Life-threatening air rifle injuries to the heart in three boys

Air Gun Ballistic Projectile Lodged in the Interventricular Septum of an Asymptomatic Dog

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A gunshot to a dog embedded a metallic projectile in the interventricular septum.

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Direct cardiac penetration or venous embolism to the heart were hypothesized.

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No effusion, shunting, arrhythmia, or hemodynamic compromise was present.

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Serial echocardiography to monitor for delayed cardiac complications was elected.

Percutaneous removal of air-bullet gunshot: case report and literature review

Background

Cardiac air bullet injuries are rare but can be associated with significant morbidity and mortality.

Case presentation

We are presenting a young male child who sustained an accidental injury to the chest by an air rifle. Bullet entered the right ventricle from the anterior part of the chest and was identified in the RV side of the interventricular septum by echocardiography and chest CT scan. There was mild pericardial effusion but no valvular injury. The bullet was removed in the cath lab, and the patient was discharged home on the second day.

Conclusions

It is reasonable to try foreign body removal in the cath lab, for certain cases, and avoid cardiac surgery.

Nonpowder Firearm Injuries to Children Treated in Emergency Departments

OBJECTIVES

To investigate nonpowder firearm injuries treated in US emergency departments among children <18 years old.

METHODS

National Electronic Injury Surveillance System data from 1990 through 2016 were analyzed.

RESULTS

An estimated 364 133 (95% confidence interval 314 540-413 727) children <18 years old were treated in US emergency departments for injuries related to nonpowder firearms from 1990 to 2016, averaging 13 486 children annually. From 1990 to 2016, the number and rate of nonpowder firearm injuries decreased by 47.8% (P < .001) and 54.5% (P < .001), respectively. Most injuries occurred among 6- to 12-year-olds (47.4%) and 13- to 17-year-olds (47.0%). Boys accounted for 87.1% of injured children, the most common diagnosis was foreign body (46.3%), and 7.1% of children were admitted. BB guns accounted for 80.8% of injuries, followed by pellet guns (15.5%), paintball guns (3.0%), and airsoft guns (0.6%). The rate of eye injuries increased by 30.3% during the study period. Eye injuries accounted for 14.8% of all injuries and the most common diagnoses were corneal abrasion (35.1%), hyphema (12.5%), globe rupture (10.4%), and foreign body (8.6%).

CONCLUSIONS

Although the number and rate of nonpowder firearm injuries declined during the study period, nonpowder firearms remain a frequent and important source of preventable and often serious injury to children. The severity and increasing rate of eye injuries related to nonpowder firearms is especially concerning. Increased prevention efforts are needed in the form of stricter and more consistent safety legislation at the state level, as well as child and parental education regarding proper supervision, firearm handling, and use of protective eyewear.

Neurosurgical Care of Nonpowder Firearm Injuries: A Narrative Review of the Literature

Background

Nonpowder firearms discharge a projectile using compressed gases. Unlike traditional firearms, there is a perception that nonpowder guns do not cause serious injury. However, intracranial injury disproportionally affects children and can cause significant neurological disabilities and mortality. Management of nonpowder firearm injuries has received little attention in the literature and presents unique surgical challenges.

Materials and Methods

We conducted a narrative review of the literature of the management of nonpowder firearm injuries with particular emphasis on intracranial injury.

Results

Modern nonpowder firearms have muzzle velocities which are capable of penetrating the skin, eyes, and bone. Direct intracranial injury commonly results from entrance of projectile through thinner portions of the skull. Operative intervention is needed to debride and safely explore the trajectory to remove fragments which can easily cause neurovascular injury.

Conclusions

Neurosurgeons play a crucial role in managing serious nonpowder firearm injuries. A multidisciplinary team is needed to manage the direct results of penetrating injury and long-term sequalae.

Uneventful survival of a rural child after penetrating cardiac injury by a thorn: a case report

Background

Paediatric penetrating cardiac injury is extremely rare, precluding published management guidelines, therefore warranting a case-by-case approach with learning points gleaned from each case.

