Serious and fatal air gun injuries: more than meets the eye

Prophylactic removal of a migratory missile from the cerebral ventricles: case report

BACKGROUND AND IMPORTANCE

Nonpowder firearm injuries to the head pose major health risks, with retained fragments potentially causing harmful sequelae that require neurosurgical intervention.

CLINICAL PRESENTATION

We report the case of 2-year-old girl who sustained an accidental gunshot wound to the head. She sustained a penetrating ballistic intracranial injury caused by a BB shot from a rifle. At presentation, she was neurologically intact with a punctate laceration on her left forehead. Head CT demonstrated a small depressed left frontal skull fracture, a small intracerebral hematoma, and a 5-mm metallic bullet fragment in the deep left frontal lobe near the frontal horn of the left lateral ventricle. She was admitted to the hospital and managed nonoperatively with levetiracetam and intravenous antibiotics, and discharged home in good condition. Follow-up CT in 1 week showed slight migration of the metallic bullet fragment to the left, placing it at the anterior horn of the lateral ventricle. Six weeks later, follow-up CT showed migration of the bullet to the temporal horn of the left lateral ventricle. Intraventricular migration of the bullet raised concern that it could move further to obstruct the foramen of Monro or cerebral aqueduct. Therefore, we removed the bullet through a small left temporal craniotomy with image guidance using a microsurgical approach through a translucent tube.

CONCLUSION

The authors discuss the rationale and technique for removing a nonpowder firearm bullet that has migrated within the cerebral ventricles.

Targeting safety: Exploring trends and risk factors in pediatric head and neck BB gun injuries and hospitalization

OBJECTIVE

To examine head and neck injuries caused by BB (Ball Bearing) guns treated in US emergency departments among children under 18 to identify trends in injury frequency over time and risk factors associated with severe injuries leading to hospital admission.

METHODS

This retrospective study utilized data from the National Electronic Injury Surveillance System (NEISS), a single database, to analyze head and neck injuries caused by BB guns between 1993 and 2019. The analysis explored demographic characteristics and injury patterns, including sex, age, incidence, injury location, hospital type, and disposition. Linear regression was employed to assess trends in the yearly frequency of injuries, while univariate and multivariate binary logistic regression was used to calculate the odds ratios associated with hospitalization.

RESULTS

A total of 4041 cases of pediatric head and neck injuries caused by BB guns and treated in US emergency departments were identified. Most patients were male (84 %), with the highest proportion of injuries occurring in the 10-14 age group (49.7 %). The face (35.8 %) and eye (27.4 %) were the most affected injury sites, and 7.5 % of patients required hospital admission. No significant linear trend was observed in injury frequency over the study period. However, children aged four and under had higher odds of hospitalization (OR 2.77, 95 % CI 1.61-4.75) despite a lower incidence of injuries. Injuries to the eye (OR 12.37, 95 % CI 8.31-18.43) and neck (OR 7.58, 95 % CI 4.76-12.06) were strong predictors of hospital admission.

CONCLUSION

Pediatric BB gun-related head and neck injuries remain a source of emergency room visits nationally. Younger children are at increased risk of admission to the hospital. Eye and neck injuries were the strongest predictors of hospital admission. Implementing safety precautions for younger children is crucial, as injuries might be more severe in this age group.

Endoscopic pediatric endonasal retrieval of transorbital projectile: An illustrative multimedia report

Air guns, particularly BB (ball-bearing or bullet ball) guns, have gained significant power and velocity over the last few decades. More than 145,000 pediatric patients suffered injuries attributed to air guns in the United States between 2001 and 2011, and approximately 22,000 pediatric emergency department visits are attributed to air gun-related injuries annually (Hyak et al., 2020 [1]). This study aims to describe an effective surgical technique in addressing maxillofacial injuries caused by BB gun projectiles in the pediatric population. We present a detailed surgical approach for endoscopic endonasal retrieval of a transorbital projectile in a 13-year-old male who sustained a maxillofacial BB gun injury, with the goal of restoring sinonasal function in a minimally invasive fashion.

