Epidemiology of firearm injuries in a Scandinavian trauma center

Epidemiology of civilian's gunshot wound injuries admitted to intensive care unit: A retrospective, multi-center study

BACKGROUND

Few studies investigated the outcome of patients admitted to intensive care unit (ICU) for gunshot wounds (GSW). The purpose of this study was to determine the 28-day mortality, and to analyze the impact of variables on the mortality of patients admitted to ICU with GSW in four French University Hospitals level-1 regional trauma centers.

METHOD

All medical files of adult patients (above fifteen years old) admitted to four French University Hospitals level-1 regional trauma centers for GSW were retrospectively analyzed from January 1st 2015 to June 30th 2021. The primary aim was to determine 28-day death rate of patients admitted in ICU for GSW. The secondary aim was to describe biological parameters, injuries and management of patients admitted to our ICUs, and to identify the variables associated with the 28-day mortality rate. A multivariate analysis allowed determining independent mortality factors. A Kaplan-Meier analysis compared mortality according to head injury.

RESULTS

Among 17,262 patients screened, 173 (1 %) were admitted for GSW and 162 were analyzed. The 28-day mortality rate was 24.7 %. 77.5 % of deaths occurred within the first 48 h after ICU admission, and 87.5 % of deaths within three days of ICU admission. The 28-day death rate of patients with head injury was significantly higher as compared to patients without head injury (p < 0.001). Out of forty deaths, twenty-three (57.5 %) were due to head injury, and nine (22.5 %) were due to bleeding. The mechanisms were assault (45.1 %), suicide (34.6 %), accident (4.9 %) and unidentified (15.4 %). In a multivariate analysis, variables associated with the 28-day death rate were age, pre-hospital Glasgow coma score, and Injury Severity Score.

CONCLUSION

GSW represented 1 % of ICU admission. The 28-day mortality rate was 24.7 %. 77.5 % of deaths occurred within the first 48 h due to head injuries and bleeding. Head injuries were associated with significantly higher mortality rate.

Importance of injury severity in the choice of treatment and its impact on prognosis in gunshot fractures

PURPOSE

The management of femur and tibia fractures resulting from gunshot injuries is a challenge for orthopedic surgeons. One-stage and two-stage treatments are applied according to the anatomical location and severity of the injury. In this study, the importance of injury severity and anatomical location was evaluated in the choice of treatment method and its impact on prognosis in cases of lower extremity gunshot fractures.

METHODS

A total of 124 patients who met the study criteria were evaluated. They were grouped separately according to the anatomical location of the injury (femur, n = 73; tibia, n = 51) and the surgical method (one-stage, n = 77; two-stage, n = 47). The demographic characteristics of the patients, fracture classification, presence of neurological or vascular damage at the time of diagnosis, anatomical location of the injury, surgical procedure, and follow-up time were recorded. The time of union and the presence of malunion were evaluated radiologically. Finally, patients were assessed clinically with the New Injury Severity Score (NISS) and leg length discrepancy (LLD) calculated through measurements made on lower extremity orthoroentgenograms.

RESULTS

The rate of vascular injury and the number of Gustilo-Anderson type IIIB and IIIC cases were significantly higher in the two-stage treatment group (p = 0.001 and p = 0.000, respectively). The infection rate was also higher in the two-stage group; therefore, time to union was significantly longer (p = 0.004 and p = 0.05, respectively). LLD was higher among patients who received two-stage treatment (p = 0.015). According to the NISS scale used in clinical assessment, better scores were obtained for the one-stage group (p = 0.002). In comparisons made according to anatomical location, no significant difference was found between femur and tibia injuries.

CONCLUSION

Regardless of anatomical location and treatment method, injuries of higher severity such as Gustilo-Anderson type IIIB and IIIC are correlated with higher rates of complications such as vascular injury, postoperative infection, delayed union, and LLD. Furthermore, in cases of severe injuries, a two-stage approach is commonly favored.

Increased Incidence and Mortality of Civilian Penetrating Traumatic Brain Injury in Sweden: A Single-Center Registry-Based Study

BACKGROUND

Penetrating trauma to the head and neck has increased during the past decade in Sweden. The aim of this study was to characterize these injuries and evaluate the outcomes for patients treated at a tertiary trauma center.

METHODS

Swedish trauma registry data were extracted on patients with head and neck injuries admitted to Karolinska University Hospital (Stockholm, Sweden) between 2011 and 2019. Outcome information was extracted from hospital records, with the primary endpoints focusing on the physiological outcome measures and the secondary endpoints on the surgical and radiological outcomes.

RESULTS

Of 1436 patients with penetrating trauma, 329 with penetrating head and neck injuries were identified. Of the 329 patients, 66 (20%) had suffered a gunshot wound (GSW), 240 (73%) a stab wound (SW), and 23 (7%) an injury from other trauma mechanisms (OTMs). The median age for the corresponding 3 groups of patients was 25, 33, and 21 years, respectively. Assault was the primary intent, with 54 patients experiencing GSWs (81.8%) and 158 SWs (65.8%). Patients with GSWs had more severe injuries, worse admission Glasgow coma scale, motor, scores, and a higher intubation rate at the injury site. Most GSW patients underwent major surgery (59.1%) as the initial procedure and were more likely to have intracranial hemorrhage (21.2%). The 30-day mortality was 45.5% (n = 30) for GSWs, 5.4% (n = 13) for SWs, and 0% (n = 0) for OTMs. There was an annual increase in the incidence and mortality for GSWs and SWs.

