- Email: [email protected]
Air Guns: A Contemporary Review of Injuries at Six Pediatric Level I Trauma Centers
j o u r n a l o f s u r g i c a l r e s e a r c h a p r i l 2 0 2 0 ( 2 4 8 ) 1 e6
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.JournalofSurgicalResearch.com
Air Guns: A Contemporary Review of Injuries at Six Pediatric Level I Trauma Centers Nadja Apelt, MD,a Cynthia Greenwell, BSN, RN,b,* Jefferson Tweed, MS,b David M. Notrica, MD,c R Todd Maxson, MD,d Nilda M. Garcia, MD,e Karla Lawson, PhD, MPH,f James W. Eubanks III, MD,g Robert W. Letton Jr., MD,h,1 and David Schindel, MDa a
Surgery Department, Children’s Medical Center, The Flagship of Children’s HealthSM, Dallas, Texas Tauma Department, Children’s Medical Center, The Flagship of Children’s HealthSM, Dallas, Texas c Surgery Department, Phoenix Children’s Hospital, Phoenix, Arizona d Surgery Department, Arkansas Children’s Hospital, Little Rock, Arkansas e Surgery Department, Dell Children’s Medical Center, Austin, Texas f Trauma Department, Dell Children’s Medical Center, Austin, Texas g Surgery Department, Le Bonheur Children’s Hospital, Memphis, Tennessee h Surgery Department, The Children’s Hospital at OU Medical Center, Oklahoma City, Oklahoma b
article info
abstract
Article history:
Background: Studies spanning the last three decades demonstrated the injury causing
Received 16 August 2019
capability of air gun (AG) projectiles. Recent studies have suggested the impact and inci-
Received in revised form
dence of these injuries may be declining because of edcational efforts. We hypothesize that
22 October 2019
injuries in the pediatric population resulting from AGs remain a significant health concern.
Accepted 3 November 2019
Methods: A retrospective review (1/1/2007 to 12/31/2016), of AG-injured children < 19 years
Available online xxx
old, was performed across six level I Pediatric Trauma Centers, part of the ATOMAC research consortium. AG injuries were defined as injuries sustained by ball-bearing or
Keywords:
pellet air-powered guns. Paint ball and soft foam AGs were excluded. Following institu-
Pediatric
tional review board approval, patients were identified by ICD code from the trauma reg-
Air gun
istry. Included were demographic data, injury severity scores, length of stay (LOS), outcome
Pellet gun
at discharge, and overall cost of admission. Descriptive statistics and parametric tests were
Traumatic injury
employed.
Firearms
Results: A total of 499 patients sustained injuries. Mean age 9.5 (4.0) y; 81% of victims were
BB gun
male; all survived to hospital discharge. 30% (n ¼ 151) required operative intervention. Hospital LOS was 2.3 (2.2) d; with mean cost of $23,756 ($34,441). Injury severity score mean of 3.7 (4.6) on admission. Over 40% of the injuries to the head/thorax that were severe (AIS 3) required operative intervention (P < 0.001). Conclusions: AG injuries to the head or thorax seen at trauma centers were likely to require operative management. While no fatalities occurred, the cost was substantial. This study demonstrates pediatric injuries resulting from AG projectiles remain a significant health concern. ª 2019 Elsevier Inc. All rights reserved.
* Corresponding author. Children’s Medical Center, 1935 Medical District Dr, Mail slot D1416, Dallas, TX, 75235. Tel.:þ913-620-2626; fax: 214-456-8652. E-mail address: [email protected] (C. Greenwell). 1 present address: Department of Surgery, Nemours Children’s Specialty Care, 807 Children’s Way, Jacksonville, FL 32207. 0022-4804/$ e see front matter ª 2019 Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.jss.2019.11.002
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j o u r n a l o f s u r g i c a l r e s e a r c h a p r i l 2 0 2 0 ( 2 4 8 ) 1 e6
Introduction Air guns (AGs) expel projectiles, typically a ball-bearing (BB) or lead pellet, via the force of compressed air or CO2. This differentiates them from powder firearms, which use gunpowder to generate energy to launch its projectile. Studies spanning three decades have demonstrated the injury capability of the AG. Yet parents with children that own AGs still have misconceptions of the dangers involved according to a 2000 publication.1 This may be, in part, due to the lack of awareness that contemporary AGs available to the general consumer are capable of achieving projectile velocities and penetration capabilities that approach or exceed that of some powder firearms.2 A report from 2002 examined trends in AG injuries by looking at data from the National Electronic Injury Surveillance System (NEISS). These authors stated the AG fatal and nonfatal injury rates had declined since early 1990 and attributed this to increasing numbers of prevention efforts.1,3 However, AG injuries remain a significant public health concern especially in the pediatric population. Reports from 2011 cite AGs as the cause of 16,451 injuries with 10,288 (62.5%) of these involving children age 19 or younger.4,5 The potential injury and financial burden of such injuries on society are likely significant. The aim of this research was to perform a contemporary review of the trauma registries at six level I pediatric trauma centers (PTCs) for those injuries resulting from AGs and determine their severity and incidence. An additional aim was to examine the potential financial burden on the population resulting from these AG injuries.
