Good news, bad news: An analysis of 11,294 gunshot wounds (GSWs) over two decades in a single center

Identifying mental health outcomes and evidence-based psychological interventions for supporting pediatric gunshot wound patients: A systematic review and proposed conceptual model

BACKGROUND

Accidental and assault gunshot wounds (GSWs) are the second leading cause of injury in the United States for youth ages 1- to 17-years-old, resulting in significant negative effects on pediatric patients' mental health functioning. Despite the critical implications of GSWs, there has yet to be a systematic review synthesizing trends in mental health outcomes for pediatric patients; a gap the present review fills. Additionally, this review identifies evidence-based psychological interventions shown to be effective in the treatment of subclinical symptoms of psychological disorders in the general population.

METHODS

A comprehensive search was conducted using five databases: American Psychological Association (APA) PsycInfo, APA PsycArticles, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Education Resource Information Center (ERIC), and Medical Literature Analysis and Retrieval Systems Online (MEDLINE). Twenty-two articles met inclusion criteria.

RESULTS

Findings suggest pediatric GSW patients are at a significantly elevated risk for mental health disorders when compared to other- (e.g., motor vehicle collision) and non-injured youth. Disorders include post-traumatic stress, disruptive behavior, anxiety, depression, and substance use. Hospital-based violence intervention programs, cultivating supportive relationships with adults in one's community, and trauma-focused outpatient services were identified as effective interventions for treating subclinical psychological symptoms.

CONCLUSIONS

Depicted in the proposed conceptual model, the present study delineates a direct association between pediatric GSWs and subsequent onset of mental health disorders. This relation is buffered by evidence-based psychological interventions targeting subclinical symptoms. Results suggest brief psychological interventions can help treat mental health challenges, minimizing risk for significant long-term concerns. Cultural adaptations to enhance the utility and accessibility of interventions for all patients are recommended.

Comprehensive Framework of Firearm Violence Survivor Care: A Review

Importance

Firearm violence is a public health crisis placing significant burden on individuals, communities, and health care systems. After firearm injury, there is increased risk of poor health, disability, and psychopathology. The newest 2022 guidelines from the American College of Surgeons Committee on Trauma require that all trauma centers screen for risk of psychopathology and provide referral to intervention. Yet, implementing these guidelines in ways that are responsive to the unique needs of communities and specific patient populations, such as after firearm violence, is challenging.

Observations

The current review highlights important considerations and presents a model for trauma centers to provide comprehensive care to survivors of firearm injury. This model highlights the need to enhance standard practice to provide patient-centered, trauma-informed care, as well as integrate inpatient and outpatient psychological services to address psychosocial needs. Further, incorporation of violence prevention programming better addresses firearm injury as a public health concern.

Conclusions and Relevance

Using research to guide a framework for trauma centers in comprehensive care after firearm violence, we can prevent complications to physical and psychological recovery for this population. Health systems must acknowledge the socioecological context of firearm violence and provide more comprehensive care in the hospital and after discharge, to improve long-term recovery and serve as a means of tertiary prevention of firearm violence.

Advanced interventions in the pre-hospital resuscitation of patients with non-compressible haemorrhage after penetrating injuries

Abstract

Early haemorrhage control and minimizing the time to definitive care have long been the cornerstones of therapy for patients exsanguinating from non-compressible haemorrhage (NCH) after penetrating injuries, as only basic treatment could be provided on scene. However, more recently, advanced on-scene treatments such as the transfusion of blood products, resuscitative thoracotomy (RT) and resuscitative endovascular balloon occlusion of the aorta (REBOA) have become available in a small number of pre-hospital critical care teams. Although these advanced techniques are included in the current traumatic cardiac arrest algorithm of the European Resuscitation Council (ERC), published in 2021, clear guidance on the practical application of these techniques in the pre-hospital setting is scarce. This paper provides a scoping review on how these advanced techniques can be incorporated into practice for the resuscitation of patients exsanguinating from NCH after penetrating injuries, based on available literature and the collective experience of several helicopter emergency medical services (HEMS) across Europe who have introduced these advanced resuscitation interventions into routine practice.