CONCLUSIONS

Between 2011 and 2019, an increasing annual trend was found in the incidence and mortality from penetrating head and neck trauma in Stockholm, Sweden. GSW patients experienced more severe injuries and intracranial hemorrhage and underwent more surgical interventions compared with patients with SWs and OTMs.

Risk factors and mortality associated with undertriage after major trauma in a physician-led prehospital system: a retrospective multicentre cohort study

PURPOSE

To assess the incidence of undertriage in major trauma, its determinant, and association with mortality.

METHODS

A multicentre retrospective cohort study was conducted using data from a French regional trauma registry (2011-2017). All major trauma (Injury Severity Score ≥ 16) cases aged ≥ 18 years and managed by a physician-led mobile medical team were included. Those transported to a level-II/III trauma centre were considered as undertriaged. Multivariable logistic regression was used to identify factors associated with undertriage.

RESULTS

A total of 7110 trauma patients were screened; 2591 had an ISS ≥ 16 and 320 (12.4%) of these were undertriaged. Older patients had higher risk for undertriage (51-65 years: OR = 1.60, 95% CI [1.11; 2.26], p = 0.01). Conversely, injury mechanism (fall from height: 0.62 [0.45; 0.86], p = 0.01; gunshot/stab injuries: 0.45 [0.22; 0.90], p = 0.02), on-scene time (> 60 min: 0.62 [0.40; 0.95], p = 0.03), prehospital endotracheal intubation (0.53 [0.39; 0.71], p < 0.001), and prehospital focussed assessment with sonography [FAST] (0.15 [0.08; 0.29], p < 0.001) were associated with a lower risk for undertriage. After adjusting for severity, undertriage was not associated with a higher risk of mortality (1.22 [0.80; 1.89], p = 0.36).

CONCLUSIONS

In our physician-led prehospital EMS system, undertriage was higher than recommended. Advanced aged was identified as a risk factor highlighting the urgent need for tailored triage protocol in this population. Conversely, the potential benefit of prehospital FAST on triage performance should be furthered explored as it may reduce undertriage. Fall from height and penetrating trauma were associated with a lower risk for undertriage suggesting that healthcare providers should remain vigilant of the potential seriousness of trauma associated with low-energy mechanisms.

Gunshot Injury to the Face With Atypical Non-linear Bullet Trajectory: A Case Report

The disruptive effect of firearm missiles on body tissues depends on many factors. However, it mainly relates to the bullet's physical and dynamic properties and tissue-related factors. We encountered an unusual case of a gunshot injury wherein the bullet traversed the neck with an upward and non-linear trajectory with an exit from the contralateral side of the neck without damaging any vital neck organs. A 26-year-old male presented with a gunshot wound to the chin from close range. A bullet entry hole was observed on the right side of the chin, encircled by the abrasion collar, with tattoo marks around the area. The patient was conscious, with normal vital signs and no injury to the cranial nerves or aerodigestive tract. The CT imaging of the patient revealed the injury tract traversing through the muscles of the floor of the mouth to involve the left carotid and left parapharyngeal space, along with the left sternocleidomastoid muscle, with an exit hole below the left mastoid in the posterior triangle of the neck. A bullet usually travels through the body in a straight line or pathway; however, its non-linear trajectories depend on the projectile's dynamics and its interaction with the body tissues. The present case emphasizes understanding wound ballistics to know the erratic bullet trajectories in the victim's body and their interpretation, irrespective of their entry site.

A 10-Year Epidemiologic Overview of Firearm Injuries in Southern West Virginia

The firearm mortality rate in West Virginia (WV) increased over the past four years and is currently 50% higher than the national rate. These alarming statistics, combined with the urban-to-rural shift in firearm injuries, prompted this 10-year epidemiologic overview. To the best of the authors' knowledge, the current study stands alone as the only report of its kind on firearm injuries in the rural setting of southern WV. Firearm injuries were common in White males within the age range of 20-49 years. Assault, which is typically identified as an urban problem, was found to be the most common injury in the study population. In our data series, injury severity score was the strongest predictor of mortality, followed by self-inflicted cause of injury and trauma to the neck/head region.

CT after emergency surgery in penetrating trauma: a seven-year experience in a level I Nordic trauma center

BACKGROUND

Patients with severe penetrating trauma may require emergency surgery on arrival, and postoperative computed tomography (CT) can reveal significant additional injuries.

PURPOSE

To determine the utility of postoperative CT performed within 48 h of emergency surgery after penetrating trauma.

MATERIAL AND METHODS

Trauma registry data were retrieved over a seven-year period at a single level 1 trauma center. All patients aged ≥17 years, admitted with penetrating injury, who underwent urgent surgery and postoperative CT imaging within 48 h, were included. Pre- and intraoperative medical records were compared to CT findings. Age, sex, Injury Severity Score (ISS), New Injury Severity Score (NISS), 30-day mortality, injury mechanism, surgical intervention, and intensive care unit length of stay were extracted.

