Epidemiologic changes in gunshot wounds in Washington, DC, 1983-1990

Patterns of anatomical injury and anaesthesia procedures in wounded Ukrainian soldiers from Anti-Terrorist Operation/Operation Joint Forces: 2014-2021

INTRODUCTION

The study aims to analyse the causes and anatomical patterns of explosive and gunshot wounds in Ukrainian soldiers acquired during the Anti-Terrorist Operation/Operation Joint Forces. We also investigated how general and regional anaesthesia procedures affected post-operative pain in wounded soldiers.

METHODS

A retrospective observational study was done based on the medical records of Ukrainian soldiers wounded in the Anti-Terrorist Operation/Operation Joint Forces between 2014 and 2021. The collected data included the American Society of Anesthesiologists score, mechanism of injury, the pattern of anatomical injury, pain intensity and the choice of anaesthesia given. Pain intensity was diagnosed using a Numerical Rating Scale.

RESULTS

A total of 280 combat casualties with explosive (75.7%) and gunshot (24.3%) wound injuries were included in the study. Most of the wounded soldiers had one body region affected by injury (59.3%). In most of the cases, the affected body regions were lower (48.2%) and upper (33.8%) limbs. In 62.5% of patients, regional anaesthesia was used, while general anaesthesia was used in 37.5% of cases. The pain significantly decreased after initial treatment at the field medical unit regardless of the anaesthesia type or the number of affected body regions.

CONCLUSION

Understanding the sources and anatomical patterns of war-related injuries in recent conflicts is an important element in reducing the mortality and suffering of wounded soldiers. The high percentage of injured extremities in our cohort emphasises the importance of regional anaesthesia in contemporary wars.

Reciprocal Learning Between Military and Civilian Surgeons: Past and Future Paths for Medical Innovation

Numerous surgical advances have resulted from exchanges between military and civilian surgeons. As part of the U.S. National Library of Medicine Michael E. DeBakey Fellowship in the History of Medicine, we conducted archival research to shed light on the lessons that civilian surgery has learned from the military system and vice-versa. Several historical case studies highlight the need for immersive programs where surgeons from the military and civilian sectors can gain exposure to the techniques, expertise, and institutional knowledge the other domain provides. Our findings demonstrate the benefits and promise of structured programs to promote reciprocal learning between military and civilian surgery.

The Effect of Large-Capacity Magazine Bans on High-Fatality Mass Shootings, 1990-2017

Objectives. To evaluate the effect of large-capacity magazine (LCM) bans on the frequency and lethality of high-fatality mass shootings in the United States.Methods. We analyzed state panel data of high-fatality mass shootings from 1990 to 2017. We first assessed the relationship between LCM bans overall, and then federal and state bans separately, on (1) the occurrence of high-fatality mass shootings (logit regression) and (2) the deaths resulting from such incidents (negative binomial analysis). We controlled for 10 independent variables, used state fixed effects with a continuous variable for year, and accounted for clustering.Results. Between 1990 and 2017, there were 69 high-fatality mass shootings. Attacks involving LCMs resulted in a 62% higher mean average death toll. The incidence of high-fatality mass shootings in non-LCM ban states was more than double the rate in LCM ban states; the annual number of deaths was more than 3 times higher. In multivariate analyses, states without an LCM ban experienced significantly more high-fatality mass shootings and a higher death rate from such incidents.Conclusions. LCM bans appear to reduce both the incidence of, and number of people killed in, high-fatality mass shootings.

The Association of Firearm Caliber With Likelihood of Death From Gunshot Injury in Criminal Assaults

IMPORTANCE

A foundational issue in firearms policy has been whether the type of weapon used in an assault affects the likelihood of death.

OBJECTIVE

To determine whether the likelihood of death from gunshot wounds inflicted in criminal assaults is associated with the power of the assailant's firearm as indicated by its caliber.

DESIGN, SETTING, AND PARTICIPANTS

Cross-sectional study with multivariate analysis of data on shooting cases extracted by the authors from police investigation files for assaults that took place in Boston, Massachusetts, between January 1, 2010, and December 31, 2014. These data were analyzed between October 1, 2017, and February 18, 2018. In all cases the victim sustained 1 or more gunshot wounds in circumstances that the Boston Police Department deemed criminal. The working sample included all 221 gun homicides and a stratified random sample of 300 nonfatal cases drawn from the 1012 that occurred during the 5-year period. Seven nonfatal cases were omitted because they had been misclassified.

EXPOSURES

The primary source of variation was the caliber of the firearm used to shoot the victim.

MAIN OUTCOMES AND MEASURES

Whether the victim died from the gunshot wound(s).

