Pediatric firearm mortality in the United States, 2010 to 2016: A National Trauma Data Bank analysis

Presentation and Management of Self-Inflicted Gunshot Wounds to the Face

Self-inflicted gunshot wounds (SI-GSW) to the head and face are associated with significant morbidity and mortality. Patients who do survive their injuries often face life-altering disfigurement and disability. To effectively care for these patients, providers must not only detect and address the immediate life-threatening injuries, but also plan for long-term definitive reconstruction. This review provides an overview of presentation and management of SI-GSW to the face, including initial stabilization and workup, assembly of a multidisciplinary care team, surgical reconstruction of soft tissue and bony defects, and long-term management to address aesthetic and functional goals. Emphasis is placed on the role of plastic and reconstructive surgeons in SI-GSW reconstruction; however, a better understanding of these complex injuries and their management can help all health care providers better optimize care for this high-risk population.

A Decade of Firearm Injuries: Children Caught in the Crossfire

INTRODUCTION

Firearm injuries (FIs) are the leading cause of preventable morbidity and mortality in pediatric patients. In this study, we aim to define evolving trends and avenues for prevention.

METHODS

Following institutional review board approval, medical records of patients presenting to our two State-Designated Level 1 Pediatric Trauma Centers for treatment of FIs from 2010 to 2019 were retrospectively reviewed. Data was analyzed with Chi-Squared and Student's t-test; P-value <0.05 was significant.

RESULTS

1037 FI encounters from 1005 unique patients aged 0-21 y were included. 70.4% (n = 730) were determined to be assaults, 26.1% (n = 271) unintentional, and 1.7% (n = 18) self-inflicted injuries. Overall mortality was 4.5% (n = 45). FI victims were most commonly African American (n = 836, 80.6%), male (n = 869, 83.8%), aged 13-17 (n = 753, 72.6%), and from single-parent families (n = 647, 62.4%). The incidence of FIs increased significantly over the last 5 y of the study (2010-2014, 6.8 FIs/month), compared to 2015-2019 (averaging 10.6 FIs/month, P < 0.0001). Concurrently, FI related fatality increased from an average of 2.6 deaths/year (2010-2014) to 6.4 deaths/year (2015-2019, P = 0.064). Results were subanalyzed for pediatric patients aged 0-14 y. For the entire cohort, 12.1% (n = 116) recidivists were identified. Geographic patterns of injury were identified, with 75% of all FIs clustered in a single urban region.

CONCLUSIONS

Incidence of pediatric FIs is increasing in recent years, with high mortality rates. Violence and recidivism are geographically concentrated, offering an opportunity for targeted interventions.

A decade of firearm injuries: Have we improved?

BACKGROUND

Firearm injuries are a growing public health issue, with marked increases coinciding with the coronavirus disease 2019 (COVID-19) pandemic. This study evaluates temporal trends over the past decade, hypothesizing that despite a growing number of injuries, mortality would be unaffected. In addition, the study characterizes the types of centers affected disproportionately by the reported firearm injury surge in 2020.

METHODS

Patients 18 years and older with firearm injuries from 2011 to 2020 were identified retrospectively using the National Trauma Data Bank (NTDB®). Trauma centers not operating for the entirety of the study period were excluded to allow for temporal comparisons. Joinpoint regression and risk-standardized mortality ratios (SMR) were used to evaluate injury counts and adjusted mortality over time. Subgroup analysis was performed to describe centers with the largest increases in firearm injuries in 2020.

RESULTS

A total of 238,674 patients, treated at 420 unique trauma centers, met inclusion criteria. Firearm injuries increased by 31.1% in 2020, compared to an annual percent change of 2.4% from 2011 to 2019 ( p = 0.01). Subset analysis of centers with the largest changes in firearm injuries in 2020 found that they were more often Level I centers, with higher historic trauma volumes and percentages of firearm injuries ( p < 0.001). Unadjusted mortality decreased by 0.9% from 2011 to 2020, but after controlling for demographics, injury characteristics and physiology, there was no difference in adjusted mortality over the same time period. However, among patients with injury severity scores ≥25, adjusted mortality improved compared with 2011 (SMR of 0.950 in 2020; 95% confidence interval, 0.916-0.986).

