Patients Sustaining Gunshot Wounds Research Articles

Selective nonoperative versus operative management of liver gunshot injuries: a retrospective cohort study.

Experience accumulated over the last decades suggests nonoperative management (NOM) of civilian gunshot liver injuries can be safely applied in selected cases. This study aims to compare the outcomes of selective NOM versus operative management (OM) of patients sustaining gunshot wounds (GSW) to the liver. A registry-based retrospective cohort analysis was performed for the period of 2008 to 2016 in a Brazilian trauma referral. Patients aged 16-80 years sustaining civilian GSW to right-sided abdominal quadrants and liver injury were included. Baseline data, vital signs, grade of liver injury, associated injuries, injury severity scores, blood transfusion requirements, liver- and non-liver-related complications, length-of-stay (LOS), and mortality were retrieved from individual registries. A total of 54 patients were eligible for analysis, of which 37 underwent NOM and 17 underwent OM. The median age was 25 years and all were male. No statistically significant differences were observed between groups regarding patients' demographics, injury scores, grade of liver injury and associated lesions. NOM patients tended to sustain higher-grade injuries (86.5% vs 64.7%; p = 0.08), and failure of conservative management was recorded in two (5.4%) cases. The rate of complications was 48% with no between-group statistically significant difference. Blood transfusion requirements were significantly higher in the OM group (58.8% vs 21.6%; p = 0.012). The median LOS was seven days. No deaths were recorded. Patients with liver GSW who are haemodynamically stable and without peritonitis are candidates for NOM. In this study, NOM was safe and effective even in high-grade injuries.

Causes of early mortality in pediatric trauma patients.

Trauma is the leading cause of death in children, and most deaths occur within 24 hours of injury. A better understanding of the causes of death in the immediate period of hospital care is needed. Trauma admissions younger than 18 years from 2009 to 2019 at a Level I pediatric trauma center were reviewed for deaths (n = 7,145). Patients were stratified into ages 0-6, 7-12, and 13-17 years old. The primary outcome was cause of death, with early death defined as less than 24 hours after trauma center arrival. There were 134 (2%) deaths with a median age of 7 years. The median time from arrival to death was 14.4 hours (interquartile range, 0.5-87.8 hours). Half (54%) occurred within 24 hours. However, most patients who survived initial resuscitation in the emergency department died longer than 24 hours after arrival (69%). Traumatic brain injury was the most common cause of death (66%), followed by anoxia (9.7%) and hemorrhage (8%). Deaths from hemorrhage were most often in patients sustaining gunshot wounds (73% vs. 11% of all other deaths, p < 0.0001), more likely to occur early (100% vs. 50% of all other deaths, p = 0.0009), and all died within 6 hours of arrival. Death from hemorrhage was more common in adolescents (21.4% of children aged 13-17 vs. 6.3% of children aged 0-6, and 0% of children aged 7-12 p = 0.03). The highest case fatality rates were seen in hangings (38.5%) and gunshot wounds (9.6%). Half of pediatric trauma deaths occurred within 24 hours. Death from hemorrhage was rare, but all occurred within 6 hours of arrival. This is a critical time for interventions for bleeding control to prevent death from hemorrhage in children. Analysis of these deaths can focus efforts on the urgent need for development of new hemorrhage control adjuncts in children. Epidemiological study, level IV.

An Analysis of Adherence to Tactical Combat Casualty Care Guidelines for the Administration of Tranexamic Acid.

Hemorrhage is the leading cause of potentially survivable deaths in combat. Previous research demonstrated that tranexamic acid (TXA) administration decreased mortality among casualties. For casualties expected to receive a transfusion, the Committee on Tactical Combat Casualty Care (TCCC) recommends TXA. Despite this, the use and adherence of TXA in the military prehospital combat setting, in accordance with TCCC guidelines, is low. We sought to analyze TXA administration and use among combat casualties reasonably expected to require blood transfusion, casualties with tourniquet placement, amputations, and gunshot wounds. Based on TCCC guidelines, we measured proportions of patients receiving prehospital TXA: casualties undergoing tourniquet placement, casualties sustaining amputation proximal to the phalanges, patients sustaining gunshot wounds, and patients receiving ≥10 units of blood products within 24h of injury. Univariable and multivariable analyses were also completed. Within our dataset, 255 subjects received TXA. Four thousand seventy-one subjects had a tourniquet placed, of whom 135 (3.3%) received prehospital TXA; 1899 subjects had an amputation proximal to the digit with 106 (5.6%) receiving prehospital TXA; and 6660 subjects had a gunshot wound with 88 (1.3%) receiving prehospital TXA. Of 4246 subjects who received ≥10 units of blood products within the first 24h, 177 (4.2%) received prehospital TXA. We identified low TXA administration despite TCCC recommendations. Future studies should seek to both identify reasons for limited TXA administration and methods to increase future utilization.