RESULTS

Out of 1262 patients, 38 fulfilled the study criteria (36 men [94.7%], 2 women [5.3%]; mean age = 31.5 years. Stab wound (SW) was the most common injury mechanism (26/38, 68.4%) followed by gunshot wound (GSW; 10/38, 26.3%). Patients with GSWs were more severely injured than SW victims (median NISS = 34 [range = 3-75]; for GSWs = 34; for SWs = 26; P = 0.045). Out of 38 patients, 20 (52.6%) had additional findings at postoperative CT. Six patients (15.8%) had unidentified or underestimated findings at CT that were severe enough to warrant additional surgery or angiography.

CONCLUSION

Postoperative CT imaging after emergency surgery in penetrating trauma is an important tool in evaluating the injury panorama. Out of 38 patients, 6 (15.8%) had findings at postoperative CT that warranted additional surgical or angiographic intervention.

Epidemiological characteristics and comparative outcome of blast versus gunshot injuries of the extremities in Somalia

BACKGROUND

War conflicts and terror-related injuries constitute a significant public health problem in Somalia. We aim to characterize and compare the injury characteristics of gunshot and blast injuries of the extremities.

METHODS

The data of 333 patients with gunshot and blast injuries of the extremities over three years were retrospectively reviewed. The demographics, injury characteristics, and outcomes were analyzed.

RESULTS

Most of the patients had injuries due to gunshot casualties compared with blast victims (n = 222, 66.7% vs. n = 111, 33.3%). Patients with gunshot wounds (GSW) had a more significant proportion of males than those with blast wounds (BW) (95.5% vs. 85.6%, P < 0.001). There were more open extremity fractures in GSW casualties (96.4% vs. 81.1%). The BW victims had significantly higher associated injuries (52.3% vs. 18.5%, P < 0.001). The BW group had a higher injury severity score (ISS ≥ 16 in 55%, P < 0.001). The need for an intensive care unit (ICU) admission was significantly higher in the BW patients (18% vs. 6.3%, P < 0.001); as well as the length of hospital stay (LOS) was higher in the BW group compared with the GW patients (> 2-week hospital stay in 31% vs. 19%, P < 0.04). About a 2.7% mortality rate was observed in BW (P < 0.014).

CONCLUSION

Gunshot and explosion injuries comprise the majority of war and terror-related trauma of the extremities. These injury mechanisms differ in the body regions involved, the severity of the injury, duration of hospital stay, need for ICU admission, and mortality. Assessment and management of such devastating casualties require a complex and multidisciplinary approach.

Atypical Firearm Injury to the Anterior Triangle of the Neck With an Unusual Projectile Trajectory: A Rare Case Report

The use of firearms is increasing in our society, which increases the incidence of gunshot injuries in developing countries like India. Gunshot injuries in the neck regions are significantly associated with high mortality and morbidity because of the major vascular and other vital structures present in the neck. However, it's very rare that a bullet may have a trajectory that passes through the neck region and does not damage the vital structures. We present one such case of gunshot injury to the neck. A 20-year-old male reported to the emergency department after sustaining a gunshot wound to the left anterior cervical region of the neck. On examination, the right sternocleidomastoid muscle was taut and tender to the touch. It is very rare that a bullet injury in the neck without damage to even a single vital structure. The most critical steps in managing patients with high-velocity penetrating injuries to the head and neck region are securing an airway, controlling hemorrhage, and identifying and repairing residual traumatic deformities at the earliest possible key points for the best outcome.

THE MANAGEMENT OF THE VICTIMS WITH GUNSHOT WOUNDS OF THE EXTREMITIES WITH EXTENSIVE DEFECTS OF THE SOFT TISSUES AT THE LEVEL OF QUALIFIED MEDICAL CARE. CASE-SERIES

OBJECTIVE

The aim: To highlight the original experience of diagnosis and treatment of patients with gunshot wounds of the extremities with extensive defects of the soft tissues.

PATIENTS AND METHODS

Materials and methods: The total number of treated patients with massive gunshot wounds from February 2022 to March 2023 was 60 males. Basic labo¬ratory tests, X-rays of the affected limbs were performed to all patients. USS of the vessels with color Doppler was performed to those casualties who had no peripheral pulses on the wounded extremity. All injured persons underwent wound debridement and fasciotomy on the day of admission, 8 more casualties underwent surgical interventions on the major vessels and nerves.

RESULTS

Results: Good treatment outcomes for patients with extensive soft tissue injury were achieved by early surgical intervention to remove non-viable tissue. Limb preservation was achieved in 98.3% of cases.

CONCLUSION

Conclusions: The study's conclusion emphasizes the importance of a multidisciplinary approach to treating patients with gunshot wounds to the limbs with extensive soft tissue injury. Early surgical interventions with the removal of non-viable tissues are necessary for good outcomes. Revascularization of the affected limb is essential in case of major vessel injury if there is no thread to the life.

Demographics, Radiological Findings, and Predictors of Prolonged Hospitalization in Civilian Gunshot Wound Patients

Objective

This study aims to characterize the demographic, clinical, and radiological features of gunshot wound (GSW) patients as well as identify predictors of prolonged hospitalization.

