eart is the prrimary factor in determinin ng whether an n ECD will affe ect the heart. This risk is judged j to be extremely lo ow in field use e. Page 1 of 12 • diac event rellated to a TA ASER ECD disscharge is de eemed to be extremely The risk of an adverse card ow. Howeverr, it is not po ossible to predict nor test against the entire e spectru um of potentiial human lo ph hysiologies or conditions such s as unpre edictable com mbinations of drugs of unkknown concen ntration or orrigin in the prresence of un nderlying card diac or other disease. d Furtthermore, a la aw enforceme ent officer w have no means to diagn will nose these factors in any event. e • ac Arrest (SC CA) is a leadin ng cause of death d in the United U States, claiming an estimated Sudden Cardia 25,000 lives each e year. These T deathss occur on go olf courses, in n airports, durring physical exertions, 32 from startle orr other stimu uli, or just ab bout anywherre. Should Sudden S Card diac Arrest occur o in a sccenario involv ving a TASER R discharge to o the chest arrea – it would place the law w enforcemen nt agency, th he officer, and d TASER Inte ernational in the difficult sittuation of tryin ng to ascertain what role, if any, the TA ASER ECD could have played p in a unique u situatiion that cann not be replica ated in huma an clinical sa afety evaluatiions. In orde er to reduce the t risk of su uch an event,, and in light of the fact th hat frontal ap pplications off TASER ECD Ds have been n found to be more effectivve when the probes are ta argeted at th he lower tors so (engaging g the balanccing muscles of the pelvvic triangle) we w have low wered the re ecommended point of aim from the centter of mass to o the lower ce enter of masss for frontal discharges. W believe this recommen We ndation will im mprove the effective use of o TASER EC CDs while also further in ncreasing saffety margins and enhanccing the ability to defend d such cases in post evvent legal prroceedings. Overrview and d Training g Implicattions 1. We W have iss sued a new w TASER Targeting T G Guide that will apply for the new X XREP impa act munitio on as well as a ECDs su uch as the X26, M26 and X3. Noote, we ha ave lowered the t recommended point off aim from cen nter of mass to t lower-cente er of mass for front sh hots. The blu ue highlighted d area in the adjacent a targe et man repressents the prefferred target area. a There are three reasons: a. Simpliffy targeting fo or all TASER systems to one easy to re emember map p, avoiding ch hest shots when possible p and the risk of a head/eye h sho ot in a Preferred Target Areas in Blue dynam mic situation, as a is standard d for impact munitions m b. When possible, avo oiding chest shots s with ECDs avoids the controversy abo out whether ECDs E do or do o not affect the human heart. c. Close--spread ECD discharges to o the front of the body are more effective e when n at least one e probe is in th he major muscle es of the pelvvic triangle or thigh region. B Back shots re emain the pre eferred area when practical. 2. W When dea aling with h exhaustted indiv viduals p persons exhibiting e symptom ms of dis stress agitated/exc cited deliriium: orr orr a. Once e officers engage e in capture prrocedures,, it is important to t minimizze the dura ation of the e gle. New ressearch showss that physicaal struggle, sim mulated by punching a physical strugg heavy bag at full in ntensity, can cause acido osis that can reach dange erous levels in only 45 second ds of intense e exertion, sttarting from a resting statte. Accordin ngly, officers engaging subjec cts in a physiccal struggle or in an exhau ustive state sh hould develop p a plan to ca apture and Page 2 of 12 restrain the subjectt as expeditio ously as possible to minimize the duratiion of struggle and the advers se physiologiccal effects. The T physiologic effects of a TASER ECD D discharge of o up to 15 second ds was signifficantly less than t that of either e fleeing (simulated with w a sprint) or o fighting (simula ated with the e heavy bag).. This resea arch shows th hat the TASE ER ECD, as part p of an overall capture plan n, is a viable option o to help p minimize the e duration of the t struggle. b. When n encoun ntering su ubjects ex xhibiting symptoms s s of exha austion, distre ess or agitated/excitted deliriu um, refer to o your age ency’s guiidelines for