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Trends in pediatric firearm-related injuries over the past 10 years at an urban pediatric hospital
Journal of Pediatric Surgery 50 (2015) 1184–1187
Contents lists available at ScienceDirect
Journal of Pediatric Surgery journal homepage: www.elsevier.com/locate/jpedsurg
Trends in pediatric firearm-related injuries over the past 10 years at an urban pediatric hospital Michelle Veenstra ⁎, Vaishali Patel, Lydia Donoghue, Scott Langenburg Department of Pediatric Surgery, Children’s Hospital of Michigan, 3901 Beaubien Blvd, Detroit, MI 48201, USA
a r t i c l e
i n f o
Article history: Received 2 July 2014 Received in revised form 7 March 2015 Accepted 7 March 2015 Key words: Firearms Gunshot wounds Pediatric Trauma Urban
a b s t r a c t Purpose: Firearm injuries are the second most common cause of trauma deaths in American children. We reviewed gunshot wounds treated at an urban children’s hospital to determine the most likely time for injuries to occur over 10 years. Methods: A retrospective chart review was completed for patients with a firearm injury from January 2003 to December 2012. Patients were excluded if over 17 years or readmitted. Demographics, injury circumstances, interventions, and outcomes were reviewed for 289 patients. Chi square and ANOVA analyses were completed. Alpha was chosen as p b 0.05. Results: Mean age was 12 years, 74% were male and 80% African American. Unintentional injuries occurred in 26% and violence related in 72%. The most common months of injury were August and June, the least common November and October. Unintentional injuries were more likely to occur during the day and violence related injuries were more likely at night (p = 0.01). The incidence was lowest 2008–2010 and highest in 2006 and 2011. Mortality was 3.5%. Conclusions: We noted an increasing incidence of pediatric firearm related injuries in the last two years of the study with over half requiring operative intervention. Most injuries were violence related and occurred in a large city during summer months. © 2015 Elsevier Inc. All rights reserved.
Firearm injuries present a large health risk to the pediatric population. They are the second leading cause of trauma death in this age group and those who survive may have high morbidity, affecting the remainder of their lives [1,2]. The United States has the highest rate of firearm-related deaths among high-income countries [2]. In 2008, there were 14,831 visits to Emergency Departments in the United States for pediatric firearm injuries [3]. In 2010, there were a total of 2711 deaths by firearm, averaging 7 deaths per day, and 15,576 injuries from firearms in the pediatric population [1,4]. In addition, there is a large economic burden to society in response to these injuries [5,6]. In 2009, an average of 20 pediatric patients were admitted to a hospital daily with firearm injuries and the estimated direct cost of managing these injuries was $146,710,029 [7]. Many studies have evaluated pediatric firearm injuries in the past 20 years to identify patients who may be at risk. These studies have evaluated laws, firearm possession, and demographics to develop prevention strategies [8–12]. Few studies have looked at the months or time of day when firearm injuries are most likely to occur. Studies of pediatric and adult patients have found that weekends are the most likely days to be shot [7,13–15]. Children under age 14 had no month of increased likelihood while patients ages 15–19 had a peak in August ⁎ Corresponding author at: Children's Hospital of Michigan, Department of Pediatric Surgery, 3901 Beaubien Blvd, Detroit, MI 48201, USA. Tel.: +1 313 745 5839; fax: +1 313 966 7696. E-mail address: [email protected] (M. Veenstra). http://dx.doi.org/10.1016/j.jpedsurg.2015.03.042 0022-3468/© 2015 Elsevier Inc. All rights reserved.