Methods

In this retrospective study, a consecutive sampling method was used, including all patients with GSWs in any anatomical region. Data collection included demographic and clinical information, radiological findings, treatment specifics, and outcome variables, such as hospitalization length of stay (LOS) as the primary outcome. To identify predictive factors associated with prolonged LOS, logistic regression analysis was used.

Results

We studied 212 GSW cases, including 95.8% were men and 4.2% were women. The mean age of the studied group was 30.17±7.80 years. GSWs occurred in extremities (80.2%), abdomen (9.0%), thorax (4.7%), and head or neck (5.2%). Two patients (0.9%) had both abdominal and thoracic GSWs. The most prevalent radiological study was an X-ray (83.0%). Patients with head and neck GSWs had the longest emergency department stay, while patients with abdominal GSW patients had the shortest (p=0.068). The highest rates of blood product transfusion were observed in abdominal GSWs (63.2%), emergency surgery (63.2%), and ICU admission (42.1%). Head and neck GSWs had the longest hospitalization LOS (7.5 days). Longer LOS was significantly associated with abnormalities in radiological findings, receiving blood products, and ICU admission (p≤0.001). Significant predictors of prolonged LOS were major abnormalities in radiological findings [odds ratio (OR)=5.3; 95% confidence interval (CI):2.8-10.2], head and neck GSWs (OR=6.1; 95% CI:1.2-31.9), and blood product transfusion (OR=4.1; 95% CI: 1.0-16.3).

Conclusion

This study provides insights into factors influencing prolonged hospitalization in GSW patients, highlighting the importance of radiological findings, head and neck injuries, and blood product transfusion.

Gunshot injuries: experience in a tertiary health facility in the Niger Delta Region of Nigeria

Introduction

the incidence of gunshot injuries and its negative socio-economic impact has assumed an alarming dimension in our environment in recent times as a result of increase in various criminal activities arising largely from poverty including armed robbery, insurgencies, banditry, kidnappings, political thuggery and the like. We share our experience in our centre.

Methods

a retrospective study of cases of gunshot injuries seen, admitted and managed at our health facility over a three-year period. Relevant information including: biodata, circumstances surrounding shooting, type/caliber of gun used, etc. were obtained from patient's case notes and other sources. Data were analysed using SPSS version 18.

Results

forty-one gunshot injury patients made up of 37 males and 4 females were studied. About 68% of the patients fell within the age group of 20-39 years. Students were the most commonly affected group (21%). Armed robbery was the most common aetiology of GSI in our patients (43.9%). Low-velocity guns were largely used (46%). The extremities were the most commonly injured (65.9%). Fractures occurred in 63.4% of patients the femur being the most frequently fractured (22.6%). Patients received various treatment modalities including, wound debridement (78%) and exploratory laparotomies (26.8%) while 3 (7.35%) of them died.

Conclusion

armed robbery and other criminal activities continue to constitute important factors responsible for GSI in our environment. There is need for government and all stakeholders to do more in terms of fighting crime in addition to placing policies to alleviate socioeconomic deprivation.

Epidemiology of ballistic fractures in the United States: A 20-year analysis of the Firearm Injury Surveillance Study

INTRODUCTION

Ballistic (i.e., gunshot-induced) fractures present unique treatment challenges and can be associated with high rates of complications and considerable morbidity. Large-scale epidemiologic data on these types of fractures are scarce. There is concern that gun-related violence may be on the rise, potentially increasing the burden of ballistic orthopaedic trauma, but there are few contemporary studies on the topic. The aim of this study, therefore, was to investigate the incidence and demographics of patients with ballistic fractures in the United States (US) over the last 20 years.

MATERIALS AND METHODS

This descriptive epidemiology study retrospectively analyzed the Firearm Injury Surveillance Study to identify cases of ballistic fractures in the US from 2000 to 2019. Overall and annual numbers of fractures and fracture incidence rates (IRs), patient demographics, incident characteristics, and temporal trends were analyzed. Patients of all ages were included. Ballistic fractures were grouped by anatomic location for comparisons (non-spine axial, spine, upper extremity, lower extremity).

RESULTS

An estimated N = 240,555 patients (n = 8,322 unweighted cases) sustained ballistic fractures over the 20-year study period for an overall IR of 39.2 per 1,000,000 person-years at-risk (PYR). Overall, lower extremity fractures accounted for the largest percentage of cases (45.9%; IR=18.8 PYR), followed by upper extremity fractures (32.8%; IR=13.4 PYR), non-spine axial fractures (16.1%; IR=6.6 PYR), and spine fractures (5.2%; IR=2.1 PYR). Diaphyseal femur fractures were the most common ballistic fractures overall. Nearly three-fourths (71.2%) of all cases occurred in males in the second through fourth decades. The most common injury intent was assault (71.8%) and a majority of patients (71.2%) required hospital admission. Accounting for population growth yielded a significantly increasing incidence of all ballistic fractures over the study period from 15.7 PYR in 2000 to 96.8 PYR in 2019 (average annual percent change=10.3, p < 0.00001).

