Content review for this game:
Pertaining to the ESRB rating.

Blood and gore: Blood spurts in heavy amounts and in a thick, jelly-like consistency whenever you hit or shoot an enemy, and gradually oozes onto their skin/clothes as you hit and/or shoot them. However, blood does not splatter on wall/floors or linger, but many of the enemies do have existing blood stains on their clothes, and there is tons of static blood splattered and smeared all over the floors and walls of Rapture (city's name).

Bodies do linger, and you see many bloodied, severely burned, skinned, disfigured, and overall mutilated human (including three children, and even cat) corpses spread throughout (an extreme example being a heavily bloodied and disfigured female corpse pinned to the floor by surgical instruments in her arms and both eyes). If you set enemies on fire they'll scream in haunting tones, and after they die, you can see their blistered and severely burned bodies in detail. There is no option to turn blood off in this game.

Splicers--your main enemy--are former humans gone mad, and have an overall grotesque and bizarre appearance. For example, one of the splicer types (a "Thugger") is dressed in a ruined and heavily bloodied 60's style suit, has a wide and wild blood-shot eye (the other is missing and covered with a bloody piece of gauze), and has a bloodied bandage wrapped around his swollen and blood covered head. There are several more types of these splicers (male and female) that have a similarly horrific look, like former surgeons who have heavily bloodied masks and frocks, etc.

Specific scenes of blood & gore:

• An early scene shows a splicer stab an unmutated human in the stomach (with heavy blood splatter), and then pins him against the window of your transport device, finishing him off with another slice to the torso, killing the man (and splattering blood on your window).
• While crawling in the catwalks over a ruined stage, you spot a "Little Sister" (explained in intense violence) for the first time. At first she goes about her work, extracting ADAM (genetic material for the game's powers) from a dead body, by puncturing a large syringe into its body (with blood and squishing sound effects). When you reach ground level, you see a splicer (through a separated window) approach the Little Sister, causing her to scream, making the splicer hit her with the butt of his gun (bad idea). This alerts the Big Daddy (explained in intense violence), who slams the splicer up against a wall, and then drills into the splicer's middle with his huge drill arm (with a heavy amount of blood effects). To finish the splicer off, the Big Daddy slams him into the tempered glass separator (which your safely behind) until the splicer's body breaks through (resulting in blood splatter on the glass).
• A once surgeon of Rapture is now a twisted and demented butcher, with a trail of blood (including bizarre messages written in it) leading to his door. Once you finally reach him, you see him jabbing his scalpels into a wriggling female splicer (in what appears to be a operating theater) multiple times (with nauseating, squishing sounds) resulting in tons of blood spurting from her body, and dripping thickly from the table to the floor--all the while he mumbles about how he can't make anything perfect enough.
• A brief scene shows a splicer trying to kill a Little Sister. But before he can, a mysterious (and physically normal) woman shoots him a couple of times, resulting in blood spurting from his body.
• In a later area, you come across a room with charred and bloodied human remains hanging from a pipe, with an attached battery still drawing a current through the dead body (he was tortured for info).
• One area has a closed off elevator opening and closing on a dead and bloodied body's head (over and over).
• When you near Andrew Ryan's office, you see several mutilated corpses hanging on either wall by pikes in their chests and/or heads. Andrew Ryan then tells you by radio that he hung everyone of them, and that there's a spot for you.
• A main villain gives you a golf club and tells you to kill him (with mind control). You then hit him hard with the club (resulting in a sickening crunching and squishing sound, a large gash on the man's face, and heavy amounts of blood flinging from his face onto the floor), and proceed to do this two more times. When you hit him the last time, the golf club's tip embeds in his temple (breaking off), resulting in a heavy amount of blood spurting from his crushed head (with appropriate sound effects).
• In a later area you see the bloodied autopsy room where they examined the failed/obsolete Little Sister, with their bloody dresses in a large pile.

Drug reference: This category refers solely to the game's power-ups called "plasmids," which imbue the main character with powers like electricity, flame and telekinesis. To use these powers, you take a large syringe filled with the specific power's formula, and inject it into your upper wrist, resulting in a violent reaction while it reconfigures your genetic structure. Other than this, there are no actual real-world illegal or prescription drugs in this game.