CONCLUSION

Firearm injuries pose an increasing burden to trauma systems, with Level I and high-volume centers seeing the largest growth in 2020. Despite increasing numbers of firearm injuries, mortality has remained unchanged over the past decade.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level III.

Trends in youth risk behaviours and firearm injury in the USA over 20 years

BACKGROUND

Firearm injuries are the leading cause of death in children and adolescents in the USA. We hypothesised that high rates of risky behaviour in high school students are associated with firearm injury and death in this population.

METHODS

We obtained data from the Youth Behaviour Risk Survey of the Centers for Disease Control and Prevention (CDC) and combined it with data from the CDC Web-based Injury Statistics Query and Reporting System, CDC Wide-ranging Online Data for Epidemiologic Research and American Community Survey, 2001-2020. We examined trends over time using a non-parametric test for trends.

RESULTS

The percentage of high school-aged youth carrying a weapon in the preceding 30 days ranged from 13.2% in 2019 to 18.5% in 2005, without a statistically significant trend over time (p=0.051). Those carrying a weapon to school peaked at 6.5% in 2005 and steadily downtrended to 2.8% in 2019 (p=0.004). Boys consistently reported higher rates of weapon carriage, with white boys reporting higher rates than black boys. Firearm homicides among adolescents 14-18 years showed no significant change, ranging from 4.0 per 100k in 2013 to 8.3 per 100k in 2020. This varied considerably by sex and race, with black boys suffering a rate of nearly 60 per 100 000 in 2020 and white girls rarely exceeding 1/100 000 during the study period.

CONCLUSION

Self-reported weapon carriage among teens in the USA has steadily downtrended over time. However, shooting injuries and deaths have not. While the former suggests progress, the latter remains concerning.

LEVEL OF EVIDENCE

Level III; retrospective cohort study.

Addressing health equity in pediatric surgical care in the United States- Progress and challenges

There are notable inequities in health outcomes for children based on their social determinants of health (SDOH), including where they are born and live, their primary language, their race and ethnicity, socioeconomic status, and more. These health inequities are not restricted to resource limited settings; here we highlight three broad topics that are relevant to pediatric surgeons in the United States (US): access to care and disparities, and examples of inequities in firearm-related injuries and appendicitis. Most of our patients will at some point require operative interventions, yet there can be significant challenges in accessing this care and navigating our health systems, particularly around complex perioperative care. There are significant opportunities to improve equitable care by helping patients navigate our health systems and connecting them with additional resources, including screening for primary care services. Firearm-related injuries are now the leading cause of death in children in the US, with significant associated morbidity for non-fatal injuries. There are notable inequities in the risk of injury and types of injuries experienced by children based on their SDOH. Appendicitis is one of the most common pathologies managed by pediatric surgeons, with similar inequities in the rates of perforated appendicitis based on a child's SDOH. For both issues, addressing the inequities our patients experience requires moving upstream and working towards prevention. Key opportunities include better research and data to understand the drivers for observed inequities, multidisciplinary collaboration, community engagement, and public health advocacy among others. As a profession, we have a responsibility to work to address the health inequities our patients experience.

Does Trauma Center Volume Account for the Association Between Trauma Center Verification Level and In-Hospital Mortality among Children Injured by Firearms in California?

BACKGROUND

Heterogeneity in trauma center designation and injury volume offer possible explanations for inconsistencies in pediatric trauma center designation's association with lower mortality among children. We hypothesized that rigorous trauma center verification, regardless of volume, would be associated with lower firearm injury-associated mortality in children.

STUDY DESIGN

This retrospective cohort study leveraged the California Office of Statewide Health Planning and Development patient discharge data. Data from children aged 0 to 14 years in California from 2005 to 2018 directly transported with firearm injuries were analyzed. American College of Surgeons (ACS) trauma center verification level was the primary predictor of in-hospital mortality. Centers' annual firearm injury volume data were analyzed as a mediator of the association between center verification level and in-hospital mortality. Two mixed-effects multivariable logistic regressions modeled in-hospital mortality and the estimated association with center verification while adjusting for patient demographic and clinical characteristics. One model included the center's firearm injury volume and one did not.

