PTS 2014 PLENARY PAPER

Nonpowder firearms cause significant pediatric injuries Michelle Veenstra, MD, Jai Prasad, MD, Heather Schaewe, MSN, RN, Lydia Donoghue, MD, and Scott Langenburg, MD, Detroit, Michigan We hypothesize that nonpowder firearms cause significant injuries in children, often requiring intervention. We have noted a difference in demographics of children presenting with injuries from nonpowder firearms compared with patients injured by powder firearms. We reviewed our institution’s experience with patients with nonpowder firearm injuries to evaluate these aspects. METHODS: A retrospective chart review was completed for all patients with a firearm injury from 2003 through February 2013 to a pediatric urban Level I trauma center. Patients were excluded if they were 18 years of age or older or readmitted. Demographics, injury circumstances, interventions, and outcomes were reviewed for 303 patients. The W2 test and analysis of variance were completed with a statistical significance of p G 0.05. RESULTS: There were 57 nonpowder firearm injuries and 246 injuries from other firearms. Injuries occurred from BB, pellet, and paintball guns. Treatment included computed tomography scan in 39 patients, three bedside procedures, one angiography, and operative intervention in 25 patients. The most common injury locations were the eye (n = 37), head (n = 7), and neck (n = 6). Children injured by nonpowder firearms were less likely to be female (p = 0.04), more likely to be white (p G 0.01), and less likely to be injured in a violence-related event (p G 0.01). CONCLUSION: Nonpowder firearms can cause severe pediatric injuries requiring operative intervention and significant radiographic exposure from computed tomography scans. Prevention and education are important in decreasing this risk in the pediatric population and should be targeted to a different population than powder firearm prevention. (J Trauma Acute Care Surg. 2015;78: 1138Y1142. Copyright * 2015 Wolters Kluwer Health, Inc. All rights reserved.) LEVEL OF EVIDENCE: Epidemiologic study, level V. KEY WORDS: Urban; pediatric; firearm; trauma; nonpowder. BACKGROUND:

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onpowder firearms, including BB, airsoft, pellet, and paintball guns, remain a significant source of injury to children. The National Electronic Injury Surveillance SystemYAll Injury Program (NEISS-AIP) operated by the US Consumer Product Safety Commission with the Centers for Disease Control and Prevention’s National Center for Injury Prevention and Control reported 200,645 nonfatal BB/pellet gun injuries between 2003 and 2013, of whom 127,742 (63.6%) occurred in children.1 Although 24 states regulate nonpowder firearms to some degree, only 13 US states restrict sale of nonpowder firearms to a child (defined variably as any person from less than 18 years old to less than 12 years old) and an additional 8 states explicitly regulate their possession on school grounds.2,3 Michigan law treats all high-power and/or high-caliber nonpowder guns as firearms, and all restrictions on possession and purchase are applied, along with registration requirements. This excludes smooth bore rifles or handguns made for BB pellets not exceeding 0.177 caliber powered by gas or air. There is

Submitted: November 17, 2014, Revised: January 22, 2015, Accepted: January 26, 2015. From the Department of Pediatric Surgery, Children’s Hospital of Michigan, Detroit, Michigan. This study was presented at the 1st annual meeting of the Pediatric Trauma Society, November 14Y15, 2014, in Chicago, Illinois. Address for reprints: Michelle Veenstra, MD, Children’s Hospital of Michigan, Department of Pediatric Surgery, 3901 Beaubien Blvd, Detroit, MI 48201; email: [email protected]. DOI: 10.1097/TA.0000000000000642

an age restriction of 18 years old on possession, use, and transfer when not in the presence of an adult. Bullets traveling at a velocity greater than 36 m/s can pierce human skin, 39 m/s can pierce an eye, and 106 m/s can fracture mature bone.4,5 Larger-caliber bullets penetrate tissues at lower velocities.6 Nonpowder firearms have velocities anywhere from 80 m/s to 300 m/s and have been noted to cause injuries up to 20 to 60 feet away.4,5 In comparison, many powder handguns have similar muzzle velocities of 300 m/s.4,5 Pellets have several designs, including wad cutter, sharp pointed, round nosed, and hollow pointVeach designed for different purposes. BBs are small spherical ball bearings, and paintball guns fire spherical shells filled with dye.6 There have been many case series and reviews7,8 of both fatal and serious nonfatal injuries from nonpowder firearms across the years; however, with the exception of an epidemiologic study from Philadelphia,9 there is little recent information on the epidemiology and outcomes of such injuries in local populations. We reviewed all patients presenting to our Level I urban pediatric trauma center with firearm injuries between 2003 and 2013 to ascertain the demographics, injury patterns, and outcomes from nonpowder firearms. We secondarily compared the data from patients with nonpowder firearm injuries with those with powder firearm injuries to identify differences that can help focus preventive efforts.