Intense violence: You come to, water and flame all around. As you struggle to breathe, you realize you're underwater. You strain to reach the top, and when you finally surface, you find your plane in ruins and crashed in the ocean. You see a building in the distance. When you reach it, you find a docked pod and enter it; it submerges in the water, a screen comes up, it starts playing what appears to be an advertisement. You find out you're on your way to "Rapture," an underwater city created by Andrew Ryan, a man who thinks that the world doesn't belong to God, the poor, or all of man, but to him. This is the reason he has created this city, so that he can rule, with his science no longer constricted by "petty" morality. When you arrive you find it to be in complete ruins, and learn that the citizens of Rapture have turned into horrific monsters because of this "science" without morality. Time to find out why you're here...

Once you learn the basic controls, get a couple of your first weapons and learn about plasmids, you're set free into Rapture. The base gameplay revolves around you exploring the city while shooting, hitting and zapping enemies with your powers, solving some minor puzzles and scavenging for inventory, all the while trying to figure out what the heck is going on. The game has a survival/horror feel; with dark, bloodied and ruined areas (desolate, but occupied); flickering lights; and plenty of JUMP out of your seat moments commonly associated with this genre.

The enemies themselves are quite horrific, bizarre and hostile, with you constantly being pursued by them (making it very suspenseful, and being furthered by the fact that the game's environment makes you feel like you're really there). When they see you they'll storm in with blunt/sharp objects (like pipes, rakes, and some have guns, grenades, plasmid, etc.), all the while yelling and taunting you with curse words and gibberish. This carries into their behavior, as they act moderately disturbed--an example being an early scene with a female splicer, who stands in front of a baby carriage singing a modified (and demented) version of "Hush Little Baby" to a gun (instead of a baby). Or some disturbed spider splicers, who'll sing, "Jesus Loves Me," and then afterwards yell, "Father! Why have you forsaken me!?"

To fend off the strange and very hostile enemies, you'll be using a variety of weapons like a wrench, pistol, revolver, machine gun, crossbow (which functions as a sniper rifle), grenade launcher, chemical-thrower (which spews flame, ice, etc.), in addition to the plasmids like electricity (which can be used to activate on the fritz machery or shock enemies standing in water, etc.), flame (which can melt ice, set enemies on fire, etc.), telekinesis (which can be used to reach far away objects and fling enemy grenades back their way), and multiple types of ammo for each weapon, like armor piercing rounds, etc.

The combat is moderately intense with very destructible environments/objects, and because of the Havoc physics engine, enemies will fly (after an explosion) and contort in awkward positions after you do away with them. You can even freeze enemies with either your powers or chemical-thrower, and then shatter their bodies into multiple pieces with your wrench after the fact. However, although the combat is very violent and the enemies you fight are grotesque and horrific, there is surprisingly--as this is a survival/horror game--no gibbing (meaning enemy bodies don't explode into multiple bloody chunks) or dismemberment (as in, you can't lop off heads arms, etc).

Another main gameplay element, and moral choice, involves the Little Sisters and Big Daddies. The Little Sisters are former little girls who were transformed by the scientists of Rapture to collect ADAM (the genetic material which is used to buy the game's plasmid powers), and are dressed in frilly and now ruined dresses, with horrifically pale gray skin and large yellow eyes. Their job is to extract ADAM from dead human bodies with a large syringe, and then store it in a slug, which is embedded in their stomachs. For protection, they have the Big Daddy: a once human, now entirely encased in a huge old-fashioned diving suit, complete with a drill for an arm and a high powered gun in the other. He'll do anything to protect her from harm, but as long as you leave the Little Sister alone, he'll leave you be.

A few hours into the game, you'll come across your first accessible Little Sister. Before you can make any choice on what to do with her, a mysterious (normal human) woman gives you a device and says you can either kill the Little Sister (this isn't shown), which will reward you with a large amount of ADAM, or you can use a serum she gives you to cure the Little Sister, making her a normal little girl again-- but you'll get less ADAM. The woman then tells you that she runs a shelter for these reformed Little Sisters, and although she can't reward you now, she'll be able to if you just wait. You now have this choice every time you come across a Little Sister, but you'll have to deal with the Big Daddy first (no matter what choice you make afterwards). And even if you choose to save her, she can still be killed by a splicer, or you--it's entirely your choice.

This choice with the Little Sisters ultimately affects the ending, and if you save them during the game, they'll offer you the city, you'll refuse, and give them a better life. If you kill them during the game, the remaining girls will still offer you the city, you'll accept, kill any outsider who comes near, and rule the girls in hate and fear. So, for a horror game, the story is surprisingly profound and is about how blind, arrogant, selfish, and immoral men can ruin life for everyone else--especially the children. And although this game is in no way appropriate for younger teens, let alone children, if you're an adult who can handle the moderate and disturbing horror elements, then this story actually has a good, moral (albeit tragic) message.

Specific scenes of intense violence: