Gun orientation in self-inflicted craniomaxillofacial gunshot wounds: risk factors associated with fatality

Firearm-Related Traumatic Brain Injuries in Adults: A Scoping Review

BACKGROUND AND OBJECTIVES

Firearm-related traumatic brain injury (TBI) has emerged as a significant public health issue in the United States, coinciding with a rapid increase in gun-related deaths. This scoping review aims to update our understanding of firearm-related TBI in adult populations.

METHODS

A comprehensive search of 6 online databases yielded 22 studies that met the inclusion criteria. The reviewed studies predominantly focused on young adult men who were victims of assault, although other vulnerable populations were also affected.

RESULTS

Key factors in evaluating patients with firearm-related TBI included low Glasgow Coma Scale scores, central nervous system involvement, hypotension, and coagulopathies at presentation. Poor outcomes in firearm-related TBIs were influenced by various factors, including the location and trajectory of the gunshot wound, hypercoagulability, hemodynamic instability, insurance status, and specific clinical findings at hospital admission.

CONCLUSION

Proposed interventions aimed to reduce the incidence and mortality of penetrating TBIs, including medical interventions such as coagulopathy reversal and changes to prehospital stabilization procedures. However, further research is needed to demonstrate the effectiveness of these interventions. The findings of this scoping review hope to inform future policy research, advocacy efforts, and the training of neurosurgeons and other treating clinicians in the management of firearm-related TBI.

What Factors Influence the Hospitalization of Self-Inflicted Craniomaxillofacial Gunshot Wounds?

Study Design

The following retrospective cohort study was competed using data from the Nationwide Inpatient Sample a database from the Healthcare Cost and Utilization Project (HCUP).

Objective

The objective of this retrospective cohort study is to compare the hospitalization outcomes of managing maxillofacial trauma attempted suicide among handguns, shotguns, and hunting rifles.

Methods

The primary predictor variable was the type of firearm. The outcome variables were the hospital charges (U.S. dollars) and length of stay (days). We used SPSS version 25 for Mac (IBM Corp., Armonk, NY, USA) to conduct all statistical analyses.

Results

A final sample of 223 patients was statistically analyzed. Relative to patients within the Q2 median household income quartile, patients in the Q4 median household income quartile added +$ 172'609 (P < .05) in hospital charges. Relative to patients living in "central" counties of metro areas, patients in micropolitan counties added +13.18 days (P < .05) to the length of stay. Relative to patients in the Q2 median household income quartile, patients in Q3 added +9.54 days (P < .05) while patients in Q4 added +11.49 days (P < .05) to the length of stay.

Conclusions

Being within the highest income quartile was associated with increased hospital charges. Patients living in micropolitan counties have prolonged hospitalization relative to patients in metropolitan counties. Relative to the second income quartile, length of stay was higher in the third income quartile and highest in the fourth income quartile. Increase income grants access to deadlier firearms.

Self-inflicted craniomaxillofacial gunshot wounds by handguns are more deadly than those by shotguns: an NIS study

PURPOSE

The purpose of the present study is to determine whether handguns discharged at the craniomaxillofacial region are associated with greater fatality in suicide attempts relative to shotguns.

METHODS

The following retrospective cohort study was completed using the Nationwide Inpatient Sample (NIS), a Healthcare Cost and Utilization Project (HCUP) database. The primary predictor variable was the type of firearm (handguns vs. shotguns). The primary outcome variable was prognosis (fatality vs. no fatality). A binary logistic regression was performed to determine the risk of mortality of all predictor variables.

RESULTS

Our final sample consisted of 223 patients. Handguns (85.2%) were the most popular firearm. Relative to black patients, white patients were over three times more likely to die (p < 0.05). Compared to patients who were transferred in, patients not transferred in were eight times more likely to die (p = 0.000). Relative to patients who were admitted electively, patients who were not admitted electively were 16.7 times more likely to die (p < 0.01). Finally, relative to patients who used shotguns, patients who used handguns were 3.4 times more likely to die (p = 0.002).

CONCLUSION

Self-inflicted gunshot wounds to the maxillofacial region by handguns were more lethal than shotguns.

Socioeconomic Profile is Associated with the Type of Firearm Injuries to the Head and Neck

PURPOSE

Socioeconomic status (SES) describes social standing of an individual or a group. SES has been directly associated with violence. The purpose of this study is to measure the association between SES profiles and firearm injuries (FIs) to the head and neck.