Use of ShotSpotter detection technology decreases prehospital time for patients sustaining gunshot wounds.

Shorter prehospital time in patients sustaining penetrating trauma has been shown to be associated with improved survival. Literature has also demonstrated that police transport (vs. Emergency Medical Services [EMS]) shortens transport times to a trauma center. The purpose of this study was to determine if ShotSpotter, which triangulates the location of gunshots and alerts police, expedited dispatch and transport of injured victims to the trauma center. All shootings which occurred in Camden, NJ, from 2010 to 2018 were reviewed. Demographic, geographic, response time, transport time, and field intervention data were collected from medical and police records. We compared shootings where the ShotSpotter was activated versus shootings where ShotSpotter was not activated. Incidents, which did not occur in Camden or where complete data were not available, were excluded as were patients not transported by police or EMS. There were 627 shootings during the study period which met inclusion criteria with 190 (30%) activating the ShotSpotter system. Victims involved in shootings with ShotSpotter activation were more severely injured, more likely to be transported by police, less likely to undergo trauma bay resuscitative measures, and more likely to receive blood products. Mortality, when adjusted for distance, Trauma, and Injury Severity Score, Injury Severity Score, and shock index, was not significantly different between ShotSpotter and non-ShotSpotter incidents. ShotSpotter activation significantly reduced both the response time as well as transport time for both police and EMS (all p < 0.05). The activation of the ShotSpotter technology increased the likelihood of police transport of gunshot victims. Furthermore, the use of this technology resulted in shorter response times as well as transport times for both police and EMS. This technology may be beneficial in enhancing the care of victims of penetrating trauma. Therapeutic/Care management, level III.

Expectoration of a bullet after gunshot wound to the chest

Over the last century, only four cases have been published of patients sustaining gunshot wounds to the chest, managed nonoperatively, who eventually expectorated the bullet. We report the case of a hemodynamically stable 24-year-old male whose bullet was found in the left pulmonary hilum on admission computed tomography (CT) scan. Further workup revealed no obvious aerodigestive injury. Shortly after extubation, he expectorated the bullet onto the floor. Little is known about how to manage these stable, yet challenging patients.

Gunshot Injuries in the Elderly: Patterns and Outcomes. A National Trauma Databank Analysis

Trauma in the elderly (≥ 55 years) accounts for a significant proportion of admissions to trauma centers. Our understanding of the epidemiology and outcomes associated with penetrating injury in this age segment of the population, however, is severely limited. The aim of the present study therefore was to investigate the incidence and type of injuries sustained by elderly patients from firearms and the impact of age on outcomes. This was a 5-year National Trauma Databank (NTDB) study. Injury demographics, mortality rates, and lengths of stay in the Intensive Care Unit (ICU) and the hospital were analyzed. Elderly patients ≥ 55 years old were assigned to one of three categorical strata: 55-64 years old, 65-74 years old, and ≥ 75 years old. During the study period, 98,242 patients were admitted for firearm-related injuries, and 3,190 (3.2%) of them were ≥ 55 years old. Within the elderly age segment of the population, 1,676 patients (52.5%) were 55-64 years of age, 727 (22.8%) were 65-74 years of age, and 787 (24.7%) were ≥ 75 years old. The incidence of severe trauma [Injury Severity Score (ISS) ≥ 16] in the elderly age strata was 43.3, 46.8, and 57.6%, respectively (p < 0.001). Patients ≥ 75 years old were significantly more likely than patients 55-74 years old to suffer self-inflicted injuries. The most commonly encountered injury in elderly patients was gunshot wounds to the head, which increased in a stepwise fashion with advancing age (25.8, 31.6, and 39.4% respectively; p < 0.001). The crude mortality rate in all patients sustaining gunshot wounds increased progressively with age. Within the elderly age segment, mortality ranged from 28.5% in the age stratum 55-64 years, to 55.4% in the stratum ≥ 75 years (adjusted p < 0.001). Intensive care unit and hospital length of stay increased with advancing age but peaked and remained stable among the elderly age groups. An admission Glasgow Coma Score (GCS) ≤ 8, an ISS ≥ 16, hypotension on admission, age, self-inflicted injury, and injury sustained by assault were factors independently associated with death in patients ≥ 55 years. Injury from firearms is not uncommon in the elderly patient population and is primarily a result of self-inflicted gunshot wounds to the head. These patients sustain a high burden of injury and a high rate of mortality, which increases with advancing age.