RESULTS

The cohort included 2,409 children with a mortality rate of 8.6% (n = 206). Adjusted odds of mortality were lower for children at adult level I (adjusted odds ratio [aOR] 0.38, 95% CI 0.19 to 0.80), pediatric (aOR 0.17, 95% CI 0.05 to 0.61), and dual (aOR 0.48, 95% CI 0.25 to 0.93) trauma centers compared to nontrauma/level III/IV centers. Firearm injury volume did not mediate the association between ACS trauma center verification and mortality (aOR/10 patient increase in volume 1.01, 95% CI 0.99 to 1.03).

CONCLUSIONS

Trauma center verification level, regardless of firearm injury volume, was associated with lower firearm injury-associated mortality, suggesting that the ACS verification process is contributing to achieving optimal outcomes.

Population Density and Triage of Pediatric Firearm Injuries in a Rural Trauma System

BACKGROUND

Rural pediatric firearm injuries require regional pediatric and trauma expertise. We evaluated county-level population density associations with transport, hospital interventions, and patient outcomes at a Level I pediatric trauma center serving a rural, statewide catchment area.

MATERIAL AND METHODS

The trauma registry of the only in-state pediatric trauma center was reviewed for firearm injuries in patients < 18 between 1/2013 and 3/2020. County-level population density was classified according to the United States Office of Management and Budget definitions for rural, micropolitan, and metropolitan areas.

RESULTS

364 patients were identified, including 7 patients who were re-injured. Mean age was 11.3 ± 4.5 y and patients were 79.4% male. 59.3% were transferred from a referring hospital. Median injury severity score was 5 (IQR 1-10); 88.0% required trauma center admission, and 48.2% required operative intervention. 7.4% were injured in a rural county, 46.4% in a micropolitan county, and 46.2% in a metropolitan county. Patients from rural counties were more likely to be unintentionally injured (72.0%) than those from micropolitan (54.4%) or metropolitan counties (44.0%, P = .04). While need for inpatient admission and length of stay were similar, those transported from rural counties had significantly longer transport times (P < .01) and less frequent need for operative intervention (P = .03), as well as trends toward lower injury severity (P = .08) and mortality (P = .06).

CONCLUSION

Management of pediatric firearm injury is a unique challenge with significant regional variability. Opportunities exist for outreach, telehealth, and decision support to ensure equitable distribution of resources in rural trauma systems.

LEVEL OF EVIDENCE

Epidemiological, Level III.

Pediatric vs Adult or Mixed Trauma Centers in Children Admitted to Hospitals Following Trauma: A Systematic Review and Meta-Analysis

Importance

Adult trauma centers (ATCs) have been shown to decrease injury mortality and morbidity in major trauma, but a synthesis of evidence for pediatric trauma centers (PTCs) is lacking.

Objective

To assess the effectiveness of PTCs compared with ATCs, combined trauma centers (CTCs), or nondesignated hospitals in reducing mortality and morbidity among children admitted to hospitals following trauma.

Data Sources

MEDLINE, Embase, and Web of Science through March 2023.

Study Selection

Studies comparing PTCs with ATCs, CTCs, or nondesignated hospitals for pediatric trauma populations (aged ≤19 years).

Data Extraction and Synthesis

This systematic review and meta-analysis was performed following the Preferred Reporting Items for Systematic Review and Meta-analysis and Meta-analysis of Observational Studies in Epidemiology guidelines. Pairs of reviewers independently extracted data and evaluated risk of bias using the Risk of Bias in Nonrandomized Studies of Interventions tool. A meta-analysis was conducted if more than 2 studies evaluated the same intervention-comparator-outcome and controlled minimally for age and injury severity. Subgroup analyses were planned for age, injury type and severity, trauma center designation level and verification body, country, and year of conduct. Grading of Recommendations Assessment, Development, and Evaluation (GRADE) was used to assess certainty of evidence.