RESULTS

The final sample of 511 gunshot victims and survivors (n = 220 fatal; n = 291 nonfatal) was predominantly male (n = 470 [92.2%]), black (n = 413 [80.8%]) or Hispanic (n = 69 [13.5%]), and young (mean [SD] age, 26.8 [9.4] years). Police investigations determined firearm caliber in 184 nonfatal cases (63.2%) and 183 fatal cases (83.2%). These 367 cases were divided into 3 groups by caliber: small (.22, .25, and .32), medium (.38, .380, and 9 mm), or large (.357 magnum, .40, .44 magnum, .45, 10 mm, and 7.62 × 39 mm). Firearm caliber had no systematic association with the number of wounds, the location of wounds, circumstances of the assault, or victim characteristics, as demonstrated by χ2 tests of each cluster of variables and by a comprehensive multinomial logit analysis. A logit analysis of the likelihood of death found that compared with small-caliber cases, medium caliber had an odds ratio of 2.25 (95% CI, 1.37-3.70; P = .001) and large caliber had an odds ratio of 4.54 (95% CI, 2.37-8.70; P < .001). Based on a simulation using the logit equation, replacing the medium- and large-caliber guns with small-caliber guns would have reduced gun homicides by 39.5%.

CONCLUSIONS AND RELEVANCE

Firearms caliber was associated with the likelihood of death from gunshot wounds in criminal assault. Shootings with larger-caliber handguns were more deadly but no more sustained or accurate than shootings with smaller-caliber handguns. This conclusion is of direct relevance to the design of gun policy.

Critical Violent Injury in the United States: A Review and Call to Action

OBJECTIVE

This review provides an overview of what is known about violent injury requiring critical care, including child physical abuse, homicide, youth violence, intimate partner violence, self-directed injury, firearm-related injury, and elder physical abuse.

DATA SOURCES

We searched PubMed, Scopus, Ovid Evidence-Based Medicine Reviews, and the National Guideline Clearinghouse. We also included surveillance data from the Centers for Disease Control and Prevention and National Trauma Data Bank.

STUDY SELECTION

Search criteria limited to articles in English and reports of humans, utilizing the following search terms: intentional violence, intentional harm, violence, crime victims, domestic violence, child abuse, elder abuse, geriatric abuse, nonaccidental injury, nonaccidental trauma, and intentional injury in combination with trauma centers, critical care, or emergency medicine. Additionally, we included relevant articles discovered during review of the articles identified through this search.

DATA EXTRACTION

Two hundred one abstracts were reviewed for relevance, and 168 abstracts were selected and divided into eight categories (child physical abuse, homicide, youth violence, intimate partner violence, self-directed injury, firearm-related injury, and elder physical abuse) for complete review by pairs of authors. In our final review, we included 155 articles (139 articles selected from our search strategy, 16 additional highly relevant articles, many published after we conducted our formal search).

DATA SYNTHESIS

A minority of articles (7%) provided information specific to violent injury requiring critical care. Given what is known about violent injury in general, the burden of critical violent injury is likely substantial, yet little is known about violent injury requiring critical care.

CONCLUSIONS

Significant gaps in knowledge exist and must be addressed by meaningful, sustained tracking and study of the epidemiology, clinical care, outcomes, and costs of critical violent injury. Research must aim for not only information but also action, including effective interventions to prevent and mitigate the consequences of critical violent injury.

Management dilemma in penetrating head injuries in comatose patients: Scenario in underdeveloped countries

Background:

The optimal management of patients with minimal injury to brain has been a matter of controversy and this is especially intensified when the patient has a poor neurological status. This is important in the regions where neurosurgical services are limited and patient turnover is disproportionate to the available resources. We aimed to determine the effectiveness of aggressive management in coma patients after penetrating missile injuries of the brain.

Methods:

All the patients of gunshots or blast injuries were included if they had a Glasgow Coma Scale score of less than 8 after initial resuscitation and had no other injury that could explain their poor neurological status. The indication for emergency surgery was evidence of a mass lesion causing a significant mass effect; otherwise, debridement was done in a delayed fashion. The patients who were not operated were those with irreversible shock or having small intracranial pellets with no significant scalp wounds. The patients who had a Glasgow outcome score of 1, 2, or 3 were classified as having an unfavorable outcome (UO) and those with scores 4 and 5 were classified as having a favorable outcome (FO).

Results:

We operated 13 patients and the rest 13 were managed conservatively. The characteristics of the patients having a favorable outcome were young age (OR = 28, P = 0 .031), normal hemodynamic status (OR = 18, P = 0.08), presence of pupillary reaction (OR = 9.7, P = 0.1), and injury restricted to one hemisphere only (OR = 15, P = 0.07). All of the patients who were in shock after resuscitation died while 25% of the patients with a normal hemodynamic status had a favorable outcome.

Conclusions:

In developing countries with limited resources, the patients who are in a comatose condition after sustaining penetrating missile injuries should not be managed aggressively if associated with bihemispheric damage, irreversible shock, or bilateral dilated nonreacting pupils. This is especially important in the event of receiving numerous patients with the same kind of injuries.

Damage Control Philosophy in Polytrauma

Severe traumatic injury is a public health care problem; with injuries accounting for 12% of the global mortality. Continued improvement in the survival of severely injured trauma patients is a paramount goal. Bailout/damage control surgery following trauma has developed as a major advance in surgical practice in the last twenty years. The principles of damage control surgery defied the traditional surgical teaching of definitive operative intervention and were slow to be adopted. Currently, damage control surgery has been successfully utilized to manage traumatic thoracic, abdominal, extremity, and peripheral vascular injuries. In addition, damage control surgery has been extrapolated for use in general, vascular, cardiac, urologic, and orthopaedic surgery. Stone et al were the first to describe the "bailout" approach of staged surgical procedures for severely injured patients. This approach emerged after their observation that early death following trauma was associated with severe metabolic and physiologic derangements following severe exsanguinating injuries. Profound shock along with major blood loss initiates the cycle of hypothermia, acidosis, and coagulopathy. During the 1980s, hypothermia, acidosis, and coagulopathy were described as the "trauma triangle of death" which makes the prolonged and definitive operative management of trauma patients dangerous. The management technique, now described as "damage control" by Rotondo et al, involves a multiphase approach, in which reoperation occurs after correction of physiologic abnormalities.