METHODS After obtaining institutional review board approval (no. 093513MP4E), a review of our trauma database identified J Trauma Acute Care Surg Volume 78, Number 6

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all patients presenting to Children’s Hospital of Michigan after a firearm injury from 2003 to 2013. Patients were identified through a hospital-specific trauma database. 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 320 patients identified in the database, of whom 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 303 charts were reviewed, and data were obtained from the Emergency Department, trauma team, and emergency medical service documentation when available. Data abstracted included demographics (patient age, gender, race/ethnicity, 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 (LOS), mortality, and disposition). The intent of injury included categories of violence related, unintentional, and self-inflicted injuries. The violencerelated 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-hour intervals starting at midnight. The injuries sustained and hospital stay 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 hours and delayed intervention was recorded. Length of hospital stay and disposition at discharge were also reviewed. Patients with missing data were removed from the analysis of who shot the firearm, leaving 44 nonpowder injuries (77%) and 206 powder injuries (83%) analyzed. Statistical analysis was completed with SPSS version 21 (IBM Corporation, Somers, NY). A value of p G 0.05 was defined as statistically significant. Analysis of variance with Bonferroni correction and W2 analysis were completed with a statistician.

The mean age was 11 years (range, 0Y17 years). The highest prevalence of injury was among children 10 to 13 years old (23%), followed closely by the 14- to 17-year-old age group (19%). The highest rates of injury were during the spring and summer months as expected. Figure 1 shows the time of day injuries most commonly occurred for each gun group. Nonpowder injuries occurred after school between the hours of noon and 8 PM, whereas most powder injuries occurred after 8 pm. Girls were less likely to be injured by nonpowder firearms than other firearms (Table 1). Also, a significantly higher number of whites were injured by nonpowder firearms than from other firearms (Table 1). Most injuries with nonpowder firearms were unintentional (68%), with the rest having a violent intent (32%). As expected, 81% of injuries with other firearms were related to violence and only 17% were unintentional (Fig. 2). The shooter in nonpowder firearm injuries (n = 44) was often a friend or family member (58%) or the victim himself (29%), and only 13% of injuries were inflicted by strangers. Conversely, assailants unknown to the victim inflicted 71% of injuries sustained with other firearms (n = 206) (Fig. 3). The most commonly injured site was the eye, comprising 63% of all injuries, followed by the head (12%), neck (10%), extremities (8%), abdomen (5%), and the chest (2%) (Fig. 4). Nonpowder firearms when compared with other firearms were significantly more likely to injure the eye (p G 0.01) and the head and neck (p G 0.01). Computed tomography (CT) scans were performed in 68% of the nonpowder firearm injuries, most of which were for the orbit and the head. In comparison, only 36% of patients with powder firearm injuries underwent a CT scan. Twenty-five patients (44%) required an operative intervention, of whom three required multiple surgeries. Operative intervention was required in 45% of BB gun, 31% of pellet gun, and 100% of paintball gun injuries. There was not a difference in the need for operative intervention between powder and nonpowder firearm injuries (p = 0.07). There were no deaths during the study period from nonpowder firearm injuries. All patients admitted to the hospital were discharged home, and the length of hospital stay ranged from 0 to 8 days, with a median of 1 day (IQR, 1Y3

TABLE 1. Patient Demographics of Nonpowder and Powder Injuries

RESULTS Three hundred three patients presented with a firearm injury during the 11-year study period. Fifty-seven (18.8%) had a nonpowder gun injury (pellet, BB, or paintball gun). There were 42 (74%) BB gun injuries, 13 (23%) pellet gun injuries, and 2 (3%) paintball gun injuries. Boys were injured much more often than girls (84%). African American children (46%) formed the largest cohort, followed closely by whites (37%) (Table 1). New Injury Severity Score for nonpowder injuries ranged from 1 to 14, with a median of 1 (interquartile range [IQR], 1Y2).