Main Outcome(s) and Measure(s)

Primary outcomes were mortality, complications, functional status, discharge destination, and quality of life. Secondary outcomes were resource use and processes of care, including computed tomography (CT) and operative management of blunt solid organ injury (SOI).

Results

A total of 56 studies with 286 051 participants were included overall, and 34 were included in the meta-analysis. When compared with ATCs, PTCs were associated with a 41% lower risk of mortality (OR, 0.59; 95% CI, 0.46-0.76), a 52% lower risk of CT use (OR, 0.48; 95% CI, 0.26-0.89) and a 64% lower risk of operative management for blunt SOI (OR, 0.36; 95% CI, 0.23-0.57). The OR for complications was 0.80 (95% CI, 0.41-1.56). There was no association for mortality for older children (OR, 0.71; 95% CI, 0.47-1.06), and the association was closer to the null when PTCs were compared with CTCs (OR, 0.73; 95% CI, 0.53-0.99). Results remained similar for other subgroup analyses. GRADE certainty of evidence was very low for all outcomes.

Conclusions and Relevance

In this systematic review and meta-analysis, results suggested that PTCs were associated with lower odds of mortality, CT use, and operative management for SOI than ATCs for children admitted to hospitals following trauma, but certainty of evidence was very low. Future studies should strive to address selection and confounding biases.

Functional impairment associated with nonfatal pediatric firearm injuries

BACKGROUND

Firearm injury is now the leading cause of death for children in the United States. Functional morbidity among survivors also contributes to the public health burden of firearm injury but has not been quantified in children. This study aimed to assess functional impairment among survivors of pediatric firearm injury.

METHODS

We analyzed an 8-year (2014-2022) retrospective cohort of children (0-18 years) treated for firearm injuries at 2 urban level 1 pediatric trauma centers. The Functional Status Scale was used to assess functional impairment among survivors at discharge and at follow-up. Functional impairment was defined using multisystem (Functional Status Scale ≥8) and single-system (Functional Status Scale = 7) definitions.

RESULTS

The cohort included 282 children with a mean age of 11.1 (standard deviation 4.5) years. In-hospital mortality was 7% (n = 19). Functional impairment (Functional Status Scale ≥8) was present in 9% (n = 24) of children at discharge and in 7% (n = 13/192) at follow-up. Mild impairment in a single domain (Functional Status Scale = 7) was seen in 42% (n = 110) of the cohort at discharge. This impairment persisted to follow-up in most (67%, n = 59/88) of these children.

CONCLUSION

Functional impairment at discharge after firearm injury is common among children surviving transport in these trauma centers. These data highlight the added value of non-mortality metrics in assessing the health burden of pediatric firearm injuries. The collective impact of mortality and functional morbidity should be considered when advocating for resources to protect children.

Pediatric firearm injury related emergency department visits and hospitalizations: a population-based study in the United States

Background

Firearm injury (FI) is the leading cause of death in children and adolescents in the United States (US). We describe the epidemiology of pediatric FI-associated emergency department (ED) visits and hospitalizations in the US stratified by race and ethnicity.

Methods

Data on pediatric (0-17-year-olds) FI were analyzed using the 2019 Nationwide Emergency Department Sample (NEDS) and Kids' Inpatient Database (KID), the largest all-payer databases in the US for ED visits and pediatric hospitalizations, respectively. FI encounters were stratified by race and ethnicity. Poisson regression was used to identify factors associated with in-hospital mortality. Sampling weights were applied to generate nationally representative estimates.