proper p resp ponse. Thhese subjectss are at signnificant risk of o arrest-relate ed death. Immed diate medical attention may reduce this risk. 3. The T primary y risk of se erious inju ury or death h during ECD deploy yment is ris sk re elated to fa alls. Users s should be reminded to avoid deploying g ECDs on p persons on n elevated platforms p o other pllaces wherre a fall can be more or in njurious. This bulletin shou uld be distrributed to all ECD-ce ertified officers. Page 3 of 12 Medical Re esearch Update Details Recent human R n medical research continu ues to affirm the general safety s of TAS SER® electron nic control 1 devices (E ECDs or devices). In 2008 8 alone, over 30 new medical studies were w published in paper, ab bstract, or poster forrm on TASER R technology. Some of the ese studies presented p gro ound breaking g research in the areas of human physiologica al changes an nd cardiac sa afety. In addition, several new ECD fie eld-use epidem miological studies were w published.2 Dr. James Jauchem published a new article on deaths in n custody3 foccusing on excited de elirium and ECDs.4 Two new n books we ere published d, one solely dedicated to ECDs5 and one o with a 6 significantt chapter on ECDs. E Some of these stu udies provide ed substantial evidence confirming gene erally held beliefs re egarding the effects of law w enforceme ent force and d restraint in the areas of human phyysiological changes and a cardiac safety. s Physiolog gic Changes s7 La aw enforcem ment personne el are freque ently called upon u to deal with individu uals in crisiss who are physiologically compro omised8 and are a at a heigh htened risk of serious injuryy or death. The T restraint and a arrest process can c introduce e additional physiologic changes c thatt may worsen a person’ss baseline ph hysiology. These changes may include signifficant acidosis, cardiac arrrest, or othe er medical co onditions9. Recent R US Bureau off Justice Stattistics showed d 2,002 US arrest-related a deaths for th he period 200 03-2005; 55% % of which were hom micides, 13% involved drugs or alcohol, and 0.1% invvolved use of a baton or TA ASER device.. A. A Acidosis A Acidosis refers s to a condiition of decre easing pH (u usually meassured in bloo od plasma). Although numerouss conditions can c cause aciidosis, law en nforcement pe ersonnel com mmonly confro ont individualss who are susceptible to developing acidosis because b of th he individual’ss behaviors th hat may includ de: illicit or prrescription drug use, intoxication, agitation, de elirium, physiccal exertion, fighting, resissting arrest and a restraint, or fleeing from office ers. Many of these behaviors occur in combination c a may be additive. and a A Acidosis is a condition c that occurs acrosss a spectrum m. While both h a pH of 7.35 and 6.20 in ndicate an acidotic state; these 2 pH levels are e clinically ve ery different. The lower va alue of 6.20 iss likely to be lethal and the upperr value of 7.35 would likelyy not even be e physically noticeable n to an individual. An individu ual can be acidotic (b by definition) but NOT be in any danger physiologically. For insstance, brisklly walking up p flights of stairs wou uld make mos st people acid dotic, but would not put one e in any mediical danger. R Recent human n medical ressearch investtigated the physiologic he ealth risks asssociated with h physical exertion similar s to resis sting arrest orr fleeing from police officerrs, as well as, those risks associated a with certain control tools tested for th law enforcement contrrol tools. The three law enforcement e heir effects on n causing acidosis were w law enfo orcement can nine for captu ure and restra aint, oleoresin n capsicum (O OC) spray exxposure to the face and a neck, and d TASER ECD D exposure fo or 10 and 15 seconds s to th he torso. The researchers measured m acidosis changes c asso ociated with th he above physsical exertion n and police to ools and found the followin ng: Muscle contractions from TASER T devicce exposures for up to 10 and 15 seco onds in reste ed human • M su ubjects resultted in minima al increases in acidosis that did not ap pproach a dan ngerous level and was cllinically not no oticed by the test subjects. • Physical activity similar to fighting f and resisting r or fle eeing from la aw enforceme ent produced the worst an nd most clinic