in the 1990s while an analysis in Alabama found an increased incidence the second half of the year [13,16]. Unintentional pediatric injuries peaked between 4 and 5 pm and assaults peaked between 8 and 9 pm in a review of the National Trauma Database in the early 1990s [14]. The primary objective of this study was to determine the months and time of day when pediatric patients are more likely to sustain a firearm injury. The secondary objectives were to evaluate demographics and trends in the number of firearm injuries and operative interventions. 1. Methods After obtaining IRB approval (#093513MP4E), a review of our trauma database identified all patients presenting to Children’s Hospital of Michigan after a firearm injury between January 2003 and December 2012. Patients were identified through a hospital specific trauma database and included powder and nonpowder firearm injuries. A single author retrospectively reviewed all charts. All patients presenting with a firearm injury were included. Exclusion criteria were an age of 18 years or older, readmission from the same injury, or injury from the gun chamber. There were 306 patients identified in the database, of which 17 were excluded; 14 patients were 18 years of age or older, 1 patient obtained an injury from the gun chamber while loading a gun, and 2 patients were readmitted for pain and the readmission visit was excluded. The remaining 289 charts were reviewed and data were obtained from the Emergency Department, trauma team, and EMS documentation when available. Data abstracted included demographics (patient age,
M. Veenstra et al. / Journal of Pediatric Surgery 50 (2015) 1184–1187
gender, race, zip code), details around the incident (intent of injury, shooter, month and year of injury, time of injury, and city of injury), injury details (anatomic location(s), gun type), and management (procedures and operative intervention, radiographic imaging, admission status, length of stay, mortality, and disposition). The intent of injury categories included violence related, unintentional, and self-inflicted injuries. The violence related category included all assaults and drive-by shootings. Unintentional shootings were the result of a child playing with a gun and accidentally sustaining an injury whether to himself or somebody else and self-inflicted injuries included all suicides and suicide attempts. Details surrounding the incident were reviewed including year, month, time, and city of the shooting. Time of injury was evaluated in 4-h intervals starting at midnight. The injuries sustained and details of each hospital stay including admission status, intensive care admission, management, length of stay, and disposition were reviewed. Injury locations included head, neck, chest, back, abdomen/pelvis, upper extremity, and lower extremity. Multiple sites of injury were also recorded. The need for operative intervention within 24 h and for delayed intervention was recorded. Length of hospital stay and disposition at discharge were also reviewed. Patients with missing data were removed from each analysis. Statistical analysis was completed with SPSS version 21 (© Copyright IBM Corporation 2011 IBM Corporation Route 100 Somers, NY 10589) with a statistician. A p-value b0.05 was defined as statistically significant. Continuous variables were analyzed using ANOVA with Bonferroni significance, categorical variable were analyzed using Chi square, and monthly incidence was analyzed using Z-scores. 2. Results
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Fig. 1 shows the number of firearm related injuries per year. There was a decrease in incidence from 2007 to 2010, with an increase in the last two years of the study. Seventy-three patients (25%) were discharged home from the Emergency Department, 153 (53%) were admitted to the surgical floor, and 64 (22%) were admitted to the Pediatric Intensive Care Unit. The mean length of stay was 5 days (range 0–52 days). A longer length of stay was seen in females (p = 0.03) and patients with self-inflicted wounds (p b 0.01). Fig. 2 shows the most common month for injury was August (12.8%) followed by June (11.4%). The least common months were November (3.5%) and October (5.9%) (p b 0.01). Patients were more likely to be injured in the summer months (p b 0.05). Most injuries occurred in the evening hours (Fig. 3). The time of injury (N = 245) associated with the intent of injury with 75% (3) of self-inflicted wounds between 12 pm and 4 pm, 90% (57) of unintentional injuries from 12 pm to 12 am, and 80% (142) of violence-related injuries between 4 pm and 4 am (Fig. 3). Location of injury and those requiring operative intervention are seen in Fig. 4. Thirty-eight patients had injuries to multiple sites, with 10 presenting with three or more sites of injury. Multiple sites of injury were most common with violence related injuries (p = 0.03). Patients with violence related injuries had more abdomen, pelvis, back, and extremities injuries while patients with unintentional injuries were more likely to sustain head injuries and all self-inflicted injuries were to the head (p b 0.01). Surgical intervention was needed in 175 patients (61%). Of these patients, 138 (48%) had surgery within 24 h of injury, 37 (13%) underwent delayed operation, and 22 (8%) required multiple operations. Operative intervention was not associated with intent of injury (p = 0.28), age (p = 0.21), or multiple sites of injury (p = 0.89). The number of patients requiring operative intervention decreased throughout the years (p = 0.03) (Fig. 1).