Case summary

A 7-year-old boy presented to a rural hospital with a stab wound to the chest by a Withaak (Vachellia tortilis) thorn. The patient was haemodynamically stable on presentation, but a 2 cm subcutaneous, pulsatile mass was present at the cardiac apex. Echocardiography revealed a foreign body penetrating from the apex into the heart, with evidence for a fistula between a cardiac chamber and the pulsatile mass. Angiography confirmed the existence of the fistula between the right ventricle (RV) and the pulsatile mass. A controlled extraction under general anaesthaesia via median sternotomy was performed in-theatre, with blood products and cardiac bypass on standby. The patient recovered without complications and was discharged after 4 days.

Discussion

Our case illustrates the limitations of echocardiography in identifying the precise anatomical definition of penetrating cardiac injuries. Angiography is therefore indicated in such cases. The injury to the RV and the haemostatic effects of the in situ thorn were favourable prognostic factors. We believe that the mortality risk reduction of extraction under full control warrants the minor morbidity of a median sternotomy.

Homicide Using an Air Weapon

The debate over the lethality and ownership of modern, high-powered weapons has recently grabbed the headlines. High-velocity air weapons, advertised as starter guns for children, can cause lethal injuries despite non-lethal appearing wounds. Presented is a rare case of a modern, high-powered air weapon used in a homicide. A literature search yielded reports of only three previous murders by air weapon in the United States and only one involving injury to the thorax. In the current case, the killer used a diabolo pellet to penetrate the chest. The pathway tracked through the sternum, piercing the anterior pericardial sac and perforating the right ventricle, which led to a pericardial effusion. The pellet embolized to the left pulmonary artery and eventually the vasculature of the left lung. Cause of death was a penetrating gunshot wound of the chest most likely leading to cardiac tamponade. This case exemplifies several important characteristics of penetrating chest trauma from air guns: first, air rifles, with exit velocities up to 1200 feet per second, can kill and have been used in accidental deaths, homicides and suicides; secondly, diabolo pellets may embolize just as bullets can; and lastly, minor external damage may mask major internal destruction.

The Use of a Magnetic Port Finder in the Retrieval of Air Rifle BBs to the Upper Extremity

Air-powered rifles shoot ball bearings with enough kinetic energy to penetrate skin and fracture underlying bones. In addition, there are reports of these ball bearings embolizing within the vascular network, causing serious injuries such as ischemic stroke with resultant blindness. The severity of these complications warrants occasional removal of these foreign bodies; however, they can be difficult to localize. In this case report, we describe the use of a magnetic port finder, a sterilizable tool used in breast reconstruction, to localize the foreign body in situ. We believe that this tool is effective at locating ferrous foreign bodies precisely, allowing for surgical retrieval while minimizing damage to surrounding tissue.

The prevention of firearm injuries in Canadian youth

Firearm injuries are a significant and preventable cause of death in Canadian youth. Adolescent and young adult males are disproportionately affected; however, firearm-related deaths occur in youth of all ages. Canada's rate of firearm ownership is lower than that of the USA, but high compared with other upper-income countries. The availability of firearms to youth is an important factor in adolescent suicide, unintentional firearm deaths, gang homicide and school shootings. Guns should not be kept in homes or environments where children and adolescents live or play. Screening for the presence of a firearm in the home is an essential part of the safety assessment of a depressed or suicidal youth, and removal of the firearm from the home must be recommended in this situation. Legislative measures to strictly control the acquisition, transport, ownership and storage of firearms, and to reduce smuggling of firearms, are also recommended.

Anesthesia for Pediatric Chest Trauma

Thoracic trauma in children is the second most frequent cause of death in the pediatric population. The majority of these children will have multisystem injuries. Management of these patients starts with the primary survey, resuscitation, and secondary survey as described in Advanced Trauma Life Support training. Most children with thoracic injuries can be observed or treated nonoperatively. The majority of children who do need surgery will need exploratory laparotomy and may have significant blood loss. The anesthesiologist needs to be prepared to manage a patient with severe underlying respiratory derangements, ongoing blood loss, and /or cardiac dysfunction. Moreover, one-lung ventilation may be necessary for optimal surgical exposure, which will present considerable challenges.