Findings

There were 7017 pediatric ED visits with FI (NEDS); 85.0% (5961/7017) were male and 73.0% (5125/7017) were adolescents (15-17 years). Overall, 5.5% (384/7017) died in the ED; 53.1% (3727/7017) of ED encounters did not result in hospitalization. There were 2817 pediatric FI hospitalizations (KID); 84.1% (2369/2817) were male and 71.6% (2018/2817) were adolescents; 51.4% (1447/2817) of FI were unintentional, 42.8% (1207/2817) were assault-related, and 5.8% (163/2817) were self-inflicted. Black children had the highest proportion (52.6%; 1481/2817) of hospitalizations among all race and ethnicities (p < 0.0001 vs. White). White children had the highest proportion of hospitalizations for self-inflicted injuries (16.6% [91/551] vs. 4.9% [25/504; p < 0.0001] in Hispanics and 1.7% [24/1481] in Blacks; p < 0.0001). The majority (56.5%; 1591/2817) of hospitalizations were patients from low-income zip codes (median annual-household-income <$44,000); 70% (1971/2817) had Medicaid as the primary insurance payer. Overall, 8.0% (225/2817) died during FI-associated hospitalizations. Self-inflicted injuries had the highest in-hospital mortality (prevalence ratio = 8.20, 95% CI = 6.06-11.10 vs. unintentional).

Interpretation

Black children and children with lower household incomes were disproportionately impacted by FI resulting from assaults and accidents, while White children had the highest proportion of self-inflicted FI injuries. Public health and legal policy interventions are needed to prevent pediatric FI.

Funding

US National Institutes of Health.

Rising Mortality in Pediatric Self-Inflicted Firearm Trauma Associated With Distinct Anatomic Injury

INTRODUCTION

Self-inflicted injuries are the second leading cause of pediatric (10-18 y old) mortality. Self-inflicted firearm trauma (SIFT) was responsible for up to half of these deaths in certain age groups. We hypothesized that SIFT prevalence has increased and is associated with specific demographics, injury patterns, and outcomes.

MATERIALS AND METHODS

Data were abstracted from the 2007-2018 American College of Surgeons (ACS) Trauma Quality Programs Participant Use Files (TQP-PUF). Pediatric (1-17 yold) victims of firearm violence were eligible. Age, race, gender, anatomic region, and intent were abstracted. Variables were analyzed using chi-squared tests, t-tests, and single-variate linear regression models. Temporal trends were analyzed using ANCOVA tests. Multivariate logistic regressions were conducted to identify factors influencing mortality. Significance was P < 0.05.

RESULTS

There were 41,239 pediatric firearm trauma patients (SIFT: 5.5% [n = 2272]). SIFT incidence increased over the 12-y period (2007 (n = 67) versus 2018 (n = 232), P < 0.05). SIFT was significantly associated with Caucasian race, 67% (n = 1537), teenagers, 90% (n = 2056), male gender, 87% (n = 1978), and a higher median injury severity score (ISS) than other intents of injury (SIFT: 20.0 (IQR: 9.0, 25.0) versus other: 9.0 (IQR: 1.0-13.0), P < 0.001). The SIFT mortality rate was 44% (n = 1005). On multivariate regression head gunshot wounds (OR: 21.1, 95% C.I.: 9.9-45.2, P = 0.001), and ISS (OR:1.1, 95% C.I.: 1.1-1.1, P = 0.001) were significantly associated with mortality. Compared to other intents, SIFT mortality rates increased at a higher annual rate (P < 0.001).

CONCLUSIONS

Comprehensive local and federal policy changes to reduce firearms access and increase pediatric mental health support may mitigate these injuries.

Wounding patterns in pediatric firearm fatalities

INTRODUCTION

Pediatric firearm injury became the leading cause of death among U.S. children in 2020. Studies evaluating wounding patterns in military and mass casualty shootings have provided insights into treatment and potential salvageability in adults, however, similar studies in the pediatric population do not exist. Hence, our study aimed to analyze wounding patterns of pediatric firearm fatalities and associated demographics and characteristics, such as place of death, to better understand pediatric firearm injuries, potential salvageability, and opportunities to reduce firearm deaths among vulnerable pediatric populations.

METHODS

A retrospective review of the National Violent Death Reporting System from 2005-2017 was performed on patients 18 and younger. Mortalities were stratified by patient age: <12 years and 13-18 years and by intent- homicide, suicide, and unintentional. Comparative and exploratory analyses of demographics, location of death and anatomic location of wounds were performed.