cally significant acidosis. This T volitiona al activity was clearly the most m potentially harmful from a physiolo ogic standpoint and the tesst subjects cliinically felt ill following this activity. C takedo own and restrraint had the highest incre ease of acido osis levels of the law enfo orcement • Canine to ools tested. • OC O spray had the least inccrease in acid dosis levels of o the law en nforcement tools tested. This was exxpected sinc ce TASER device d application stimula ates muscless and OC spray does not. n The re esearchers op pined that sin nce OC sprayy does not ussually incapaccitate a focused person orr a person in ntoxicated on n drugs or alcohol, a the fight f or flight is likely to continue e and may result in Page 4 of 12 worsening ac w cidosis. It is likely that OC C spray, while not directlyy causing accidosis, could indirectly m make it worse.. g is a pH gra aph that depicts these res sults. The le east amount of decrease in pH is the safest. Following pH Page 5 of 12 • R Recent human n medical research also investigated the physiolo ogic health rissks associate ed with a TA ASER discha arge on an already a acido otic person. This T researc ch showed that t application of a TA ASER device e for up to 15 seconds to an exerted d, already ac cidotic perso on did not wo orsen the ac cidosis that was already present. The e following grraph depicts these t test results: pH esearch disprroves the “strraw that broke e the camel’ss back theory”” of worsening g acidosis • This medical re hat theorizes that the phyysiologic effecct from a TA ASER device discharge was w an added d acidosis th “sstraw” that co ontributed to death d from accidosis. This was essentia ally the theoryy of liability ussed in the B Betty Lou Hes ston, et al. v. City of Salina as, et al. (CA A) lawsuit whicch resulted in n a jury finding that the TA ASER devic ce contribute ed 15% to Heston’s de eath while his h own acttions, which included m methamphetam mine intoxicattion, prolonge ed physical exertion e and resisting r arre est; contribute ed 85% to hiis death. Th his new resea arch reveals the flaws in this jury verrdict since ap pplication of a TASER de evice for up to t 15 second ds to an exertted, already acidotic a perso on did not wo orsen the acid dosis that w already prresent. was n comparing volitional v actio ons by the ind dividual, the to op two worst things that a criminal susp pect could In do with re egard to acido osis are resisst and flee – in that order. These two volitional actions produce profound metabolicc acidosis tha at can make the t suspect very v ill (in add dition to any other volition nal behaviors that they may have e undertaken such as abu use of illicit drugs d or conssuming a significant amou unt of alcoho ol). When compared d with a TASE ER device application, thiss research datta indicates th hat a continue ed, prolonged d resistive struggle or o a foot chase is more dan ngerous. It appears that itt is these physical actions of resisting and fleeing that will most m worsen acidosis. a Wh hile the scienttific studies were w able to demonstrate d t this profound d effect on acidosis with w only 45 seconds of exe ertion, many arrest-related d struggles lasst much longe er. Page 6 of 12 Based on the research data referenced d above, by the t time the officers arrivve, many susspects are already significantly acidotic from their own vo olitional action ns – likely with w lower pH levels resultting in an increased d chance of in njury, worsening condition,, or possibly death, indepe endent of anyy other action n taken by the police e officers. Potential P dang ger exists in allowing the e suspect to continue with h agitated orr resistive behavior. Prolonging restraint r by alllowing a fightt or a fleeing situation mayy only serve to o worsen the suspect’s condition. The TASER R device, with h a good probe spread ma ay represent a tool that will w allow quickk restraint and EMS care. H Human medica al tests have, for the mosst part, been limited to 15--second ECD D applicationss. Recent animal research tested d the physiolo ogical effectss of ECD exposures up to 30 minutes on anesthetizzed swine and conclluded that “Th he dose doess not seem to o be cumulatiive. We did not n observe an a accumulattion of the TASER® [ECD] effectt to a ‘toxic’ level. There was no incre eased mortality with longe er