Metal projectile injuries in cats: review of 65 cases (2012-2014)

OBJECTIVES

The objective of this study was to compare the prevalence of different types of injuries caused by various types of projectiles among urban, suburban and rural cats of different ages in order to predict the type of injury sustained.

METHODS

For the period 1 January 2012 to 30 April 2014, the medical records of cats with metal projectile injuries (PIs) were searched from the archive of the university's small animal diagnostic imaging centre. Age, sex, owner address, admission during a weekend or on a working day, month of admission, projectile position (head and neck; thoracic region; abdominal region, including lumbosacral spine; forelimbs; and hindlimbs, including tail), number of projectiles, presence of a wound and fracture related to the projectile, and the type of projectile were recorded for each cat.

RESULTS

Sixty-five cats with PIs were admitted during the defined period. In 38.5% of cats the projectiles found upon radiography were incidental findings. The frequency of PIs peaked in March. Airgun projectiles were found in 80.0% of the cats. PIs in two or more body regions were found in 29.2% of the cats. Among the cats that had only been shot in one body region, the projectile was most frequently found in the abdominal region, including the lumbosacral spine (41.3%).

CONCLUSIONS AND RELEVANCE

These results might prompt clinicians to evaluate closely and screen for feline PIs in emergency situations.

[The classification of the injuries inflicted to the human body by gunshots from the pneumatic weapons]

The classification of the injuries inflicted to the human body by gunshots from the pneumatic weapons remains to be developed. The objective of the present work was to elaborate the classification of the injuries caused by gunshots from the pneumatic weapons based on the analysis of 98 expert

CONCLUSION

and acts of forensic medical expertises (surveys) of living subjects (n=76) and corpses (n=22) affected by gunshots from the pneumatic weapons. These materials were collected from the bureaus of forensic medical expertise in different regions of the Ukraine during the period from 2006 till 2015. In addition, scientific publications concerned with the problem of interest were used along with the relevant explanatory and terminological dictionaries. The terminology and the conceptual framework proposed by the author in the earlier papers provided a basis for the development of the first standard classification of the injuries inflicted to the human body by gunshots from the pneumatic weapons categorized into 15 groups. It is believed that this classification will lay the foundation for the common approach of forensic medical experts to the examination and analysis of the data on the gunshots from the pneumatic weapons used to be found on the bodies of living subjects and the corpses. Moreover, it may be useful for the clinicians in their diagnostic and therapeutic practices and for the legal practitioners engaged in the quality assessment of the results of forensic medical expertises. It is recommended to present information about the gunshots from the pneumatic weapons in the accounting documents in a separate line.

Dangerous Toys for Teenagers: Air Weapons

Introduction

Air weapons are used for sport, hunting, firearm training or just for fun, especially by teenagers, worldwide. These weapons are generally regarded as toys, and injuries from these weapons are thought to be harmless by users, parents and even officials. Improvements in weapons technology make the penetration power of these toys similar to conventional hand guns. To increase awareness about the serious injuries associated with these guns.

Case Presentation

The medical records of four teenage boys shot by air weapons between January 2012 and January 2013 in Mersin, Turkey, were retrospectively reviewed in this study. Of the four boys, two needed prompt thoracic intervention due to pneumo/hemothorax, one needed urgent abdominal exploration due to pneumoperitoneum and bleeding from the spleen and one was treated conservatively.

Conclusions

Air weapons can cause serious injuries among children. Increased public awareness, limitations to their usage and strict legislation are needed to protect children.

Shot through the heart-firepower and potential lethality of air weapons

Although certain air weapons attain muzzle velocities comparable to some firearms, their successful use for committing suicide is rarely seen. Herein, we report a case of a young female died shortly after urgent admission to the hospital with penetrating gunshot wound to the chest. The autopsy revealed perforation of the pericardium and two perforative defects to the right heart ventricle. Injury was inflicted by a 0.177 caliber pellet, fired from an air rifle found near her body. Investigation ruled the death as suicide. The used air rifle fired the pellet with the energy density of 1.9 J/mm(2) , substantially above the threshold for inflicting injury. The pellet penetrated through two layers of cotton fabric and several layers of tissue to inflict fatal injury to the heart. In addition, we provide an insight into the wounding potential of air weapons, which illustrates the need for greater caution in handling those devices.