Materials and methods This institutional review board (IRB-approved) (consentwaived) retrospective chart review examined AG injuries seen in six level I PTCs. Each site obtained research regulatory approvals from their respective institutions and IRBs. Participating study sites from the ATOMAC research consortium included Phoenix Children’s Hospital (Phoenix, AZ); Children’s Medical Center Dallas, the flagship of Children’s Health℠ (Dallas, TX); Dell Children’s Medical Center of Central Texas, (Austin, TX); Le Bonheur Children’s Hospital, (Memphis, TN); and Arkansas Children’s Hospital (Little Rock, AR). The inclusion criteria were children 0-18 y of age treated for AG injuries during the study time frame of January 1, 2007 through December 31, 2016. Injuries related to paint guns, non-AGs or firearms, and patients seen outside of the study time frame or age group were excluded. Each site queried its own trauma registries for the study data elements based on a population with the diagnosis codes that indicated injury by an AG (ICD 9 E codes 922.4, E955.6, E968.6, E985.6, and or ICD 10 E codes W34.010 A, W34.018 A). Data elements included patient demographics, pre- and inhospital laboratory values, mechanism of injury, injury severity score (ISS), abbreviated injury scale (AIS), Glasgow coma scale, emergency department disposition, hospital length of stay (LOS), intensive care unit (ICU) LOS, hospital discharge outcomes, complications, discharge disposition,
and overall cost of admission or emergency department event if possible. The AIS6 as recorded in the trauma registry was used to assess the severity and estimate the number of individual injuries. An AIS injury score of one or greater was recorded as an “injury,” and the anatomical body site or region was noted. Possible anatomical body regions for recording an injury included head and neck, face, thorax, abdomen, extremity, and external. An AIS score of 2 was recorded as a “moderate” injury, and a score of 3 or greater was recorded as a “severe injury.” Each participating site provided their total trauma volume for the study time period to assess frequency of AG patients. Total trauma volume was defined as all patients represented in the site’s respective trauma registry during the study time frame. Data for all sites were consolidated into a Microsoft (Redmond, WA) Spreadsheet. Data analysis and visualization was performed with an Anaconda distribution of Python version 3.5 with the addition of the Statsmodels library.7,8 Descriptive statistics are provided as mean and standard deviation (SD) for continuous variables and counts with percentages for categorical variables. Significance for comparisons was performed with t-tests for continuous variables or with chisquare or Fisher’s exact test as appropriate for categorical or nominal datum. Pearson correlation coefficient was used to test the linear relationship between two continuous variables. Logistic regression or ANOVA and Tukey’s honest significant difference test were performed to assess for differences in continuous variables between multiple groups, while chisquare or Fisher’s exact with a Bonferroni correction was used for nominal data elements. Linear regression was used to test relationships between variables’ associations with longitudinal date of service. A two-sided P-value of 0.05 was used as the significance threshold for statistical tests.
Results A total of 499 pediatric patients were included, and the mean age for this study group was 9.5 (SD 4.0) years old with 406 (81.3%) males. See Table 1 for the descriptive characteristics of the total study population. The injuries reviewed represented an average of 0.57% of the total trauma cases at the ATOMAC sites and remained unchanged longitudinally across the years included in this study (R2 ¼ 0.003, P ¼ 0.876). Individual centers’ study population as a percent of total trauma volume can be seen in Figure 1. Children with multiple injuries made up 12.8% (n ¼ 64) of the study population injury types. Using the AIS which divides the body into injury regions, the most frequently observed combination of injury regions was head and face (n ¼ 10), followed by face and external (n ¼ 9), head and external (n ¼ 5), and abdomen and thorax (n ¼ 5). The observed body region injury distribution is shown in Figure 2. The detailed explanation or circumstances surrounding the patient injuries, the type of AG, or the number of times struck by the projectile(s) was inconsistent and not included in this study analysis. Of the total 499 injured children, 331 (66.3%) required admission to the hospital. A total of 151 (45.6%) admitted
apelt et al pediatric air gun injuries
Table 1 e Demographic summary of study cohort. Number of AG patients
499
Age in years, avg (SD)
9.5 (4.0)
Male, n (%)
406 (81%)
Race White
217 (43%)
Hispanic
159 (32%)
African American
92 (18%)
American Indian
17 (3%)
Other/Unk/not listed
14 (3%)
Transfer from OSH, n (%)
333 (67%)
Accidental, n (%)
399 (80%)
ICU admission, n (%)
46 (9%)
ICU LOS in days, avg(SD)
2.3 (2.5)
Hospital LOS in days, avg (SD)
2.3 (2.2)
ISS, avg (SD)
3.7 (4.6)
Operative intervention, n (%)
151 (30%)
Cost, avg (SD) Mortality, n (%)
$23,756 ($34,441) 0 (0%)
AG ¼ air gun; avg ¼ mean; SD ¼ standard deviation; OSH ¼ outside hospital; ICU ¼ intensive care unit; LOS ¼ length of stay; ISS ¼ injury severity score.
patients required operative intervention. The odds ratio for operative intervention increased 2.0 (2.7-3.9, 95% CI) for each AIS body region that received an injury. Patients who sustained an injury to the AIS body region of head/face or neck experienced a higher incidence of operative intervention (49.5% versus 25.3%, P < 0.001) compared with the patients without a head/face or neck region injury. Similarly, moderate abdominal or thorax injury was associated with a higher incidence of surgical intervention (48.8% versus 28.6%, P < 0.001). Children admitted to the ICU following an AG injury were 1.8 y younger than those that were not (admitted: 8.5 years old [SD ¼ 3.8]; versus not admitted: 10.3 years old [SD ¼ 4.2]: P ¼ 0.03). While age did not correlate with a need for operative
3
intervention (OR: 9.1 years old [SD ¼ 4.1]; versus No OR: 9.7 years old [SD ¼ 3.9]; P ¼ 0.1), there was a slight but statistically significant negative correlation between injured patient age and ISS score (Pearson correlation coefficient ¼ 0.11; P ¼ 0.01). After controlling for operative intervention, injuries to abdominal/thorax or head/face or neck regions were significantly costlier compared with other body regions for both operative and nonoperative injuries (Fig. 3). The most frequent payor for patients in the study was Medicaid/governmental insurance (60.7%), followed by commercial insurance (28.9%), self/private pay (9.6%), and other/undetermined (0.8%). There was no difference among the different payors for distribution of accidental injuries in the study cohort (Table 2). All payors were also similar in terms of severity of injury and total cost of the traumatic event.
