Trends in nonfatal and fatal firearm-related injury rates in the United States, 1985-1995

A multi-decade joinpoint analysis of firearm injury severity

BACKGROUND

Non-fatal firearm injuries constitute approximately 70% of all firearm trauma injuries in the United States. Patterns of severity of these injuries are poorly understood. We analyzed the overall, age-, sex- and intent-specific temporal trends in the injury severity of firearm hospitalizations from 1993 to 2014.

METHODS

We assessed temporal trends in the severity of patients hospitalized for firearm using Nationwide Inpatient Sample (NIS) data over a 22 year period. Firearm hospitalization was identified using assault (E965x), unintentional (E922x), intentional self-harm (E955x), legal (E970) and undetermined (E985x) International Classification of Diseases, Ninth Revision, Clinical Modification (ICD9) codes. Injury severity was measured using the computed New Injury Severity Score (NISS). We used survey weighted means, SD and annual percent change (APC), and joinpoint regression to analyze temporal trends.

RESULTS

A weighted total of 648 662 inpatient admissions for firearm injury were analyzed. Firearm injury severity demonstrated a significant annual increase of 1.4% (95% CI=1.3 to 1.6), and was driven by annual increases among young adults (APC=1.4%, 95% CI=1.3 to 1.5), older adults (APC=1.5%, 95% CI=1.3 to 1.6), female (APC=1.5%, 95% CI=1.3 to 1.6) and male (APC=1.4%, 95% CI=1.3 to 1.6) hospitalizations. The annual increase among assault/legal injuries was 1.4% (95% CI=1.3 to 1.5), similar to unintentional (APC=1.4%, 95% CI=1.3 to 1.6), intentional self-harm (APC=1.5%, 95% CI=1.4 to 1.6) and undetermined (APC=1.4%, 95% CI=1.3 to 1.6).

CONCLUSIONS

The severity of hospitalized firearm injuries increased significantly from 1993 to 2014. This annual increase reflects a move towards hospitalization of more serious injuries, and outpatient management of less serious injuries across the board, suggesting a mounting burden on the US healthcare system.

LEVEL OF EVIDENCE

Level IV.

The Hidden Epidemic of Firearm Injury: Increasing Firearm Injury Rates During 2001-2013

Investigating firearm injury trends over the past decade, we examined temporal trends overall and according to race/ethnicity and intent in fatal and nonfatal firearm injuries (FFIs and NFIs) in United States during 2001-2013. Counts of FFIs and estimated counts of NFIs were obtained from the Centers for Disease Control and Prevention's Web-based Injury Statistics Query and Reporting System. Poisson regression was used to analyze overall and subgroup temporal trends and to estimate annual change per 100,000 persons (change). Total firearm injuries (n = 1,328,109) increased annually by 0.36 (Ptrend < 0.0001). FFIs remained constant (change = 0.02; Ptrend = 0.22) while NFIs increased (change = 0.35; Ptrend < 0.0001). Homicide FFIs declined (change = -0.05; Ptrend < 0.0001) while homicide NFIs increased (change = 0.43; Ptrend < 0.0001). Suicide FFIs increased (change = 0.07; Ptrend < 0.0001) while unintentional FFIs and NFIs declined (changes = -0.01 and -0.09, respectively; Ptrend < 0.0001 and 0.005). Among whites, FFIs (change = 0.15; Ptrend < 0.0001) and NFIs (change = 0.13; Ptrend < 0.0001) increased; among blacks, FFIs declined (change = -0.20; Ptrend < 0.0001). Among Hispanics, FFIs declined (change = -0.28; Ptrend < 0.0001) while NFIs increased (change = 0.55; Ptrend = 0.014). The endemic firearm-related injury rates during the first decade of the 21st century mask a shift from firearm deaths towards a rapid rise in nonfatal injuries.

State Firearm Legislation and Nonfatal Firearm Injuries

OBJECTIVES

We investigated whether stricter state-level firearm legislation was associated with lower hospital discharge rates for nonfatal firearm injuries.

METHODS

We estimated discharge rates for hospitalized and emergency department-treated nonfatal firearm injuries in 18 states in 2010 and used negative binomial regression to determine whether strength of state firearm legislation was independently associated with total nonfatal firearm injury discharge rates.

RESULTS

We identified 26 744 discharges for nonfatal firearm injuries. The overall age-adjusted discharge rate was 19.0 per 100 000 person-years (state range = 3.3-36.6), including 7.9 and 11.1 discharges per 100 000 for hospitalized and emergency department-treated injuries, respectively. In models adjusting for differences in state sociodemographic characteristics and economic conditions, states in the strictest tertile of legislative strength had lower discharge rates for total (incidence rate ratio [IRR] = 0.60; 95% confidence interval [CI] = 0.44, 0.82), assault-related (IRR = 0.58; 95% CI = 0.34, 0.99), self-inflicted (IRR = 0.18; 95% CI = 0.14, 0.24), and unintentional (IRR = 0.53; 95% CI = 0.34, 0.84) nonfatal firearm injuries.

CONCLUSIONS

There is significant variation in state-level hospital discharge rates for nonfatal firearm injuries, and stricter state firearm legislation is associated with lower discharge rates for such injuries.

Firearm-related hospitalization and risk for subsequent violent injury, death, or crime perpetration: a cohort study

BACKGROUND

Risk for violent victimization or crime perpetration after firearm-related hospitalization (FRH) must be determined to inform the need for future interventions.

OBJECTIVE

To compare the risk for subsequent violent injury, death, or crime perpetration among patients with an FRH, those hospitalized for noninjury reasons, and the general population.

DESIGN

Retrospective cohort study.

SETTING

All hospitals in Washington.

PATIENTS

Patients with an FRH and a random sample of those with a non-injury-related hospitalization in 2006 to 2007 (index hospitalization).

MEASUREMENTS

Primary outcomes included subsequent FRH, firearm-related death, and the combined outcome of firearm- or violence-related arrest ascertained through 2011.

RESULTS

Among patients with an index FRH (n = 613), rates of subsequent FRH, firearm-related death, and firearm- or violence-related arrest were 329 (95% CI, 142 to 649), 100 (CI, 21 to 293), and 4221 (CI, 3352 to 5246) per 100 000 person-years, respectively. Compared with the general population, standardized incidence ratios among patients with an index FRH were 30.1 (CI, 14.9 to 61.0) for a subsequent FRH and 7.3 (CI, 2.4 to 22.9) for firearm-related death. In survival analyses that accounted for competing risks, patients with an index FRH were at greater risk for subsequent FRH (subhazard ratio [sHR], 21.2 [CI, 7.0 to 64.0]), firearm-related death (sHR, 4.3 [CI, 1.3 to 14.1]), and firearm- or violence-related arrest (sHR, 2.7 [CI, 2.0 to 3.5]) than those with a non-injury-related index hospitalization.

LIMITATION

Lack of information on whether patients continued to reside in Washington during follow-up may have introduced outcome misclassification.

CONCLUSION

Hospitalization for a firearm-related injury is associated with a heightened risk for subsequent violent victimization or crime perpetration. Further research at the intersection of clinical care, the criminal justice system, and public health to evaluate the effectiveness of interventions delivered to survivors of firearm-related injury is warranted.

PRIMARY FUNDING SOURCE

Seattle City Council and University of Washington Royalty Research Fund.

Fatal firearm injuries in autopsy cases at central Bangkok, Thailand: a 10-year retrospective study

Even though there have been previously published reports on firearm injuries in various countries, the incidence and pattern of death from firearm injuries in Thailand have not been studied before. In present study, 149 fatal firearm injuries from 2002 to 2011 were reviewed. At total of 7126 autopsies, fatal firearm injuries comprised of 2.09% (n = 149) of total autopsies cases. Among those victims, 136 were male (91.3%), 13 (8.7%) were female. The youngest age of victim was 10 years and the oldest was 79 years. Mean age of the victims was 33.79 years and median age was 30 years. Outdoor incident was the most common scene of crime. Night time incident (18:00 PM-05:59 AM) was higher than day time one. Most of the cases occurred in week ends (n = 52). Homicide (77.2%) was the most frequent manner of death. Head/face and chest were the most common sites of entrance. The autopsy report also study on entrance wound, range and types of projectiles. Blood alcohol concentration was examined in 122 cases and 38 victims showed positive results, 11 cases revealed using of illegal substances in blood and urine analysis. This study also included the association between manner of death and other factors. Age group, time of incidence, place of incidence, number of entrance wound and range showed statistically significant association with manner of death.

State-specific, racial and ethnic heterogeneity in trends of firearm-related fatality rates in the USA from 2000 to 2010

OBJECTIVES

To document overall, racial, ethnic and intent-specific spatiotemporal trends of firearm-related fatality rates (FRF rates) in the USA.

DESIGN

Cross-sectional study per year from 2000 to 2010.

SETTING USA PARTICIPANTS

Aggregate count of all people in the USA from 2000 to 2010.

OUTCOME MEASURES

Data from the Web-based Injury Statistics Query and Reporting System from 2000 to 2010 was used to determine annual FRF rates per 100,000 and by states, race, ethnicity and intent.

RESULTS

The average national 11-year FRF rate was 10.21/100,000, from 3.02 in Hawaii to 18.62 in Louisiana: 60% of states had higher than national rates and 41 states showed no temporal change. The average national FRF rates among African-Americans and Caucasians were 18.51 and 9.05/100,000 and among Hispanics and non-Hispanics were 7.13 and 10.13/100,000; Hispanics had a decreasing change of -0.18, p trend<0.0001. In states with increasing trends (Florida and Massachusetts), Caucasians and non-Hispanics drove the rise; while in states with decreasing trends (California, North Carolina, Arizona, Nevada, New York, Illinois, Maryland), Hispanics and African-Americans drove the fall. The average national FRF rates due to homicides (4.1/100,000) and suicides (5.8/100,000) remained constant, but varied between states.

CONCLUSIONS

Endemic national FRF rates mask a wide variation in time trends between states. FRF rates were twice as high in African-Americans than Caucasians but decreased among Hispanics. Efforts to identify state-specific best practices can contribute to changes in national FRF rates that remain high.

Policy statement--Role of the pediatrician in youth violence prevention

Youth violence continues to be a serious threat to the health of children and adolescents in the United States. It is crucial that pediatricians clearly define their role and develop the appropriate skills to address this threat effectively. From a clinical perspective, pediatricians should become familiar with Connected Kids: Safe, Strong, Secure, the American Academy of Pediatrics' primary care violence prevention protocol. Using this material, practices can incorporate preventive education, screening for risk, and linkages to community-based counseling and treatment resources. As advocates, pediatricians may bring newly developed information regarding key risk factors such as exposure to firearms, teen dating violence, and bullying to the attention of local and national policy makers. This policy statement refines the developing role of pediatricians in youth violence prevention and emphasizes the importance of this issue in the strategic agenda of the American Academy of Pediatrics.

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.

Trends in hospitalization for firearm-related injury in Finland from 1990 to 2003

BACKGROUND

The firearm-related mortality in Finland is one of the highest in Europe. The study objective was to describe the incidence trends and nature of firearm-related injury hospitalizations in Finland between 1990 and 2003.

METHODS

We included all firearm-related injury hospitalizations between 1990 and 2003. The data were obtained from the Finnish National Hospital Discharge Register. Only events with traumatic physical injuries were included.

RESULTS

The overall incidence of firearm-related injury hospitalization was 5.1 (95% confidence interval [CI]: 34.5-5.7) per 100,000 person-years in 1990 and 2.6 (95% CI: 2.1-3.0) in 2003. The absolute numbers were 254 and 133, respectively. Unintentional injuries accounted for 44% of injuries during the study period. Hospitalization incidence resulting from intentional firearm-related injuries (self-inflicted and assault) remained unaltered over the study period. Men's injury incidence was 10.0 times (95% CI: 8.8-11.4) that of women's. Young men aged 15 to 34 years displayed the highest incidence figures. The most common types of the firearm-related injuries were open wounds (52%) and fractures (17%). Anatomically they involved the head and the neck (35%), the lower limb (28%), and the trunk (19%).

CONCLUSIONS

Although the total incidence of firearm-related injuries decreased in Finland during the 14-year study period, the incidence of intentional firearm-related injuries remained at the same level. Finding information on the risk factors of firearm-related injuries and the reasons for the steady level of intentional injuries are the next steps toward preventive measures.

Gun-related eye injury in the United States, 1993-2002

OBJECTIVE

To present the descriptive epidemiology of gun-related eye injury in the United States from 1993 through 2002.

METHODS

Data from the National Electronic Injury Surveillance System was used to estimate the number of patients treated in the United States for gun-related eye injury (GEI) (air guns and firearms), air gun-related eye injury (AEI) (BB/pellet guns and rifles) and firearm-related eye injury (FEI) (all powder discharge guns) during the time period 1993 through 2002. Rates were calculated according to age, gender, race, weapon type and circumstances surrounding the injury event (e.g., locale and intent).

RESULTS

The rate of gun-related eye injury in the United States declined to 7.5 per 1,000,000 in 2002 from 14.8 per 1,000,000 in 1993, representing a decline of approximately 5.4% per year (p = 0.0002), due primarily to a decline in the rate of FEI (6.7% per year, p = 0.029). The rate of AEI was relatively constant. GEI rates were highest among those aged 10-19 years, males, and Blacks. The overall rate of AEI was higher than the rate of FEI (6.0 per 1,000,000 and 5.1 per 1,000,000, respectively). According to race, the rate of FEI was higher than the rate of AEI in Blacks whereas the rate of AEI was higher than the rate of FEI in Whites and Hispanics. The majority of GEIs occurred at home and were unintentional.

CONCLUSION

The rate of gun-related eye injury in the United States declined from 1993 through 2002 primarily due to a reduction in firearm-related eye injury, whereas the rate of air gun-related eye injury remained constant. Persons who were young, Black, and male were at highest risk for gun-related eye injury.

Injury-related deaths among Finnish adolescents in 1971-2002

The purpose of our study was to examine the nationwide trends in the age- and sex-specific incidence rates of fatal injuries among 10-19-year-old adolescents in Finland, a country with a well-defined white population of 5.2 million. A population-based study was based on Official Cause-of-Death Statistics of Finland. We included adolescents aged 10-19 years who died because of an injury in 1971-2002. During the study period, the incidence of injury-related deaths declined considerably, from 43.0 (per 100,000 persons) (95% confidence interval (CI): 38.5, 47.5) in 1971 to 19.9 (95% CI: 16.5, 23.4) in 2002 (p<0.001). The decrease was seen in both genders. The decline in injury deaths was mainly due to decrease of deaths in traffic accidents. A sharp peak in boys' suicides was found during economic depression. To sum up, the incidence of adolescent injury deaths declined considerably in Finland between 1971 and 2002. The reasons for this positive development are probably multifactorial, including improvements in traffic safety and emergency services. The trend in intentional deaths showed no change during the 32-year study period and therefore prevention of adolescent violence and suicides should also receive attention.

Outcomes in children and young adults who are hospitalized for firearms-related injuries

OBJECTIVES

To compare outcomes by intent of nonfatal firearms-related injuries in a hospitalized population, newborn to 19 years of age, and estimate the national incidence of ensuing disability.

METHODS

Descriptive statistics and comparative analysis using chi(2), odds ratio, and t test were applied to data from the National Pediatric Trauma Registry (NPTR) and the National Electronic Injury Surveillance System of the US Consumer Product Safety Commission. Demographics, preinjury medical history, scene of injury, primary body part injured, severity of injury, utilization of resources, short-term and long-term disability, medical cause of disability, and disposition at discharge were studied.

RESULTS

NPTR unintentional (n = 268) and assault-related firearms-related injuries (n = 506) were compared. In both groups, the majority of patients were male (80%). Compared with the unintentionally injured, the assaulted children were older and more frequently black (59.3% vs 32.5%). Approximately 17% in both groups had a preinjury history of medical/psychosocial problems. Unintentional injuries occurred mainly in private dwellings (75.7%), and assaults occurred in public places/street (53.8%). In both groups, injuries to multiple body regions were prevalent, and a substantial proportion sustained injuries of serious to critical level. Most children were transported by ambulance, but a significant proportion in the unintentional group were transported by helicopter. The rate of admission to the intensive care unit was approximately 40% for both groups. The unintentionally injured had a higher rate of surgical intervention (66.8% vs 50.8%) and stayed in the hospital longer than the assaulted ones (median: 5 days vs 3 days). Almost half of the children in both groups were discharged with disability, and approximately 87% returned to their home. Applying the NPTR disability rate to National Electronic Injury Surveillance System estimates of hospitalization suggests that approximately 3200 children nationwide develop disability from firearms-related injuries annually.

CONCLUSIONS

Nonfatal firearms-related injuries in a pediatric population are associated with a high use of medical resources and lasting disability. Public policies should be developed and implemented to reduce the occurrence of these catastrophic events.

An analysis of pediatric gunshot wounds treated at a Level I pediatric trauma center

BACKGROUND

We reviewed the incidence and injury severity of children with gunshot wounds (GSWs) at our hospital.

METHODS

We compared trauma registry, emergency unit (EU), and admissions data from January 1993 to June 1996 (period I) and July 1996 to December 1999 (period II). Outcome measures included EU disposition (death, immediate operation, pediatric intensive care unit, ward), injury severity, mortality, and injury cause (accidental, intentional).

RESULTS

We treated 437 children for GSWs in the EU, with 238 (54%) admissions and 199 discharges. Comparing period I versus period II, patients treated declined from 288 to 149 (-52%, p < 0.001), and admissions decreased from 159 to 79 (-50%, p < 0.001). Injury severity increased from 35% to 57% (p < 0.001). Patients requiring immediate operations increased from 20% to 42% (p < 0.001). Direct ward admissions declined from 65% to 43% (p < 0.001). Deaths occurred in 3% of patients in both time periods. Accidental and intentional GSWs were evenly divided.

CONCLUSION

An alarming number of children, an average of 62 children annually, were treated for GSWs at our hospital. Despite a 52% reduction in GSWs, the percentage of severely injured patients increased by 63%. These data emphasize the importance of prevention, education, early assessment, and operative treatment.

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.

Physical and psychological outcomes 8 months after serious gunshot injury

BACKGROUND

The purpose of this study was to determine the health status and psychological distress of gunshot injury victims 8 months after hospital discharge.

METHODS

Sixty patients admitted to a Level I trauma center for firearm-related injuries were interviewed during their hospitalization and again 8 months postdischarge. Health status was measured using the Medical Outcomes Study 36-Item Short Form Health Survey (SF-36). Symptoms of posttraumatic stress (avoidance and intrusion) were assessed using the Impact of Event Scale.

RESULTS

Subjects were predominantly young (mean age, 30 years), male (92%), and African-American (95%). Mean SF-36 scores at follow-up were significantly worse than preinjury scores for all subscales (p < 0.05). Symptoms of posttraumatic stress were common; 39% of respondents reported severe intrusive thoughts and 42% reported severe avoidance behaviors. Admission Injury Severity Scores did not predict poor health status 8 months postdischarge, but intrusion symptoms were strongly associated with lower SF-36 scores.

CONCLUSION

Many hospitalized survivors of gunshot injuries report significant long-term declines in physical and/or mental health. Injury severity at hospital admission may not be predictive of long-term health status.

Emergency medicine and public health: new steps in old directions

Emergency medicine and public health have opportunities to interact in at least 4 areas: surveillance of diseases, injuries, and health risks; monitoring health care access; delivering clinical preventive services; and developing policies to protect and improve the public's health. Recent, cross-cutting initiatives and innovations in these 4 areas follow pathways first explored more than a generation ago and provide an important impetus for future work. An analysis of recent contributions also points to various obstacles and challenges that must be addressed to take full advantage of existing and rapidly developing ties between emergency medicine and public health. The connections between these 2 fields will continue to create important partnership opportunities and the strong possibility of achieving new benefits for patients, the public, and the professionals who serve them.

American Academy of Pediatrics. Media violence. Committee on Public Education

The American Academy of Pediatrics recognizes exposure to violence in media, including television, movies, music, and video games, as a significant risk to the health of children and adolescents. Extensive research evidence indicates that media violence can contribute to aggressive behavior, desensitization to violence, nightmares, and fear of being harmed. Pediatricians should assess their patients' level of media exposure and intervene on media-related health risks. Pediatricians and other child health care providers can advocate for a safer media environment for children by encouraging media literacy, more thoughtful and proactive use of media by children and their parents, more responsible portrayal of violence by media producers, and more useful and effective media ratings.

Violent injuries among adolescents: declining morbidity and mortality in an urban population

STUDY OBJECTIVE

Adolescent homicide rates are decreasing nationally for unclear reasons. We explore changes in intentional injury morbidity and mortality within the context of other injuries and specific causes.

METHODS

We performed surveillance of hospital, medical examiner, and vital records for nonfatal injury among adolescents age 10 to 19 years living in the District of Columbia from June 15, 1996, to June 15, 1998, and fatal injury from 1989 to 1998.

RESULTS

Over the 2-year study period, 15,190 adolescents were seen for injury, resulting in an event-based rate of 148 injuries per 1,000 adolescents per year; 7% required hospitalization, and 0.8% died. Interpersonal intentional injuries accounted for 25% of all injuries, 45% of hospitalizations, and 85% of injury deaths. Assault morbidity decreased with no change noted for unintentional and self-inflicted injury. Firearm injuries, stabs, and assaults with other objects showed the largest decrease, with no decrease in unarmed assaults. Injury mortality peaked in 1993 and has declined since. Firearms caused 72% to 90% of all injury deaths from 1989 to 1998, most the result of homicide.

CONCLUSION

There has been a decline in intentional injury rates over the study periods related to decreased weapon injury; data suggest a change in the lethality of fighting methods but no change in unarmed fighting behavior.

National estimates of non-fatal firearm related injuries other than gunshot wounds

OBJECTIVE

To characterize non-fatal firearm related injuries other than gunshot wounds (non-GSWs) treated in hospital emergency departments in the United States that occur during routine gun handling and recreational use as well as violence related use of a firearm.

METHODS

Cases were identified through the National Electronic Injury Surveillance System (NEISS). During the study period, 1 January 1993 through 31 December 1996, NEISS consisted of a nationally representative sample of 91 hospitals in the United States having at least six beds and providing 24 hour emergency services.

RESULTS

An estimated 65 374, or an average of 16,300 per year, non-fatal, non-GSWs were treated in American hospital emergency departments during the four year study period. Fifty seven per cent of all the non-fatal, non-GSWs were violence related, most of which involved being struck by a firearm. The majority of unintentional non-fatal, non-GSWs were self inflicted and occurred during routine gun handling or recreational use of a firearm; 43% of these injuries resulted from gun recoils.

CONCLUSIONS

Non-fatal, non-GSWs make a notable contribution to the public health burden of firearm related injuries. Firearm related injury prevention programs should focus on not only the reduction of gunshot wounds but also the reduction of unintentional and violence related non-GSWs.

Lethality of firearm-related injuries in the United States population

STUDY OBJECTIVE

To characterize differences in the lethality of firearm-related injuries in selected demographic subgroups using national representative data on fatal and nonfatal firearm-related injuries. We also characterize the lethality of firearm-related injuries by intent of injury and anatomic location of the gunshot wound.

METHODS

We analyzed case-fatality rates (CFRs) of firearm-related injuries in the United States by using death data from the National Vital Statistics System and data on nonfatal injuries treated in US hospital emergency departments from the National Electronic Injury Surveillance System. National estimates of crude and age-adjusted CFRs are presented by sex, race/ethnicity, age, intent, and primary body part affected.