Injury-adjusted mortality of patients transported by police following penetrating trauma

BACKGROUND

More than a decade ago, the city of Philadelphia began allowing police transport of penetrating trauma patients.

OBJECTIVES

  The objective was to determine the relation between prehospital mode of transport (police department [PD] vs. Philadelphia Fire Department (PFD) emergency medical services [EMS]) and survival in subjects with proximal penetrating trauma.

METHODS

The authors performed a retrospective cohort study of prospectively collected trauma registry data. All subjects who sustained proximal penetrating trauma and who presented to a Level I urban trauma center over a 5-year period (January 1, 2003, to December 31, 2007) were included. Mortality for subjects presenting by EMS was compared to that of those who arrived by PD transport in unadjusted and adjusted analyses. Unadjusted analyses were performed using the chi-square test, Wilcoxon rank sum test, and Student's t-test. Adjusted analyses were performed using logistic regression using the Trauma Injury Severity Score (TRISS) methodology. Data are presented as percentages, odds ratios (ORs), and 95% confidence intervals (CIs). Total hospital length of stay was examined as a secondary outcome.

RESULTS

Of the 2,127 subjects, 26.8% were transported to the emergency department (ED) by PD, and 73.2% by EMS. The mean(±standard deviation [SD]) age of PD subjects was 26.3 (±9.1) years and 92% were male versus EMS subjects whose mean (±SD) age was 31.5 (±11.8) years and of whom 87% were male. Overall, 70.8% sustained a gunshot wound (GSW), and 29.2% sustained a stab wound (SW). Overall Injury Severity Score (ISS) was 11.21 (ISS for PD, 14.2±17.5; for EMS, 10.1±14.5; p<0.001), and 16.6% of the subjects died (PD, 21.4±0.41%; EMS, 14.8±0.36%; p<0.001). In unadjusted analyses, PD subjects were more likely to die than EMS subjects (OR=1.6, 95% CI=1.2 to 2.0; p<0.001). When adjusting for injury severity using TRISS, there was no difference in survival between PD and EMS subjects (OR=1.01, 95% CI=0.63 to 1.61). Median length of hospital stay was 1 day and did not differ according to mode of prehospital transport (p=0.159).

CONCLUSIONS

Although unadjusted mortality appears to be higher in PD subjects, these findings are explained by the more severely injured population transported by PD. The current practice of permitting police officers to transport penetrating trauma patients should be continued.

The Number of Gunshot Wounds Does Not Predict Injury Severity and Mortality

It is presumed that as the number of gunshot wounds (GSWs) increases, so do the Injury Severity Score (ISS) and mortality risk. We hypothesized that the number of bullet wounds relates to ISS and death; however, a single GSW to the head is ominous. We reviewed the charts of all GSW patients admitted to a trauma center from 2004 to 2006 (n = 531). We analyzed patient demographics, ISS, and mortality. There was no correlation with the number of GSWs with either ISS or mortality. There was only a 0.3 per cent increased risk of death for each additional GSW ( r2 = 0.12). Patients with a single GSW versus multiple GSWs had no difference in mortality (9.1 vs 8.4%, P = 0.8). A single GSW to the head carried a 50 per cent mortality risk. For those who sustained both head and body GSWs, each additional GSW did not increase mortality ( r2 = 0.007). Our study shows that the number of GSWs has no affect on mortality or ISS. Internal triage and management of gunshot victims should not be affected by the categorization of patients as having a single versus multiple GSWs.

Outcomes related to the number and anatomic placement of gunshot wounds

OBJECTIVES

Firearm wounding patterns have changed, and patients more commonly present with multiple gunshot wounds (GSWs). We hypothesized that multiple GSW are associated with increased mortality risk and increased hospital length of stay (LOS).

METHODS

Medical charts were abstracted for patients with GSW during a 4-month period. GSW to each of six anatomic regions were quantified. Proportions, medians, and trends were compared, and relative risks of death were computed.

RESULTS

Among 111 patients, GSW per patient ranged from 1 to 12. Most (62%) patients sustained GSW to a single region. The median number of regions involved increased with the number of GSW (p < 0.01). Patients with multiple regions injured were more likely to die in the emergency department (16% vs. 12%, p < 0.05) or be admitted (72% vs. 52%, p < 0.01). Intensive care unit and hospital LOS increased (p < 0.05) with the number of regions involved.

CONCLUSIONS

Multiple GSW are associated with higher mortality, more intensive care unit days, and longer LOS. Changing wounding patterns seem to have increased morbidity and mortality associated with firearm injuries. These data have associated health policy implications.