Discussion Federal legislation regulating the transfer of ownership, possession, or use of AGs does not exist but instead allows for states to determine their own laws.9 These laws can vary state by state substantially. Some states impose age restrictions on AG possession, use, or transfer of ownership. Uniquely, local legislation in New York City, NY, prohibits the sale or possession of any AG without the appropriate licensure.4 Maine, Michigan, Nevada, New Jersey, and Rhode Island have the most substantial laws regarding AGs defining them as firearms and therefore imposing the same restrictions on their possession, use, purchase, and transfer of ownership.4 In addition to some states taking action, the United States Consumer Product Safety Commission (US CPSC) in 2012 did publish a consumer safety alert that reads as follows: WARNING; Not a toy; Adult Supervision required; Misuse and careless use may cause serious injury or death; May be dangerous up to 350 yards; Recommended for use by those 16 y of age or older.4 Despite such measures, this review demonstrates that significant life-altering injuries caused by contemporary AGs remains a major societal concern as seemingly younger age children are the most vulnerable
Fig. 1 e Percentage of trauma patients seen with air gun injuries. Location of participating pediatric trauma centers and the ratio of air gun injury patients to total trauma volume at each of the seven participating centers. Total trauma volume was calculated as the total number of patients included in the trauma registry for the study period. (Color version of figure is available online.)
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j o u r n a l o f s u r g i c a l r e s e a r c h a p r i l 2 0 2 0 ( 2 4 8 ) 1 e6
Fig. 2 e Injury severity distribution counts by body region. Number of patients who sustained an injury to an Abbreviated Injury Scale (AIS) body region. Each region is stratified by severe (AIS 3 or greater) and nonsevere injury (AIS less than 3). A patient will appear multiple times if they sustained injury in multiple regions.
population. The present study showed no change in the percentage of patients being injured by NPGs in comparison with other traumatic injuries across the 10-y study time frame. The most current NEISS data available are from 2018. In 2018, there were 12,660 estimated total injuries of all ages due to AGs, 489 of these involved children 0-4 years old; 4707 children ages 5-14 years old; and 4, 077 children ages 1524 years old.10 For 45 y, the NEISS data collection has been associated with consumer products from US hospital emergency departments across the country. The NEISS data originates from a sample of 96 hospitals that include children’s hospitals and is available to the public through CPSC’s National Injury Information Clearinghouse and online.11 In an article published in 2017 based on stated estimates derived from NEISS data, Dandu et al. reported that the vast majority (92%) of AG injuries in that study were treated and released in the ED.12 The present multisite study found that only 44% of the AG patients could be treated and released from the ED.
These conflicting results suggest that estimates derived from NEISS data may in fact understate the true severity of injuries sustained in AG accidents. Dandu et al. did find similar trends in male composition and age of the cohort leading to the conclusion that increased safety measures and public education was needed.12 The present study is unique in that it documents ICU LOS and ISS resulting from AG injuries at six Level I trauma centers. The authors would suggest that ICU LOS and ISS may be potential surrogates for understanding the injury potential for AG projectiles. Prior studies regarding AG injuries are, unfortunately, absent of this information. In 1982, a study from Dallas, Texas (this current study’s ATOMAC host site) by Blocker et al. reported a series of seven children severely injured by AG projectiles.13 These authors documented the injury causing capability of multiple-pump air rifles capable of achieving a projectile velocity as high as 710 ft/s.14 More contemporary publications report muzzle velocities of 1000 to 1200 ft/s in a
Fig. 3 e Cost of visit by injury region. Boxplot of patient encounter cost in thousands of dollars. Patients are grouped by those who sustained injuries to the Abd (abdomen) and thorax, HFN (head, face, and neck), and all other body regions (extremities and external). Patient cohort is separated into those who incurred an OR visit and those who did not. A patient with an injury sustained to the Abd and thorax, or HFN was substantially more expensive than patients who had injuries only to other body regions. **Mean differences in thousands of dollars with 95% CI: All others versus Abd and Thorax 34.1 (15.6 to 52.6, P < 0.001) with OR visit, and 15.9 (1.0 to 30.9, P [ 0.034, P [ 0.034) without OR visit, All others versus HFN 17.0 (0.6 to 33.3, P [ 0.04) with OR visit, and without OR visit 28.2 (14.2 to 42.2, P < 0.001).
apelt et al pediatric air gun injuries
Table 2 e Primary payor and injury intent. Primary payor
Accidental
Intentional
Unknown Intent
Medicaid/govt insurance
233 (77%)
24 (8%)
46 (15%)
Commercial insurance
124 (86%)
6 (4%)
14 (10%)
38 (79%)
2 (4%)
8 (17%)
Self/private pay Other Total
4 (100%) 399 (80%)
0 (0%) 32 (6%)
0 (0%) 68 (14%)
Incident classification based on data in the trauma registry stratified by primary payor. Data are presented as count of patients and percentages.