Alcohol and fatal penetration of the cranium by an airgun pellet—a case study from Poland

Background

Airguns with the energy of ejected pellets below 17 J are not considered weapons in Poland, can be purchased without permission, and do not require registration. The mere possession of this kind of airgun does not entail any legal consequences, unless it is used for an unauthorized purpose. Sports and recreational shooting do not have to take place within shooting ranges. However, the improper use of this type of weapon can lead to serious injuries and death. In addition, the impact of high blood alcohol content on pain perception can lead to a lack of awareness of the gunshot.

Case presentation

A 36-year-old woman died a few hours after a head injury inflicted by a 5.50-mm caliber pellet fired from an air gun. The first pellet penetrated perpendicularly through the left temporal bone to the brain. The gunshot tract of this head wound was 6 cm long and ran horizontally and perpendicularly to the surface of the squamous part of the temporal bone. The tract ran through the skin of the skull, the left temporal muscle, and the squamous part of the temporal bone (where the bone was only 1.5 mm thick). The pellet then penetrated the cerebral dura mater, cerebral pia mater on the borderline of the left temporal and frontal lobes, and left lateral wall of the sphenoidal sinus. The victim did not complain of pain due to a high level of alcohol intoxication (0.35 blood alcohol content). The pellet from the second shot (on the foot) penetrated the right foot and was inflicted by the victim.

Conclusion

The victim died not earlier than 3 h after being shot as a result of intracranial injuries that caused hemorrhage. The outcomes of this study indicated that high alcohol content resulted in reduced awareness of the victim and no apparent symptoms of developing intracranial injuries.

Forensic assessment of a life-threatening penetrating abdominal air gun injury

Air guns are considered mostly harmless by the public opinion, but projectiles shot from common air guns can penetrate skin and thus able to cause severe, even life-threatening injury. The prevalence of air gun injuries is constantly high, but severe injuries occur rarely. Forensic evaluation of air gun injuries can be challenging since the shot wound characteristics produced by combustion in case of firearm injuries are missing. Despite these difficulties, the topic of air gun injuries is mostly overlooked in forensic literature, and there are no guidelines available which can help the assessment of specific cases. A case of an air gun injury is reported, where the projectile penetrated the abdominal wall and created multiple bowel injury. The complex assessment of all available information (macroscopic and microscopic appearance of entrance wound, types of injuries, CT findings, and crime scene reconstruction) helped to uncover the truth about the circumstances of the injury.

A case of an air gun bullet paranasal sinuses injury in an 11-year-old male

Non-powder firearms, such as BB guns, are considered safer than traditional firearms and are often marketed toward younger demographics as children’s toys. Recent advances in compressed-gas technology have drastically increased the firing power of these types of firearms, which has caused them to be more dangerous and capable of causing severe injury. We report the case of an 11-year-old male admitted for nasal injury caused by a BB gun pellet. The projectile had an unpredictable course: it pierced the skin of his left nasal sidewall, traversed through the soft tissues of the nose to the right nasal cavity violating the posterior septum, and lodged in the right posterior ethmoids adjacent to the posterior attachment of the middle turbinate. The metallic foreign object was successfully retrieved from the right nasal cavity via an endoscopic approach after minimal endoscopic dissection, guided by the preoperative radiologic imaging.

Airgun Wound with Superior Sagittal Sinus Involvement in a Child: Case Report and Review of the Literature

INTRODUCTION

Although still considered quite harmless, nonpowder guns (NPG) may cause severe head injuries in children. We present the case of a depressed skull fracture with superior sagittal sinus involvement following NPG injury. Decision-making and surgical management are discussed, and the current literature concerning NPG-related pediatric head injuries is reviewed.

CASE PRESENTATION

A 4-year-old boy hit by a compressed-air rifle came to our center. CT scan showed a depressed skull fracture of the occipital bone on the midline and intracranial penetration of some fragments of the pellet. CT angiography documented a compression of the superior sagittal sinus without thrombosis. Soon after hospital admission, the patient showed deterioration of the neurological status suggesting intracranial hypertension. Surgery was performed with fracture elevation, removal of metal fragments, and wound debridement. The patient had a full recovery without subsequent neurological deficits.