The age range was 7 weeks to 17 years with a mean of 11.8 years. There were 214 male patients (74%) and 75 female patients (26%). Males were more likely to have an unintentional (30%) or selfinflicted injury (2%) while 83% of female injuries were violencerelated (p = 0.04). The most common race was African American (80%), followed by Caucasian (11%), and Hispanic (6%). The remaining 3% were unknown, multiple, or other. African American and Hispanic children had more violence-related injuries while most Caucasians had unintentional or self-inflicted wounds (p b 0.01). There were 208 patients (72%) injured due to violence. There were 75 unintentional shootings (26%) and five self-inflicted wounds (1.7%). In the cases where a shooter was identified (N = 234), 146 cases (51%) were identified as a stranger, 54 (23%) as a family member, friend, or neighbor, and 35 (15%) were obtained by a self-inflicted wound, intentional or unintentional. Mortality was 3.5% (10), five patients were pronounced dead in the Emergency Department and five died during treatment. Mortality was associated with location of injury with 90% having a head injury and 10% with a chest injury (p b 0.01).
The most commonly injured patient was an African American male in the city, congruent with other studies in urban areas [7,10,15–17]. We did have a larger percent of violence-related injuries compared to some studies but consistent with national numbers [2,10,16–18]. Females were more likely to have an injury from violence than males, who had more unintentional and self-inflicted injuries. This is possibly due to fewer unintentional and self-inflicted injuries in females because they may be less likely to play with firearms or use firearms for suicide attempts. The mortality rate when a patient reached our Emergency Department was 3.5%, however it is likely that many patients who died never made it to the hospital or presented to a different hospital. This mortality rate is lower than reported pediatric firearm mortality rates in similar studies [3,10,15,16,18]. We did not find a higher mortality rate in younger children as reported by Senger et al [16].
Fig. 1. Number of firearm related injuries and those requiring operative intervention. There was a recent increase in the number of firearm related injuries seen in our pediatric hospital. Fewer patients are requiring operative intervention.
Fig. 2. Number of firearm related injuries by month and intent. Over 40% of injuries occurred during summer months.
3. Discussion
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M. Veenstra et al. / Journal of Pediatric Surgery 50 (2015) 1184–1187
Fig. 3. Time of injury is associated with intent (p = 0.01). Self-inflicted injuries occurred earlier in the day, followed by unintentional and then violence-related injuries overnight.
There was an association between the time of injury and injury intent. The greatest number of injuries was violence-related and occurred between 4 pm and 4 am, consistent with other studies [3,7,15]. This information should be used to focus prevention programs and discussion regarding prevention on afternoon and evening hours. It is clear that children are more likely to be unintentionally shot by a firearm in the evening hours after school and in violence related events during the night. A child is more likely to have a firearm injury in the summer in Detroit, particularly June and August, with the lowest incidence in November and October. July was the most common month for injury in Alabama, but there were also more injuries in the end of the year in that same study [16]. The difference in the incidence in later months of the year could be due to colder weather in Michigan compared to Alabama during the winter. A national review in the 1990s found no peak month for children under the age of 14, but a peak in August for teenagers [13]. More children are outside during summer months and weekends and more likely to be unintentionally involved in violent or unintentional shootings. This information can be used to develop preventive summer or weekend programs that provide children a safe, observed environment. Currently, there are many after school, weekend, and summer programs available, however none targets firearm injury prevention. It may be more effective to focus education for parents and children in the spring and summer, when children are most likely to discover and play with guns while unsupervised and not at school. The differences seen between studies reinforce that preventive strategies should be based on data from local areas to create the best prevention programs for each city. Nationally, the incidence of firearm injuries has been steadily decreasing until 2010 [2,6], but institution specific reports have shown increases after decreasing in the 1990s [15]. At our institution, there was an increase in injuries over the last two years of this study. Despite this, we found that the number of patients undergoing surgical intervention for firearm injuries is decreasing. The operative rate of 61% in this study reflects patients who underwent an operation at any point