significant proportion of AGs, underscoring the trend for everincreasing projectile speeds.14 If AG projectile velocities increase as is the current trend, resulting injuries will likely have an increased risk of higher severity. In our cohort, one-third of all children seen for AG injuries required operative intervention. The average cost for a single AG trauma event approached $24,000. This amount does not include subsequent rehabilitation costs or future financial impact resulting from these childhood injuries. This is a significant injury burden caused by a weapon that remains subject to few if any, specific regulation. In this study cohort, 80% of the incidents were classified as accidental and potentially preventable. Furthermore, the high incidence of accidental incidents persisted throughout sociodemographic stratifications. As with any retrospective data set, this cohort is not without limitations. While all participating hospitals have similar trauma registries with near identical data definitions, there may be unseen variation in how data is recorded and that introduces undetected bias. As trauma registries will only capture patients requiring transfer to a PTC, there is a cohort of patients with minor injuries that present for medical attention at nontrauma centers and are not represented in this study cohort. These data censoring may cause our research results to contain fewer, but more severely injured patients than the total injured by AGs in the respective catchment areas. This is underscored by the high numbers of transfers in the data set. Also, AIS scoring is based on the most severe injury to the region, so the total number of injuries present may be an underrepresentation of what was really seen. The retrospective nature of this study, and the often-unreliable history from patients in this population prevented the collection of key variables regarding gun type, gun ownership, and the number of times the AG may have been fired.
5
by a weapon that remains subject to few, if any, specific regulations. In the study cohort, 80% of the incidents were classified as accidental, and potentially preventable. Furthermore, the high incidence of accidental incidents persisted throughout sociodemographic stratifications. AG weapons are capable of serious and even potentially life-altering to lifethreatening injuries and should be considered a significant health concern. This study suggests that current legislature, including product warning signs, etc., has not significantly impacted the intended demographics of injured users. This study team determined further research into pediatric AG injury prevention is warranted. In reviewing the data presented, the contemporary AG available to the pediatric population of today, reveals continued injury potential and remains a significant health concern.
Acknowledgment Authors’ contribution: DS and CG conceptualized the study idea and format. CG created the study documents and handled all communication between study team sites and host and worked with the host site Trauma Registrar SG, to collect, host site data. JT and DS analyzed data results first locally then all site data as well. NA created the first manuscript draft and assisted in the revisions, as well as DMN, TTM, NMG, JWE, RWL, JT, DS, and CG. Contributors’ Statement Dr David Schindel conceptualized the study idea, assisted in determining the data elements to be collected, drafted, reviewed, and revised the final manuscript. Dr Nadja Apelt reviewed the collected data and participated in the analysis, as well as the initial draft of the manuscript and all revisions that followed. Jefferson Tweed reviewed the collected data and performed data analysis, and contributed to the initial draft, revisions, and final submitted manuscript. Dr David Notrica, Dr Todd Maxson, Dr Nilda Garcia, Dr Karla Lawson, Dr James Eubanks, and Dr Robert Letton all participated in confirming the accuracy of the data from their sites and participated in the revisions and approval of the final manuscript. Cynthia Greenwell created the study protocol, the data collection tool, presented the initial idea to the multisite study consortium, collected data for host site, and coordinated data collection from all participating sites, assisted in the original draft of the manuscript as well as all revisions and submitted to the journal for the study team.
Conclusion If AG projectile velocities increase as is the current trend, resulting injuries will likely increase in severity. In our cohort, one-third of all children seen for AG injuries required operative intervention, with an average hospital cost approaching $24,000. This amount does not include subsequent rehabilitation costs or future financial impact resulting from these childhood injuries. This is a significant injury burden caused
Disclosure The authors reported no proprietary or commercial interest in any product mentioned or concept discussed in this article. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
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references
1. Nguyen MH, Annest JL, Mercy JA, Ryan GW, Fingerhut LA. Trends in BB/pellet gun injuries in children and teenagers in the United States, 1985-99. Inj Prev. 2002;8:185e191. 2. Freeman JJ, Bachier-Rodriquez M, Staszak J, Feliz A. A comparison between non- powder gun and powder-gun injuries in a young pediatric population. Injury. 2017;48:1951e1955. 3. Available at: http://sor.senate.ca.gov/sites/sor.senate.ca.gov/ files/Pellet Guns and BB Guns.pdf. Accessed May 18, 2016. 4. Non-powder Guns Policy Summ. Law center to prevent gun Violence. Available at: http://smartgunlaws.org/non-powderguns-policy summary/. Accessed May 12, 2012. 5. Pellet guns and BB guns: Dangerous Playthings in the Open Market. Prepared by Max Vanzi, Senate Office of Research. Available at: https://sor.senate.cal.gov/sites/sor. senate.ca.gov/files/. Accessed July, September, and November, 2019. 6. Damore DT, Ramundo ML, Hanna JP. Parental Attitudes toward BB and pellet guns. Clin Pediatr. 2000:281e284.
7. Palmer CS, Gabbe BJ, Cameron PA. Defining major trauma using the 2008 abbreviated injury scale. Inj Jan. 2016;47:109e115. 8. Anaconda Distribution for Python. Available at: https://www. anaconda.com/download/. Accessed 7/29/2019, and September, 2019. 9. Seabold S, Perktold J. Statsmodels: econometric and statistical Modeling with Python. In: Proceedings of the 9th Python in Science Conference. 2010:57e61. 10. National Electronic Injury Surveillance System (NEISS). NEISS data Highlights- Calendar Year 2018. 2019. Available at: https://www.cpsc.gov/Research–Statistics/NEISS-InjuryData. Accessed 01/28/2019 and 07/29/2019. 11. CPSC Safety Alert. BB Guns Can Kill. https://www.cpsc.gov/ s3fs_public/5089.pdf. Accessed January 1, 2012. 12. Dandu KV, Carniol ET, Sanghvi S, Baredes S, Eloy JA. A 10year analysis of head and neck injuries involving nonpowder firearms. Otolaryngol Head Neck Surg. 2017;165:853e856. 13. Blocker S, Coln D, Chang J. Serious air rifle injuries in children. Pediatrics. 1982;69:751. 14. Laraque D. Injury risk of Nonpowder guns. Pediatr. 2004;114:1357e1361.