Experimental effect of shots caused by projectiles fired from air guns with kinetic energy below 17 J

Pursuant to the Polish Weapons and Ammunitions Law (Legal Gazette No 53/1999 item 549 with subsequent amendments), air guns with kinetic energy of the fired projectiles below 17 J are not regarded as weapons. The aim of the study was to assess the potential effect of shots caused by projectiles of various mass and structure fired from air guns with kinetic energy below 17 J on human soft tissues. As a model of soft tissue, we used 20% gelatin blocks. After shooting, we measured the depth of gelatin block penetration by pellets fired from various distances and compared these results with autopsy findings. The results demonstrated that examined pneumatic guns may cause serious injuries, including damage to the pleura, pericardium, liver, spleen, kidneys, femoral artery, and thoracic and abdominal aorta. Experiment shown that gelatin blocks do not reflect fully the properties of the human body.

A contribution to the discussion on the safety of air weapons

Firearms legislation in the UK stems from the Firearms Act 1968 with its definition of a firearm as a lethal barrelled weapon of any description. The Act allows certain exceptions to be held without licence, most notably air weapons although these are limited by The Firearms (Dangerous Air Weapons) Rules 1969 and related regulations to below 12ft lb (16.3J) for air rifles and below 6ft lb (8.1J) for air pistols. Despite this there are occasional fatalities, typically 1 or 2 each year in the UK, from legally owned air weapons. In the USA there are over 20,000 visits each year to emergency departments due to injuries from air weapons and paintball guns. Despite this, limited research appears to have been carried out into the safety of air weapons and the present study tries to address this. Fresh samples of animal tissue were obtained from an abattoir or butcher and were embedded in ballistic gelatin. Pig heart, lung, liver and shoulder were used. By firing pellets into gelatin alone and into the combination of the gelatin and animal tissue it was possible to compare gelatin as a model for these tissues. The depth of penetration was similar but the residual track appeared to remain more open in the animal tissue. Pellets penetrated completely through the organ, with total penetration of gelatin and organ being typically around 10-15cm. Samples of pig, cow and chicken skin were placed in contact with the gelatin or embedded in the gelatin to simulate the effect of skin on penetration into a body. Chicken skin had no effect, pig skin stopped the pellet and cow skin was perforated by the pellet. If cow skin was embedded in the gelatin there was little effect on the total amount of penetration, but cow skin on the front surface of the gelatin reduced penetration by about 30%. Computed tomography was used to examine the pellet track and to calculate the volume of damage produced. However, due to the similar densities of gelatin and organ a technique had to be developed to differentiate phases. A barium salt paste was applied to outer surfaces and iodine solution or barium nitrate solution containing red food colouring was injected into the pellet track to enhance the contrast of the track. The track through the gelatin tended to enclose itself whereas the track through the organ remained more open, presumably due to the inhomogeneity of the fibrous nature of the tissue. Pellets were also fired at construction materials (wood, plasterboard and brick) and computed tomography used to determine the volume of damage created. Pellets perforated single layers of wood and plasterboard and would embed in a second layer. However, if the two layers were in contact the pellet did not penetrate the first layer. An air rifle pellet could therefore perforate house construction materials, although the resultant kinetic energy would be low and further damage would be limited. Some of the possible physical parameters are discussed that might help predict the degree of damage caused, but from this study it is not possible to define a limit which could be proposed as safe.

Penetrating cardiac trauma in adolescents: a rare injury with excessive mortality

BACKGROUND

Penetrating cardiac injuries in pediatric patients are rarely encountered. Likewise, the in-hospital outcome measures following these injuries are poorly described.

METHODS

All pediatric patients (<18years) sustaining penetrating cardiac injuries between 1/2000 and 12/2010 were retrospectively identified using the trauma registry of an urban level I trauma center. Demographic and admission variables, operative findings, and hospital course were extracted. Outpatient follow-up data were obtained through chart reviews and cardiac-specific imaging studies.