Mean age (range) Race/ethnicity, n (%) African American White Hispanic Other/multiple Gender, n (%) Male Female

Nonpowder Injuries

Powder Injuries

p

11 y (6 wkY17 y)

12 y (6 moY17 y)

0.36 G0.01*

26 (46) 21 (37) 4 (7) 6 (10)

216 (88) 11 (5) 13 (5) 6 (2)

48 (84) 9 (16)

175 (71) 71 (29)

0.04*

*p G 0.05

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Figure 1. Nonpowder firearms were most common between noon and 8 PM, whereas powder firearm injuries occurred throughout the night, with the highest incidence after 8 PM.

laceration, one radial nerve injury, and one radius fracture requiring operative intervention. Two patients sustained severe eye injuries from paintball guns, both of whom required operative exploration. One patient underwent enucleation and eye implant, and the other developed a traumatic cataract requiring additional surgery. Paintball guns and their use in war games are relatively new phenomena, and there are reports of ocular injuries.6 In a review from Canada, air guns were the single largest cause of enucleation secondary to trauma.5 Our data reinforce the severity of the injuries these guns cause to the eyes. There were two patients with BB gun injuries who sustained skull fractures and intracranial injuries, both requiring operative intervention. O’Neil et al.11 reported 3

days). This was significantly shorter than the LOS for patients with powder injuries, with a median of 2 days (IQR, 1Y6 days) (p = 0.004).

DISCUSSION Nonpowder guns continue to be a significant source of injury and disability in the pediatric age group. Our data, in concordance with national data, indicate the potential for serious injury with nonpowder firearms and suggests the need for a high index of suspicion especially in the head and neck region.6 In comparing powder and nonpowder firearms, we observed a similar pattern of increased incidence in the summer months and a similar age distribution with most injuries occurring in adolescents (10Y15 years) as compared with earlier reports.9 Interestingly, the eye was the most commonly injured body area (63%), followed by the head and neck and extremities. Prior authors have reported the extremities to be the most commonly injured body site, although ophthalmologic injures were associated with a high rate of operative intervention9 or prolonged inpatient care.10 This may reflect a referral bias because most extremity injuries in the earlier report tended not to require operative intervention and were discharged from the emergency department after appropriate local wound care. Consistent with other reports,9 there were relatively few abdominal (5%) and thoracic injuries (2%). However, one of the three patients who sustained an abdominal injury required operative intervention for intestinal perforation. In addition, a second patient had a grade 3 splenic laceration that was managed nonoperatively. This is consistent with a high rate of intra-abdominal organ injury reported with intraperitoneal penetration of projectiles and potential for serious injury from nonpowder firearms.9 Serious injuries in our series included multiple ophthalmologic injuries requiring operative interventions, a carotid artery injury, two skull fractures and intracranial injuries, one patient with multiple small-bowel enterotomies, one splenic 1140

Figure 2. Most nonpowder injuries were unintentional, and the majority of powder injuries were violence related (p G 0.001). * 2015 Wolters Kluwer Health, Inc. All rights reserved.

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the initial injury occurred outside of the city limits of Detroit. Many of these injuries occurred in the suburbs surrounding the city compared with many powder firearm injuries that occurred in specific zip codes within city limits. There was no difference in the need for operative intervention between powder and nonpowder firearm injuries; however, patients with powder firearm injuries had longer LOS and higher mortality, suggesting more severe injuries. 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 I trauma center, and many patients were transferred after initial evaluation at an outside hospital. Data from other hospitals in the area were not included. In addition, these data were obtained from one hospital in one city and may not be representative of other areas of the country. There were no deaths from nonpowder firearms reported in our series. This, however, does not negate the lethal potential of nonpowder guns. The Consumer Product Safety Commission attributes approximately 4 deaths per year to high-powered air rifles since the 1990s.6 As suggested by Scribano et al.,9 a level of suspicion for serious injury similar to that in firearms should be maintained for patients of nonpowder gun injuries despite the often trivial skin wound. It is possible that parents who allow unsupervised possession of nonpowder firearms by their children may be underestimating the potential of injury from these devices.12 It is important that people purchasing nonpowder firearms are educated on the safety and proper usage of these weapons. Many people do not know state laws and restrictions or the potential for serious injury from nonpowder firearms. Education of the population in the injury potential of nonpowder guns is essential within a public health initiative to reduce preventable injury to children from nonpowder guns and firearms. Figure 3. Nonpowder injuries were most commonly caused by friends or family members or a patient shooting himself, whereas powder injuries were often caused by strangers (p = 0.001).