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.JournalofSurgicalResearch.com
Air Guns: A Contemporary Review of Injuries at Six Pediatric Level I Trauma Centers Nadja Apelt, MD,a Cynthia Greenwell, BSN, RN,b,* Jefferson Tweed, MS,b David M. Notrica, MD,c R Todd Maxson, MD,d Nilda M. Garcia, MD,e Karla Lawson, PhD, MPH,f James W. Eubanks III, MD,g Robert W. Letton Jr., MD,h,1 and David Schindel, MDa a
Surgery Department, Children’s Medical Center, The Flagship of Children’s HealthSM, Dallas, Texas Tauma Department, Children’s Medical Center, The Flagship of Children’s HealthSM, Dallas, Texas c Surgery Department, Phoenix Children’s Hospital, Phoenix, Arizona d Surgery Department, Arkansas Children’s Hospital, Little Rock, Arkansas e Surgery Department, Dell Children’s Medical Center, Austin, Texas f Trauma Department, Dell Children’s Medical Center, Austin, Texas g Surgery Department, Le Bonheur Children’s Hospital, Memphis, Tennessee h Surgery Department, The Children’s Hospital at OU Medical Center, Oklahoma City, Oklahoma b
article info
abstract
Article history:
Background: Studies spanning the last three decades demonstrated the injury causing
Received 16 August 2019
capability of air gun (AG) projectiles. Recent studies have suggested the impact and inci-
Received in revised form
dence of these injuries may be declining because of edcational efforts. We hypothesize that
22 October 2019
injuries in the pediatric population resulting from AGs remain a significant health concern.
Accepted 3 November 2019
Methods: A retrospective review (1/1/2007 to 12/31/2016), of AG-injured children < 19 years
Available online xxx
old, was performed across six level I Pediatric Trauma Centers, part of the ATOMAC research consortium. AG injuries were defined as injuries sustained by ball-bearing or
Keywords:
pellet air-powered guns. Paint ball and soft foam AGs were excluded. Following institu-
Pediatric
tional review board approval, patients were identified by ICD code from the trauma reg-
Air gun
istry. Included were demographic data, injury severity scores, length of stay (LOS), outcome
Pellet gun
at discharge, and overall cost of admission. Descriptive statistics and parametric tests were
Traumatic injury
employed.
Firearms
Results: A total of 499 patients sustained injuries. Mean age 9.5 (4.0) y; 81% of victims were
BB gun
male; all survived to hospital discharge. 30% (n ¼ 151) required operative intervention. Hospital LOS was 2.3 (2.2) d; with mean cost of $23,756 ($34,441). Injury severity score mean of 3.7 (4.6) on admission. Over 40% of the injuries to the head/thorax that were severe (AIS 3) required operative intervention (P < 0.001). Conclusions: AG injuries to the head or thorax seen at trauma centers were likely to require operative management. While no fatalities occurred, the cost was substantial. This study demonstrates pediatric injuries resulting from AG projectiles remain a significant health concern. ª 2019 Elsevier Inc. All rights reserved.
* Corresponding author. Children’s Medical Center, 1935 Medical District Dr, Mail slot D1416, Dallas, TX, 75235. Tel.:þ913-620-2626; fax: 214-456-8652. E-mail address: [email protected] (C. Greenwell). 1 present address: Department of Surgery, Nemours Children’s Specialty Care, 807 Children’s Way, Jacksonville, FL 32207. 0022-4804/$ e see front matter ª 2019 Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.jss.2019.11.002
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j o u r n a l o f s u r g i c a l r e s e a r c h a p r i l 2 0 2 0 ( 2 4 8 ) 1 e6
Introduction Air guns (AGs) expel projectiles, typically a ball-bearing (BB) or lead pellet, via the force of compressed air or CO2. This differentiates them from powder firearms, which use gunpowder to generate energy to launch its projectile. Studies spanning three decades have demonstrated the injury capability of the AG. Yet parents with children that own AGs still have misconceptions of the dangers involved according to a 2000 publication.1 This may be, in part, due to the lack of awareness that contemporary AGs available to the general consumer are capable of achieving projectile velocities and penetration capabilities that approach or exceed that of some powder firearms.2 A report from 2002 examined trends in AG injuries by looking at data from the National Electronic Injury Surveillance System (NEISS). These authors stated the AG fatal and nonfatal injury rates had declined since early 1990 and attributed this to increasing numbers of prevention efforts.1,3 However, AG injuries remain a significant public health concern especially in the pediatric population. Reports from 2011 cite AGs as the cause of 16,451 injuries with 10,288 (62.5%) of these involving children age 19 or younger.4,5 The potential injury and financial burden of such injuries on society are likely significant. The aim of this research was to perform a contemporary review of the trauma registries at six level I pediatric trauma centers (PTCs) for those injuries resulting from AGs and determine their severity and incidence. An additional aim was to examine the potential financial burden on the population resulting from these AG injuries.
