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Ramsey WA, O'Neil CF, Shatz CD, Lyons NB, Cohen BL, Saberi RA, Gilna GP, Meizoso JP, Pizano LR, Schulman CI, Proctor KG, Namias N. Nationwide Analysis of Firearm Injury Versus Other Penetrating Trauma: It's Not All the Same Caliber. J Surg Res 2024; 294:106-111. [PMID: 37866065 DOI: 10.1016/j.jss.2023.09.067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 08/25/2023] [Accepted: 09/24/2023] [Indexed: 10/24/2023]
Abstract
INTRODUCTION Ballistic injuries cause both a temporary and permanent cavitation event, making them far more destructive and complex than other penetrating trauma. We hypothesized that global injury scoring and physiologic parameters would fail to capture the lethality of gunshot wounds (GSW) compared to other penetrating mechanisms. METHODS The 2019 American College of Surgeons Trauma Quality Programs participant use file was queried for the mortality rate for GSW and other penetrating mechanisms. A binomial logistic regression model ascertained the effects of sex, age, hypotension, tachycardia, mechanism, Glasgow Coma Scale, ISS, and volume of blood transfusion on the likelihood of mortality. Subgroup analyses examined isolated injuries by body regions. RESULTS Among 95,458 cases (82% male), GSW comprised 46.4% of penetrating traumas. GSW was associated with longer hospital length of stay (4 [2-9] versus 3 [2-5] days), longer intensive care unit length of stay (3 [2-6] versus 2 [2-4] days), and more ventilator days (2 [1-4] versus 2 [1-3]) compared to stab wounds, all P < 0.001. The model determined that GSW was linked to increased odds of mortality compared to stab wounds (odds ratio 4.19, 95% confidence interval 3.55-4.93). GSW was an independent risk factor for acute kidney injury, acute respiratory distress syndrome, venous thromboembolism, sepsis, and surgical site infection. CONCLUSIONS Injury scoring systems based on anatomical or physiological derangements fail to capture the lethality of GSW compared to other mechanisms of penetrating injury. Adjustments in risk stratification and reporting are necessary to reflect the proportion of GSW seen at each trauma center. Improved classification may help providers develop quality processes of care. This information may also help shape public discourse on this highly lethal mechanism.
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Affiliation(s)
- Walter A Ramsey
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida; Ryder Trauma Center, Jackson Memorial Hospital, Miami, Florida.
| | - Christopher F O'Neil
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida; Ryder Trauma Center, Jackson Memorial Hospital, Miami, Florida
| | - Connor D Shatz
- University of Miami Miller School of Medicine, Miami, Florida
| | - Nicole B Lyons
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida; Ryder Trauma Center, Jackson Memorial Hospital, Miami, Florida
| | - Brianna L Cohen
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida; Ryder Trauma Center, Jackson Memorial Hospital, Miami, Florida
| | - Rebecca A Saberi
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida; Ryder Trauma Center, Jackson Memorial Hospital, Miami, Florida
| | - Gareth P Gilna
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida; Ryder Trauma Center, Jackson Memorial Hospital, Miami, Florida
| | - Jonathan P Meizoso
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida; Ryder Trauma Center, Jackson Memorial Hospital, Miami, Florida
| | - Louis R Pizano
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida; Ryder Trauma Center, Jackson Memorial Hospital, Miami, Florida
| | - Carl I Schulman
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida; Ryder Trauma Center, Jackson Memorial Hospital, Miami, Florida
| | - Kenneth G Proctor
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida; Ryder Trauma Center, Jackson Memorial Hospital, Miami, Florida
| | - Nicholas Namias
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida; Ryder Trauma Center, Jackson Memorial Hospital, Miami, Florida
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Tatebe LC, Cone JT, Slidell MB, Chang G, Jonikas M, Stewart A, Doherty J, Arunkumar P, Schlanser V, Dennis AJ. When public health crises collide: 5 years of pediatric firearm injury prevention opportunities. Trauma Surg Acute Care Open 2023; 8:e001026. [PMID: 37303982 PMCID: PMC10254944 DOI: 10.1136/tsaco-2022-001026] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Accepted: 03/08/2023] [Indexed: 06/13/2023] Open
Abstract