CONCLUSION

These data suggest that the nationwide burden of ballistic fractures in the US has increased significantly in the last two decades. Ballistic fractures are associated with significant morbidity and societal cost, and increasing injury rates highlight the need for future research aimed at better understanding the ideal treatment of these types of fractures and their outcomes.

A characterization of trauma laparotomies in a scandinavian setting: an observational study

BACKGROUND

Despite treatment advances, trauma laparotomy continuous to be associated with significant morbidity and mortality. Most of the literature originates from high volume centers, whereas patient characteristics and outcomes in a Scandinavian setting is not well described. The objective of this study is to characterize treatments and outcomes of patients undergoing trauma laparotomy in a Scandinavian setting and compare this to international reports.

METHODS

A retrospective study was performed in the Copenhagen University Hospital, Rigshospitalet (CUHR). All patients undergoing a trauma laparotomy within the first 24 h of admission between January 1st 2019 and December 31st 2020 were included. Collected data included demographics, trauma mechanism, injuries, procedures performed and outcomes.

RESULTS

A total of 1713 trauma patients were admitted to CUHR of which 98 patients underwent trauma laparotomy. Penetrating trauma accounted for 16.6% of the trauma population and 66.3% of trauma laparotomies. Median time to surgery after arrival at the trauma center (TC) was 12 min for surgeries performed in the Emergency Department (ED) and 103 min for surgeries performed in the operating room (OR). A total of 14.3% of the procedures were performed in the ED. A damage control strategy (DCS) approach was chosen in 18.4% of cases. Our rate of negative laparotomies was 17.3%. We found a mortality rate of 8.2%. The total median length of stay was 6.1 days.

CONCLUSION

The overall rates, findings, and outcomes of trauma laparotomies in this Danish cohort is comparable to reports from similar Western European trauma systems.

Surviving the Scene in Civilian Penetrating Brain Injury: Injury Type, Cause and Outcome in a Consecutive Patient Series in Austria

Background

Penetrating brain injury (PBI) is a heterogeneous condition with many variables. Few data exist on civilian PBI. In some publications, PBI differentiation between low-velocity injury (LVI) and high-velocity injury (HVI) is made, but exact definitions are not given yet. The incidence of PBI depends heavily on the country of origin. Furthermore, captive bolt pistol (CBP) injuries represent a rare type of LVI and almost no reports exist in the human medical literature. Treatment of PBI has been controversially discussed due to high morbidity and mortality with results varying considerably between series. Prognostic factors are of utmost importance to identify patients who presumably benefit from treatment.

Methods

A retrospective, single-center analysis of a consecutive patient series was performed from September 2005 to May 2018. We included all patients with PBI who reached our hospital alive and received any neurosurgical operative procedure.

Results

Of 24 patients, 38% died, 17% had an unfavourable outcome, and 46% had a favourable outcome. In total, 58% of patients with PBI were self-inflicted. Leading causes of injury were firearms, while captive bolt pistols were responsible for 21% of injuries. LVI represented 54%, and HVI represented 46%. The outcome in HVI was significantly worse than that in LVI. A favourable outcome was achieved in 69% of LVI and 18% of HVI. Low GCS and pathological pupillary status at admission correlated significantly with an unfavourable outcome and death.

Conclusions

PBI is a heterogeneous injury with many variables and major geographical and etiological differences. Differentiation between LVI and HVI is crucial for decision-making and predicting outcomes. In patients presenting with object trajectories crossing the midline, no favourable outcome could be achieved. Nevertheless, in total, a favourable outcome was possible in almost half of the patients who succeeded in surgery.

Gunshot-Related Upper Extremity Nerve Injuries at a Level 1 Trauma Center

PURPOSE

Gunshot wounds can result in a spectrum of injuries to nerves, with little data to guide definitive treatment. We performed a retrospective evaluation of gunshot-related upper extremity injuries in an urban trauma center to analyze epidemiology, associated injuries, and short-term outcomes. We hypothesized that gunshot-related injuries would involve soft tissue cavitation, inducing axonotmesis and neuropraxia rather than neurotmesis injuries.

METHODS

All patients over the age of 16 with upper extremity gunshot trauma from May 2018 to May 2019 were identified through the University of Chicago orthopaedic and general surgery trauma databases. Initial nerve injuries were identified by physical examination. Patient demographic data, soft tissue and skeletal injury, treatment modality, and return of function were collected.

RESULTS

Ballistic injuries in 1302 patients were treated over 12 months. We identified 126 upper extremity gunshot injuries in 117 patients. Thirty-eight upper extremities (38 patients) had a documented nerve deficit (38/126, 30%) with a follow-up rate of 94% (34/36) at a mean of 351 days after injury (median, 202 days; range, 13-929 days). One patient had a subacute transradial amputation, and 1 patient was deceased at final follow-up. The presence of vascular injury and fracture increased the rate of neurologic injury after gunshot injuries. At the most recent follow-up, 68% (23/34) of patients with upper extremity injury had improvement in nerve function as measured by objective clinical assessment, with 24% (8/34) experiencing full recovery at an average of 368 days (median, 261 days; range, 41-929 days).

CONCLUSIONS

Nerve injury after ballistic trauma to the upper extremity is common. Vascular injury and fractures were associated with a higher risk of nerve injury. Short-term improvement in nerve function was seen in over half the cohort, suggesting a predominance of neuropraxic effects.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic IV.