DISCUSSION/CONCLUSION

Modern airguns may produce severe penetrating head injuries in children. Parents and physicians should be aware of the danger of NPG. Depressed skull fracture and dural venous sinus involvement can occur, and even a stable neurological condition may worsen. In such instances, a thorough preoperative assessment including vascular imaging is mandatory. The surgical risk is not negligible due to the possible injury of the sinus wall and subsequent intraoperative bleeding. This has to be weighted against potential complications of the penetrating injury, such as infection, sinus thrombosis, and intracranial hypertension. Our case suggests that prompt surgical treatment can be a safe and effective option.

Accidentally lodged airgun pellet in maxilla during childhood play retrieved surgically after a decade

Non-powder firearm-related injuries to the head and neck carry the potential risk of significant morbidity and mortality. Such penetrating injuries tend to be under-reported and trivialised especially in children. Air gun pellet injury may cause damage to both soft tissue and bone. Some metals, when embedded in body tissue, can evoke a foreign body reaction or release toxins over time. It therefore becomes imperative to retrieve these pellets. We present one such case of accidental lodgement of airgun pellet in the right maxilla of a 12-year-old boy during childhood play with an airgun which went unnoticed at that time and was surgically retrieved after a decade. The patient had not suffered from any neurosensory deficit.

Patterns of Pediatric Firearm-Related Ocular Trauma in the United States

Importance

Gun violence represents a substantial public health issue, and firearm-related injuries rank second among the causes of injury-related deaths in children aged 0 to 17 years in the United States. Ocular trauma from firearm-related injuries can lead to devastating vision loss, but little is known to date about the specific demographics and characteristics of such injuries in children.

Objective

To evaluate the epidemiologic pattern of pediatric firearm-related ocular injuries.

Design, Setting, and Participants

This retrospective analysis used deidentified data from the National Trauma Data Bank, the largest national registry of hospitalized trauma cases in the United States. The firearm-related ocular injuries (n = 1972) of pediatric patients (defined as those younger than 21 years) hospitalized between January 1, 2008, and December 31, 2014, were analyzed. Statistical analyses were conducted from July 15, 2017, to June 15, 2019.

Exposure

Firearm-related ocular trauma.

Main Outcomes and Measures

Pediatric patients with firearm-related ocular injuries were identified using International Classification of Diseases, Ninth Revision, Clinical Modification codes and external causes of injury codes. Patient demographics (age, sex, and race/ethnicity), type of ocular injury, injury intent, geographic location, length of hospital admission, health insurance status, disposition at discharge, Injury Severity Score (ISS), and Glasgow Coma Scale (GCS) score were collected.

Results

A total of 8715 firearm-related ocular injuries were identified. Of these injuries, 1972 (22.6%) occurred in pediatric patients, most of whom were male (1678 [85.1%]) and adolescents (1037 [52.6%]), with a mean (SD) age of 15.2 (5) years. Common locations of injury were home (761 [38.6%]) and street (490 [24.8%]). Mean (SD) hospital length of stay was 7.6 (12) days, ISS was 16 (13.1), and GCS score was 11 (5.1). The most common types of firearm-related ocular injuries were open wound of the eyeball (820 [41.6%]) and ocular adnexa (502 [25.5%]), orbital injuries or fractures (591 [30.0%]), and contusion of the eye or adnexa (417 [21.1%]). Patients aged 0 to 3 years had greater odds of unintentional injuries (odds ratio [OR], 4.41; 95% CI, 2.51-7.75; P < .001) and injuries occurring at home (OR, 5.39; 95% CI, 2.81-10.38; P < .001), and those aged 19 to 21 years had greater odds of assault injuries (OR, 2.17; 95% CI, 1.77-2.66; P < .001) and injuries occurring on the street (OR, 1.61; 95% CI, 1.3-1.98; P < .001). Black patients had the greatest odds of having injuries with assault intention (OR, 4.53; 95% CI, 3.68-5.59; P < .001), and white patients had the greatest likelihood for self-inflicted injury (OR, 7.1; 95% CI, 5.92-9.51; P < .001). Traumatic brain injury resulted mostly from self-inflicted trauma (OR, 5.99; 95% CI, 4.16-8.63; P < .001), as did visual pathway injuries (OR, 2.86; 95% CI, 1.95-4.20; P < .001). The inpatient mortality rate was 12.2%.