Objectives Prior publications on pediatric firearm-related injuries have emphasized significant social disparities. The pandemic has heightened a variety of these societal stresses. We sought to evaluate how we must now adapt our injury prevention strategies. Patients and methods Firearm-related injuries in children 15 years old and under at five urban level 1 trauma centers between January 2016 and December 2020 were retrospectively reviewed. Age, gender, race/ethnicity, Injury Severity Score, situation, timing of injury around school/curfew, and mortality were evaluated. Medical examiner data identified additional deaths. Results There were 615 injuries identified including 67 from the medical examiner. Overall, 80.2% were male with median age of 14 years (range 0-15; IQR 12-15). Black children comprised 77.2% of injured children while only representing 36% of local schools. Community violence (intentional interpersonal or bystander) injuries were 67.2% of the cohort; 7.8% were negligent discharges; and 2.6% suicide. Median age for intentional interpersonal injuries was 14 years (IQR 14-15) compared with 12 years (IQR 6-14, p<0.001) for negligent discharges. Far more injuries were seen in the summer after the stay-at-home order (p<0.001). Community violence and negligent discharges increased in 2020 (p=0.004 and p=0.04, respectively). Annual suicides also increased linearly (p=0.006). 5.5% of injuries were during school; 56.7% after school or during non-school days; and 34.3% were after legal curfew. Mortality rate was 21.3%. Conclusions Pediatric firearm-related injuries have increased during the past 5 years. Prevention strategies have not been effective during this time interval. Prevention opportunities were identified specifically in the preteenage years to address interpersonal de-escalation training, safe handling/storage, and suicide mitigation. Efforts directed at those most vulnerable need to be reconsidered and examined for their utility and effectiveness. Level of evidence Level III; epidemiological study type.
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Affiliation(s)
- Leah C Tatebe
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Jennifer T Cone
- Department of Surgery, University of Chicago Pritzker School of Medicine, Chicago, Illinois, USA
| | - Mark B Slidell
- Department of Surgery, University of Chicago Comer Children's Hospital, Chicago, Illinois, USA
| | - Grace Chang
- Department of Surgery, Mount Sinai Hospital, Chicago, Illinois, USA
| | - Meghan Jonikas
- Department of Surgery, Mount Sinai Hospital, Chicago, Illinois, USA
| | - Amy Stewart
- Department of Surgery, Advocate Lutheran General Hospital, Park Ridge, Illinois, USA
| | - James Doherty
- Department of Surgery, Advocate Christ Medical Center, Oak Lawn, Illinois, USA
| | - Ponni Arunkumar
- Department of Pathology, Northwestern University, Chicago, Illinois, USA
| | | | - Andrew J Dennis
- Department of Trauma, Cook County Health, Chicago, Illinois, USA
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Population-Based Assessment of Urban Versus Rural Child Fatalities From Firearms in a Midwestern State. J Surg Res 2023; 283:52-58. [PMID: 36370682 DOI: 10.1016/j.jss.2022.10.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 08/22/2022] [Accepted: 10/15/2022] [Indexed: 11/11/2022]
Abstract
INTRODUCTION Several studies have evaluated differences in firearm injury patterns among children based on regionalization. However, many of these studies exclude patients who die before arriving at a trauma center. We therefore hypothesize that important population-based differences in pediatric firearm injuries may be uncovered with the inclusion of both prehospital firearm mortalities and patients treated at a tertiary children's hospital. METHODS Patients less than 15 y of age who sustained a firearms-related injury/death between the years 2012 and 2018 were identified in: (1) death certificates from the Office of Vital Statistics State of Indiana and (2) Riley Hospital for Children at Indiana University Health Trauma Registry. Counties of injury were classified as either urban, midsized, or rural based on the National Center for Health Statistic's population data. Significant variables in univariate analysis were then assessed using multivariate logistic regression models. RESULTS A total of 222 patients were identified. Median age of firearm injury survivors was 13 (interquartile range 7-14), while the median age of nonsurvivors was 14 (interquartile range 11-15), P = 0.040. The proportion of suicide was significantly higher in rural counties (P < 0.001). When controlling for shooter intent, patients from a rural or midsized county had statistically significant higher odds of dying before reaching a hospital than their urban counterpart (rural odds ratio [OR] 5.67 [95% confidence interval {CI} 2.23, 14.38]; midsized OR 6.53 [95% CI 2.43, 17.46]; P < 0.001). CONCLUSIONS Important differences exist between pediatric firearm injuries based on where they occur. Public health initiatives aimed at reducing pediatric firearm injury and death should not exclude rural pediatrics patients.