Incidence, Demographics, and Outcomes of Penetrating Trauma in Sweden During the Past Decade

Trauma injury is the sixth leading cause of death worldwide, and interpersonal violence is one of the major contributors in particular regarding injuries to the head and neck. The incidence, demographics, and outcomes of penetrating trauma reaching hospitals in Sweden are not known. We report the largest, nationwide epidemiological study of penetrating injuries in Sweden, using the Swedish Trauma Registry (SweTrau). A multi-center retrospective descriptive study of 4,776 patients was conducted with penetrating injuries in Sweden, between 2012 and 2018. Due to the increase in coverage of the SweTrau registry during the same period, we chose to analyze the average number of cases for the time intervals 2013-2015 and 2016-2018 and compare those trends to the reports of the Swedish National Council for Crime Prevention (Brå) as well. A total of 663 patients had Injury Severity Score (ISS) ≥ 15 at admission and were included in the study. Three hundred and sixty-eight (55.5%) were stab wounds (SW), 245 (37.0%) gunshot wounds (GSW), and 50 (7.5%) other traumas. A majority of the cases involved injuries to the head, neck, and face. SW increased from 145 during 2013-2015 to 184 during the second period of 2016-2018. The increase was greater for GSW from 92 to 141 during the same respective periods. This trend of increase over time was also seen in head, neck, and face injuries. The 30-day mortality was unaffected (48-47%) in GSW and trended toward lower in SW (24-21%) when comparing 2013-2015 with 2016-2018. Patients with head trauma had 45% mortality compared to 18% for non-head trauma patients. Head trauma also resulted in worse outcomes, only 13% had Glasgow outcome score (GOS) 5 compared to 27% in non-head trauma. The increasing number of cases of both SW and GSW corresponded well with reports from Brå although further studies also are needed to address deaths outside of hospitals and not registered at the SweTrau. The majority of cases had injuries to the head, neck, and face and were associated with higher mortality and poor outcomes. Further studies are needed to understand the contributing factors to these worse outcomes in Sweden and whether more targeted trauma care of these patients can improve outcomes.

Epidemiology of firearm injuries in Sweden

BACKGROUND

Gun violence is a global health problem. Population-based research on firearm-related injuries has been relatively limited considering the burden of disease. The aim of this study was to analyze nationwide epidemiological trends of firearm injuries.

METHODS

This is a retrospective nationwide epidemiological study including all patients with firearm injuries from the Swedish Trauma Registry (SweTrau) during the period 2011 and 2019. Registry data were merged with data from the Swedish National Council for Crime Prevention and the Swedish Police Authority.

RESULTS

There were 1010 patients admitted with firearm injuries, 96.6% men and 3.4% women, median age 26.0 years [IQR 22.0-36.3]. The overall number of firearm injuries increased on a yearly basis (P < 0.001). The most common anatomical injury location was lower extremity (29.7%) followed by upper extremity (13.8%), abdomen (13.8%), and chest (12.5%). The head was the most severely injured body region with a median abbreviated injury scale (AIS) of 5 [IQR 3.2-5]. Vascular injuries were mainly located to the lower extremity (42%; 74/175). Majority of patients (51.3%) had more than one anatomic injury location. The median hospital length of stay was 3 days [IQR 2-8]. 154 patients (15.2%) died within 24 h of admission. The 30-day and 90-day mortality was 16.7% (169/1010) and 17.5% (177/1010), respectively. There was an association between 24-h mortality and emergency department systolic blood pressure < 90 mmHg [OR 30.3, 95% CI 16.1-56.9] as well as the following injuries with AIS ≥ 3; head [OR 11.8, 95% CI 7.5-18.5], chest [OR 2.3, 95% CI 1.3-4.1], and upper extremity [OR 3.6, CI 1.3-10.1].

CONCLUSIONS

This nationwide study shows an annual increase of firearm-related injuries and fatalities. Firearm injuries affect people of all ages but more frequently young males in major cities. One in six patients succumbed from their injuries within 30 days with most deaths occurring within 24 h of hospital admission. Given the impact of firearm-related injuries on society additional research on a national level is critical.

Health status after penetrating major trauma in Victoria, Australia: a registry-based cohort study

PURPOSE

As few studies have examined long-term health after penetrating injury, this population-based registry study sought to assess health outcomes up to 24 months post-injury.

METHODS

Major trauma patients with penetrating trauma (2009-2017) were included from the Victorian State Trauma Registry (N = 1,067; 102 died, 208 were lost to follow-up). The EQ-5D-3L was used to measure health status at 6, 12 and 24-months. Mixed linear and logistic regressions were used to examine predictors of summary scores, and problems versus no problems on each health dimension.

RESULTS

Average health status summary scores were 0.70 (sd = 0.26) at 6 and 12 months, and 0.72 (sd = 0.26) at 24 months post-injury. Prevalence of problems was consistent over time: mobility (24-26%), self-care (17-20%), usual activities (47-50%), pain/discomfort (44-49%), and anxiety/depression (54-56%). Lower health status and reporting problems was associated with middle-older age, female sex, unemployment; pre-injury disability, comorbid conditions; and assault and firearm injury versus cutting/piercing.