Firearm injuries: epidemic then, endemic now

There has been a transition in US firearm injuries from an epidemic phase (mid-1980s to early 1990s) to an endemic one (since the mid-1990s). Endemic US firearm injuries merit public health attention because they exact an ongoing toll, may give rise to new epidemic outbreaks, and can foster firearm injuries in other parts of the world. The endemic period is a good time for the development of ongoing prevention approaches, including assessment and monitoring of local risk factors over time and application of proven measures to reduce these risk factors, development of means to address changing circumstances, and ongoing professional and public education designed to weave firearm injury prevention into the fabric of public health work and everyday life.

Impact of handgun types on gun assault outcomes: a comparison of gun assaults involving semiautomatic pistols and revolvers

OBJECTIVE

To examine whether gun assaults committed with semiautomatic pistols are more injurious and lethal than those committed with revolvers.

SETTING

Jersey City, New Jersey from 1992 through 1996.

METHODS

Using police records on fatal and non-fatal handgun assaults, t tests and chi(2) tests were employed to determine if attacks with pistols result in more shots fired than those with revolvers, leading to more gunshot victims and more severely wounded victims.

RESULTS

More shots were fired in attacks with pistols (average = 3.2 to 3.7) than in attacks with revolvers (average = 2.3 to 2.6). Although pistol use was unrelated to the probability that an incident resulted in any injury or death, it was associated with a 15% increase in the number of wounded victims in those cases in which people were shot (1.15 per pistol case, 1.0 per revolver case), implying that the total number of gunshot victims may have been 9.4% lower had pistols not been used in any attacks. Pistol use was not related to the number of wounds per gunshot victim.

CONCLUSIONS

The findings provide limited evidence that recent growth in the production and use of pistols has contributed to higher levels of gunshot victimizations. However, available data did not permit an assessment of whether the associations between gun types and assault outcomes are mediated by characteristics of incidents and actors.

Hospitalization for firearm-related injuries in the United States, 1997

BACKGROUND

Firearm-related injuries are a serious public health problem in the United States. Despite the magnitude of this problem, prior national estimates of nonfatal, firearm-related morbidity have been limited to an emergency department-based surveillance system. The objective of this study was to assess and report the information available on firearm-related injuries in an existing national database, derived from hospital discharge data.

METHODS

Cross-sectional analysis of the 1997 Nationwide Inpatient Sample (NIS), a stratified probability sample of 1012 nonfederal community hospitals from 22 states. The database was queried using E codes to identify firearm-related injuries. The SUDAAN software program was used to convert raw counts into weighted counts that represent national estimates and 95% confidence intervals (CIs).

RESULTS

An estimated 35,810 (95% CI, 32,615-38,947) cases nationwide were identified, of which 86% were male. Assault was the leading cause of firearm-related hospitalization, followed by unintentional injury. The mean length of stay (LOS) for patients with a firearm-related assault was 6 days. Seven percent of all firearm cases died during the hospitalization. The total estimated hospital charges for firearm-related injuries in the United States in 1997 was over $802 million, and 29% of the patients admitted for this condition were uninsured.

CONCLUSIONS

Firearm-related injuries rank highest among all conditions in the number of uninsured hospital stays, and the average LOS is much longer compared to other medical conditions. National estimates derived from the NIS are consistent with previous estimates, and NIS provides additional information not available from other data sources.

Adolescent violence. Assessment of nurses' attitudes and educational needs

Adolescent violence is a major public health problem. Because of their roles in community and hospital settings, nurses have an opportunity to limit the epidemic of violence. The purpose of this study was to examine the perceived levels of knowledge, the value of further education, resource utilization, and attitudes of nurses caring for adolescent victims of violence. Data were collected from 60 nurses employed at an urban public hospital. Results of the study indicate that 50% of the respondents had high scores on the perceived knowledge section of the survey. However, the majority of nurses (82.5%) felt inadequately educated about violence. The attitudes reported with the most frequency were frustration (78%), anger (59%), and powerlessness (58%). The results of this study indicate a need for additional violence education for nurses, particularly in the areas of available resources and intervention for adolescent victims of violence.

Factors associated with assault-related firearm injuries in male adolescents

PURPOSE

To identify factors associated with an increased prevalence of assault-related firearm injuries in male adolescents.

METHODS

This study is a retrospective comparison of two samples of adolescent males from the same geographic localities regarding their involvement in the juvenile justice system (court involvement) and injury status (current or prior firearm injury at the time of the study). The subjects included adolescent male patients admitted to an urban, Level I trauma center for assault-related firearm injuries (court-involved and noncourt- involved, n = 65); and incarcerated juvenile offenders (prior firearm injury and no known firearm injury, n = 267).

RESULTS

Two-thirds of the male assault-related pediatric firearm injury victims treated over a two-year period were involved in the juvenile justice system (court involved). Court-involved adolescents were almost 22 times more likely to have sustained an assault-related firearm injury, when compared to noncourt-involved patients with firearm injuries. Additional analysis documented recent substance use and/or involvement in criminal offenses in 82% of the victims. For most of the juvenile offenders (88%), court involvement preceded their injuries. Analysis of the injury patterns revealed an increased prevalence of truncal injuries (injuries to thorax or abdomen) in the court-involved victims, when compared to their noncourt-involved peers (40% and 14% for the court-involved and noncourt-involved samples, respectively; p <.05). Incarceration was associated with a 17-fold increase in the firearm injury prevalence over the court-involved, but not incarcerated, sample.