durations of o TASER [ECD] exp posure”.10 Please see “Atttachment A” for a summarry of related human h mediccal research. B B. Cardia ac The conclusion ns of recentlyy published human medica al cardiac stud dies are summ marized as fo ollows: • n summary, th his review of the t scientific literature sug ggests that the e immediate induction of ventricular v In fib brillation by th he direct elecctrical effects of the TASE ER X26 on the e normal adu ult heart is un nlikely and th hat the indu uction of de elayed cardiac arrest by b this mechanism is extremely unlikely.11 • Although hearrt rate increa A ased in some cases, the ere were no cardiac dyssrhythmias, or o interval m morphology ch hanges in hum man subjectss who receive ed a TASER discharge d bassed on a 12-lead ECG pe erformed imm mediately beffore and within 1 minute after a a TASER device acttivation.12 Th he cardiac 13 ch hanges were also evaluate ed in acidotic,, exhausted humans h and the same conclusion was reached. r • D application in a physiccally exhaustted adult hum man did not cause a Prolonged 15--second ECD etectable ch hange in the eir 12-lead ECGs. Theo ories of CEW W-induced dysrhythmias d are not de su upported.14 • A 10-second ECD exposu ure in an ideal cardiac axxis applicatio on did not de emonstrate co oncerning ta achyarrhythmias using hum man models. The swine model m may have limitationss when evalua ating ECD te echnology.15 • n a resting ad dult population n, the ECD did d not affect the recordable cardiac ele ectrical activitty within a In 24 4-hour period d following a standard 5-ssecond application. The authors a were e unable to detect d any in nduced electrrical dysrhythmias or signiificant direct cardiac cellular damage that t may be related to su udden and unexpected de eath proxima al to ECD exp posure. Addittionally, no evidence e of dangerous d hyyperkalemia or o induced accidosis was fo ound. The au uthors recomm mended furth her study in th he area of th he in-custody death phenomenon to bettter understan nd its causes..16 • Human voluntteers exposed to a single H e shock from m a ECD did d not develop p an abnorm mal serum troponin I lev vel 6 hours after exposu ure, suggestin ng that there e was no myocardial m ne ecrosis or in nfarction.17 • CEW [Conduc C cted Energy Weapon W or ECD] E exposure produced no detectablle dysrhythmias and a sttatistically significant increa ase in heart rate. r Overall, TASER CEW W exposure appears a to be e safe and w tolerated from well f a cardiovascular stan ndpoint in thiss population. This T study inccreases the cumulative c Page 7 of 12 hu uman subjectt experience of o CEW expo osure with con ntinuous ECG G monitoring and a includes 28 2 full 5-s exxposures18. • Relatively larg R ge variations about the X2 26 operating level were found f not to result in fibrrillation or assystole19. • CEW exposure C e produced no n detectable dysrhthmiass and a statistically significcant incresase in heart ra ate. Overall, TASER CEW W exposure appears a to be e safe and well tolerated from f a cardiovascular sttandpoint in th his population n. This studyy increases th he cumulative human subje ect experiencce of CEW exxposure with continuous ECG E monitorin ng and includes 28 full 5-s exposures20. Conclusion regarding g the potenttial for cardiac effects: Researche ers have been n able to dem monstrate changes in heart rate and rhythm consistent wiith cardiac pa acing and, in some casess, ventricular fibrillation (VF) in sm mall swine, an n arrhythmia that can be fatal f without in ntervention, and a have concluded that th he a close distance between b the ECD dart and d the heart iss the primary factor in dete ermining whetther an ECD will affect the heart.. The thresho old for VF ha as been estim mated to be 12.6 1 times that for cardiacc pacing21. This risk is judged to be extremelly low in field d use. In order to increasse the safety margin and since field experience shows tha at ECD discha arges are effe ective when deployed d to th he large musccles of the back, abdomen, legs and pelvic tria angle, users should s aim fo or the back or (when pracctical) toward the mid lowe er abdomen and a avoid intentiona ally targeting the t chest are ea with probe e applications to increase effectiveness e s and avoid th he remote potential risk r of cardiac c effect. Revised Warnings W A Attached are th he