Conclusions and Relevance

This study found that pediatric firearm-related ocular injuries from 2008 through 2014 were predominantly sight-threatening and associated with traumatic brain injury. If the possible risk factors, including sex, age, race/ethnicity, and injury intention, can be confirmed for 2015 through 2019, these findings may be useful in developing strategies to prevent pediatric firearm-related ocular injuries.

Pediatric intracranial arterial injuries by penetrating gunshot wounds: an institutional experience

PURPOSE

Pediatric intracranial injuries due to penetrating gunshot wounds are a rare entity that is often fatal. A subset of patients may experience an intracerebral arterial injury; however, literature on the pediatric population is limited. This study analyzes a large institution's experience with pediatric head gunshot wounds and intracranial arterial injuries.

METHODS

All pediatric patients ≤ 18 years of age who presented to our institution with a penetrating gunshot wound from 2008 to 2018 were retrospectively analyzed.

RESULTS

Thirty-seven patients presented with an intracerebral penetrating gunshot injury. There were 18 deaths (49%) in the cohort. A total of 20 patients (54%) had vascular imaging. Of the remaining 17 patients with no vascular imaging, 13 (35%) died before any vascular studies were obtained. Four (20%) of the 20 patients with vascular imaging experienced an intracerebral arterial injury. Three of these 4 patients died before treatment could be administered. One patient with a firearm injury underwent embolization of a distal middle cerebral artery pseudoaneurysm and was discharged home with a Glasgow Outcome Scale score of 5 on follow-up.

CONCLUSION

Pediatric patients with penetrating intracranial gunshot wounds often die before vascular imaging can be obtained.

Navigation-guided neuroendoscopic removal of an intracranial migratory pellet from the thalamus of a 4-year-old girl

Extraction of a bullet fragment seated in deep brain parenchyma utilizing a neuroendoscope has not been previously reported in the literature. The authors report the case of a 4-year-old patient who presented after a pellet gun injury with a projectile located 6 cm intracranially and lodged within the posterior thalamus and near the posterior limb of the internal capsule. Initial operative repair included repair of a CSF leak with duraplasty, minimal brain debridement, and elevation of a depressed skull fracture. Subsequent CT at 2 months postoperatively revealed migration of the deep intracranial pellet. This finding correlated with intermittent worsening neurological symptoms and signs. A rigid 3-mm neuroendoscope with CT stereotactic navigation was then used to remove the pellet fragment from the thalamus. The patient returned home with alleviation of clinical symptoms and an uneventful postoperative recovery. This case demonstrates that navigation-guided neuroendoscopy can be successfully used to remove projectile fragments from deep brain structures, especially when the migration is along the initial path of the bullet. This technique represents another low-risk curative option in the management of retained bullet fragments in gunshot wound injuries to the head.

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.

Gun-related eye injuries: A primer

Gun-related eye injuries are relatively common in the context of gunshot wounds to the head and neck. Many of the fundamental principles of gunshot wound management apply to the care of these patients, but the complex anatomy and functional relationships of the periocular region do pose special challenges. We provide a focused primer for physicians seeking a more in-depth understanding of gun-related eye injuries and present 3 representative cases outlining the spectrum of pathology, provide a focused review of the relevant ballistics concepts, and discuss the management of injuries to the periocular soft tissues, orbital structures, and globe. We found that good cosmetic and functional results can often be achieved with appropriate early intervention, but visual prognosis may remain guarded despite optimal treatment.

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.

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.

Penetrating head injuries in children due to BB and pellet guns: a poorly recognized public health risk