RESULTS

During the 11-year study period, 32 of the 4569 pediatric trauma admissions (0.7%) sustained penetrating cardiac injuries. All patients were male and the majority suffered stab wounds (81.2%). The mean systolic blood pressure on admission was 28.8±52.9mmHg and the mean ISS was 46.9±27.7. Cardiac chambers involved were the right ventricle (46.9%), the left ventricle (43.8%), and the right atrium (18.8%). Overall, 9 patients (28.1%) survived to hospital discharge. Outpatient follow-up echocardiography was available for 4 patients (44.4%). An abnormal echocardiography result was found in 1 patient, demonstrating hypokinesia and tricuspid regurgitation.

CONCLUSIONS

Penetrating cardiac trauma is a rare injury in the pediatric population. Cardiac chambers predominantly involved are the right and left ventricles. This injury is associated with a low in-hospital survival (<30%).

Anesthesia for a thoracic BB gun injury

Pediatric anesthesiologists care for children with penetrating trauma from nonpowder (BB and pellet) guns. We present the case of a 9-year-old boy who required urgent median sternotomy for cardiac tamponade after sustaining a close-range BB gun injury to the chest. After summarizing the epidemiology of nonpowder gun injuries in children, we clarify the nomenclature, ballistics, and mechanisms of these guns, discuss the tendency to minimize these kinds of injuries, explain bullet embolization, and review (by body area) current clinical management issues.

An investigation into the behaviour of air rifle pellets in ballistic gel and their interaction with bone

Although air weapons are considerably lower in power than other firearms, there is increasing concern that serious injuries can result from their misuse. The present study was therefore carried out to improve understanding of the terminal ballistic behaviour of air rifle pellets. Pellets were fired into ballistic gel under a variety of conditions. The pellets penetrated further than anticipated from their low cross-sectional density, and Bloom number was not necessarily a good guide to gel behaviour. Pellet penetration into the gel decreased with increasing gel concentration, and appeared to be linear at higher concentrations. Pointed pellets penetrated up to 50% further than rounded pellets. Power and range affect penetration, but other factors are also important, and power alone is not a simple guide to potential penetration. Test firings were also carried out firing pellets into ballistic gel that contained sections of animal bone. Computed tomography (CT) and visual observation were employed to record the interactions. CT scanning showed potential as a tool for examining pellet damage. The bone appeared to be undamaged, but the pellets were severely deformed on impact. If the pellet strikes the bone at an angle, less energy is absorbed by the impact and the pellet fragments may ricochet and cause further damage in the gel. A tentative model is proposed for estimating the energy absorbed by the impact.

Nonsurgical management of cardiac missiles

Modern air-powered pellet guns are capable of propelling their projectiles at velocities of 250 to 930 ft/s depending on their propulsion system-rivaling traditional small caliber firearms in the potential for serious soft tissue injuries. Management decisions regarding thoracic/cardiac pellet gun injuries must be based on the presentation and stability of the patient and the location of the retained pellet. We present a report of the nonsurgical management of an 8-year-old girl with a retained pericardial pellet and small stable effusion.

Conservative management of retained cardiac missiles: case report and literature review

Intracardiac foreign bodies may be caused by direct penetrating trauma, embolization from injury to another area of the body, or iatrogenically from fragments of intravascular access devices. Penetrating cardiac trauma commonly presents with a hemodynamically unstable patient necessitating emergent life-saving procedures. Missile embolization to the heart can occur after injury to systemic and pulmonary veins. Central venous access devices may fracture after placement and embolize. Especially in the setting of penetrating cardiac trauma, these intracardiac foreign bodies require expeditious removal. Limited data exist regarding the conservative management of intracardiac material after trauma. We present the case of a 42-year-old male soldier injured in a mortar blast in Iraq who suffered multiple injuries to include a right hemopneumothorax and soft tissue injuries to the chest and both lower extremities that was found to have a 2-cm by 2-mm intracardiac metal fragment. Additional imaging revealed a metallic fragment localized to the interatrial septum. The patient suffered no adverse sequelae from nonoperative management. A review of the world literature regarding the subject of posttraumatic retained cardiac missiles (RCMs) is also included to help future surgeons in the management of this rare entity.