during the study period, however only 48% of patients had an operation within 24 h of presentation. This is larger than the 17%–32% reported in similar studies evaluating intervention at initial presentation [15,16]. Non-operative management of blunt injuries is widely accepted and in the past twenty years non-operative management of penetrating injuries has been discussed in both adult and pediatric populations [19–22]. There is a high rate of solid organ injury in blunt trauma to the abdomen while firearm and other penetrating injuries often injure hollow organs, requiring operative management [20]. These studies are largely patients with stab wounds but include some firearm injuries and base non-operative management on clinical exam findings suggesting lack of major injury and hemodynamic stability. Velmahos et al. evaluated a large group of adult patients with abdominal gunshot wounds and found that one third of patients with anterior abdominal wounds and two thirds of posterior abdominal gunshot wounds can be managed non-operatively [19]. We had one patient with a splenic laceration from a nonpowder firearm that was managed nonoperatively. The majority of non-operative management in this study was extremity and superficial wounds. Many patients discharged from the Emergency Department in the later years of the study did not return for foreign body removal or may have followed up at another institution leading to a false trend. A study of children with retained bullets found that 22% had a complication while 13% required removal, regardless of the body area injured [21]. This study also found 13% of patients undergoing delayed operation, many for retained bullets. We did not find that increased use of imaging or less severe injuries were associated with the increase in non-operative management. There were no major changes in gun laws during the study period. Michigan requires a person to be 18 years old and register all guns except long guns. Permits are required for concealed weapons and carrying weapons in cars and open carry is allowed. Michigan does have a stand-your-ground law and requires that gunlocks be provided with a gun sale, however there is no requirement for safe storage in the home. Multiple studies have shown a benefit to storage of firearms locked as well as educating parents and distributing gunlocks [1,2,10]. Laws requiring safe storage of firearms have resulted in a decrease of firearm related suicides, but laws to restrict the sale of firearms have not had the same effect, possibly due to the high rate of illegally obtaining firearms [2]. There are many limitations to this study, most inherent to a retrospective chart review. Some patients’ charts were missing information and the information included required accurate reporting from the patients. We did not review police data around these injuries. There is a selection bias as the hospital is a pediatric level one trauma center and many patients were transferred after initial evaluation at an outside hospital. Data from other hospitals in the area, including mortality, were not included. In addition, these data were obtained from one hospital in one city and may not represent data in other areas of the country. 4. Conclusions Firearm related injuries are a large public health problem in the pediatric population. Injuries are most common in the summer months and least common in November. Based on these data, preventive programs focusing on the summer months and evening hours would be of benefit. We did see a recent increase in the number of firearm related injuries presenting to our children’s hospital with a concomitant trend toward non-operative management. Despite national attention and changes in laws and prevention strategies, firearm injuries continue to cause significant morbidity and mortality to the pediatric population. References
Fig. 4. Location of injury and number requiring operative intervention. The most common location of injury was the head and extremity with the highest percentage of operative intervention occurring in head and abdomen/pelvis injuries.
[1] Nance ML, Krummel TM, Oldham KT. Trauma Committee of the American Pediatric Surgical Association. Firearm injuries and children: a policy statement of the American Pediatric Surgical Association. J Am Chem Soc 2013;217(5):940–6.
M. Veenstra et al. / Journal of Pediatric Surgery 50 (2015) 1184–1187 [2] Council on Injury, Violence, and Poison prevention executive committee. Firearmrelated injuries affecting the pediatric population. Pediatrics 2012;130:e1416–23. [3] Allareddy V, Nalliah RP, Rampa S, et al. Firearm related injuries amongst children: estimates from the nationwide emergency department sample. Injury 2012;43:2052–4. [4] Palfrey JS, Palfrey S. Preventing gun deaths in children. N Engl J Med 2013;368(5): 401–3. [5] Eber GB, Annest JL, Mercy JA, et al. Nonfatal and fatal firearm-related injuries among children aged 14 years and younger: United States 1993–2000. Pediatrics 2004;113: 1686–92. [6] Lee J, Quraishi SA, Bhatnagar S, et al. The economic cost of firearm-related injuries in the United States from 2006 to 2010. Surgery 2014;155:894–8. [7] Leventhal JM, Gaither JR, Sege R. Hospitalizations due to firearm injuries in children and adolescents. Pediatrics 2014;133:219–25. [8] Carter PM, Walton MA, Newton MF, et al. Firearm possession among adolescents presenting to an urban emergency department for assault. Pediatrics 2013;132:213–21. [9] Barkin SL, Finch SA, Ip EH, et al. Is office-based counseling about media use, timeouts, and firearm storage effective? Results from a randomized, controlled trial. Pediatrics 2008;122:e15–25. [10] Lee J, Moriary KP, Tashjian DB, et al. Guns and states: pediatric firearm injury. J Trauma Acute Care Surg 2013;75(1):50–3. [11] Safavi A, Rhee P, Pandit V, et al. Children are safer in states with strict firearm laws: a National Inpatient Sample study. J Trauma Acute Care Surg 2013;75:50–3. [12] Srinivasan S, Mannix R, Lee LK. Epidemiology of paediatric firearm injuries in the USA, 2001–2010. Arch Dis Child 2014;99:331–5.