OBJECT Nonpowder guns, defined as spring- or gas-powered BB or pellet guns, can be dangerous weapons that are often marketed to children. In recent decades, advances in compressed-gas technology have led to a significant increase in the power and muzzle velocity of these weapons. The risk of intracranial injury in children due to nonpowder weapons is poorly documented. METHODS A retrospective review was conducted at 3 institutions studying children 16 years or younger who had intracranial injuries secondary to nonpowder guns. RESULTS The authors reviewed 14 cases of intracranial injury in children from 3 institutions. Eleven (79%) of the 14 children were injured by BB guns, while 3 (21%) were injured by pellet guns. In 10 (71%) children, the injury was accidental. There was 1 recognized assault, but there were no suicide attempts; in the remaining 3 patients, the intention was indeterminate. There were no mortalities among the patients in this series. Ten (71%) of the children required operative intervention, and 6 (43%) were left with permanent neurological injuries, including epilepsy, cognitive deficits, hydrocephalus, diplopia, visual field cut, and blindness. CONCLUSIONS Nonpowder guns are weapons with the ability to penetrate a child's skull and brain. Awareness should be raised among parents, children, and policy makers as to the risk posed by these weapons.

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.

Ballistic parameters of .177 (4.5 mm) caliber plastic-sleeved composite projectiles compared to conventional lead pellets

The capability of conventional air gun lead pellets (diabolo pellets) to cause severe injuries or fatalities even at low kinetic energy levels is well documented in medical literature. Modern composite hunting pellets, usually a metal core (made of steel, lead, zinc, or a zinc and aluminum alloy) encased in a plastic sleeve, are of special forensic and traumatological interest. These projectiles are advertised by the manufacturers to discharge at higher velocities than conventional air gun pellets, thus generating very high tissue-penetrating capabilities. Lack of experimental data on these uncommon air gun projectiles induced this work. Ballistic parameters of 12 different caliber .177 (4.5 mm) composite pellets, discharged from two spring-piston air guns (Weihrauch HW 35, Webley CUB) and three pneumatic air guns (Walther LGR, Walther LG400, Walther LP300), were investigated using a ballistic speed measurement system and compared to a conventional diabolo pellet (RWS Meisterkugel) as reference projectile. Although overall results were inconsistent, for some projectile-weapon combinations (particularly spring-piston air guns), a significant change of the kinetic energy (-53 up to +48 %) to the reference projectile was observed. The data provided in this work may serve as a basis for forensic investigation as well as traumatological diagnosis and treatment of injuries caused by these uncommon projectiles.

Country made scare gun vs. air gun--a comparative study of terminal ballistics using gelatine blocks

Country made scare gun also called as bandook in the vernacular language designed with an intention of scaring away the menacing animals is not only unique and effective but also potentially lethal and has found wide spread usage in the rural parts of India. Here an attempt has been made to study the characteristic features such as physical dimensions, mechanism of action of this weapon and to compare its penetrating ability with that of air gun, whose potential lethality is a well-documented fact, using the ballistic gelatine blocks at various ranges. It is hoped that keeping the existence of such firearms in mind by the forensic experts might help to solve the unexplained and bizarre firearm injuries encountered in day to day practice.

Clinical pattern of pediatric ocular trauma in fast developing country

BACKGROUND

Ocular trauma is a significant problem in pediatric patients. Also, leads to visual loss throughout the world there are no data of pediatric ocular trauma in Arabian Gulf Countries in the current literature.

AIM

To study the epidemiology, mechanism, causes and outcome of serious ocular trauma requiring hospital admission, in children below 16years of age.

STUDY DESIGN

A retrospective cohort study.

SUBJECTS

All pediatric patients (up to 16years of age) presenting with ocular injuries to a tertiary care pediatric ophthalmology and Pediatric Accident Emergency Department 1 January 2005 to 30 December 2009.

METHODS

Each file was studied to find out the demographic data, mechanism and cause of injury. The definitions and classifications of ocular trauma in our study were modified from the Ocular Trauma Classification Group guidelines and Birmingham Eye Trauma Terminology Presenting and final visual acuity were recorded along with details of anterior and posterior segment evaluation.

RESULTS

Hundred and six files of the children admitted to ophthalmology ward with the diagnosis of ocular trauma between 2005 and 2009 were reviewed. Majority were boys (77.4%). The mean age at admission was 6.63years. A higher incidence of ocular trauma was noted in children above 5years than those below (58.5%). Most number of trauma occurred at home (42.5%, n=45) followed by street (35.8% n=34), school (12.3%, n=13), sporting area (5.7%, n=6). Also, eight patients (8.5%) involved in Road Traffic Accidents (RTA). Closed globe injury occurred more frequently than open globe injury (59.4% vs. 40.6%). Initial visual acuity was more than 6/60 in (55.6%) patients of closed globe while in open globe injury was (37.3%). Final visual acuity was more than 6/18 in (82.5%) patients of closed globe injury group and in (63%) patients of open globe injury group. Severe impairment of vision was found in (11.6%) and blindness (4.7%) only in open globe injury group.