pediatric patients sustaining intracranial injuries from pellet/ BB guns, 2 of whom required operative intervention. There was a clear difference in the demographics of patients injured with nonpowder firearms compared with powder firearms. There were fewer females who sustained injuries from nonpowder guns, and nonpowder guns were more likely to injure whites than other firearms. This is notable because approximately 70% of patients presenting to our emergency department are of nonwhite ethnicity. Most injuries were unintentional, and the shooter was often a friend or a family member, suggesting that these injuries occur commonly in a recreational environment. Patients injured with powder firearms were more likely shot by a stranger, with violent intent, and were more likely African American. In addition, the majority of these patients were transfers from outside facilities and

Figure 4. Location of nonpowder firearm injuries.

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AUTHORSHIP Each author contributed substantially to the design, analysis, and interpretation of data presented in this article. M.V. performed data collection.

ACKNOWLEDGMENT There was no funding received for this work.

DISCLOSURE The authors declare no conflicts of interest.

REFERENCES 1. Centers for Disease Control and Prevention: Nonfatal Injury Data, Nonfatal Injury 2001Y2013YBB/Pellet Gun Injury 2003Y13. Injury Prevention and Control: Data & Statistics Web site. http://webappa.cdc.gov/ sasweb/ncipc/nfirates2001.html Updated March 28, 2013. Accessed November 13, 2013. 2. US Department of TreasuryYBureau of Alcohol, Tobacco and Firearms. State Laws and Published OrdinancesYFirearms. Available at: https:// www.atf.gov/publications/firearms/state-laws/31st-edition/index.html. 23rd Edition. 2001. ATF OnlineYP 5300.5.2001. 3. Law Center to Prevent Gun ViolenceYNon-Powder Guns Policy Summary. Available at: http://smartgunlaws.org/non-powder-guns-policy-summary. Updated October 28, 2013. Accessed November 13, 2013.

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4. DeCou JM, Abrams RS, Miller RS, Touloukian RJ, Gauderer MW. Lifethreatening air rifle injuries to the heart in three boys. J Pediatr Surg. 2000;35(5):785Y787. 5. Marshall DH, Brownstein S, Addison DJ, Mackenzie SG, Jordan DR, Clarke WN. Air guns: the main cause of enucleation secondary to trauma in children and young adults in the greater Ottawa area in 1974Y93. Can J Ophthalmol. 1995;30(4):187Y192. 6. Laraque D. American Academy of Pediatrics Committee on Injury, Violence, and Poison Prevention. Injury risk of nonpowder guns. Pediatrics. 2004;114(5):1357Y1361. 7. Christoffel KK, Tanz R, Sagerman S, Hahn Y. Childhood injuries caused by nonpowder firearms. Am J Dis Child. 1984;138(6):557Y561. 8. Walsh IR, Eberhart A, Knapp JF, Sharma V. Pediatric gunshot woundsVpowder and nonpowder weapons. Pediatr Emerg Care. 1988; 4(4):279Y283. 9. Scribano PV, Nance M, Reilly P, Sing RF, Selbst SM. Pediatric nonpowder firearm injuries: outcomes in an urban pediatric setting. Pediatrics. 1997;100(4):E5. 10. Bouhaimed M, Alwohaib M, Alabdulrazzaq S, Jasem M. Toy gun ocular injuries associated with festive holidays in Kuwait. Graefes Arch Clin Exp Ophthalmol. 2009;247(4):463Y467. 11. O’Neill PJ, Lumpkin MF, Clapp B, Kopelman TR, Matthews MR, Cox JC, et al. Significant pediatric morbidity and mortality from intracranial ballistic injuries caused by nonpowder gunshot wounds. A case series. Pediatr Neurosurg. 2009;45(3):205Y209. 12. Damore DT, Ramundo ML, Hanna JP, Dayan PS. Parental attitudes toward BB and pellet guns. Clin Pediatr (Phila). 2000;39(5):281Y284.

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Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.

Nonpowder firearms cause significant pediatric injuries.

We hypothesize that nonpowder firearms cause significant injuries in children, often requiring intervention. We have noted a difference in demographic...
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