Materials and methods This institutional review board (IRB-approved) (consentwaived) retrospective chart review examined AG injuries seen in six level I PTCs. Each site obtained research regulatory approvals from their respective institutions and IRBs. Participating study sites from the ATOMAC research consortium included Phoenix Children’s Hospital (Phoenix, AZ); Children’s Medical Center Dallas, the flagship of Children’s Health℠ (Dallas, TX); Dell Children’s Medical Center of Central Texas, (Austin, TX); Le Bonheur Children’s Hospital, (Memphis, TN); and Arkansas Children’s Hospital (Little Rock, AR). The inclusion criteria were children 0-18 y of age treated for AG injuries during the study time frame of January 1, 2007 through December 31, 2016. Injuries related to paint guns, non-AGs or firearms, and patients seen outside of the study time frame or age group were excluded. Each site queried its own trauma registries for the study data elements based on a population with the diagnosis codes that indicated injury by an AG (ICD 9 E codes 922.4, E955.6, E968.6, E985.6, and or ICD 10 E codes W34.010 A, W34.018 A). Data elements included patient demographics, pre- and inhospital laboratory values, mechanism of injury, injury severity score (ISS), abbreviated injury scale (AIS), Glasgow coma scale, emergency department disposition, hospital length of stay (LOS), intensive care unit (ICU) LOS, hospital discharge outcomes, complications, discharge disposition,
and overall cost of admission or emergency department event if possible. The AIS6 as recorded in the trauma registry was used to assess the severity and estimate the number of individual injuries. An AIS injury score of one or greater was recorded as an “injury,” and the anatomical body site or region was noted. Possible anatomical body regions for recording an injury included head and neck, face, thorax, abdomen, extremity, and external. An AIS score of 2 was recorded as a “moderate” injury, and a score of 3 or greater was recorded as a “severe injury.” Each participating site provided their total trauma volume for the study time period to assess frequency of AG patients. Total trauma volume was defined as all patients represented in the site’s respective trauma registry during the study time frame. Data for all sites were consolidated into a Microsoft (Redmond, WA) Spreadsheet. Data analysis and visualization was performed with an Anaconda distribution of Python version 3.5 with the addition of the Statsmodels library.7,8 Descriptive statistics are provided as mean and standard deviation (SD) for continuous variables and counts with percentages for categorical variables. Significance for comparisons was performed with t-tests for continuous variables or with chisquare or Fisher’s exact test as appropriate for categorical or nominal datum. Pearson correlation coefficient was used to test the linear relationship between two continuous variables. Logistic regression or ANOVA and Tukey’s honest significant difference test were performed to assess for differences in continuous variables between multiple groups, while chisquare or Fisher’s exact with a Bonferroni correction was used for nominal data elements. Linear regression was used to test relationships between variables’ associations with longitudinal date of service. A two-sided P-value of 0.05 was used as the significance threshold for statistical tests.
Results A total of 499 pediatric patients were included, and the mean age for this study group was 9.5 (SD 4.0) years old with 406 (81.3%) males. See Table 1 for the descriptive characteristics of the total study population. The injuries reviewed represented an average of 0.57% of the total trauma cases at the ATOMAC sites and remained unchanged longitudinally across the years included in this study (R2 ¼ 0.003, P ¼ 0.876). Individual centers’ study population as a percent of total trauma volume can be seen in Figure 1. Children with multiple injuries made up 12.8% (n ¼ 64) of the study population injury types. Using the AIS which divides the body into injury regions, the most frequently observed combination of injury regions was head and face (n ¼ 10), followed by face and external (n ¼ 9), head and external (n ¼ 5), and abdomen and thorax (n ¼ 5). The observed body region injury distribution is shown in Figure 2. The detailed explanation or circumstances surrounding the patient injuries, the type of AG, or the number of times struck by the projectile(s) was inconsistent and not included in this study analysis. Of the total 499 injured children, 331 (66.3%) required admission to the hospital. A total of 151 (45.6%) admitted
apelt et al pediatric air gun injuries
Table 1 e Demographic summary of study cohort. Number of AG patients
499
Age in years, avg (SD)
9.5 (4.0)
Male, n (%)
406 (81%)
Race White
217 (43%)
Hispanic
159 (32%)
African American
92 (18%)
American Indian
17 (3%)
Other/Unk/not listed
14 (3%)
Transfer from OSH, n (%)
333 (67%)
Accidental, n (%)
399 (80%)
ICU admission, n (%)
46 (9%)
ICU LOS in days, avg(SD)
2.3 (2.5)
Hospital LOS in days, avg (SD)
2.3 (2.2)
ISS, avg (SD)
3.7 (4.6)
Operative intervention, n (%)
151 (30%)
Cost, avg (SD) Mortality, n (%)
$23,756 ($34,441) 0 (0%)
AG ¼ air gun; avg ¼ mean; SD ¼ standard deviation; OSH ¼ outside hospital; ICU ¼ intensive care unit; LOS ¼ length of stay; ISS ¼ injury severity score.
patients required operative intervention. The odds ratio for operative intervention increased 2.0 (2.7-3.9, 95% CI) for each AIS body region that received an injury. Patients who sustained an injury to the AIS body region of head/face or neck experienced a higher incidence of operative intervention (49.5% versus 25.3%, P < 0.001) compared with the patients without a head/face or neck region injury. Similarly, moderate abdominal or thorax injury was associated with a higher incidence of surgical intervention (48.8% versus 28.6%, P < 0.001). Children admitted to the ICU following an AG injury were 1.8 y younger than those that were not (admitted: 8.5 years old [SD ¼ 3.8]; versus not admitted: 10.3 years old [SD ¼ 4.2]: P ¼ 0.03). While age did not correlate with a need for operative
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intervention (OR: 9.1 years old [SD ¼ 4.1]; versus No OR: 9.7 years old [SD ¼ 3.9]; P ¼ 0.1), there was a slight but statistically significant negative correlation between injured patient age and ISS score (Pearson correlation coefficient ¼ 0.11; P ¼ 0.01). After controlling for operative intervention, injuries to abdominal/thorax or head/face or neck regions were significantly costlier compared with other body regions for both operative and nonoperative injuries (Fig. 3). The most frequent payor for patients in the study was Medicaid/governmental insurance (60.7%), followed by commercial insurance (28.9%), self/private pay (9.6%), and other/undetermined (0.8%). There was no difference among the different payors for distribution of accidental injuries in the study cohort (Table 2). All payors were also similar in terms of severity of injury and total cost of the traumatic event.