CONCLUSIONS

These results suggest that involvement in substance use and/or the criminal justice system is associated with an increased risk of firearm injuries in male adolescents, and that an increased level of involvement in the juvenile justice system is associated with a concomitant increase in firearm injuries.

Evaluating the Role of Physical and Radiographic Examinations in Assessing Bullet Tract Termination for Gunshot Victims

Knowledge of the path of a bullet and how it terminates is critical for expeditious assessment and optimal management of patients with gunshot wounds. To assess the accuracy of physical examination and X-rays in these patients, a prospective study was undertaken for all gunshot victims seen for a 1-year period on a single trauma service. The paramedics and trauma surgeons' physical examinations were evaluated for whether a bullet tract could be accurately categorized as 1) through and through, 2) graze, 3) palpable under dermis, or 4) retained (ie, not palpable). The impact of X-rays was assessed with regard to how it affected the trauma surgeons' categorization. A total of 78 patients were seen with a total of 120 bullet tracts. Seventy-seven per cent were injured by assault, and 64 per cent were shot with a 9-mm or .38-caliber handgun. Twenty of 60 (33%) bullet tracts on the torso terminated with a missile that was palpable under dermis, but only 2 of 10 neck (20%), 1 of 28 extremity (4%), and 1 of 22 head/face (5%) did so. Paramedics evaluated 15 torso bullet tracts that ended palpable under dermis, of which they detected 5 (33%). Upon initial examination, the trauma surgeon detected 11 of 20 torso bullet tracts that ended palpable under dermis (55%), and detected 14 of the 20 after X-rays were done (70%). Overall, obtaining X-rays changed the categorization for 15 of 111 bullet tracts (13%). We conclude that bullet tracts on the torso result in a subcutaneously palpable bullet one-third of the time, much more frequently than in other body regions. Paramedics only detect one-third of subcutaneously palpable missiles on the torso. X-rays change the categorization of bullet tracts infrequently. We recommend that a careful examination of the skin of the torso to detect palpable missiles be incorporated into the secondary survey of patients with wounds to that body region.

Management of gunshot wounds at a Sydney teaching hospital

BACKGROUND

Injuries caused by firearms account for only a small percentage of trauma admissions and deaths in Australia but are frequently the subject of media and public attention. The present study examines the epidemiology and management of firearm injuries presenting to St Vincent's Hospital, which is located at the edge of the central business district of Sydney.

METHODS

The medical records of all patients presenting to St Vincent's with a gunshot wound (GSW) from January 1988 to December 1998 were analysed. Additional details were acquired from New South Wales State Coroner's Court reports and media archives, especially major newspapers.

RESULTS

Seventy-four patients presented to St Vincent's Hospital with 103 GSW. The age (mean +/- SD) was 31+/-11 years. Sixty-seven patients (91%) were male. Alcohol was identified as a factor in 24 cases (32%) while other drugs were indicated in four cases (5%). Ten patients (14%) had intentionally self-inflicted wounds, seven (9%) had accidental wounds and 57 (77%) had wounds that were caused by crime-related violence. Sixty patients (81%) underwent operation for their injury. Thirty complications were seen in 18 patients (24%). Eleven patients (15%) died. The length of hospital stay (mean +/- SEM) was 18+/-9 days.

CONCLUSIONS

The incidence of trauma due to firearms has not increased at St Vincent's hospital in the period 1988-98. Most GSW were inflicted in the setting of criminal violence, with a high proportion due to handguns. Patients were mostly young men, and alcohol or other drugs were frequently involved. Outcomes are comparable to other centres managing large volumes of penetrating trauma.

Penetrating craniocerebral injuries in a civilian population in mid-Europe

Our current neurosurgical understanding of civilian penetrating craniocerebral injuries is based on US metropolitan series. It is unknown whether all principles applied to these patients are relevant in the Mid-European setting with its distinct epidemiology. The objective of this study was to characterize our patients with penetrating craniocerebral injuries, to analyze their outcome, and to identify relevant prognostic factors. Thirty-two patients with penetrating craniocerebral injuries were entered into the study. Patient evaluation comprised neurological, laboratory and radiographic analyses. Motivating factors were suicide (75%), assault (13%), and accident (9%). Initial GCS score, coagulopathy on admission, and radiographic extent of injury could be identified as outcome predictors (P < 0.001). An aggressive therapeutic approach to patients with GCS 3-7 reduced mortality when compared to a conservative management (67 vs. 91%). Due to major differences in epidemiology and outcome of our penetrating craniocerebral injury patients when compared to major US metropolitan series, current therapeutic strategies applied to this patient population in mid-Europe should be reconsidered. The results of our study justify an aggressive neurosurgical approach even in those patients that are thought to have a deleterious prognosis. Predictive variables identified in this study and a novel CT-grading algorithm may help in decision making.

Why firearm injury surveillance?

With the current progress of state firearm injury surveillance systems reported in this issue of the Journal, questions about the logical progression of these efforts are being raised. This article reviews the current state of firearm injury data, discusses the importance of firearm injury surveillance, and offers suggestions for maximizing the potential of future efforts in this area.