Graphical Abstract

Characteristics of Adult Patients for Violence-Related Injuries Presenting to a Level 1 Trauma Center in Midwest United States

BACKGROUND

Hospital violence intervention programs (HVIPs) have recently been initiated in trauma centers across the United States. However, violence-related injuries have unique factors and issues that should be addressed in the health care provided in emergency departments.

PURPOSE

This study aimed to characterize the patient population presenting at a level 1 ACS verified trauma center, with a chief complaint of violent trauma, and identify characteristics of patients most at risk for violence-related trauma.

METHODS

The cross-sectional retrospective study examined patients' electronic health records, at least 18 years, with a diagnosis of blunt or penetrating injury treated by the emergency and trauma team at level 1 ACS verified trauma center in the Midwest.

RESULTS

Assault injuries accounted for most of the mechanisms that required treatment at the hospital and disposed to home. Nearly 80% of the population had no documentation of the relationship of the assailant. The average age of the patients was 33 years and black males. Eleven patients were treated in the emergency department twice for a trauma-related injury during the six-month data collection.

CONCLUSION

Injuries from violence require comprehensive care from various healthcare disciplines, similar to managing acute and chronic illnesses. The American College of Surgeons (ACS) guidelines support the development of an HVIP to identify risk factors and treatment plans for any patient exposed to violence. This research demonstrates that HVIPs should provide standardized screening and follow-up care while in the emergency department or immediately following the hospital to reduce the cyclical events.

Derivation and Validation of a Score Using Prehospital Data to Identify Adults With Trauma Requiring Early Laparotomy

IMPORTANCE

A scoring tool to identify which adults with traumatic injury will require early laparotomy could help improve prehospital triage and system readiness.

OBJECTIVE

To develop and validate a prediction model using prehospital information for early laparotomy following trauma.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study analyzed data from the 2017 version of the American College of Surgeons Trauma Quality Improvement Program database. All adult patients with traumatic injury aged 18 years or older who were admitted to a US trauma center in 2017 were included. Patients were randomly assigned to a derivation or validation cohort. Data were collected and analyzed between July 2020 and September 2020.

MAIN OUTCOMES AND MEASURES

The primary outcome was laparotomy within 2 hours of hospital arrival. A scoring system was developed to predict early laparotomy using a logistic regression model in the derivation cohort. This was validated in the validation cohort using the area under the receiver operating characteristic curve.

RESULTS

A total of 379 890 US adults with traumatic injury were included; 190 264 patients were in the derivation cohort and 189 626 patients were in the validation cohort. The cohorts had the same proportion of laparotomy within 2 hours of hospital arrival (1.1%). The median (IQR) age was 32 (25-46) years in the early laparotomy group and 54 (33-72) years in the group with no early laparotomy. The early laparotomy group contained 113 776 of 188 211 (60.5%) male patients, while the group with no early laparotomy contained 1702 of 2053 (82.9%) male patients. The variable most strongly associated with early laparotomy was penetrating injury to the head, neck, torso, or extremities proximal to the elbow or knee (odds ratio, 13.47; 95% CI, 12.22-14.86) with a point value of 10 (maximum overall score 20). Other variables included in the scoring system were the male sex, a systolic blood pressure less than 90 mm Hg, a Glasgow Coma Scale of less than or equal to 13, having chest wall instability or deformity, pelvic fracture, and high-risk blunt mechanism. In the validation cohort, the C statistic of the scoring system was 0.78 (95% CI, 0.77-0.79).

CONCLUSIONS AND RELEVANCE

In this study, a novel scoring tool using prehospital information was derived and validated to identify which adults with traumatic injury will require laparotomy within 2 hours of hospital arrival. This tool may help trauma professionals allocate operative team resources before patient arrival.