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[13] Loder RT. Temporal variation in United States firearm injuries 1993–2008: results from a national data base. J Inj Violence Res 2014;6:1–15. [14] Li G, Baker SP, DiScala C, et al. Factors associated with the intent of firearm-related injuries in pediatric trauma patients. Arch Pediatr Adolesc Med 1996;150(11): 1160–5. [15] Davis JS, Castilla DM, Schulman CI, et al. Twenty years of pediatric gunshot wounds: an urban trauma center’s experience. J Surg Res 2013:e1–5. [16] Senger C, Keijzer R, Smith G, et al. Pediatric firearm injuries: a 10-year single-center experience of 194 patients. J Pediatr Surg 2011;46:927–32. [17] Martin CA, Unni P, Landman MP, et al. Race disparities in firearm injuries and outcomes in Tennessee children. J Pediatr Surg 2012;47:1196–203. [18] Hendry PL, Suen A, Kalynych CJ, et al. A 6-year retrospective review of pediatric firearm injuries: do patients b14 years of age differ from those 15–18 years of age? J Trauma Acute Care Surg 2014;77:S41–5. [19] Velmahos GC, Demetriades D, Toutouzas KG, et al. Selective nonoperative management of 1,856 patients with abdominal gunshot wounds: should routine laparotomy still be the standard of care? Ann Surg 2001;234:395–403. [20] Cigdem MK, Abdurrahman O, Siga M, et al. Selective nonoperative management of penetrating abdominal injuries in children. J Trauma 2009;67:1284–7. [21] Mazotas IG, Hamilton NA, McCubbins MA, et al. The long-term outcome of retained foreign bodies in pediatric gunshot wounds. J Trauma Nurs 2012;19:240–5. [22] Demetriades D, Hadjizacharia P, Constantinou C, et al. Selective nonoperative management of pendtrating abdominal solid organ injuries. Ann Surg 2006;244: 620–8.
Contents lists available at ScienceDirect
Journal of Pediatric Surgery journal homepage: www.elsevier.com/locate/jpedsurg
Trends in pediatric firearm-related injuries over the past 10 years at an urban pediatric hospital Michelle Veenstra ⁎, Vaishali Patel, Lydia Donoghue, Scott Langenburg Department of Pediatric Surgery, Children’s Hospital of Michigan, 3901 Beaubien Blvd, Detroit, MI 48201, USA
a r t i c l e
i n f o
Article history: Received 2 July 2014 Received in revised form 7 March 2015 Accepted 7 March 2015 Key words: Firearms Gunshot wounds Pediatric Trauma Urban
a b s t r a c t Purpose: Firearm injuries are the second most common cause of trauma deaths in American children. We reviewed gunshot wounds treated at an urban children’s hospital to determine the most likely time for injuries to occur over 10 years. Methods: A retrospective chart review was completed for patients with a firearm injury from January 2003 to December 2012. Patients were excluded if over 17 years or readmitted. Demographics, injury circumstances, interventions, and outcomes were reviewed for 289 patients. Chi square and ANOVA analyses were completed. Alpha was chosen as p b 0.05. Results: Mean age was 12 years, 74% were male and 80% African American. Unintentional injuries occurred in 26% and violence related in 72%. The most common months of injury were August and June, the least common November and October. Unintentional injuries were more likely to occur during the day and violence related injuries were more likely at night (p = 0.01). The incidence was lowest 2008–2010 and highest in 2006 and 2011. Mortality was 3.5%. Conclusions: We noted an increasing incidence of pediatric firearm related injuries in the last two years of the study with over half requiring operative intervention. Most injuries were violence related and occurred in a large city during summer months. © 2015 Elsevier Inc. All rights reserved.