Discussion Federal legislation regulating the transfer of ownership, possession, or use of AGs does not exist but instead allows for states to determine their own laws.9 These laws can vary state by state substantially. Some states impose age restrictions on AG possession, use, or transfer of ownership. Uniquely, local legislation in New York City, NY, prohibits the sale or possession of any AG without the appropriate licensure.4 Maine, Michigan, Nevada, New Jersey, and Rhode Island have the most substantial laws regarding AGs defining them as firearms and therefore imposing the same restrictions on their possession, use, purchase, and transfer of ownership.4 In addition to some states taking action, the United States Consumer Product Safety Commission (US CPSC) in 2012 did publish a consumer safety alert that reads as follows: WARNING; Not a toy; Adult Supervision required; Misuse and careless use may cause serious injury or death; May be dangerous up to 350 yards; Recommended for use by those 16 y of age or older.4 Despite such measures, this review demonstrates that significant life-altering injuries caused by contemporary AGs remains a major societal concern as seemingly younger age children are the most vulnerable
Fig. 1 e Percentage of trauma patients seen with air gun injuries. Location of participating pediatric trauma centers and the ratio of air gun injury patients to total trauma volume at each of the seven participating centers. Total trauma volume was calculated as the total number of patients included in the trauma registry for the study period. (Color version of figure is available online.)
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Fig. 2 e Injury severity distribution counts by body region. Number of patients who sustained an injury to an Abbreviated Injury Scale (AIS) body region. Each region is stratified by severe (AIS 3 or greater) and nonsevere injury (AIS less than 3). A patient will appear multiple times if they sustained injury in multiple regions.
population. The present study showed no change in the percentage of patients being injured by NPGs in comparison with other traumatic injuries across the 10-y study time frame. The most current NEISS data available are from 2018. In 2018, there were 12,660 estimated total injuries of all ages due to AGs, 489 of these involved children 0-4 years old; 4707 children ages 5-14 years old; and 4, 077 children ages 1524 years old.10 For 45 y, the NEISS data collection has been associated with consumer products from US hospital emergency departments across the country. The NEISS data originates from a sample of 96 hospitals that include children’s hospitals and is available to the public through CPSC’s National Injury Information Clearinghouse and online.11 In an article published in 2017 based on stated estimates derived from NEISS data, Dandu et al. reported that the vast majority (92%) of AG injuries in that study were treated and released in the ED.12 The present multisite study found that only 44% of the AG patients could be treated and released from the ED.
These conflicting results suggest that estimates derived from NEISS data may in fact understate the true severity of injuries sustained in AG accidents. Dandu et al. did find similar trends in male composition and age of the cohort leading to the conclusion that increased safety measures and public education was needed.12 The present study is unique in that it documents ICU LOS and ISS resulting from AG injuries at six Level I trauma centers. The authors would suggest that ICU LOS and ISS may be potential surrogates for understanding the injury potential for AG projectiles. Prior studies regarding AG injuries are, unfortunately, absent of this information. In 1982, a study from Dallas, Texas (this current study’s ATOMAC host site) by Blocker et al. reported a series of seven children severely injured by AG projectiles.13 These authors documented the injury causing capability of multiple-pump air rifles capable of achieving a projectile velocity as high as 710 ft/s.14 More contemporary publications report muzzle velocities of 1000 to 1200 ft/s in a
Fig. 3 e Cost of visit by injury region. Boxplot of patient encounter cost in thousands of dollars. Patients are grouped by those who sustained injuries to the Abd (abdomen) and thorax, HFN (head, face, and neck), and all other body regions (extremities and external). Patient cohort is separated into those who incurred an OR visit and those who did not. A patient with an injury sustained to the Abd and thorax, or HFN was substantially more expensive than patients who had injuries only to other body regions. **Mean differences in thousands of dollars with 95% CI: All others versus Abd and Thorax 34.1 (15.6 to 52.6, P < 0.001) with OR visit, and 15.9 (1.0 to 30.9, P [ 0.034, P [ 0.034) without OR visit, All others versus HFN 17.0 (0.6 to 33.3, P [ 0.04) with OR visit, and without OR visit 28.2 (14.2 to 42.2, P < 0.001).
apelt et al pediatric air gun injuries
Table 2 e Primary payor and injury intent. Primary payor
Accidental
Intentional
Unknown Intent
Medicaid/govt insurance
233 (77%)
24 (8%)
46 (15%)
Commercial insurance
124 (86%)
6 (4%)
14 (10%)
38 (79%)
2 (4%)
8 (17%)
Self/private pay Other Total
4 (100%) 399 (80%)
0 (0%) 32 (6%)
0 (0%) 68 (14%)
Incident classification based on data in the trauma registry stratified by primary payor. Data are presented as count of patients and percentages.
significant proportion of AGs, underscoring the trend for everincreasing projectile speeds.14 If AG projectile velocities increase as is the current trend, resulting injuries will likely have an increased risk of higher severity. In our cohort, one-third of all children seen for AG injuries required operative intervention. The average cost for a single AG trauma event approached $24,000. This amount does not include subsequent rehabilitation costs or future financial impact resulting from these childhood injuries. This is a significant injury burden caused by a weapon that remains subject to few if any, specific regulation. In this study cohort, 80% of the incidents were classified as accidental and potentially preventable. Furthermore, the high incidence of accidental incidents persisted throughout sociodemographic stratifications. As with any retrospective data set, this cohort is not without limitations. While all participating hospitals have similar trauma registries with near identical data definitions, there may be unseen variation in how data is recorded and that introduces undetected bias. As trauma registries will only capture patients requiring transfer to a PTC, there is a cohort of patients with minor injuries that present for medical attention at nontrauma centers and are not represented in this study cohort. These data censoring may cause our research results to contain fewer, but more severely injured patients than the total injured by AGs in the respective catchment areas. This is underscored by the high numbers of transfers in the data set. Also, AIS scoring is based on the most severe injury to the region, so the total number of injuries present may be an underrepresentation of what was really seen. The retrospective nature of this study, and the often-unreliable history from patients in this population prevented the collection of key variables regarding gun type, gun ownership, and the number of times the AG may have been fired.