Intracranial gunshot wounds in utero: case report and review

BACKGROUND AND IMPORTANCE

We present a rare case of an in utero intracranial gunshot wound with survival of the baby and neurosurgical intervention in the first 6 h of life.

CLINICAL PRESENTATION

A pregnant 19-year old sustained multiple gunshot wounds and underwent an emergency cesarean section. At the time of delivery, there was a penetrating wound noted to the uterus and to the left side of the baby's head. The baby was taken urgently for craniotomy. Thorough washout was performed, and a pericranial graft was harvested from the frontal vertex to assist in dural closure. The largest displaced bone fragment was soaked in betadine and sutured back into place. The baby was observed for several days and then discharged home with normal neurological examination.

CONCLUSION

There are scattered reports of in utero intracranial gunshot wounds in the literature dating back to the nineteenth century; however, our case appears to be the first reported that involved urgent surgical intervention.

Firearm injuries during legal interventions Nationwide analysis

INTRODUCTION

There is limited literature on firearm injuries during legal interventions. The purpose of this study was to examine the epidemiology, injury characteristics, and outcomes of both civilians and law enforcement officials (LEOs) who sustained firearm injuries over the course of legal action.

METHODS

Retrospective observational study using data from the National Trauma Data Bank (2015-2017) was performed. All patients who were injured by firearms during legal interventions were identified using the International Classification of Disease, Tenth Revision, external cause of injury codes. The study groups were injured civilian suspects and police officers. Demographics, injury characteristics, and outcomes were analyzed and compared between the groups. Primary outcomes were the clinical and injury characteristics among the victims.

RESULTS

A total of 1,411 patients were included in the study, of which 1,091 (77.3%) were civilians, 289 officers (20.5%), and 31 bystanders (2.2%). Overall, 95.2% of patients were male. Compared with LEOs, civilians were younger (31 vs. 34 years, p = 0.007) and more severely injured (median Injury Severity Score, 13 vs. 10 [p = 0.005]; Injury Severity Score >15, 44.4% vs. 37.1% [p = 0.025]). Civilians were more likely to sustain severe (Abbreviated Injury Scale, ≥3) intra-abdominal injuries (26.8% vs. 16.1%, p < 0.001) and spinal fractures (13.0% vs. 6.9%, p = 0.004). In-hospital mortality and overall complication rate were similar between the groups (mortality: civilians, 24.7% vs. LEOs, 27.3% [p = 0.360]; overall complications: civilians, 10.3% vs. LEOs, 8.4% [p = 0.338]).

CONCLUSION

Firearm injuries during legal interventions are associated with significant injury burden and a higher mortality than the reported mortality in gunshot wounds among civilians. The mortality and overall complication rate were similar between civilian suspects and law enforcement officials.

LEVEL OF EVIDENCE

Epidemiologic, level IV.

Caught in the crossfire: 37 Years of firearm violence afflicting America's youth

INTRODUCTION

Publicly available firearm data are difficult to access. Trauma registry data are excellent at documenting patterns of firearm-related injury. Law enforcement data excel at capturing national violence trends to include both circumstances and firearm involvement. The goal of this study was to use publicly available law enforcement data from all 50 states to better define patterns of firearm-related homicides in the young.

METHODS

All homicides in individuals 25 years or younger in the United States over a 37-year period ending in 2016 were analyzed: infant, 1 year or younger; child, 1 to 9 years old; adolescent, 10 to 19 years old; and young adult, 20 to 25 years old. Primary data files were obtained from the Federal Bureau of Investigation and comprised the database. Data analyzed included homicide type, situation, circumstance, month, firearm type, and demographics. Rates of all homicides and firearm-related homicides per 1 million population and the proportion of firearm-related homicides (out of all homicides) were stratified by year and compared over time using simple linear regression.