RESULTS

Each year during the study period (July 1992 through December 1995), an estimated 132,687 persons sustained gunshot wounds that resulted in death or treatment in an ED. The overall age-adjusted CFR among persons who sustained firearm-related injuries was 31.7% (95% confidence interval [CI] 27.7 to 35.6). The age-adjusted CFR for persons who were alive when they arrived for treatment in an ED (11. 3%; 95% CI 9.4 to 13.2) was about one third as large as the overall CFR. The age-adjusted CFR varied by sex, race/ethnicity, and age, but these differences depended on intent of injury. For assaultive injuries, the age-adjusted CFR was 1.4 times higher for females (28. 7%) than males (20.6%). For intentionally self-inflicted injuries, the age-adjusted CFR was 1.1 higher for males (77.7%) than females (69.1%). For assaults, the age-adjusted CFR was 1.5 times higher for whites (29.5%) than blacks (19.2%). For assaultive and intentionally self-inflicted injuries among persons 15 years and older, the age-specific CFR increased with age. Persons shot in the head (age-adjusted CFR, 61.0%) were 3.3 times as likely to die as those shot in other body parts (age-adjusted CFR, 18.7%).

CONCLUSION

The lethality of firearm-related injuries was influenced strongly by the intent of injury and body part affected. The high lethality of firearm-related injuries relative to other major causes of injury emphasizes the need to continue prevention efforts and efforts to improve access to care and treatment (including emergency medical and acute care services) to reduce the number and increase survivability of firearm-related injuries.

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.

Medical care solicitation by criminals with gunshot wound injuries: a survey of Washington, DC, jail detainees

BACKGROUND

The best estimates of nonfatal gunshot wounds in the United States come from hospital emergency room data and may miss, among other things, wounded individuals who do not seek medical treatment. Criminals may be those least likely to rely on professional care for their wounds. This study provides evidence of whether medical care is solicited by criminals after gunshot wounds. In addition, the circumstances of the injury events are described.

METHODS

A case series of 79 detainees at a Washington, DC, jail who had previously been shot in 93 separate incidents were interviewed using a standardized questionnaire. Data were obtained concerning the age and race of the victim, the location of the wound, and the length of hospital stay.

RESULTS

In 92% of the incidents, respondents reported going to the hospital; one-third of those shot were hospitalized for more than 1 week. More than half (54%) had been hit in the head or torso, and 40% had a current disability attributable to the wound.

CONCLUSION

Among these "criminals," the vast majority reported that they obtained professional care for their gunshot wounds. Such evidence suggests that individuals previously thought unlikely to enter the medical care system after a firearm injury usually do so. Statistics on medically treated nonfatal gunshot wounds probably do not substantially underestimate the actual number of nonfatal shootings.

Child and adolescent injury and death from urban firearm assaults: association with age, race, and poverty

OBJECTIVE

To describe rates and trends in the incidence of non-fatal and fatal firearm assault among children (16 years old or younger) over an 11 year period in Chicago, Illinois and to identify the socioeconomic characteristics of community areas where assaults are common.

METHODS

The Chicago Police Department (CPD) records from 1986 through 1996 were reviewed for children assaulted with a firearm. United States census data for 1990 for Chicago were used to calculate incidence rates; census data were also used for community area (defined by census tract) socioeconomic descriptions.

RESULTS

The CPD recorded 11,163 pediatric firearm assaults during the study period: 10,571 non-fatal and 592 (5%) fatal. From 1986 through 1996 non-fatal assaults more than doubled, with the highest rates in 1994; fatal assaults tripled, with rates peaking in 1993-94. Significant increases in non-fatal firearm assaults occurred among black and Hispanic males and females. In 1994, compared with white males, the relative risk of non-fatal assault was 7.0 (95% confidence interval (CI) 5.3 to 9.1) for black males and 3.3 (95% CI 2.5 to 4.4) for Hispanic males; the relative risk was 1.5 (95% CI 1.1 to 2.1) for black females. A handgun was the firearm used in most assaults (88% of non-fatal and 84% of fatal). Within community areas, the correlation between non-fatal and fatal assault incidence was strong (r=0.80, p<0.001). The proportion of families with income below the 1989 poverty level ($12,674) and the per cent black race in the community area together accounted for 70% of the variance in assault rates.

CONCLUSIONS

From 1986 to 1994 there were significant increases in both non-fatal and fatal firearm assaults, usually by handguns; thereafter, rates declined. Urban children who were victims of non-fatal firearm assault appear to come from the same population as those who suffer fatal assaults. Black and Hispanic youth living in poverty were at particular risk.