METHODS

This cross-sectional study reviewed patients at Grady Memorial Hospital in Atlanta, Georgia from January 2016 to June 2021. The study included patients who sustained FIs to the head and neck. The primary predictor variable was Distressed Community Index as a surrogate for SES. The primary outcome variable was type of FI (assault-induced firearm injury [AFI] or self-inflicted firearm injury [SFI]). Covariates were patient characteristics, distribution, and severity of FI. Univariate and bivariate analyses were calculated. The χ² test was used for categorical variables. Independent t test was used for continuous variables. Statistical significance was P < .05.

RESULTS

Six hundred ninety-four patients met inclusion criteria. AFIs were statistically more frequent in young (AFI = 32.2; SFI = 42.2; P ≤ .001) and/or Black patients (AFI: n = 483, 86.3%; SFI: n = 40, 29.9%; P ≤ .001). Patients who sustained AFIs were statistically more likely to live in areas associated with high Distressed Community Index score (AFI: 64.8, range = 3.7 to 99.7; SFI: 54.4, range = 2.8 to 98; P ≤ .001). A statistically significant number of SFI patients presented with lower Glasgow Coma Scale score (AFI: 10.7, range = 3 to 15; SFI: 5.5, range = 3 to 15; P ≤ .001), and/or required tracheostomy (AFI: n = 56, 10%; SFI: n = 27, 20.1%; P = .005).

CONCLUSIONS

Patients who lived in economically distressed areas were positively associated with AFIs to the head and neck. However, SFIs were statistically more sever. More studies on the impact of current gun prevention programs and how to be addressed to at-risk populations is needed.

Are Facial Gunshot Wounds More Fatal When They Are Self-Inflicted or Other-Inflicted?

Study Design

This was a retrospective cohort study of the 2014 Nationwide Emergency Department Sample (NEDS).

Objective

Intraoral and submental projectile entry points may be less fatal than other facial entry points due to the indirect access to the intracranial structures and the protection offered by the intervening maxillofacial complex. Because intraoral and submental trajectories are almost always present in the setting of attempted suicide, this study sought to determine if intent (self-harm versus other-harm) influenced mortality in facial gunshot wound (GSW) patients.

Methods

All patients with a diagnosis of a facial fracture secondary to firearm injury were included in the study sample. The primary predictor was self-harm. Secondary predictors were derived from patient, injury, and hospitalization characteristics. The study outcome was death. Univariate time to event analyses were conducted for all study predictors. A multivariate regression model for mortality was created using all relevant predictors.

Results

The final sample included 668 facial GSW injuries, of which 19.3% were attributed to self-harm. Self-inflicted GSWs were more likely to involve the mandible (58.9 vs 46.0%, P < 0.01), ZMC/maxilla (47.3 vs 32.5%, P < 0.01), and intracranial cavity (48.1 vs 22.6%, P < 0.01). The overall mortality rate was 7.3%, and the mean time to death was 2.2 days. After controlling for pertinent covariates, the risk of mortality was independently decreased with mandibular injury (HR = 0.36, P = 0.03). However, mortality was increased by self-harm intent (HR = 3.94, P < 0.01) and intracranial involvement (HR = 11.24, P < 0.01).

Conclusions

Consistent with a pattern of intraoral and submental entry points, self-inflicted facial GSWs demonstrated higher rates of mandibular injury. Despite this finding, self-harm injuries still carried a higher incidence of intracranial injury and a greater independent risk of mortality. Our results refute any notion that the mechanism and trajectory of self-inflicted GSWs is less fatal.

Facial Reconstruction Following Self-Inflicted Gunshot Wounds: Predictors, Complications, and Acceptable Outcomes

Background: Self-inflicted gunshot wounds (SIGSWs) produce devastating facial defects that are challenging to reconstruct, but are rarely reported in large cohorts in the literature. This study sought to characterize these injuries, and identify parameters influencing complications and outcomes among survivors following facial reconstruction. Methods: A retrospective cohort study was performed identifying 22 patients with SIGSWs to the face reconstructed at our center from 2009 to 2019. Charts were reviewed for patient, injury, and reconstructive details and course. Outcomes were statistically compared to various parameters. Results: The most common firearm, orientation, and injured structure were the handgun (40.9%), submental (59.1%), and mandible (68.2%), respectively. Patients averaged a 21.7-day length of stay (LOS), 17.4 h to debridement, 2.6 days to bony fixation, 5.4 reconstructive surgeries, and 7 (31.8%) patients received at least one free flap. Fifteen (68.2%) patients had at least one major complication, although functional outcomes were ultimately relatively good overall. Notable outcome associations included submental orientation with a longer LOS (p = 0.027), external fixation with a longer LOS (p = 0.014), financial stressors with a shorter LOS (p = 0.031), and severe soft tissue injury with an increased total number of reconstructive surgeries (p = 0.039) and incomplete reconstruction (p = 0.031). There were no cases of suicidal recidivism. Conclusions: Reconstruction following facial SIGSW is challenging for both patient and surgeon, and carries a high rate of complications. However, patients can regain substantial function following reconstruction and the achievement of satisfactory outcomes.

Survival Following Self-Inflicted Gunshot Injuries to the Face Using the National Trauma Data Bank

INTRODUCTION

Self-inflicted gunshot wounds to the face frequently result in devastating injuries; however, there is a paucity of large experiences describing determinants of mortality and outcomes.

METHODS

Using the National Trauma Databank from 2007 to 2015, patients suffering self-inflicted firearm facial injuries were included.

RESULTS

Over 9 years 7869 patients were included: 87.7% were male, 46.4% suffered traumatic brain injury (TBI) and overall in-hospital mortality was 44.7%. The majority (67.8%) of in-hospital mortality occurred within the first 24 hours. Using multiple regression, advanced age (>65 years), presence of TBI, admission hypotension, and decreased Glasgow coma score were each independently associated with increased odds of mortality (all P < 0.001). Mandible or combined mandible/midface fracture injury patterns were most likely to survive (P < 0.001). Of those surviving to hospital discharge, the median [interquartile range] length of stay was 13 [6, 23] days, 86.6% required an intensive care unit stay with 67% requiring intubation and 42.5% tracheostomy. Among survivors, the combined mandible and midface fracture pattern resulted in the highest rates of tracheostomy (70.5%), gastrostomy tube placement (50.5%), and facial operations (87.0%) with a median [interquartile range] of 5 [3, 7] operative trips (all P < 0.001).

CONCLUSIONS

Self-inflicted facial firearm injuries are highly morbid injuries with the majority of in-hospital deaths occurring the first hospital day. Differences including concomitant TBI, facial injury pattern, neurologic status, and presence of hypotension on admission were independently associated with survival/death. More extensive facial injuries (combined mandible and midface fracture patterns) were more likely to survive and required more intensive interventions.

A 14-Year Review of Craniomaxillofacial Gunshot Wounds in a Resource-Limited Setting

This study analyzed the prevalence, clinical characteristics, and management of civilian-type craniomaxillofacial gunshot wounds (CGSWs) seen over a 14-year period in a Northern Nigerian teaching hospital. A retrospective study of all hospital records relating to CGSWs from January 2000 to December 2013 was conducted to determine the prevalence of CGSWs. Information retrieved included site of injury, type of projectile, management protocol, as well as duration of hospitalization. A total of 46 admissions for CGSWs were recorded during the period under review from a total of 2,228 maxillofacial admissions. This gave a prevalence of 2.1% for CGSWs (95% confidence interval = 1.56-2.81). Sex distribution was 14.3:1 (M:F) with overall mean age of 32.9 ± 8.4 years. Average length of hospitalization was 17.7 (±15.56) days. Management of CGSWs consisted of emergency care, preliminary intervention, definitive reconstruction, revisions, and rehabilitation. Conclusively, analysis of the yearly incidence of CGSWs showed that the incidence and severity increased within the past 2 years under review (18 cases, 39.13%; χ² trend = 7.7, p = 0.006). This period was noted to correspond with heightened violence within the region mostly due to the acts of unknown gunmen and insurgents.

Our Treatment Approaches in Severe Maxillofacial Injuries Occurring After Failed Suicide Attempts Using Long-Barreled Guns

Maxillofacial traumas with long-barreled guns may sometimes cause catastrophic results by means of smashing in facial structures. In these patients, reconstruction strategies of both fragmented/lost soft and hard tissues still remain controversial. In their clinic, the authors treated 5 patients with severely injured face after failed suicide attempt between 2008 and 2013. In this study, the authors aimed to present their clinical experiences on these severely injured maxillofacial gunshot traumas and offer a treatment algorithm to gain a result as possible as satisfactory in terms of functionality and appearance.