new Produ uct Warnings which have been b updated d based on th his new huma an medical research. Go to www w.TASER.com m for the complete Producct Warnings document d and d glossary of terms for Law Enforcement. A questions regarding thiis Training Bu Any ulletin should be directed to t the TASER R Internationa al Training Departme ent at (800) 97 78-2737 or byy email to Tra aining@TASE ER.com. Page 8 of 12 AT TTACHMENT TA Acidosis A is worrse from conttinued exertio on when comp pared to a TA ASER device application. a T This does • Acidosis no ot support an association between b TAS SER device ap pplications an nd sudden death due to wo orsening accidosis. It doe es support a worsening w acidosis from co ontinued exerrtion independent of TASE ER device ap pplication.22 • echnology that will be used to control da angerous, agittated or The TASER XREP™ projecctile is new te otentially viole ent persons in n the community. It will allo ow greater law w enforcement and suspecct safety po be ecause of its ability to help p control indivviduals from a greater dista ance. The initial investigation into th he physiologic c effect that th his device will have on hum mans with reg gard to serum m biomarkers was w done w the unfinis with shed product while under development. d Prolonged ECD E applicatio on with this in nitial de esign caused d small but sta atistically insig gnificant chan nges in measured serum biomarkers. b These sm mall changes would likely result in limite ed clinical significance. It appears a that the t tested de evelopmentall XREP ECD represents an adequate risk/benefit rattio if used for its intended pu urpose.23 Furrther testing of o the final XR REP product iss now underw way. • o clinically sign nificant or lassting statistica ally significantt changes in cardiovascula c ar, There were no ctate or pH levvels in human n subjects afte er a 5 second d TASER activvation.24 ellectrolyte, lac • Markers of acid M dosis and carrdiac injury we ere similar am mong acidoticc subjects who o underwent bo oth sham and d real prolong ged CEW exposure. Prolon nged CEW exxposure in hum mans does no ot appear to o have an effe ect with regarrd to worsenin ng acidosis that is already present.25 • o worrisome changes c in me easured serum m biomarkerss. There was a significant decrease d There were no n serum lactatte after expossure. This datta does not su upport a caussal relationship between EC CD drivein sttun applicatio ons and worse ening physiolo ogy.26 • n this resting adult a populatiion, the TASE ER X26 device did not affe ect the recorda able cardiac electrical e In acctivity within a 24-hour perriod following a standard fivve-second (s) application. The authorss were un nable to detect any induce ed electrical dysrhythmias or o significant direct cardiacc cellular dam mage that m be related may d to sudden and a unexpecte ed death proxximal to CEW W exposure. Additionally, A no evvidence of da angerous hype erkalemia or induced acido osis was foun nd. Further sttudy in the area of the in n-custody dea ath phenomen non to better understand u itss causes is re ecommended d.27 • Cardio-respiratory and bloo C od parameterss were followe ed before and d for 60 min after a a 5 s TAS SER exxposure on 21 men and women law enfforcement offficer volunteers.28 • …the repeated … d use of electrro-muscular incapacitating g devices in a short period of time is, at least, fe easible, with the caveat tha at some medical monitoring g of subjects may be required (to obserrve fa actors such as s lactate and acidosis).29 • d TASER devvice exposure es had only tra ansient effectts on blood fa actors, which all Three repeated eturned to pre e-exposure levels, with the e exception off hematocrit (w which remained elevated after a 3 h). re Since the incre ease in this fa actor was lesss than that wh hich may occu ur after short periods of exxercise, it iss unlikely that this would be e an indicatorr of any seriou us harm.30 • ntoxicated adu ults with prolo onged CEW exposure e dem monstrate sma all transient in ncreases in measures m In off acidosis and d no change in markers of cardiac injuryy. The increassed acidosis was w not cliniccally siignificant and self correcte ed.31 Page 9 of 12 Stress • Alpha-amylase A e had the grea atest increase e from baselin ne at 10–15 min m with the defensive d tacttics drill. C Cortisol had th