Intentional and unintentional injury in the State of Nevada: 1989-1992

INTRODUCTION

Data from a large population-based trauma registry were used to assess risk factors and outcomes associated with injuries that were either caused unintentionally, were self-inflicted, or resulted from an assault.

DESIGN

A retrospective analysis was conducted of all cases of serious trauma (N = 19,505) occurring in the State of Nevada during the 4-year period from January 1, 1989, through December 31, 1992. The outcome measures of interest were Injury Severity Score, hospitalization, and mortality.

RESULTS

Of all patients with unintentional injuries, 9.9% died compared with 44.8% of those whose injuries were intentionally caused. Nearly half (49.0%) of all deaths occurred in persons who were intentionally injured. Of the intentional injuries, 70% were from assaults. Self-inflicted injuries accounted for 5.2% of all injuries but 28.2% of the deaths in the registry. Firearms were most often used in both assaults (38.8%) and self-inflicted injuries (87.4%). Logistic regressions showed that, compared with unintentional injuries, assaults were more likely to occur in urban counties, among males, African Americans, and young adults. Also, compared with unintentional injuries, self-inflicted injuries were more likely to occur in urban counties, among Caucasian, and the 65+ age group.

CONCLUSION

Although the overwhelming number of injuries in the registry were unintentionally caused, deaths from intentionally caused injuries accounted for almost half of all deaths. The data from Nevada's registry provided the ability to identify who is at risk for trauma-related injury and death. Prevention programs should be designed to target these populations. As prevention programs are implemented, trauma registries such as Nevada's will provide a sound source of data for assessing long-term trends in injury patterns.

Weapons of choice: previous criminal history, later criminal activity, and firearm preference among legally authorized young adult purchasers of handguns

OBJECTIVE

To determine whether there is an association between criminal activity and preference for a particular class of handgun among young adults who purchase handguns legally.

DESIGN

Historical cohort study.

MATERIALS AND METHODS

Subjects were 5,360 authorized purchasers of handguns in California in 1988 who were 21 to 25 years of age, divided into two groups: all eligible purchasers with a previous criminal history (n = 2,765), and a random sample of purchasers with no such history (n = 2,595). Handguns were classified as small and inexpensive or larger and expensive. Associations were assessed by relative risks adjusted for gender and race or ethnicity.

MEASUREMENTS AND MAIN RESULTS

Handgun purchasers with a previous criminal history were more likely than those without such a history to purchase a small, inexpensive handgun (relative risk (RR) = 1.28; 95% confidence interval (CI), 1.16-1.42). Among handgun purchasers with no previous criminal history, those who purchased a small, inexpensive handgun were more likely than purchasers of other handguns to be charged with new crimes after handgun purchase (RR = 1.73; 95% CI, 1.34-2.24) and were nearly twice as likely to charged with new crimes involving firearms or violence (RR = 1.93; 95% CI, 1.38-2.69).

CONCLUSION

In this population, criminal activity both before and after handgun purchase was associated with a preference for small, inexpensive handguns.

Geographic variation in serious nonfatal firearm injuries in Pennsylvania

OBJECTIVE

The purpose of this study was to characterize the geographic epidemiology of serious nonfatal firearm injuries (NFFI) within Pennsylvania during a 6-year period.

METHODS

A historical review of data from the Pennsylvania Trauma System Foundation trauma registry was completed using county-level data. Based on a format adapted from the United States Department of Agriculture, NFFI in Pennsylvania were classified by their county of occurrence: central city counties, metropolitan counties, nonmetropolitan counties, or rural counties. Population-based rates of NFFI were then calculated, as were NFFI as a proportion of the number of injuries within each region. These rates were stratified by intent of injury, scene of injury, and type of firearm.

RESULTS

A total of 100,703 trauma cases were reported to the Pennsylvania Trauma System Foundation from 1988 through 1993, of which 5,847 were serious NFFI. Nonfatal firearm assaults increased from rural counties to central city counties, whereas unintentional NFFI decreased (p < 0.05). A 225% increase in the number of NFFI, from 445 cases in 1988 to 1,004 cases in 1993, was noted in the central city counties. Comparatively, the increase in the noncity regions was 145%, from 182 cases in 1988 to 263 in 1993. Nonfatal firearm injuries occurred most often at home in noncity counties (rural, nonmetropolitan, and metropolitan counties) (47.9%). This is in contrast to central city counties, where NFFI occurred significantly more often in the street (53.5%) (p < 0.05). Handgun NFFI increased, whereas rifle NFFI decreased, from rural counties to central city counties (p < 0.05). Relative to population size, the risk of shotgun injuries was greatest in central city counties and lowest in rural counties. Shotgun injuries also accounted for a significantly longer hospital stay (15.06 days) compared with handgun injuries (10.38 days) and rifle injuries (11.81 days) (p < 0.05).

CONCLUSION

Significant variation in NFFI was observed across population-based regions in Pennsylvania. Rural areas demonstrated relatively high risks of NFFI committed unintentionally, in the home, and with rifles. As regional populations increase, relatively high risks of NFFI, committed as assaults, in the street, and by handguns, are highlighted. Although handguns were the most prominent firearm associated with NFFI, nonfatal shotgun injuries produced substantially longer hospital stays and may be an underappreciated cause of nonfatal firearm assaults in the urban setting.