Assessment of Initial Base Deficit as a Predictor of Outcome: Mechanism of Injury Does Make a Difference

Initial base deficit in injured patients has been shown to predict the adequacy of resuscitation and outcome. The usefulness of base deficit as a predictor of outcome, however, may be dependent on the mechanism of injury. We conducted a retrospective review of the trauma registry, supplemented by chart review, of all trauma patients treated at a Level I trauma center from January 1995 through July 2001. Data collected included mechanism of injury, base deficit, Injury Severity Score, and outcome. From 1995 through 2001 a total of 3275 patients (23% of trauma admissions) at a mean age of 34 +/- 15 years had a base deficit recorded at the time of admission. The patients were 78 per cent male, and the mechanism of injury was blunt trauma in 58.2 per cent. Mortality increased with successive increases in base deficit but was markedly lower for a given base deficit in those patients having sustained stab wounds and/or severe lacerations as compared with those with gunshot wounds or blunt trauma. The value of the base deficit as a predictor of outcome depends upon the mechanism of injury and appears most useful for patients sustaining gunshot wounds or blunt trauma. Future studies in patients with penetrating trauma using base deficit as a predictor of outcome should separate patients with gunshot wounds from those with stab wounds or lacerations.

Patients with gunshot wounds to the head do not require cervical spine immobilization and evaluation.

The purpose of this study was to determine the incidence of indirect spinal column injury in patients sustaining gunshot wounds to the head. A retrospective review of patient records and autopsy reports was conducted of patients admitted with gunshot wounds to the head between July of 1990 and September of 1995 were included. Those with gunshot wounds to the neck and those who were dead on arrival were excluded. A total of 215 patients were included in the study. Cervical spine clearance in 202 patients (93%) was determined either clinically, radiographically, or by review of postmortem results. No patients sustained indirect (blast or fall-related) spinal column injury. Three patients had direct spinal injury from bullet passage that were apparent from bullet trajectory. More intubation attempts occurred in patients with cervical spine immobilization (49 attempts in 34 patients with immobilization versus five attempts in four patients without cervical spine immobilization, p = 0.008). Indirect spinal injury does not occur in patients with gunshot wounds to the head. Airway management was compromised by cervical spine immobilization. Protocols mandating cervical spine immobilization after a gunshot wound to the head are unnecessary and may complicate airway management.

Gunshot wounds of the female breast: a risk for intra-abdominal injury.

We report the results of a clinical study of female patients sustaining gunshot wounds to a breast. Thirteen homicides were reviewed by the Fulton County Medical Examiner. A prospective series of patients treated by the Grady Memorial Hospital Trauma Service included eight additional cases. Ten (48%) of the combined series of 21 patients had significant intra-abdominal injury; of these, five (24%) had injuries confined to the abdomen as a result of a missile striking a breast. A wound pattern consisting of a superior breast entrance wound, an inferior breast exit wound, and an inframammary thoracoabdominal reentry wound was noted in five patients, four of whom had intra-abdominal injuries and three only intra-abdominal injuries. Careful examination for this wound pattern should alert the clinician to the possibility of intra-abdominal injury. One should anticipate a 50% incidence of intra-abdominal injury in female patients sustaining gunshot wounds to a breast.

Peritoneal lavage. Its unreliability in gunshot wounds of the lower chest and abdomen.

The accuracy of peritoneal lavage in patients with gunshot wounds has not been previously reported. A prospective study comprised of 168 patients was designed to determine the reliability of physical examination and peritoneal lavage. Patients sustaining gunshot wounds to the lower chest and abdomen underwent clinical assessment followed up by lavage prior to operation. There was 20.2% false-negative and 15.9% false-positive physical examination results. Of the patients. 25.4% with a false-negative lavage results had a positive celiotomy. Six of 15 patients with false-negative lavage results had RBC counts less than 1,000/cu mm. Gunshot wounds differ from stab wounds because of the unpredictable trajectory, blast effect, and high likelihood of visceral injury. It can be concluded from this study that because of the inconsistent results of both lavage and physical examination, patients who sustain gunshot wounds are best treated by exploratory celiotomy.