Imaging Evaluation of Pediatric Chest Trauma

Following a discussion of the various imaging manifestations of pediatric chest trauma by anatomic location, the authors discuss their diagnostic approach to the pediatric multitrauma patient with an emphasis on chest imaging.

Injury risk of nonpowder guns

Nonpowder guns (ball-bearing [BB] guns, pellet guns, air rifles, paintball guns) continue to cause serious injuries to children and adolescents. The muzzle velocity of these guns can range from approximately 150 ft/second to 1200 ft/second (the muzzle velocities of traditional firearm pistols are 750 ft/second to 1450 ft/second). Both low- and high-velocity nonpowder guns are associated with serious injuries, and fatalities can result from high-velocity guns. A persisting problem is the lack of medical recognition of the severity of injuries that can result from these guns, including penetration of the eye, skin, internal organs, and bone. Nationally, in 2000, there were an estimated 21840 (coefficient of variation: 0.0821) injuries related to nonpowder guns, with approximately 4% resulting in hospitalization. Between 1990 and 2000, the US Consumer Product Safety Commission reported 39 nonpowder gun-related deaths, of which 32 were children younger than 15 years. The introduction of high-powered air rifles in the 1970s has been associated with approximately 4 deaths per year. The advent of war games and the use of paintball guns have resulted in a number of reports of injuries, especially to the eye. Injuries associated with nonpowder guns should receive prompt medical management similar to the management of firearm-related injuries, and nonpowder guns should never be characterized as toys.

Trends in BB/pellet gun injuries in children and teenagers in the United States, 1985-99

OBJECTIVE

To characterize national trends in non-fatal BB/pellet gun related injury rates for persons aged 19 years or younger in relation to trends in non-fatal and fatal firearm related injury rates and discuss these trends in light of injury prevention and violence prevention efforts.

SETTING

The National Electronic Injury Surveillance System (NEISS) includes approximately 100 hospitals with at least six beds that provide emergency services. These hospitals comprise a stratified probability sample of all US hospitals with emergency departments. The National Vital Statistics System (NVSS) is a complete census of all death certificates filed by states and is compiled annually.

METHODS

National data on BB/pellet gun related injuries and injury rates were examined along with fatal and non-fatal firearm related injuries and injury rates. Non-fatal injury data for all BB/pellet gun related injury cases from 1985 through 1999, and firearm related injury cases from 1993 through 1999 were obtained from hospital emergency department records using the NEISS. Firearm related deaths from 1985 through 1999 were obtained from the NVSS.

RESULTS

BB/pellet gun related injury rates increased from age 3 years to a peak at age 13 years and declined thereafter. In contrast, firearm related injury and death rates increased gradually until age 13 and then increased sharply until age 18 years. For persons aged 19 years and younger, BB/pellet gun related injury rates increased from the late 1980s until the early 1990s and then declined until 1999; these injury rates per 100 000 population were 24.0 in 1988, 32.8 in 1992, and 18.3 in 1999. This trend was similar to those for fatal and non-fatal firearm related injury rates per 100 000 which were 4.5 in 1985, 7.8 in 1993, and 4.3 in 1999 (fatal) and 38.6 in 1993 and 16.3 in 1999 (non-fatal). In 1999, an estimated 14 313 (95% confidence interval (CI) 12 025 to 16 601) cases with non-fatal BB/pellet gun injuries and an estimated 12 748 (95% CI 7881-17 615) cases with non-fatal firearm related injuries among persons aged 19 years and younger were treated in US hospital emergency departments.

CONCLUSIONS

BB/pellet gun related and firearm related injury rates show similar declines since the early 1990s. These declines coincide with a growing number of prevention efforts aimed at reducing injuries to children from unsupervised access to guns and from youth violence. Evaluations at the state and local level are needed to determine true associations.