Firearm injuries present a large health risk to the pediatric population. They are the second leading cause of trauma death in this age group and those who survive may have high morbidity, affecting the remainder of their lives [1,2]. The United States has the highest rate of firearm-related deaths among high-income countries [2]. In 2008, there were 14,831 visits to Emergency Departments in the United States for pediatric firearm injuries [3]. In 2010, there were a total of 2711 deaths by firearm, averaging 7 deaths per day, and 15,576 injuries from firearms in the pediatric population [1,4]. In addition, there is a large economic burden to society in response to these injuries [5,6]. In 2009, an average of 20 pediatric patients were admitted to a hospital daily with firearm injuries and the estimated direct cost of managing these injuries was $146,710,029 [7]. Many studies have evaluated pediatric firearm injuries in the past 20 years to identify patients who may be at risk. These studies have evaluated laws, firearm possession, and demographics to develop prevention strategies [8–12]. Few studies have looked at the months or time of day when firearm injuries are most likely to occur. Studies of pediatric and adult patients have found that weekends are the most likely days to be shot [7,13–15]. Children under age 14 had no month of increased likelihood while patients ages 15–19 had a peak in August ⁎ Corresponding author at: Children's Hospital of Michigan, Department of Pediatric Surgery, 3901 Beaubien Blvd, Detroit, MI 48201, USA. Tel.: +1 313 745 5839; fax: +1 313 966 7696. E-mail address: [email protected] (M. Veenstra). http://dx.doi.org/10.1016/j.jpedsurg.2015.03.042 0022-3468/© 2015 Elsevier Inc. All rights reserved.
in the 1990s while an analysis in Alabama found an increased incidence the second half of the year [13,16]. Unintentional pediatric injuries peaked between 4 and 5 pm and assaults peaked between 8 and 9 pm in a review of the National Trauma Database in the early 1990s [14]. The primary objective of this study was to determine the months and time of day when pediatric patients are more likely to sustain a firearm injury. The secondary objectives were to evaluate demographics and trends in the number of firearm injuries and operative interventions. 1. Methods After obtaining IRB approval (#093513MP4E), a review of our trauma database identified all patients presenting to Children’s Hospital of Michigan after a firearm injury between January 2003 and December 2012. Patients were identified through a hospital specific trauma database and included powder and nonpowder firearm injuries. A single author retrospectively reviewed all charts. All patients presenting with a firearm injury were included. Exclusion criteria were an age of 18 years or older, readmission from the same injury, or injury from the gun chamber. There were 306 patients identified in the database, of which 17 were excluded; 14 patients were 18 years of age or older, 1 patient obtained an injury from the gun chamber while loading a gun, and 2 patients were readmitted for pain and the readmission visit was excluded. The remaining 289 charts were reviewed and data were obtained from the Emergency Department, trauma team, and EMS documentation when available. Data abstracted included demographics (patient age,
M. Veenstra et al. / Journal of Pediatric Surgery 50 (2015) 1184–1187
gender, race, zip code), details around the incident (intent of injury, shooter, month and year of injury, time of injury, and city of injury), injury details (anatomic location(s), gun type), and management (procedures and operative intervention, radiographic imaging, admission status, length of stay, mortality, and disposition). The intent of injury categories included violence related, unintentional, and self-inflicted injuries. The violence related category included all assaults and drive-by shootings. Unintentional shootings were the result of a child playing with a gun and accidentally sustaining an injury whether to himself or somebody else and self-inflicted injuries included all suicides and suicide attempts. Details surrounding the incident were reviewed including year, month, time, and city of the shooting. Time of injury was evaluated in 4-h intervals starting at midnight. The injuries sustained and details of each hospital stay including admission status, intensive care admission, management, length of stay, and disposition were reviewed. Injury locations included head, neck, chest, back, abdomen/pelvis, upper extremity, and lower extremity. Multiple sites of injury were also recorded. The need for operative intervention within 24 h and for delayed intervention was recorded. Length of hospital stay and disposition at discharge were also reviewed. Patients with missing data were removed from each analysis. Statistical analysis was completed with SPSS version 21 (© Copyright IBM Corporation 2011 IBM Corporation Route 100 Somers, NY 10589) with a statistician. A p-value b0.05 was defined as statistically significant. Continuous variables were analyzed using ANOVA with Bonferroni significance, categorical variable were analyzed using Chi square, and monthly incidence was analyzed using Z-scores. 2. Results