CONCLUSION

Most eye injuries in children are preventable so this reflects the importance of health education, adult supervision and application of appropriate measures that is necessary for reducing the incidence and severity of trauma.

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.

Airsoft gun-related ocular injuries: novel findings, ballistics investigation, and histopathologic study

PURPOSE

To describe the ocular injuries related to airsoft gun bullets, investigate the ballistics of airsoft bullets, record real-time impact of the bullets on an eye, and investigate the histopathologic changes within the cornea after being hit by an airsoft gun bullet.

DESIGN

Retrospective, interventional case series and experimental animal study.

METHODS

All consecutive cases of patients with airsoft gun-related ocular injuries during 2006 to 2008 were included in this study. Porcine eyes were used for high-speed video photographs of bullet impacts. Rabbit eyes were used for the histopathologic investigation. All patients were treated in the Department of Ophthalmology at Soroka University Medical Center, Beer-Sheva, Israel. Laboratory investigations were performed at Ben-Gurion University of the Negev, Beer-Sheva, Israel. The main outcome measures were ocular injuries of the patients, ballistics of the airsoft bullets, nature of corneal deformation upon impact, and corneal histopathologic changes after the hit.

RESULTS

Fifty-nine patients with a mean age of 9.8 +/- 3.8 years (range, 2.8 to 26 years) were examined; 49 were male (83.1%). The ocular injuries included hyphema, corneal edema, corneal erosion, traumatic mydriasis, and posterior segment involvement. A novel, "donut" form of corneal erosion was seen and also demonstrated by the histopathologic investigation. Substantial anterior segment deformation was recorded in real-time using the high-speed video camera.

CONCLUSIONS

Airsoft gun injuries affect mainly young men and can be visually threatening. Typical ocular injuries along with a unique form of corneal erosion can be seen.

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.

Should airguns be banned?

In this article, we express concerns regarding the availability of airguns, the injuries that they cause and their abuse as weapons of assault. We wish to stimulate debate on this topic and report a 5-year retrospective analysis of all airgun injuries to the head and neck, presenting to Alder Hey Children's Hospital, Liverpool, from June 1998 to June 2003. We identified 16 patients who suffered such injuries with ages ranging from 5 to 15 years. The majority of cases were violent assaults, which is not in accordance with previous published reports. All of these occurred in public places outside the home. Most incidents occurred through the spring and summer period. Six patients required overnight stay in hospital. Nine patients required operative procedures to remove the airgun pellets. Two patients had serious eye injuries resulting in loss of vision. Two patients had penetrating neck injuries requiring exploration of the wound. The remaining group had either skin-penetrating injuries with lodgement of fragments in subcutaneous tissues or non-skin penetrating injuries. This study highlights serious injuries arising from the abuse of airguns as weapons of assault. Airguns are readily available to people without license. Recent legislation has increased the minimum age at which airguns can be carried in a public place, but we believe that stricter legislation is required to produce a reduction in the number of airgun-related injuries.

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.

Ocular air gun injuries: a one-year surveillance study in the UK and Eire (BOSU). 2001-2002

AIMS

The vulnerability of the eye means that ocular air gun injuries figure prominently in the medical literature. This Study reports the results of the first ocular air gun injury surveillance study.

METHODS

Ocular air gun injuries were reported to the British Ophthalmic Surveillance Unit (BOSU; United Kingdom and Eire) for the period November 2001-December 2002 (13 months). Two questionnaires were used to collect demographic details, circumstances of injury, details of injuries, medical management and outcome.