RESULTS

Of 8,527 pediatric firearm mortalities identified, 4,728 were homicides, 3,180 were suicides and 619 were unintentional injuries. Suicide victims were most likely to be dead on scene and >90% of suicide victims suffered head/neck injuries. For victims of homicide, younger children were more likely to die on scene (61% vs 44% p < 0.001). The pattern of injury in homicides differed for younger children compared to adolescents, with younger children with more head/neck injuries and older children more thoracic, thoracoabdominal, abdominal, and junctional injuries. In both age groups, children with extremity, abdominal and thoracoabdominal injuries were more likely to die later in the emergency department or inpatient setting.

CONCLUSIONS

Wounding patterns across pediatric firearm mortalities in the U.S. vary by age and intent. The majority of pediatric firearm deaths were due to head/neck injuries. Children with homicide and unintentional deaths had more wounding pattern variation, including more injuries to the thorax and abdomen, and a much lower rate of dead-on scene than suicide victims. Our study of wounding patterns among U.S. children killed by firearms highlights the complexity of these injuries and offers opportunities for tailored public health strategies across varying vulnerable pediatric populations.

National trends in pediatric firearm and automobile fatalities

BACKGROUND

Successful public health policies and injury prevention efforts have reduced pediatric automobile fatalities across the United States. In 2019, firearm injuries exceeded motor vehicle crashes (MVC) as the leading cause of childhood death in Colorado. We sought to determine if similar trends exist nationally and if state gun laws impact firearm injury fatality rates.

METHODS

Annual pediatric (≤19 years-old) fatality rates for firearm injuries and MVCs were obtained from the CDC WONDER database (1999-2020). State gun law scores were based on the 2014-2020 Gifford's Annual Gun Law Scorecard and strength was categorized by letter grades A-F. Poisson generalized linear mixed models were used to model fatality rates. Rates were estimated for multiple timepoints and compared between grade levels.

RESULTS

In 1999, the national pediatric fatality rate for MVCs was 248% higher than firearm injuries (Incidence Rate Ratio (IRR) 95% Confidence Interval (CI): 2.25-2.73, p<0.0001). By 2020, the fatality rate for MVCs was 16% lower than that of firearm injuries (IRR 95% CI: 0.75- 0.93, p = 0.0014). For each increase in letter grade for gun law strength there was an 18% reduction in the firearm fatality rate (IRR 95%CI: 0.78-0.86, p<0.0001). States with the strongest gun laws (A) had a 55% lower firearm fatality rate compared to those with the weakest laws (F).

CONCLUSION

Firearm injuries are the leading cause of death in pediatric patients across the United States. State gun law strength has a significant impact on pediatric firearm injury fatality rates. New public health policies, political action, media attention and safer guns are urgently needed to curb this national crisis.

LEVEL OF EVIDENCE/STUDY TYPE

Level III, retrospective.

Social determinants of health as drivers of inequities in pediatric injury

A child's social determinants of health (SDH), including their neighborhood environment, insurance status, race and ethnicity, English language proficiency and geographic location, all significantly impact their risk of injury and outcomes after injury. Children from socioeconomically disadvantaged neighborhoods experience overall higher rates of injury and different types of injuries, including higher rates of motor vehicle-, firearm-, and violence-related injuries. Similarly, children with public insurance or no insurance, as a proxy for lower socioeconomic status, experience higher rates of injuries including firearm-related injuries and non-accidental trauma, with overall worse outcomes. Race and associated racism also impact a child's risk of injury and care received after injury. Black children, Hispanic children, and those from other minority groups disproportionately experience socioeconomic disadvantage with sequelae of injury risk as described above. Even after controlling for socioeconomic status, there are still notable disparities with further evidence of racial inequities and bias in pediatric trauma care after injury. Finally, where a child lives geographically also significantly impacts their risk of injury and available care after injury, with differences based on whether a child lives in a rural or urban area and the degree of state laws regarding injury prevention. There are clear inequities based on a child's SDH, most predominantly in a child's risk of injury and the types of injuries they experience. These injuries are preventable and the SDH provide potential upstream targets in injury prevention efforts.

Nine years of pediatric gunshot wounds: a descriptive analysis

•

Firearm injury increases with age with previous studies examining ages 0–14 vs. 15–18.

