Characteristic Features of Pediatric Firearm Fatalities-Comparisons Between Australia and the United States

An analysis of child suicide from three centers (2008-2017)

Although the overall suicide rate worldwide has changed minimally over the past 100 years, different trends have been observed over time in the USA, Australia, and New Zealand (NZ). However, few studies have focused on suicides in children (< 18 years), making evaluation of possible trends difficult. The last 20 years has also seen an increase in childhood obesity, eating disorders, and body image issues for children in many developed nations; however, few studies have shown whether a significant proportion of child suicides have an abnormal BMI. The current study evaluates child suicides (from 2008 to 2017) in South Australia (Australia), compared with the jurisdictions of Auckland (NZ) and Hennepin County (USA). Demographic data (age, sex, ethnicity), body mass index (BMI), the number of cases of youth suicide, and the method of suicide from these three regions were collected and analyzed. Across the 10-year period, the jurisdiction of Auckland had a downward trend, while Hennepin County and South Australia had increasing numbers of cases. The most common method of child suicide in all centers was hanging, occurring in > 80% of cases in South Australia and Auckland and 56% in Hennepin County. Hennepin County had a greater proportion of suicides using firearms (28%), compared to 1.9% in Auckland and 5.1% in South Australia. Unusual means of suicide were used less frequently by youth than previously.

Determining Intentionality of Pediatric Firearm Injuries by International Classification of Disease Code

OBJECTIVE

Firearm injuries are a leading cause of serious injury and death in childhood. The accuracy of International Classification of Disease (ICD) codes to assign intent is unclear. The objective of this study was to assess the validity of documented ICD codes for firearm injury intent compared with chart review.

METHODS

We performed a retrospective cohort study of children (<= 18 years) presenting to a tertiary care level 1 pediatric trauma center with firearm injuries between 2006 and 2017. We compared agreement between ICD codes and intent of injury determined by medical record review using Cohen κ. Intent for medical record review was assigned via the injury spectrum of intentionality (suicide attempt, accidental firing, mistaken target, firearm assault and unknown). For comparison with ICD codes, all medical record review cases marked as mistaken target were classified as accidental. A sensitivity analysis was then performed, coding all mistaken targets as assault.

RESULTS

There were 122 cases identified over the study period. The most common intent by ICD code was assault (n = 80, 65.6%). Medical record review categorized most injuries as mistaken targets. When mistaken target was categorized as accidental, most firearm injuries were coded as accidental (n = 89, 72.9%) Similar results were seen when mistaken target was categorized as assault, most injuries were categorized as assault (n = 79, 79.5%) Cohen κ was 0.15 when mistaken targets were categorized as accident and 0.30 when categorized as assault.

CONCLUSIONS

The ICD codes do not fully describe the intent of firearm injury. Revising ICD codes to account for mistaken targets could help to improve the validity of ICD codes for intent.

Geographic variability in homicide rates following the COVID-19 pandemic

It has been demonstrated in a number of communities that the rates of serious crimes such as homicides and intimate partner violence have increased as a result of lockdowns due to COVID-19. To ascertain whether this is a universal trend the electronic autopsy files at Forensic Science South Australia, Adelaide, Australia, were searched for all homicides occurring between January 2015 and December 2020. There were 92 cases with 17 homicides in 2015 out of a total of 1356 cases (1.3%),18 in 2016 (18/1340 = 1.3%), 23 in 2017 (23/1419 = 1.6%); 14 in 2018 (14/1400 = 1.0%), 15 in 2019 (15/1492 = 1.0%) but in 2020 there were only 5 (5/1374 = 0.4%) (p < 0.02). Thus the incidence of homicides has fallen significantly in South Australia since the beginning of the pandemic. As the occurrence of serious crimes of violence and homicide has not followed a standard pattern in different communities it will be important to evaluate specific populations and subgroups rather than merely relying on accrued national data or extrapolating from one country to another. Pathologists, epidemiologists and health officials will need to specifically monitor local trends to understand more clearly what effects, if any, the pandemic has had on particular subgroups of deaths in order to more clearly understand causal relationships.

