Outcomes of Firearm Injuries Among Children in the PICU

Abstract

Source: Bagdure D, Foster CB, Garber N, et al. Outcomes of children with firearm injuries admitted to the PICU in the United States [published online ahead of print June 7, 2021]. Pediatr Crit Care Med. doi:10.1097/PCC.0000000000002785Investigators from the University of Maryland, College Park, conducted a retrospective study to assess the morbidity and mortality among children admitted to the PICU with firearm injuries. Data for this study was obtained from 107 PICUs participating in the Virtual Pediatrics Systems (VPS) database, a consortium of PICUs that contribute demographic and clinical data on hospitalized children. VPS data from 2009–2017 were obtained for the current study.Patients with firearm injure in the VPS database using ICD codes. Among identified patients, demographics, cause of firearm injury (assault, suicide attempt, unintentional, or undetermined), site of injury, and discharge scores on validated scales for overall functional morbidity (the Pediatric Overall Performance Category; POPC) and cognitive impairment (Pediatric Cerebral Performance Category; PCPC) were abstracted from VPS. The primary outcome was death in the PICU. Secondary outcomes included discharge scores on the POPC and PCPC among those who survived, with scores categorized as normal, mild, moderate, or severe disability, or coma/vegetative state. The investigators used chi-squared tests to assess the association of demographics and clinical characteristics with outcomes.There were 1,447 identified patients admitted to the PICU for firearm injuries. Of these, 44.60 were Black, 77.50 were male, and 57.30 were 13-18 years old. The most common cause of firearm injury was unintentional (67.70), and the most common site of injury was the head or neck (30.70).Overall, 175 (120) patients died, with a higher proportion of white (41.10) children who died compared to Black (30.90) and Hispanic (6.90) children (P < 0.05). Suicide attempt was the cause of firearm injury with the highest rate of death (52 of 95 patients with suicide attempt by firearm injury died). Overall, among those who survived to discharge, most had mild disability.The investigators conclude that the mortality among children admitted to the PICU for firearm injury is high.Dr Bratton has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.The SARS-CoV-2 pandemic has intensified economic and social stressors and highlighted the presence of systemic racism in the US. Gun ownership and violent crime as well as mass shootings have increased dramatically during the past year.1 In the current study of PICU gun victims, male, teenaged, and Black children were over-represented. Younger children were more likely to have unintentional injuries compared to older children. Assault was more common among Black children, while self-inflicted injuries were more common in white children, led to head and neck injuries, and were more frequently lethal. To develop and evalu-ate prevention strategies to decrease firearm injuries and death, the investigators need to capture information on all children at risk for firearm injuries and death. Those who die prior to hospital admission and those with less severe injuries not requiring PICU care need to be included as well as those treated in adult hospi-tals. For some pediatric groups (such as Black males 15-18 years old), assault with firearms is the leading cause of death, while drowning and motor vehicle accidents remain more common in white children 1 to 10 years of age.2In order to evaluate populations at risk for firearm injuries, important factors include the relationship of the victim to the shooter, the injury intent, and determination of the impact of alcohol and drugs, gangs, poverty, racism, or access to guns. Other factors include mental illness, robbery, domestic violence, or hate crimes.3 Public support favors strict enforcement of back-ground checks prior to purchasing a gun as well as prohibition of gun sales with high-capacity magazines.3 However, the impact of legislation targeted to decrease mass shootings, or from shooters with a history of mental illness who passed a background check, remains untested.2Firearm injuries are a significant, largely preventable, cause of morbidity and mortality in children admitted to the PICU. These injuries impact males and minority groups at much higher rates.The mortality rate from firearm injuries in the current study is 5 times greater than the all-cause PICU mortality.4 As most of the injuries are unintentional, and most survivors incur neurologic morbidity, is it not time to institute preventive strategies?