Are Facial Gunshot Wounds More Fatal When They Are Self-Inflicted or Other-Inflicted?

Abstract

This was a retrospective cohort study of the 2014 Nationwide Emergency Department Sample (NEDS). Intraoral and submental projectile entry points may be less fatal than other facial entry points due to the indirect access to the intracranial structures and the protection offered by the intervening maxillofacial complex. Because intraoral and submental trajectories are almost always present in the setting of attempted suicide, this study sought to determine if intent (self-harm versus other-harm) influenced mortality in facial gunshot wound (GSW) patients. All patients with a diagnosis of a facial fracture secondary to firearm injury were included in the study sample. The primary predictor was self-harm. Secondary predictors were derived from patient, injury, and hospitalization characteristics. The study outcome was death. Univariate time to event analyses were conducted for all study predictors. A multivariate regression model for mortality was created using all relevant predictors. The final sample included 668 facial GSW injuries, of which 19.3% were attributed to self-harm. Self-inflicted GSWs were more likely to involve the mandible (58.9 vs 46.0%, P < 0.01), ZMC/maxilla (47.3 vs 32.5%, P < 0.01), and intracranial cavity (48.1 vs 22.6%, P < 0.01). The overall mortality rate was 7.3%, and the mean time to death was 2.2 days. After controlling for pertinent covariates, the risk of mortality was independently decreased with mandibular injury (HR = 0.36, P = 0.03). However, mortality was increased by self-harm intent (HR = 3.94, P < 0.01) and intracranial involvement (HR = 11.24, P < 0.01). Consistent with a pattern of intraoral and submental entry points, self-inflicted facial GSWs demonstrated higher rates of mandibular injury. Despite this finding, self-harm injuries still carried a higher incidence of intracranial injury and a greater independent risk of mortality. Our results refute any notion that the mechanism and trajectory of self-inflicted GSWs is less fatal.