Penetrating head injuries in children presenting to the emergency department in Australia and New Zealand: A PREDICT prospective study

AIM

Penetrating head injuries (pHIs) are associated with high morbidity and mortality. Data on pHIs in children outside North America are limited. We describe the mechanism of injuries, neuroimaging findings, neurosurgery and mortality for pHIs in Australia and New Zealand.

METHODS

This was a planned secondary analysis of a prospective observational study of children <18 years who presented with a head injury of any severity at any of 10 predominantly paediatric Australian/New Zealand emergency departments (EDs) between 2011 and 2014. We reviewed all cases where clinicians had clinically suspected pHI as well as all cases of clinically important traumatic brain injuries (death, neurosurgery, intubation >24 h, admission >2 days and abnormal computed tomography).

RESULTS

Of 20 137 evaluable patients with a head injury, 21 (0.1%) were identified to have sustained a pHI. All injuries were of non-intentional nature, and there were no gunshot wounds. The mechanisms of injuries varied from falls, animal attack, motor vehicle crashes and impact with objects. Mean Glasgow Coma Scale on ED arrival was 10; 10 (48%) had a history of loss of consciousness, and 7 (33%) children were intubated pre-hospital or in the ED. Fourteen (67%) children underwent neurosurgery, two (10%) craniofacial surgery, and five (24%) were treated conservatively; four (19%) patients died.

CONCLUSIONS

Paediatric pHIs are very rare in EDs in Australia and New Zealand but are associated with high morbidity and mortality. The absence of firearm-related injuries compared to North America is striking and may reflect Australian and New Zealand firearm regulations.

Increasing incidence of nonlethal inflicted injuries in paediatric homicides: A 45-year study

A retrospective study was undertaken at Forensic Science South Australia of all homicides in individuals aged <18 years from January 1970 to December 2014. 166 cases were identified (M:F = 1.5:1). The number of cases steadily declined, with the highest numbers and death rate occurring between 1970 and 1974 (N = 26; 0.37/100,000 population), and the lowest between 2010 and 2014 (N = 8; 0.1/100,000) (p < 0.01). Deaths were due to blunt force trauma (37%), gunshot wounds (19%), asphyxiation (18%), sharp force trauma (8%), poisoning (8%), burns (3%) and neglect (1%), or were undetermined (6%). There was a significant increase in numbers of accompanying nonfatal injuries (3.46 per case for 1970 and 1974, compared to 18.88 per case for 2010 and 2014). Thus, while both the absolute numbers and the rates of paediatric homicides declined significantly, numbers of nonlethal injuries increased. Whatever the underlying reason(s) for the increase in nonlethal injuries, fatal attacks on children in South Australia appear to be becoming more violent.

In harm's way: Unintentional firearm injuries in young children

PURPOSE

Firearm-related trauma represents a major source of preventable injury and death. Many firearm injuries in young children are unintentional, and the true incidence may be underestimated. We sought to characterize the morbidity of unintentional firearm injuries.

METHODS

National Trauma Data Bank data from 2007 to 2014 was obtained for patients aged 0-14 sustaining gunshot wounds (GSW). We analyzed demographics, injury severity score, hospital and ICU length of stay (LOS), ventilator days, discharge to rehab, and mortality. We categorized intention as assault, unintentional, self-inflicted or other, and compared unintentional firearm injuries against all others using Student's t test or chi-square analysis.

RESULTS

We identified 7487 GSW patients aged 0-14, of whom 2514 (33.6%) sustained unintentional injuries. The mortality rate for unintentionally injured patients was 9.2%, compared with 14.2% for all other intentions (p<0.0001). Unintentionally injured children were more likely to be male (p=0.01) and Caucasian (p<0.0001) and had lower rates of ICU admission (p=0.02), ventilator use (p=0.0004), and discharge to rehab (p<0.0001).

CONCLUSIONS

Unintentional injuries comprise one-third of firearm injuries and approximately 10% of GSW-related mortality in young children. Since these injuries are entirely preventable, our findings suggest a major opportunity to reduce disease burden.

LEVEL OF EVIDENCE

IV.