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Fig. 1 shows the number of firearm related injuries per year. There was a decrease in incidence from 2007 to 2010, with an increase in the last two years of the study. Seventy-three patients (25%) were discharged home from the Emergency Department, 153 (53%) were admitted to the surgical floor, and 64 (22%) were admitted to the Pediatric Intensive Care Unit. The mean length of stay was 5 days (range 0–52 days). A longer length of stay was seen in females (p = 0.03) and patients with self-inflicted wounds (p b 0.01). Fig. 2 shows the most common month for injury was August (12.8%) followed by June (11.4%). The least common months were November (3.5%) and October (5.9%) (p b 0.01). Patients were more likely to be injured in the summer months (p b 0.05). Most injuries occurred in the evening hours (Fig. 3). The time of injury (N = 245) associated with the intent of injury with 75% (3) of self-inflicted wounds between 12 pm and 4 pm, 90% (57) of unintentional injuries from 12 pm to 12 am, and 80% (142) of violence-related injuries between 4 pm and 4 am (Fig. 3). Location of injury and those requiring operative intervention are seen in Fig. 4. Thirty-eight patients had injuries to multiple sites, with 10 presenting with three or more sites of injury. Multiple sites of injury were most common with violence related injuries (p = 0.03). Patients with violence related injuries had more abdomen, pelvis, back, and extremities injuries while patients with unintentional injuries were more likely to sustain head injuries and all self-inflicted injuries were to the head (p b 0.01). Surgical intervention was needed in 175 patients (61%). Of these patients, 138 (48%) had surgery within 24 h of injury, 37 (13%) underwent delayed operation, and 22 (8%) required multiple operations. Operative intervention was not associated with intent of injury (p = 0.28), age (p = 0.21), or multiple sites of injury (p = 0.89). The number of patients requiring operative intervention decreased throughout the years (p = 0.03) (Fig. 1).
The age range was 7 weeks to 17 years with a mean of 11.8 years. There were 214 male patients (74%) and 75 female patients (26%). Males were more likely to have an unintentional (30%) or selfinflicted injury (2%) while 83% of female injuries were violencerelated (p = 0.04). The most common race was African American (80%), followed by Caucasian (11%), and Hispanic (6%). The remaining 3% were unknown, multiple, or other. African American and Hispanic children had more violence-related injuries while most Caucasians had unintentional or self-inflicted wounds (p b 0.01). There were 208 patients (72%) injured due to violence. There were 75 unintentional shootings (26%) and five self-inflicted wounds (1.7%). In the cases where a shooter was identified (N = 234), 146 cases (51%) were identified as a stranger, 54 (23%) as a family member, friend, or neighbor, and 35 (15%) were obtained by a self-inflicted wound, intentional or unintentional. Mortality was 3.5% (10), five patients were pronounced dead in the Emergency Department and five died during treatment. Mortality was associated with location of injury with 90% having a head injury and 10% with a chest injury (p b 0.01).
The most commonly injured patient was an African American male in the city, congruent with other studies in urban areas [7,10,15–17]. We did have a larger percent of violence-related injuries compared to some studies but consistent with national numbers [2,10,16–18]. Females were more likely to have an injury from violence than males, who had more unintentional and self-inflicted injuries. This is possibly due to fewer unintentional and self-inflicted injuries in females because they may be less likely to play with firearms or use firearms for suicide attempts. The mortality rate when a patient reached our Emergency Department was 3.5%, however it is likely that many patients who died never made it to the hospital or presented to a different hospital. This mortality rate is lower than reported pediatric firearm mortality rates in similar studies [3,10,15,16,18]. We did not find a higher mortality rate in younger children as reported by Senger et al [16].
Fig. 1. Number of firearm related injuries and those requiring operative intervention. There was a recent increase in the number of firearm related injuries seen in our pediatric hospital. Fewer patients are requiring operative intervention.
Fig. 2. Number of firearm related injuries by month and intent. Over 40% of injuries occurred during summer months.
3. Discussion
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M. Veenstra et al. / Journal of Pediatric Surgery 50 (2015) 1184–1187
Fig. 3. Time of injury is associated with intent (p = 0.01). Self-inflicted injuries occurred earlier in the day, followed by unintentional and then violence-related injuries overnight.