Factors affecting survival following self-inflicted head and neck gunshot wounds: a single-centre retrospective review

Self-inflicted head and neck gunshot wounds are a common modality of suicide in the USA. This study reviewed all self-inflicted head and neck gunshot wound patients with complete records (n=157) treated at a tertiary centre between 2002 and 2012 inclusive. The associations between mortality and patient/clinical variables were evaluated with the χ(2) test or Fisher's exact test for statistical difference testing. Outcomes recorded were death (n=92, 59%), discharge to long-term care/rehabilitation (n=58, 37%), and discharge home (n=7, 4%). The majority of patients were male (86.6%) and single/separated/divorced (55.5%). The mortality rate by site, in descending order, was temporal 82%, frontal scalp 69%, submental/intraoral 30%, and neck 25%. Involvement of the central nervous system (n=127) resulted in a 70% mortality, but a lower mortality was observed among patients with an avulsion injury (P=0.025). A tracheostomy within 24h of admission was statistically associated with improved survival (P<0.001), but confounding factors were found. Multivariate analysis revealed increasing age, temporal entry site, and the severity of central nervous system involvement to be positively associated with an increased mortality.

Survivors of self-inflicted gunshot wounds to the head: characterization of ocular injuries and health care costs

IMPORTANCE

Suicides and attempted suicides are major public health issues in the United States and around the world. Self-inflicted gunshot wounds (SIGSWs) are a common method of attempting suicide, the head being the most commonly injured body region; however, the literature lacks an overview of the orbital and ocular injuries as well as outcomes associated with SIGSWs.

OBJECTIVES

To characterize the ocular and orbital injuries and outcomes of patients presenting with SIGSWs and to examine the cost associated with these injuries.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective medical record review was performed of all patients who presented to the University of Iowa Hospitals and Clinics between 2003 to 2013 with the admitting diagnosis of self-inflicted injuries via firearms. Patients with no periorbital or ocular injuries and/or those who did not survive for at least 2 months following the incident were excluded.

MAIN OUTCOMES AND MEASURES

Ocular injuries and outcomes and health care costs and reimbursements, which were generated by a financial report obtained from the hospital finance department that included data from both the hospital billing and cost accounting systems.

RESULTS

All patients in this study (n = 18) were men with a mean age of 47.2 years. Eight patients (44.4%) displayed submental missile entry points, 7 (38.9%) displayed intraoral entry points, and 3 (16.7%) displayed pericranial entry points. Patients with pericranial entries sustained more severe ocular injuries and had poorer ocular outcomes. Seven patients (38.9%) were found at final follow-up to have visual acuity of 20/40 or better in each eye and all showed missile trajectories in the sagittal plane. The mean cost of treatment of these patients totaled $117,338 while the mean reimbursement amount was $124,388.

CONCLUSIONS AND RELEVANCE

Data regarding ocular injuries and outcomes may assist ophthalmologists in the treatment of patients with SIGSWs in the future. Many patients had extremely functional vision at final follow-ups, which highlights the importance of specialists conducting examinations and reconstructive procedures promptly, carefully, and thoroughly. Cost and reimbursement data suggest that while these cases place a large financial burden on society, they may not burden hospital systems in the same way.

Epidemiology, demographics, and outcomes of craniomaxillofacial gunshot wounds in a level I trauma center

BACKGROUND

Gunshot injuries to the craniomaxillofacial region are a challenge to the trauma and reconstructive surgeon. Although management of these injuries has been standardized and early rather than late intervention is advocated, the patient characteristics before, during, and after have been poorly elucidated.

METHODS

A prospectively maintained Level I trauma center database was queried as to gunshot wounds of the craniomaxillofacial skeleton. Over a five-year period (2007-2011), 168 patients were identified with these injuries. Charts were reviewed as to demographics, presentations, and outcomes and these were tested for significant relationships with hospital length of stay, numbers and types of procedures, morbidity, and mortality.

RESULTS

Gunshot wounds to the craniofacial skeleton resulted in 71 deaths in this patient population. Those that died were significantly older, presented with a lower GCS, had a shorter LOS, and a higher INR than those that lived. Subgroup analysis of mechanism demonstrated mortality was more likely to occur as a result of self-inflicted injury in whites and due to assault in the African-American population.

CONCLUSIONS

Data gathered from this study disputes some commonly held beliefs regarding the epidemiology of gunshot injuries and should allow for better characterization of which outcomes are consistent with which presentations.