RESULTS

A total of 105 initial and 99 follow-up questionnaires were returned. Eighty-six ocular air gun injuries occurred during the last 12 months of surveillance yielding a corrected, estimated incidence of 91-115 injuries/year. Injuries were most frequent in August/September, and 90% (95/105) of victims were men with mean age of 17.5 years (74% under 18 years). In all, 40% (32/81) of injuries occurred at home and 53% (43/81) in a public place. 23% (19/84) of injuries were deliberate, 66% (69/104) of injuries were severe and 20% (21/105) resulted in ruptured globes. In all, 54% (48/89) required hospital admission and 41 required surgery. A total of 11% (12/105) of eyes were either enucleated or eviscerated. Final visual acuity was <or=counting fingers in 29% (26/91) but >6/12 (Snellen) in 65% (59/91). Moderate/significant cosmetic deformities were recorded in 10% (8/77) and restricted ocular movements in 5% (4/72).

CONCLUSIONS

Ocular air gun injuries damage sight and leave lasting morbidity. The demographics and circumstances of injury are well documented with access to, and unsupervised use of, air guns, appearing the principal risks for injury.

Delayed intracerebral hemorrhage from an extracranial ball bullet pellet

The evaluation of superficial penetrating injuries to the face and scalp is common in the emergency department. We present a patient who presented with a ball bullet pellet to the forehead with an initially negative computerized tomographic (CT) scan of the head, who represented 18 hours later with nausea, vomiting, and mental status changes. A repeat CT scan of the head revealed intraparenchymal hemorrhage immediately posterior to the site of pellet entry. Upon review, the initial CT scan was limited by scatter artifact. In this case report, we discuss the potential for significant injury with compressed air-driven arms, the limitation of CT in the presence of metallic foreign bodies, and the significant risks associated with pediatric radiation exposure.

An unusual air gun injury to the ethmoid sinus

We report an air gun pellet in the ethmoid sinus. The entrance point was concealed in the conjunctiva of the medial canthus, sparing the eye and skin. The pellet traversed the ethmoid and was stopped by the cribriform plate. It was removed by an endoscopic approach without complications. The literature is reviewed. A high index of suspicion is required to identify penetrating foreign bodies in patients walking in with low-velocity gun injuries.

Air guns: toys or weapons?

Air guns and blank guns may appear relatively harmless at first glance, but they are, in fact, potentially destructive, even lethal, weapons. Approximately 2 to 2.5 million nonpowder firearms are sold annually, and again approximately 12.9 per 100,000 population are treated for such injuries in hospital emergency departments each year in the United States. Unfortunately, these guns are considered to be a toy for children. Therefore, incidents of air gun injuries are gradually increasing. Although such injuries may initially be considered trivial, it may signify severe internal tissue pathologies. These apparently trivial injuries may have catastrophic consequences if unnoticed. In this study, we report 4 cases with head injury due to a shot by these guns. The cases indicate that these people had used the guns belonging to their parents for the purpose of suicide. The cases also show that these machines are not innocent.

Intrauterine penetrating direct fetal head trauma following gunshot injury: a case report and review of the literature

CASE REPORT

An unusual case of an intrauterine penetrating head injury due to a pellet from an airgun is described. A 28-year-old pregnant woman, at term, shot herself intravaginally with a toy BB gun. Following a spontaneous precipitous vaginal delivery, the neonate presented with persistent seizure disorder, meningitis, cerebritis, and a right parietal region scalp swelling. Imaging studies revealed intracranial hemorrhage, and the metallic pellet was adjacent to the right lateral ventricle, which was removed through a parietal craniotomy. Computed tomography of the brain after 1 week demonstrated early abscess formation in the left frontal operculum and a subdural empyema in the posterior fossa. The abscesses were evacuated, and the meningitis was treated vigorously with broad-spectrum antibiotics. Although well for the past 6 years, the child demonstrates significant mental handicap and developmental delay.

DISCUSSION

The pathogenesis, management, and medicolegal issues pertaining to the above case are discussed, and the relevant literature is briefly reviewed.

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 prevention advice in top-selling parenting books

OBJECTIVE

Parenting books are a commonly used source of information on how to keep children and adolescents safe from injuries, the leading cause of death and disability for children aged 1 to 18 years. The content and the quality of the messages contained in these books have not been evaluated formally. The objective of this study was to determine the quantity and the quality of injury prevention messages contained in popular parenting books.