There was an association between the time of injury and injury intent. The greatest number of injuries was violence-related and occurred between 4 pm and 4 am, consistent with other studies [3,7,15]. This information should be used to focus prevention programs and discussion regarding prevention on afternoon and evening hours. It is clear that children are more likely to be unintentionally shot by a firearm in the evening hours after school and in violence related events during the night. A child is more likely to have a firearm injury in the summer in Detroit, particularly June and August, with the lowest incidence in November and October. July was the most common month for injury in Alabama, but there were also more injuries in the end of the year in that same study [16]. The difference in the incidence in later months of the year could be due to colder weather in Michigan compared to Alabama during the winter. A national review in the 1990s found no peak month for children under the age of 14, but a peak in August for teenagers [13]. More children are outside during summer months and weekends and more likely to be unintentionally involved in violent or unintentional shootings. This information can be used to develop preventive summer or weekend programs that provide children a safe, observed environment. Currently, there are many after school, weekend, and summer programs available, however none targets firearm injury prevention. It may be more effective to focus education for parents and children in the spring and summer, when children are most likely to discover and play with guns while unsupervised and not at school. The differences seen between studies reinforce that preventive strategies should be based on data from local areas to create the best prevention programs for each city. Nationally, the incidence of firearm injuries has been steadily decreasing until 2010 [2,6], but institution specific reports have shown increases after decreasing in the 1990s [15]. At our institution, there was an increase in injuries over the last two years of this study. Despite this, we found that the number of patients undergoing surgical intervention for firearm injuries is decreasing. The operative rate of 61% in this study reflects patients who underwent an operation at any point
during the study period, however only 48% of patients had an operation within 24 h of presentation. This is larger than the 17%–32% reported in similar studies evaluating intervention at initial presentation [15,16]. Non-operative management of blunt injuries is widely accepted and in the past twenty years non-operative management of penetrating injuries has been discussed in both adult and pediatric populations [19–22]. There is a high rate of solid organ injury in blunt trauma to the abdomen while firearm and other penetrating injuries often injure hollow organs, requiring operative management [20]. These studies are largely patients with stab wounds but include some firearm injuries and base non-operative management on clinical exam findings suggesting lack of major injury and hemodynamic stability. Velmahos et al. evaluated a large group of adult patients with abdominal gunshot wounds and found that one third of patients with anterior abdominal wounds and two thirds of posterior abdominal gunshot wounds can be managed non-operatively [19]. We had one patient with a splenic laceration from a nonpowder firearm that was managed nonoperatively. The majority of non-operative management in this study was extremity and superficial wounds. Many patients discharged from the Emergency Department in the later years of the study did not return for foreign body removal or may have followed up at another institution leading to a false trend. A study of children with retained bullets found that 22% had a complication while 13% required removal, regardless of the body area injured [21]. This study also found 13% of patients undergoing delayed operation, many for retained bullets. We did not find that increased use of imaging or less severe injuries were associated with the increase in non-operative management. There were no major changes in gun laws during the study period. Michigan requires a person to be 18 years old and register all guns except long guns. Permits are required for concealed weapons and carrying weapons in cars and open carry is allowed. Michigan does have a stand-your-ground law and requires that gunlocks be provided with a gun sale, however there is no requirement for safe storage in the home. Multiple studies have shown a benefit to storage of firearms locked as well as educating parents and distributing gunlocks [1,2,10]. Laws requiring safe storage of firearms have resulted in a decrease of firearm related suicides, but laws to restrict the sale of firearms have not had the same effect, possibly due to the high rate of illegally obtaining firearms [2]. There are many limitations to this study, most inherent to a retrospective chart review. Some patients’ charts were missing information and the information included required accurate reporting from the patients. We did not review police data around these injuries. There is a selection bias as the hospital is a pediatric level one trauma center and many patients were transferred after initial evaluation at an outside hospital. Data from other hospitals in the area, including mortality, were not included. In addition, these data were obtained from one hospital in one city and may not represent data in other areas of the country. 4. Conclusions Firearm related injuries are a large public health problem in the pediatric population. Injuries are most common in the summer months and least common in November. Based on these data, preventive programs focusing on the summer months and evening hours would be of benefit. We did see a recent increase in the number of firearm related injuries presenting to our children’s hospital with a concomitant trend toward non-operative management. Despite national attention and changes in laws and prevention strategies, firearm injuries continue to cause significant morbidity and mortality to the pediatric population. References
Fig. 4. Location of injury and number requiring operative intervention. The most common location of injury was the head and extremity with the highest percentage of operative intervention occurring in head and abdomen/pelvis injuries.
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