Fatal Gunshot Wounds in Young Children

Deaths related to firearms are common within the United States. Although relatively rare compared to other age groups, deaths occurring in young children represent a particularly tragic subcategory of firearms-related fatalities. This manuscript provides details regarding several cases of gunshot wound deaths occurring in young children. Included are a variety of situations and scenarios: the child was an innocent bystander struck by gunfire that was intended for another individual; unsafe firearm handling and manipulation by another individual, resulting in the child being shot; unsafe storage of a loaded firearm with resultant accidental discharge of the weapon; a young child having ready access to a loaded handgun and subsequently shooting him/herself; and the child being considered a potential intended target and being shot by another individual. The details of each case are provided, and discussion will focus on realistic strategies that, if implemented, might prevent such deaths from occurring in the future.

Suicidal childhood deaths with firearms in Antalya, Turkey

The purpose of this study was to determine the characteristics of suicidal childhood deaths with the use of firearms that occurred from 2000 to 2009 in Antalya. The autopsy reports of the Antalya branch of the Turkish Forensic Medicine Council and judicial records were reviewed retrospectively. There were 60 suicidal deaths between 0 and 18 years of age. Firearms were used in 20 cases (11 males, 9 females). The shotgun (n = 15) was the most frequently used weapon. The site of bullet entries were the chest (n = 6), abdomen (n = 5), right temple (n = 5), mouth (n = 2) and neck (n = 2). Most suicides (n = 16) were in the home. In contrast to many other studies, the most frequently used weapon for suicides was the shotgun in this study.

Firearm related injuries amongst children: estimates from the nationwide emergency department sample

OBJECTIVE

The objective of this study is to provide estimates of firearm related injuries in children seeking care in hospital based emergency departments.

METHODS

The Nationwide Emergency Department Sample (NEDS) for the year 2008 was used for the current study. All ED visits occurring amongst children aged less than or equal to 18 years and that had an External Cause of Injury (E-Code) for any of the firearm related injuries were selected for analysis.

RESULTS

A total of 14,831 ED visits (in children) in the United States had a firearm injury. The average age of the ED visits was 15.9 years. Males constituted a predominant proportion of all ED visits (89.2%). A total of 494 patients died in the emergency departments (3.4% of all ED visits) whilst 323 died following in-patient admission into the same hospital (6% of all inpatient admissions). The most frequently documented firearms were assaults by firearms and explosives (55% of all ED visits), accidents caused by firearms and air gun missiles (33.6%), and injuries by firearms that were undetermined (7.4%). The average charge for each ED visit was $3642 (25th percentile is $1146, median is $2003, and 75th percentile is $4404). The mean charge for those visits that resulted in in-patient admission into the same hospital was $70,164 (25th percentile is $16,704, median is $36,111, and 75th percentile is $74,165) and the total charges for the entire United States was about $371.33 million.

CONCLUSIONS

The current study used the largest all-payer hospital based emergency department dataset to provide national estimates of firearm related injuries amongst children in the United States during the year 2008 and highlights the public health impact of such injuries.

Recent firing range suicides in South Australia

Two cases are reported from South Australia, where deaths occurred that were due to single self-inflicted gunshot wounds to the head in individuals who were visiting indoor firearm ranges. Case 1: A 54-year-old man visiting an indoor firing range placed a .357 magnum handgun to his head and fired one shot. Case 2: A 23-year-old woman who was being instructed in firearm usage at an indoor firing range placed a 9 mm handgun to her head and fired one shot. In both cases, deaths were due to cerebral laceration with skull fracture. Firing ranges may be utilized by individuals who are seeking weapons for suicide attempts, and suicide may be successfully undertaken at such locations even while a victim is under direct supervision. In jurisdictions, where firearm ownership is strictly legislated, it may be that clubs can inadvertently provide access to firearms for this type of activity.

Air embolism: an unusual cause of delayed death following gunshot wound to the chest

A 29-year-old man was shot in the chest twice sustaining extensive contusion of the right lung. He was, however, clinically stable with no major vessel injury or significant blood loss. Unexpected cardiac arrest occurred hours after hospital admission due to left coronary artery air embolism. Lung parenchymal damage from the passage of two projectiles within the chest wall close to the pleural cavity had occurred, with disruption of the capillary-alveolar interface and passage of air into the pulmonary venous circulation. While tangential gunshot wounds to the chest wall may rarely cause air embolism, symptoms are usually immediate. The present case demonstrates, however, that death may occur unexpectedly some time after the initial trauma in an individual who is considered clinically stable.