RESULTS

A total of 171,113 incidents of firearm-related homicide were analyzed (69% of 246,437 total homicides): 5,313 infants, 2,332 children, 59,777 adolescents, and 103,691 young adults. Most (88%) were male and Black (59%) with a median age of 20 years. Firearm-related homicides peaked during the summer months of June, July, and August (median, 1,156 per year; p = 0.0032). Rates of all homicides (89 to 53 per 1 million population) and firearm-related homicides (56 to 41 per 1 million population) decreased significantly from 1980 to 2016 (β = -1.12, p < 0.0001 and β = -0.57, p = 0.0039, respectively). However, linear regression analysis identified a significant increase in the proportion of firearm-related homicides (out of all homicides) from 63% in 1980 to 76% in 2016 (β = 0.33, p < 0.0001).

CONCLUSION

For those 25 years or younger, the proportion of firearm-related homicides has steadily and significantly increased over the past 37 years, with 3 of 4 homicides firearm related in the modern era. Despite focused efforts, reductions in the rate of firearm-related homicides still lag behind those for all other methods of homicide by nearly 50%. That is, while the young are less likely to die from homicide, for those unfortunate victims, it is more likely to be due to a firearm. This increasing role of firearms in youth homicides underscores the desperate need to better direct prevention efforts and firearm policy if we hope to further reduce firearm-related deaths in the young.

LEVEL OF EVIDENCE

Epidemiological study, level III.

Surgical Treatment of Upper Extremity Gunshot Injures: An Updated Review

INTRODUCTION

Firearm morbidity and mortality have been increasing in recent years, and with this, the demand for medical personnel firearm injury treatment knowledge. Extremities contribute to a majority of firearm injuries, with these injuries being particularly complex because of neurovascular proximity within a confined space. Knowledge of firearm mechanism of injury and treatment management options is important for any trauma hand surgeon. Many factors play vital roles in the treatment of complex upper extremity (UE) gunshot wounds (GSWs). The aim of our review and case illustrations is to provide hand surgeons with an up-to-date guide for initial emergent management, soft tissue, bony, and nerve repair and reconstruction.

PATIENT AND METHODS

A literature review was conducted in the current management of UE GSW injuries, and 2 specific patient case examples were included. High-energy versus low-energy GSWs were documented and compared, as well as containment injures. Management including soft tissue, bony, and nerve injuries was explored along with patient outcome. Based on these findings, guidelines for GSW management were purposed.

CONCLUSION

Gunshot wounds of the UE encompass a group of highly heterogeneous injuries. High-energy wounds are more extensive, and concomitant injuries to bone, vessel, nerve, muscle, and soft tissue are common. Early treatment with adequate debridement, skeletal fixation, and soft tissue coverage is indicated for complex injuries, and antibiotic treatment in the pre-, peri-, and postoperative period is indicated for operative injuries. Soft tissue coverage options include the entire reconstructive ladder, with pattern of injury and considerations of wound characteristics dictating reconstructive choice. There are arguments to using either external or internal bony fixation techniques for bone fracture management, with choice tailored to the patient. For management of nerve injuries, we advocate earlier nerve repair and a shorter duration of observation before secondary reconstruction in selective cases. If transected nerve endings cannot be brought together, nerve autografts of shorter length are recommended to bridge nerve ending gaps. A significant number of patients with GSW fail to make necessary follow-up appointments, which adds to challenges in treatment.

Demographics and Incident Location of Gunshot Wounds at a Single Level I Trauma Center

Introduction

Kansas has seen a steady increase in the rate of firearm deaths and injuries. Little is known surrounding the demographic and geospatial factors of these firearm-related traumas. The purpose of this study was to describe the overall incidence of firearm-related traumas, identify high injury locations, and examine any racial/ethnic disparities that may exist.

Methods

A retrospective review was conducted of all patients 14 years or older who were admitted with a gunshot wound (GSW) to a Level I trauma center between 2016 and 2017.