he greatest inccrease at 15– –20 min with O.C. O spray. Cortisol C remained most ele evated at 40 0–60 min in th he defensive tactics drill group. Our pre eliminary data a suggests tha at physical exxertion du uring custodia al arrest may be most activvating of the human h stresss response, particularly the e syympathetic-ad drenal-medulla axis. This may m suggest that techniqu ues to limit the e duration of this t exxertion may be b the safest means m to app prehend subje ects, particula arly those at high-risk h for in n-custody de eath. Conduc cted electrical weapons we ere not more activating a of the t human strress response e than 32 otther uses of force. f Pleasse see the following graph: • A 5-second ex xposure of a TASER T X26 [d device] to hea althy law enfo orcement perssonnel does not n result in n clinically significant chang ges of physio ologic stress.33 M26, X3, X26, and © are a trademarkss of TASER Intternational, Inc., and TASER® ® is a registere ed trademark off TASER International, Inc., registe ered in the U.S. All rights rese erved. © 2009 TASER T Interna ational, Inc. 1 For a com mplete listing see s the most current c Electron nic Control Device Research h Index posted on TASER Intternational, Inc’s (TASE ER) website att www.TASER.com. 2 Bozeman n WP, Hauda WE, 2nd, He eck JJ, Graha am DD, Jr., Martin M BP, Win nslow JE. Safe ety and Injuryy Profile of Conducted d Electrical We eapons Used by b Law Enforce ement Officers Against Crimin nal Suspects. Ann Emerg Med. Jan 21 2009. 3 For more e information on o excited delirrium and custo ody related dea ath issues see e the Custody Related Death h Research Index poste ed on TASER's s website at ww ww.TASER.com m, and www.incustodydeath.ccom. 4 Jauchem, PhD, James R., Deaths in custody: c Are so ome due to ele ectronic control devices (including TASER® devices) d or nd Legal Mediccine, doi:10.101 16/j.jflm.2008.0 05.011. excited dellirium? Journal of Forensic an Page 10 1 of 12 5 Mark W. Kroll (Editor),, Jeffrey D. Ho o (Editor).TAS SER® Electronicc Control Devices: Physiolog gy, Pathology,, and Law. Springer. 6 Edited byy Raymond M. Fish and Leslie A. Geddess, Lawyers & Judges Publisshing Companyy, Inc. Electriccal Injuries: Medical an nd Bioengineering Aspects, Second Edition, Chapter 42: TASER Electron nic Control Devvices. 7 “Physiolo ogic changes” include, but arre not limited to, t changes in n: heart rate; heart h rhythm; stress s hormone es or other biochemica al neuromodullators (e.g., catecholamines c s); respiration; adrenergic states; s tissue temperature; myoglobin; potassium;; creatine kinas se; lactic acid, or o pH. 8 “Physiolo ogically compro omised” include e those person ns whose lives in rare circumsstances may be b at risk of arrrest-related death due to excited or agitated a delirium, acidosis, ca ardiac arrest, serotonin s syndrome, neurolep ptic malignant syndrome, sudden unexpected deatth in epilepsy, catecholamine e release or bu uildup, comprom mised cardiac or pulmonary conditions, sickle cell compromise, c and a drug or alco ohol use or with hdrawal. 9 Such as hyperkalemia, h rhabdomyolysiis, apnea, incre eased adrenerg gic states, or hyypercarbia. Hughes E, Kennett M,, Murray W, Werner W J, Jenkins D. Electro‐Muscular M Disru uption (EMD) bioeffects: b A study of the Effects of Continuous C Ap pplication of the e TASER X26 Waveform on Swine: Penn State S Universitty Institute for Non‐Lethal Defense Te echnologies; Nov N 30 2007. 10 11 Raymond Ideker, MD, PhD and Dere ek J. Dosdall, PhD; P Can the Direct D Cardiac Effects E of the Electric E Pulses Generated SER X26 Cause Immediate or Delayed Sudden Cardiacc Arrest in Normal Adults? The T American Journal of by the TAS Forensic Medicine M and Pa athology, Vol 28, 2 No. 3, September 2007. 12 Vilke GM M, Sloane C, Levine L S, Neum man T, Castillo E, Chan TC. Twelve-lead T ellectrocardiogra am monitoring of subjects before and d after voluntary y exposure to the t TASER X26 6. Am J Emerg g Med. Jan 200 08;26(1):1-4. 13 Ho JD, Dawes D DM, He eegaard WG, Calkins C HG, Moscati M RM and d JR Miner. Ab bsence of Elecctrocardiograph hic Change Following Prolonged Application of a Conducted Ellectrical Weap pon on Physica ally Exhausted d Adults. J Em merg Med, 2009;In Pre ess. 14 Ho J, Da awes D, Calkin ns H, Johnson M. Absence off Electrocardio ographic Chang ge Following Prolonged Appliication of a Conducted d Electrical Wea apon in Physiccally Exhausted d Adults. Acad Emerg Med 20 007;14(5):128-1 129. 