•

There is poor documentation in the literature of key demographic details surrounding the injury.

•

There are important demographic differences that exist between older adolescent (13–14 years) and younger children (0–12 years).

•

Adolescents aged 13 years and older have similar profile to older adolescents/teens and may benefit from interventions such as violence intervention programs.

Pediatric firearm violence carries significant morbidity and mortality. Studies targeting children ≤14 years are limited. Our goal was to study the distribution and determinants of GSWs in the pediatric population. We performed a retrospective review of children ≤14 years presenting with GSWs at this level 1 trauma center. This cohort was split into younger children, 0–12 years, and older children, 13–14 years. Summary and bivariate statistics were calculated using Stata v10. 142 patients (68.3% black, 76.7% male) were identified. Injuries more often occurred at home (39.6%) by family or friends (60.7%). Older children often suffered handgun injuries (85.5%) and more often were sent immediately to the OR on presentation (29.2%). Younger children more often suffered from air-gun (50%) and pistols (40%). Younger children more commonly had blood transfusions (9.4%) compared to exploratory laparotomy in older children (13.5%). The most common disposition from the ED was home (36.2%). Descriptive data entailing incident specifics such as time of injury and CPS involvement were frequently missing in the healthcare record. Older children were more likely to be injured by strangers, have longer lengths of stay especially associated with surgical operations, and have a disposition of immediate arrest compared to their younger cohort. Consequently, this group may benefit from interventions typically aimed at older patients such as violence intervention programs. When available, differences in demographics and outcomes were identified which could shape novel prevention strategies for firearm injury.

The hidden mortality of pediatric firearm violence

INTRODUCTION

Firearms and motor vehicle collisions (MVC) are leading causes of mortality in children. We hypothesized that firearm injuries would have a higher mortality than MVCs in children and a higher level of resource utilization METHODS: Trauma patients <18 years old at a Level 1 pediatric trauma center sustaining gunshot wounds (GSW) or MVCs 2009-2019 were included. The primary outcome was mortality. The secondary outcome was immediate surgery. The California Department of Public Health's Overall Injury Surveillance tool was queried for patients <18 with GSW or MVC 2006-2015 to compare statewide case fatality rates (CFRs), and analyze proportions of GSWs by intent: assault, self-inflicted, and unintentional.

RESULTS

Of 13,840 pediatric trauma patients at our institution, 295 GSWs (2.1%) and 4467 MVCs (32.3%) were included. Mortality was higher for GSWs (7.5% vs. 0.8%, p<0.0001). GSW patients were more likely to require immediate surgery (34.4% vs. 11.2%, p<0.0001). On multivariable analysis, GSW patients were 7.8-times more likely to die than MVC patients (OR 7.83, 95% CI 3.68-16.66, p<0.0001), adjusted for age, sex, and injury severity. Statewide, there were 10,790 pediatric GSWs with 1586 deaths (CFR 14.7%) vs. 710 deaths in 261,363 children in MVCs (CFR 0.3%, p<0.0001). The GSW CFR rose (13.4% to 16.5%, p = 0.05) while the MVC CFR decreased (0.5% to 0.2%, p<0.0001) in 2015 vs. 2006.

CONCLUSION

Firearm violence in pediatric patients is significantly more lethal than MVCs and is resource intensive. The case fatality rate for pediatric firearm violence is rising. Resources must be directed at preventing pediatric firearm injuries.

LEVEL OF EVIDENCE

Prognosis study, Level II.

Tangential cranial gunshot wound in an infant in historical context: illustrative case

BACKGROUND

Military neurosurgeons have long known that tangential cranial gunshot wounds can be associated with intracranial complications out of proportion to the external appearance of the injury. This phenomenon seems not to have been described in infancy.

OBSERVATIONS

An infant suffered a massive, acute subdural hemorrhage from a contralateral tangential gunshot wound that did not facture the skull.

LESSONS

Similar to adults, infants are subject to catastrophic intracranial injury from gunshots that do not penetrate the skull. The nature of the injury in this case reflected distinctive aspects of the tissue characteristics and proportions of the infant head.