CONCLUSION

Problems with usual activities, pain/discomfort and anxiety or depression are common after penetrating major trauma. Risk factor screening in hospital could be used to identify people at risk of poor health outcomes, and to link people at risk with services in hospital or early post-discharge to improve their longer-term health outcomes.

The trajectory of a low-velocity bullet from the chest to the pituitary gland

The diagnosis and treatment of gunshot injuries requires an understanding of the trajectory of the bullet in each individual case. The majority of gunshot wounds present with easily understandable trajectories resulting in a concise, stream-lined work-up. Occasionally, the initial work-up may reveal a trajectory that is atypical. This can be due to internal bullet deflection, bullet embolism, or bullets that traverse multiple body cavities. Here we present the case of a gentleman who was shot in the left posterior chest, with the bullet ultimately lying-in profile with the patient's pituitary gland. The patient suffered injuries to his left lung, left internal jugular vein, and right optic nerve. On hospital day 1, he required neurosurgical operative intervention for increased somnolence and computed tomography findings which revealed tension pneumocephalus. On hospital day 15, he was discharged home after making a full recovery with the exception of continued blindness in the right eye. Gunshot wounds involving multiple body cavities can increase the complexity of a patient's injury pattern and require increased vigilance and complete history, physical examination, and imaging to ensure optimal outcomes.

Surgical management of pediatric patients with peripheral nerve and plexus lesions caused by stray bullets

PURPOSE

Children and adolescents are frequent victims of gunshot wounds (GSW), either by direct intent or accidentaly. Lesions caused by stray bullets represent a specific type of accidental GSW and are usually associated with urban violence or aerial firing. We thereby present a series of surgically treated pediatric patients with peripheral nerve and brachial plexus lesions caused by stray bullets, referring to their clinical presentation, surgical procedures, and outcomes.

METHODS

Retrospective study of a series of seven pediatric patients treated from 2012 to 2019 for nerve and/or plexus lesions caused by stray bullets at the Peripheral Nerve Unit of the Division of Neurosurgery of Gaffrée e Guinle University Hospital (HUGG). We used the Visual Analog Scale (VAS) to evaluate pain distress and the British Medical Research Council grading system (BMRC) to assess muscle strength.

RESULTS

Patients' ages ranged from 6 to 17 years old (median of 16), and two were female. All presented preoperatively with intense pain, with a median VAS of 9 (range 7 to 10), and six also had neurological deficits. External neurolysis was conducted in all cases, whereas reconstruction with grafts was needed in four patients. All experienced improvement of pain, and those with motor deficits also experienced some level of recovery.

CONCLUSION

Pediatric patients who endure lesions by stray bullets appear to present with debilitating pain, and often with motor deficits. Multidisciplinary management comprising of surgical treatment and physical and occupational therapy may ameliorate symptoms and improve quality of life, as young patients usually fare better after surgery.

Epidemiology and characteristics of firearm injuries in a French level I trauma centre, 2009-2019

BACKGROUND

Firearm injuries (FI) are an increasing problem in Europe but there have been few European epidemiological studies on civilian FI, particularly in France. This study investigated the epidemiology of FI at a French level I trauma centre.

METHODS

A retrospective cohort study was conducted of all patients admitted to our centre with an FI between January 2009 and December 2019. We investigated the epidemiological trends of FI during the study period, and characterised the FI.

RESULTS

A total of 162 patients were victims of FI. Prevalence was 0.11% and the mean annual incidence was 10.4 per 100 000 habs. A significant increase has been observed over the last 10 years, from 5 cases in 2009 (3.1%) to 30 in 2019 (18.5%). Of the 162 victims, 85 (52.5%) died as a direct result of the FI: 72 suicides (88.9%) and 9 victims of urban violence (11.1%) (armed public environment disorder). 95.3% of the patients died before reaching at the hospital. There were 95 cases (58.7%) of suicide and 33 cases (20.4%) of urban violence. The head was shot in 87 cases (48.9%), the thorax in 32 cases (18.5%) and the lower limbs in 24 cases (13.5%). A total of 106 surgeries were performed on 54 patients (33.3%).

CONCLUSIONS

We identified 162 cases of FI with a mean annual incidence of 10.4 per 100 000 habs. A significant increase in FI was observed over the last 10 years. 52.2% of patients died, and the main context was suicide or attempted suicide.

Penetrating Spinal Cord Injury in civilians: analysis of a national database

BACKGROUND

Spinal trauma is common in polytrauma; spinal cord injury (SCI) is present in a subset of these patients. Penetrating SCI has been studied in the military; however, civilian SCI is less studied. Civilian injury pathophysiology varies given the generally lower velocity of the projectiles. We sought to investigate civilian penetrating SCI in the United States.

METHODS

We queried the National Inpatient Sample for data regarding penetrating spinal cord injury from the past 10 years (2006-2015). The National Inpatient Sample includes data of 20% of discharged patients from U.S. hospitals. We analyzed trends of penetrating SCI regarding its diagnosis, demographics, surgical management, length of stay, and hospital costs.