15 Ho JD, Dawes D DM, Re eardon RF, et al. a Echocardiographic Evalua ation of a TASE ER-X26 Appliccation in the Ide eal Human Cardiac Axxis. Acad Emerrg Med. Aug 10 0 2008. 16 Ho JD, Miner JR, Lak kireddy DR, Bultman LL, He eegaard WG. Cardiovascular C r and physiolo ogic effects of conducted electrical weapon w discharrge in resting adults. a Acad Em merg Med. Jun 2006;13(6):58 89-595. 17 Sloane CM, Chan TC C, Levine SD, Dunford JV, Neuman T, Viilke GM. Serum troponin measurement m o subjects of exposed to o the TASER X-26. X J Emerg Med. M Jul 2008;3 35(1):29-32. 18 Bozeman study Immed diate cardiovasscular effects of o the TASER X26 X conducted electrical wea apon, W P Boze eman, D G Barnes, Jrr, J E Winslow w, III, J C Johnson, III, C H Phillips, and R Alson, Eme erg. Med. J. 2009; 2 26(8): p. p 567-570; http://emj.b bmj.com/cgi/content/abstract/26/8/567?ct=ctt. 19 Beason CW, Jauchem JR, Clark CD, 3rd, Parker JE E, Fines DA. Pulse variations of a conducted d energy weap pon (similar SER X26 devic ce): effects on muscle contra action and thre eshold for ven ntricular fibrillattion. J Forensiic Sci. Sep to the TAS 2009;54(5)):1113-1118. 20 Bozeman WP, Barnes DG Jr, Winslow JE III, Johnsson JC III, Philllips CH, Alson R. “Immediate e cardiovascula ar effects of the TASER R X26 conducte ed electrical we eapon,” Emerg. Med. J. 2009, 26; 567-570. Page 11 1 of 12 21 Raymond Ideker, MD, PhD and Dere ek J. Dosdall, PhD; P Can the Direct D Cardiac Effects E of the Electric E Pulses Generated SER X26 Cause Immediate or Delayed Sudden Cardiacc Arrest in Normal Adults? The T American Journal of by the TAS Forensic Medicine M and Pa athology, Vol 28, 2 No. 3, September 2007. 22 Ho, J.D., et al., Can Prolonged TAS SER X26 Exposure or Conttinued Exertion n Contribute to o Sudden Card diac Death Through Worsening W Acidosis? 2009, Ca ardioRythm, Ho ong Kong: Dep pt. of Emergency Medicine, Hennepin H Coun nty Medical Center, Minneapolis, M MN M Dept. of o Emergencyy Medicine, Lompoc Vallley Medical Center, Lom mpoc, CA. 23 Serum Biomarker B Effects of Prolonge ed TASER XREP Device Exp posure, Jeffreyy D. Ho, MD, Donald D M. Daw wes, James R. Miner, MD,, NAME (National ( Asso ociation of Medical Examine ers) 2008 Annual Conferencce (Louisville, Kentucky); S of Eme ergency Mediciine Scientific Assembly, A Muniich Germany Sept S 2008. European Society 24 Vilke G,, Sloane C, Bo outon K, et al. Cardiovascula ar and Metabo olic Effects of the TASER on n Human Subjects. Acad Emerg Med d 2007;14(5):104-105. 25 Ho J, Da awes D, Bultma an L, et al. Phyysiologic Effectts of Prolonged d Conducted Electrical E Weapon Discharge on o Acidotic Adults. Aca ad Emerg Med d 2007;14(5):63 3. 26 Ho JD, Dawes DM, La apine AL, et al. PROLONGE ED TASER® “D DRIVE-STUN” EXPOSURE IN HUMANS DOES D NOT CAUSE WORRISOME BIOMARKER CHANGES Hennepin W H County Medical Center: C Nation nal Association n of EMS Physicianss; 2008. 27 Ho JD, Miner JR, Lak kireddy DR, Bu ultman LL, Heegaard WG. Cardiovascular and physiolo ogic effects of conducted electrical weapon w discharrge in resting adults. a Acad Em merg Med. Jun 2006;13(6):58 89-595. 28 Bouton K, K Vilke G, Cha an T, et al. Phyysiological Effe ects of a Five Second S TASER R Exposure. Sa an Diego State e University San Diego Heart Institute e: Society for Academic Emerrgency Medicine; 2007. 29 Jauchem m JR, Sherry CJ, C Fines DA, Cook C MC. Acid dosis, lactate, electrolytes, e muscle enzymess, and other facctors in the blood of Su us scrofa follow wing repeated TASER T exposu ures. Forensicc Sci Int. Aug 10 2006;161(1):20-30. 30 Jauchem m JR, Cook MC C, Beason CW.. Blood factorss of Sus scrofa following a series of three TA ASER® electro onic control device exp posures. Foren nsic Sci Int. Jul 12 2007. 31 Moscati R, Ho J, Da awes D, et al. Physiologic Effects E of Prolonged Condu ucted Electrical Weapon Disscharge on Intoxicated d Adults. Acad Emerg E Med 20 007;14(5):63-64 4. 32 Dawes D, Ho J, Mine er J. The neurroendocrine efffects of the TASER T X26: a brief report. Forensic F Sci Int. I Jan 10 2009;183(1 1-3):14-19. 33 Vilke GM M, Sloane CM, Bouton KD, et e al. Physiolog gical Effects of a Conducted Electrical E Weapon on Human n Subjects. Ann Emerg g Med. Aug 23 2007. Page 12 1 of 12