Inner city gunshot wounds

A retrospective survey was undertaken to establish the pattern and incidence of gunshot wounds seen at a South London hospital. Forty-two gunshot wounds were seen in 1993 and 1994. All the patients were under 39 years of age and 40 were male. All patients had low energy transfer injuries, having been shot with hand-guns (n = 36), seven of whom had multiple bullet or shotgun wounds (n = 6). Sixteen patients had head, neck or chest injuries, eight of whom died. Seven patients were wounded in the abdomen or pelvis and 31 had limb injuries. Thirty-six surviving patients had a total of 33 operations and a mean hospital stay of 7.65 days (range 0-105 days).

Hemodynamic effects of aortic occlusion during hemorrhagic shock and cardiac arrest

OBJECTIVE

To determine the hemodynamic consequences of aortic occlusion during controlled hemorrhagic arrest.

METHODS

Ten anesthetized, hemodynamically monitored swine were subjected to a 40 mL/kg hemorrhage over 10 minutes, followed by a 5-minute period of apnea. At this time (T15), they were randomized into an UP group (n = 5) in which the thoracic aorta was occluded or a DOWN group (n = 5) in which the aorta was not occluded. Simultaneously, volume resuscitation with shed blood plus 20 mL/kg of normal saline was performed over a 10-minute period. Cardiac massage was performed until return of spontaneous circulation (ROSC), which was defined as a sustained systolic blood pressure > 60 mm Hg. After 30 minutes of occlusion (T45), the aortic occlusion was released. Parameters measured include mixed venous and arterial blood gases, serum lactic acid levels, cardiac index, mean arterial pressure (MAP), mean pulmonary artery pressure (MPAP), coronary perfusion pressure (CoPP), and left ventricular stroke work index (LVSWI). Oxygen delivery index (DO2I) was measured using a pulmonary artery catheter, and oxygen consumption index (VO2I) was measured by direct calorimetry (Delta Trac metabolic monitor).

RESULTS

Four animals in each group achieved ROSC after 3.0 +/- 1.8 and 2.2 +/- 1.8 minutes in the occluded and nonoccluded groups, respectively. During cardiac compressions and volume resuscitation, the CoPP, MAP, and MPAP were greater in the UP group, although the differences did not achieve statistical significance. After volume resuscitation was complete and during the period of aortic occlusion (T25-T45), the UP group had significantly greater MAP (mm Hg), with a difference of 42.5 +/- 20.75 mm Hg at T25 and 44.7 +/- 19 mm Hg at T35 (p < 0.03). Despite no difference in DO2I, VO2I (mL/min/kg) was significantly lower in the UP group than in the DOWN group, 4.28 +/- 0.48 versus 8.33 +/- 0.85 at T25 (p = 0.0002) and 4.62 +/- 0.9 versus 7.09 +/- 0.72 at T35 (p = 0.0005). After release of aortic occlusion at T45, the UP group had significantly lower CoPP (mm Hg) than the DOWN group (20.5 +/- 17.3 versus 66.5 +/- 28.2 at T45, p = 0.03). LVSWI (g/kg) was also lower in the UP than in the DOWN group (18.6 +/- 8.28 versus 36.5 +/- 10.2 at T60 [p = 0.031 and 23.6 +/- 6.48 versus 48.8 +/- 15.3 at T240 [p = 0.021). After release of the occlusion, there were trends toward increased acidosis and lactic acid levels in the UP group.

CONCLUSIONS

Aortic occlusion in this controlled hemorrhagic arrest model does not result in improved salvage but is associated with impaired left ventricular function, systemic oxygen utilization, and coronary perfusion pressure in the postresuscitation period.

Costs of gunshot and cut/stab wounds in the United States, with some Canadian comparisons

This article estimates the costs of U.S. gunshot and cut/stab wound by intent. It also compares U.S. to Canadian gunshot experience. Incidence data are from published sources, the National Hospital Ambulatory Medical Care Survey (NHAMCS), and cause-coded emergency department discharge and hospital discharge data systems. Medical care payments and lost earnings per case come from National Crime Survey data, a literature review, and weighting of costs by diagnosis from Databook on Nonfatal Injury-Incidence. Costs, and Consequences by Miller et al. (The Urban Institute Press, Washington, DC. 1995) with the diagnosis distribution of penetrating injuries from the discharge data systems. Quality of life losses are estimated primarily from jury awards to penetrating injury victims. In 1992, gunshots killed 37,776 Americans; cut/stab wounds killed 4095. Another 134,000 gunshot survivors and 3,100,000 cut/stab wound survivors received medical treatment. Annually, gunshot wounds cost an estimated U.S. $126 billion. Cut/stab wounds cost another U.S. $51 billion. The gunshot and cut/stab totals include U.S. $40 billion and U.S. $13 billion respectively in medical, public services, and work-loss costs. Across medically treated cases, costs average U.S. $154,000 per gunshot survivor and U.S. $12,000 per cut/stab survivor. Gunshot wounds are more than three times as common in the U.S. than in Canada, which has strict handgun control. With the same quality of life loss per victim, gunshot costs per capita are an estimated U.S. $495 in the U.S. vs U.S. $180 in Canada. Per gun, however, the costs are higher in Canada, Gunshot wound rates rise linearly with gun ownership.