Results

Forty-nine percent of patients were Caucasian, 26.5% African American, and 19.6% Hispanic/Latino. Hispanic/Latino patients were the youngest (25.8 ± 8.8 years) and Caucasians were the oldest (34.3 ± 14.1 years, p = 0.002). Compared to Caucasian patients, African American (42.0%) and Hispanic/Latino (54.1%) patients were more likely to be admitted to the intensive care unit (ICU; p = 0.034) and experienced longer ICU lengths of stay (2.5 ± 6.3 and 2.4 ± 4.7 days, p = 0.031, respectively). African American patients (96.0%) experienced more assaults, while Caucasians were more likely to receive gunshot wounds accidentally (26.9%, p = 0.001). More African American (86.0%) and Hispanic/Latino (89.2%) patients were injured with a handgun and Caucasians sustained the highest percentage of shotgun/rifle related injuries (16.1%, p = 0.012). Most GSWs occurred in zip codes 67202, 67203, 67213, 67211, and 67214. Geographical maps indicated that GSWs occur in neighborhoods with low-income and high minority residents and in the downtown and nightclub areas of the city.

Conclusions

Most GSW victims were older Caucasian males. Racial differences were noted and injury locations concentrated in certain locations.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Operative Management of Thoracic Gunshot Wounds: More Aggressive Treatment Has Been Required over Time

Our department has a database of thoracic gunshot wounds (GSWs), which has cataloged these injury patterns over the past five decades. Prevailing wisdom on the management of these injuries suggested operative treatment beyond tube thoracostomy is not commonly required. It was our clinical impression that the operative treatment required beyond chest tube placement has greatly increased over the past several decades, whereas the operative management of cardiac GSWs seemed to be increasingly infrequent events. To test these observations, we analyzed the treatment of GSWs to the chest and heart in four distinct time periods, categorized as “historical” (1973–1975 and 1988–1990) and “modern” (2005–2007 and 2015–2017). There was a significant increase in emergent thoracotomy, delayed thoracic operations, overall operative interventions, and pulmonary resections from the historical period to the modern era. There was a decline in cardiac injuries treated, whereas the number of injuries remained constant. Mortality was unchanged between the early and later periods. Operative treatment beyond tube thoracostomy was much more prevalent for noncardiac thoracic GSWs in the past two decades than in the prior decades, whereas the number of cardiac wounds treated decreased by half.

The Effect of Large-Capacity Magazine Bans on High-Fatality Mass Shootings, 1990-2017

Objectives. To evaluate the effect of large-capacity magazine (LCM) bans on the frequency and lethality of high-fatality mass shootings in the United States.Methods. We analyzed state panel data of high-fatality mass shootings from 1990 to 2017. We first assessed the relationship between LCM bans overall, and then federal and state bans separately, on (1) the occurrence of high-fatality mass shootings (logit regression) and (2) the deaths resulting from such incidents (negative binomial analysis). We controlled for 10 independent variables, used state fixed effects with a continuous variable for year, and accounted for clustering.Results. Between 1990 and 2017, there were 69 high-fatality mass shootings. Attacks involving LCMs resulted in a 62% higher mean average death toll. The incidence of high-fatality mass shootings in non-LCM ban states was more than double the rate in LCM ban states; the annual number of deaths was more than 3 times higher. In multivariate analyses, states without an LCM ban experienced significantly more high-fatality mass shootings and a higher death rate from such incidents.Conclusions. LCM bans appear to reduce both the incidence of, and number of people killed in, high-fatality mass shootings.

Evaluation and management of abdominal stab wounds: A Western Trauma Association critical decisions algorithm

This is a recommended management algorithm from the Western Trauma Association addressing the management of adult patients with abdominal stab wounds. Because there is a paucity of published prospective randomized clinical trials that have generated Class I data, these recommendations are based primarily on published observational studies and expert opinion of Western Trauma Association members. The algorithm and accompanying comments represent a safe and sensible approach that can be followed at most trauma centers. We recognize that there will be patient, personnel, institutional, and situational factors that may warrant or require deviation from the recommended algorithm. We encourage institutions to use this as a guideline to develop their own local protocols.