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Gurien LA, Nichols L, Williamson P, Letton RW. Rethinking pediatric trauma triage. Semin Pediatr Surg 2022; 31:151214. [PMID: 36371842 DOI: 10.1016/j.sempedsurg.2022.151214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Despite advances in the delivery of trauma care, trauma remains the leading cause of death amongst the pediatric population within the United States and is one of the leading causes of death in children worldwide. Accurately triaging pediatric trauma patients is essential to minimize preventable mortality without burdening the system by utilizing unnecessary resources. This article will review the accuracy of current pediatric trauma triage practices and how it will evolve in the future including moving away from mechanism of injury towards physiologic scoring tools such as the pediatric age-adjust shock index, and intervention-based systems including. Need for Surgeon Presence and Need For Trauma Intervention. This paper will also present evidence regarding over-utilization of air transport for pediatric trauma patients and the associated unnecessary costs placed on the trauma system.
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Affiliation(s)
- Lori A Gurien
- Nemours Children's Healthcare, 807 Children's Way, Jacksonville, FL 32207, United States; Wolfson Children's Hospital, 800 Prudential Drive, Jacksonville, FL 32207, United States.
| | - Lisa Nichols
- Wolfson Children's Hospital, 800 Prudential Drive, Jacksonville, FL 32207, United States
| | - Patsy Williamson
- Wolfson Children's Hospital, 800 Prudential Drive, Jacksonville, FL 32207, United States
| | - Robert W Letton
- Nemours Children's Healthcare, 807 Children's Way, Jacksonville, FL 32207, United States; Wolfson Children's Hospital, 800 Prudential Drive, Jacksonville, FL 32207, United States
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Obesity Protects Against Operation in Pediatric Penetrating Trauma to the Torso. J Surg Res 2021; 263:57-62. [PMID: 33639370 DOI: 10.1016/j.jss.2021.01.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 01/20/2021] [Accepted: 01/25/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND Studies in the adult population are conflicting regarding whether obesity is protective in penetrating trauma. In the pediatric population, data on obesity and penetrating trauma are limited. We sought to determine if there is a different rate of operation or of survival in pediatric and adolescent patients with obesity. METHODS We queried the National Trauma Data Bank research data set from 2013 to 2016 for all patients aged 2-18 who sustained traumatic penetrating injuries to the thorax and abdomen. The cohort was divided into body mass index percentiles for gender and age using Center for Disease Control definitions. Outcomes included overall survival, whether or not an operative procedure was performed, and hospital and intensive care unit (ICU) length of stay. RESULTS We analyzed 9611 patients with penetrating trauma, of which 4285 had an operative intervention. When adjusted for other variables (age, gender, race, ICU length of stay, hospital length of stay, and Injury Severity Score), children of every body mass index percentile had similar survival. Healthy weight patients were more likely to get an operation than patients in the obese category. Length of hospital stay was similar between groups, but the ICU length of stay was longer in the overweight and obese groups compared with healthy weight and underweight groups. CONCLUSIONS Children and adolescents with obesity are less likely to undergo operation after penetrating thoracoabdominal trauma. Further study is needed to determine the reason for this difference.
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