METHODS

Top-selling parenting books for 2 major booksellers were reviewed to determine the presence and the accuracy of injury prevention messages as compared with those recommended by the American Academy of Pediatrics (AAP) through The Injury Prevention Program (TIPP) for younger children, aged 0 to 12 years, and the American Medical Association (AMA) through its Parent Package for the safety of adolescents.

RESULTS

Forty-six parenting books were reviewed, including 41 with messages related to younger children and 19 with messages related to adolescents. These books varied widely with regard to the number of injury prevention messages included. Although some books covered the great majority of TIPP messages for parents of young children, others included very few. In the case of books that address safety for adolescents, no book had more than half of the messages recommended by the AMA. Prevention of burns and motor vehicle injury were the most commonly addressed injury prevention topics in the books focused on younger children, whereas gun safety was the most prevalent injury prevention topic in books that focused on adolescents. Books that were authored by physicians addressed more of the recommended topics and messages than books that were written by authors from other professional backgrounds. The quality of messages was good, ie, consistent with the advice given by the AAP and the AMA. In only a few cases, the parenting books gave injury prevention advice that was inconsistent with recommendations.

CONCLUSIONS

Overall, books on parenting adolescents are less likely to contain injury prevention messages than those that address younger children. However, the most frequent injury prevention messages for parents of adolescents describe strategies to prevent firearm injury, a leading cause of death for children in this age group. More emphasis should be placed on prevention of motor vehicle injuries, especially as relates to adolescents. Pediatricians and primary care physicians need to be aware of the strengths and weaknesses of parenting manuals in providing adequate guidance related to injury prevention.

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.

Penetrating trauma in children

Penetrating injuries account for 10% to 20% of all pediatric trauma admissions at most centers. Gunshot wounds are responsible for the overwhelming majority of penetrating traumatic injuries and have a significantly higher mortality rate than do blunt injury mechanisms. The management of penetrating injuries can be quite challenging and often requires rapid assessment and intervention. Specific management principles are guided by the anatomic location of injury, the determination of trajectory, and the suspected organs injured. Management approaches have been adopted in large part from the more robust adult experience. However, application of these strategies to similar life-threatening injuries in the pediatric population appears appropriate.

Eye injuries in childhood: a retrospective investigation of 88 cases from 1988 to 2000

PURPOSE

To assess the frequency, causes, mechanisms, and functional outcomes of eye injuries in childhood.

METHODS

A retrospective analysis of the hospital files of patients younger than 12 years admitted to the Institute of Ophthalmology of Verona University for eye injuries from January 1, 1988, to December 31, 2000.

RESULTS

Eighty-eight cases of eye injuries (69 [78%] boys, 19 [22%] girls) were identified. The mean age at admission was 7.2 years. The most frequent causes of eye injuries were domestic accidents in patients younger than 6 years (25%) and accidents at play in those older than 6 years (35%). Scissors were the most frequent causative agents in children under 6 and toys, stones, and ball injuries in those over 6. Diagnoses, therapies implemented, ocular complications, and outcomes are reported.

CONCLUSIONS

The major causes of eye injuries in childhood are preventable; thus more adequate adult supervision and educational and legislative measures are necessary and useful in order to reduce prevalence and morbidity of these accidents.

Trans-orbital intra-cranial air gun injury

PURPOSE

To describe a case of trans-orbital intra-cranial air gun injury with a discussion on air gun related morbidity and mortality.

METHODS

Case report and literature review.

RESULTS

The air gun pellet travelled through the orbit without penetrating the globe. It passed into the middle cranial fossa through the superior orbital fissure and lodged in the temporal lobe. The patient was managed conservatively with antibiotics and antiepilectis.

CONCLUSIONS

Air gun design has changed in recent years resulting in an increased morbidity and mortality. Stricter legislation on the sale and use of these weapons needs to be implemented.

Critical care of the head and neck patient

The patient with head and neck disease has several peculiarities that need to be recognized for the treating team to offer optimal care. These arise from the primary disorders (eg, head and neck cancer or injuries) and the morbidity they might cause, the associated comorbidities, and the possible complications of treatment. A team approach involving the surgeon, the intensivist, and other caretaking personnel is essential to achieve high-quality care and ensure the best results possible.