RESULTS

In the past 10 years the incidence of penetrating SCI in all SCI patients has remained stable with a mean of 5.5% (range 4.3%-6.6%). Of the patients with penetrating SCI, only 17% of them underwent a surgical procedure, compared with 55% for nonpenetrating SCI. Patients with penetrating SCI had a longer length of stay (average 23 days) compared with nonpenetrating SCI (15 days). Hospital charges were higher for penetrating SCI: $230,186 compared with $192,022 for closed SCI. Males patients were more affected by penetrating SCI, as well as black and Hispanic populations compared with whites.

CONCLUSIONS

Penetrating SCI represents 5.5% of all SCI patients. Men, blacks, and Hispanics are disproportionally more affected by penetrating SCI. Patients with penetrating SCI have fewer surgical interventions, but their overall length of stay and hospital costs are greater compared with nonpenetrating SCI.

DNA transfer to firearms in alternative realistic handling scenarios

Firearms are the most relevant items of evidence in gun-related crimes, likely bearing various traces facilitating an objective reconstruction of the crime. Trace DNA recovered from firearm surfaces might help to identify individual(s) having handled the firearm and thereby possibly to link the firearm and the corresponding shooter, however, the interpretation of DNA traces on handled items can be challenging and requires a detailed understanding of various factors impacting DNA prevalence, transfer, persistence and recovery. Herein, we aimed at improving our understanding of factors affecting the variability of trace DNA characteristics recovered from firearms handled in gun-related crimes: Skin contact traces were recovered from various outer surfaces of two types of firearms handled in four realistic, casework-relevant handling scenarios and the corresponding trace characteristics (DNA yield, number of contributors, relative profile contribution for known and unknown contributors, LRs) were compared. Trace DNA characteristics differed distinctly between handling conditions, firearm and surface types as well as handling individuals and intraindividual deposits emphasizing the variability and complexity of trace DNA profile composition expected to be recovered from firearms after realistic handling scenarios. The obtained results can provide useful insights for forensic experts evaluating alternative activity level propositions in gun-related crimes.

Physiotherapy management of patients with trunk trauma: A state-of-the-art review

BACKGROUND

Trauma injury remains a significant health risk for all on a global level. Patients with trunk trauma suffer blood loss, inflammation and hypoxia and are at risk of developing respiratory and musculoskeletal complications during their recovery. Physiotherapists are an integral part of the interprofessional team that manages patients who sustain trunk trauma.

OBJECTIVES

To describe the physiotherapy management of adult patients with trunk trauma, their quality of life, post-discharge rehabilitation service provision, and outcome measures used in the physiotherapy management.

METHOD

A non-systematic narrative review of published literature was performed.

RESULTS

Mobilisation, functional exercises, deep breathing exercises and active coughing are used to optimise patients' respiratory and musculoskeletal functioning. Some physiotherapists educate patients on the use of pain management strategies to reduce discomfort from rib fractures, surgical sites and intercostal drainage bottle tubing. Survivors of trunk trauma experience limitations in physical function up to two years. Little is known about post-discharge rehabilitation service provision to these patients after discharge. Few physiotherapists use outcome measures as part of their daily clinical practice.

CONCLUSION

Physiotherapy management of patients with blunt or penetrating trunk trauma during hospitalisation and after discharge is a field of clinical practice that is rich for high-quality research related to service provision, cost analysis and interventions used.

CLINICAL IMPLICATIONS

Physiotherapy clinicians and researchers can use the findings of this review as a guide to their management of adult patients recovering from trunk trauma.

Imaging of penetrating thoracic trauma in a large Nordic trauma center

Background

Penetrating trauma is rarely encountered in Nordic trauma centers, yet the incidence is increasing. Typical imaging findings in penetrating trauma should thus be familiar to all radiologists.

Purpose

To evaluate incidence and imaging findings of penetrating chest trauma, gunshot wound (GSW) and stab wound (SW) injury spectrum, imaging protocols, and outcome in a large trauma center.

Material and Methods

Trauma registry data from 2013–2016 was retrieved, and imaging accessed through hospital PACS. Retrieved variables included age, gender, injury severity scores, mechanism of injury, time to CT, and 30-day mortality. Depth of thoracic, pulmonary, abdominal and skeletal injury, active bleeding, and use of chest tubes were evaluated.

Results

Of 636 patients with penetrating injuries, 443 (69.7%) underwent imaging. Of these, 161 (36.3%) had penetrating thoracic injuries. Of 161 patients with penetrating chest trauma in imaging, 151 (93.8%) were men (mean age = 34.9 years) and 10 (6.2%) were women (mean age = 40.7 years). The majority of patients had SWs (138 SW vs. 15 GSW). Patients with GSWs were more severely injured (mean ISS 17.00 vs. 8.84 [P=0.0014] and ISS≥16 in 53.3% vs. 16.7%) than SW patients. In CT, intrathoracic injuries were found in 49.4% (77/156) and active bleeding in 26.3% (41/156). Emergency surgery was performed in 6.2% (10/161) with postoperative CT imaging. Thirty-day mortality rate was 1.2% (2/161).

Conclusion

Penetrating thoracic trauma often violates intrathoracic structures and nearby compartments. Arterial phase whole-body CT is recommended as multiple injuries and active bleeding are common. CT after emergency surgery is warranted, especially to assess injuries outside the surgical field.