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by a weapon that remains subject to few, if any, specific regulations. In the study cohort, 80% of the incidents were classified as accidental, and potentially preventable. Furthermore, the high incidence of accidental incidents persisted throughout sociodemographic stratifications. AG weapons are capable of serious and even potentially life-altering to lifethreatening injuries and should be considered a significant health concern. This study suggests that current legislature, including product warning signs, etc., has not significantly impacted the intended demographics of injured users. This study team determined further research into pediatric AG injury prevention is warranted. In reviewing the data presented, the contemporary AG available to the pediatric population of today, reveals continued injury potential and remains a significant health concern.
Acknowledgment Authors’ contribution: DS and CG conceptualized the study idea and format. CG created the study documents and handled all communication between study team sites and host and worked with the host site Trauma Registrar SG, to collect, host site data. JT and DS analyzed data results first locally then all site data as well. NA created the first manuscript draft and assisted in the revisions, as well as DMN, TTM, NMG, JWE, RWL, JT, DS, and CG. Contributors’ Statement Dr David Schindel conceptualized the study idea, assisted in determining the data elements to be collected, drafted, reviewed, and revised the final manuscript. Dr Nadja Apelt reviewed the collected data and participated in the analysis, as well as the initial draft of the manuscript and all revisions that followed. Jefferson Tweed reviewed the collected data and performed data analysis, and contributed to the initial draft, revisions, and final submitted manuscript. Dr David Notrica, Dr Todd Maxson, Dr Nilda Garcia, Dr Karla Lawson, Dr James Eubanks, and Dr Robert Letton all participated in confirming the accuracy of the data from their sites and participated in the revisions and approval of the final manuscript. Cynthia Greenwell created the study protocol, the data collection tool, presented the initial idea to the multisite study consortium, collected data for host site, and coordinated data collection from all participating sites, assisted in the original draft of the manuscript as well as all revisions and submitted to the journal for the study team.
Conclusion If AG projectile velocities increase as is the current trend, resulting injuries will likely increase in severity. In our cohort, one-third of all children seen for AG injuries required operative intervention, with an average hospital cost approaching $24,000. This amount does not include subsequent rehabilitation costs or future financial impact resulting from these childhood injuries. This is a significant injury burden caused
Disclosure The authors reported no proprietary or commercial interest in any product mentioned or concept discussed in this article. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
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references
1. Nguyen MH, Annest JL, Mercy JA, Ryan GW, Fingerhut LA. Trends in BB/pellet gun injuries in children and teenagers in the United States, 1985-99. Inj Prev. 2002;8:185e191. 2. Freeman JJ, Bachier-Rodriquez M, Staszak J, Feliz A. A comparison between non- powder gun and powder-gun injuries in a young pediatric population. Injury. 2017;48:1951e1955. 3. Available at: http://sor.senate.ca.gov/sites/sor.senate.ca.gov/ files/Pellet Guns and BB Guns.pdf. Accessed May 18, 2016. 4. Non-powder Guns Policy Summ. Law center to prevent gun Violence. Available at: http://smartgunlaws.org/non-powderguns-policy summary/. Accessed May 12, 2012. 5. Pellet guns and BB guns: Dangerous Playthings in the Open Market. Prepared by Max Vanzi, Senate Office of Research. Available at: https://sor.senate.cal.gov/sites/sor. senate.ca.gov/files/. Accessed July, September, and November, 2019. 6. Damore DT, Ramundo ML, Hanna JP. Parental Attitudes toward BB and pellet guns. Clin Pediatr. 2000:281e284.
7. Palmer CS, Gabbe BJ, Cameron PA. Defining major trauma using the 2008 abbreviated injury scale. Inj Jan. 2016;47:109e115. 8. Anaconda Distribution for Python. Available at: https://www. anaconda.com/download/. Accessed 7/29/2019, and September, 2019. 9. Seabold S, Perktold J. Statsmodels: econometric and statistical Modeling with Python. In: Proceedings of the 9th Python in Science Conference. 2010:57e61. 10. National Electronic Injury Surveillance System (NEISS). NEISS data Highlights- Calendar Year 2018. 2019. Available at: https://www.cpsc.gov/Research–Statistics/NEISS-InjuryData. Accessed 01/28/2019 and 07/29/2019. 11. CPSC Safety Alert. BB Guns Can Kill. https://www.cpsc.gov/ s3fs_public/5089.pdf. Accessed January 1, 2012. 12. Dandu KV, Carniol ET, Sanghvi S, Baredes S, Eloy JA. A 10year analysis of head and neck injuries involving nonpowder firearms. Otolaryngol Head Neck Surg. 2017;165:853e856. 13. Blocker S, Coln D, Chang J. Serious air rifle injuries in children. Pediatrics. 1982;69:751. 14. Laraque D. Injury risk of Nonpowder guns. Pediatr. 2004;114:1357e1361.