Cardiopulmonary bypass for resuscitation after penetrating cardiac trauma

Cardiopulmonary bypass is only occasionally required acutely in the management of penetrating cardiac injuries, usually to allow coronary grafting. We describe a case of penetrating trauma in which cardiopulmonary bypass was used to resuscitate a patient whose cardiac lacerations were controlled in the emergency department.

Multiple organ injuries and failures caused by shock and reperfusion after gunshot wounds

Experiments were performed to observe the changes of multiple system organ failure (MSOF) and gut barrier function caused by shock and reperfusion after gunshot wounds. Eighteen dogs were divided randomly into two groups. In the experimental group, the dogs were subjected to 60 minutes of shock (40mm Hg), followed by reinfusion of shed blood after hindlimb gunshot wounds. In the control group, the dogs experienced pure gunshot wounds without shock and reperfusion. The results showed that dogs in the experimental group developed multiple system organ injuries or failures compared with the control group. The levels of malondialdehyde (MDA) values in plasma were significantly elevated in the experimental group when compared with preinjury and the control group. Gut flora disorder, bacillus intestinalis overgrowth, and bacterial translocation occurred in the experimental group. The pathological results support the gut barrier function injury. The results indicated that pure gunshot wounds do not easily injure gut barrier function and produce MSOF. Gunshot wounds with shock and reperfusion are capable of causing gut flora disorder, bacillus intestinalis overgrowth, and lead to bacterial translocation, furthermore causing MSOF. Although fluid resuscitation is a potential treatment modality, pathogenically, it can lead to MSOF.

Truncal gunshot wounds in Finland, 1985 to 1989

A nationwide survey of truncal gunshot wounds identified 119 patients managed in 34 institutions. The wounds resulted from low-velocity bullets in 69%, high-velocity bullets in 6%, and shotgun pellets in 25%. The thoracic or abdominal cavity was penetrated in 62%, and the mean Injury Severity Score was 16 (range, 1 to 57). The wounding capacity of close-range shotgun pellets equaled that of high-velocity bullets, whereas long-range (>10 meters) shotgun injuries resembled air rifle injuries in their poor ability to penetrate deeper structures and cause internal injuries. A thoracotomy or sternotomy was required in 31% of the penetrating thoracic injuries. Of 57 laparotomies, 9% were negative. In four cases (7% of all laparotomies), a significant abdominal organ injury was overlooked at the initial operation, emphasizing the importance of meticulous exploration of all abdominal organs, and especially the diaphragm and the retroperitoneal structures.

Gunshot wounds to the head in civilian practice

An aggressive surgical strategy was applied to cranial gunshot wound victims at Cook County Hospital in Chicago from 1983 to 1992. A series of 480 patients with an overall mortality rate of 34% is presented. A total of 150 patients underwent craniotomy with an operative mortality rate of 21%. Criteria for operation were Glasgow Coma Scale scores of 3 through 7 without hypotension or fixed and dilated pupils or Glasgow Coma Scale scores of 8 through 15 with intracranial bone fragments or significant clot. This study supports previous reports that even patients with severe neurological deficits and massive cerebral damage can benefit from aggressive treatment and make satisfactory recoveries.

Epidemiology of trauma deaths: a reassessment

OBJECTIVE

Recognizing the impact of the 1977 San Francisco study of trauma deaths in trauma care, our purpose was to reassess those findings in a contemporary trauma system.

DESIGN

Cross-sectional.

MATERIAL AND METHODS

All trauma deaths occurring in Denver City and County during 1992 were reviewed; data were obtained by cross-referencing four databases: paramedic trip reports, trauma registries, coroner autopsy reports and police reports.

MEASUREMENTS AND MAIN RESULTS

There were 289 postinjury fatalities; mean age was 36.8 +/- 1.2 years and mean Injury Severity Score (ISS) was 35.7 +/- 1.2. Predominant injury mechanisms were gunshot wounds in 121 (42%), motorvehicle accidents in 75 (38%) and falls in 23 (8%) cases. Seven (2%) individuals sustained lethal burns. Ninety eight (34%) deaths occurred in the pre-hospital setting. The remaining 191 (66%) patients were transported to the hospital. Of these, 154 (81%) died in the first 48 hours (acute), 11 (6%) within three to seven days (early) and 26 (14%) after seven days (late). Central nervous system injuries were the most frequent cause of death (42%), followed by exsanguination (39%) and organ failure (7%). While acute and early deaths were mostly due to the first two causes, organ failure was the most common cause of late death (61%).

CONCLUSIONS

In comparison with the previous report, we observed similar injury mechanisms, demographics and causes of death. However, in our experience, there was an improved access to the medical system, greater proportion of late deaths due to brain injury and lack of the classic trimodal distribution.

Civilian penetrating spinal firearm injuries of the spine. Results of surgical treatment with special attention to factors determining prognosis

In this study, the cases of 17 civilians with penetrating firearm injuries of the spinal cord treated between 1968 and 1990 at the Department of Neurosurgery, Hacettepe University Faculty of Medicine, were analyzed. Relevant literature was reviewed and compared with our study. The results of treatment and other factors determining mortality rate and prognosis were evaluated. Our study and the literature both appear to indicate that operative intervention is the mainstay of treatment.