Pediatric firearm injury trends in the United States: A national trauma data bank (NTDB) analysis

AIM OF STUDY

Firearm injuries are the second leading cause of injury-related death in the USA in children less than 18. We compared overall and intent-specific firearm hospitalizations across age group and race to understand recent trends.

METHODS

A retrospective cohort of 20,083 children from the national trauma data bank involved in incidences of firearm discharges from 2013 to 2017 was divided by race, discharge intent, gun type, and four age groups: infants (ages 0-2), toddlers (3-6), children (7-12), and adolescents (13-18). Discharge intent and gun type were determined by ICD-9-CM and ICD-10-CM External Causes of Injury codes. Injury severity score (ISS), hospital discharge disposition, and length of stay (LOS) were used as predictors for morbidity and mortality.

RESULTS

From 2013 to 2017, there were on an average 4016 firearm injuries reported to the NTDB (n = 20,083). 71% (n = 14,313) of the incidents were assaults. Victims who identified as African American and Caucasian made up 60% (n = 11,890) and 26% (n = 5162) of the total victims, respectively, and were predominantly male (86%, n = 17,202). Victims who identified as Caucasian made up 70% of suicides (n = 819), while African Americans made up 70% of assaults (n = 9733). 87% (n = 17,525) of the patient population were adolescents. The number of accidental firearm discharges compared to firearm assaults was greater for toddlers, while the opposite was true for infants, children, and adolescents. Average LOS by age group varied each year, though children had the highest total average LOS.  Average ISS was highest for infants and adolescents (11.5 and 10.4) and American Indians and Caucasians (10.1 and 11.1). Overall mortality rate was 6% (n = 1220) and had no significant differences between years. Mortality rate was highest for infants (7%, n = 25).

CONCLUSIONS

Adolescent males and African Americans were disproportionately affected by overall and assault-specific firearm discharges. Firearm injury prevention legislation is critical to prevent these injures.

Racial disparities in triage of adolescent patients after bullet injury

BACKGROUND

While pediatric trauma centers (PTCs) and adult trauma centers (ATCs) exhibit equivalent trauma mortality, the optimal care environment for traumatically injured adolescents remains controversial. Race has been shown to effect triage within emergency departments (EDs) with people of color receiving lower acuity triage scores. We hypothesized that African-American adolescents were more likely triaged to an ATC than a PTC compared with their White peers.

METHODS

Institutional trauma databases from a neighboring, urban Level I PTC and ATC were queried for gunshot wounds in adolescents (15-18 years) presenting to the ED from 2015 to 2017. The PTC and ATC were compared in terms of demographics, services, and outcomes. Results were analyzed using univariate analysis and logistic regression.

RESULTS

Among 316 included adolescents, 184 were treated in an ATC versus 132 in a PTC. Patients at the PTC were significantly more likely to be younger (16.1 vs. 17.5 years; p < 0.001), White (16% vs. 5%; p = 0.001), and privately insured (41% vs. 30%; p = 0.002). At each age, the proportion of Whites treated at the PTC exceeded the proportion of African-Americans. At the PTC, patients were more likely to receive inpatient and outpatient social work follow-up (89% vs. 1%, p < 0.001). Adolescents treated at the PTC were less likely to receive opioids (75% vs. 56%, p = 0.001) at discharge and to return to ED within 6 months (25% vs. 11%, p = 0.005). On multivariate logistic regression, African-American adolescents were less likely to be treated at a PTC (odds ratio, 0.30; 95% confidence interval, 0.10-0.85; p = 0.02) after controlling for age and Injury Severity Score.

CONCLUSION

Disparities in triage of African-American and White adolescents after bullet injury lead to unequal care. African-Americans were more likely to be treated at the ATC, which was associated with increased opioid prescription, decreased social work support, and increased return to ED.

LEVEL OF EVIDENCE

Therapeutic/Care Management, Level IV.

An analysis of American physician professional statements about gun violence against children

BACKGROUND

We examine the content of physician professional association statements and assess the extent to which these statements kept gun violence-especially against children-on policymakers' agendas.

METHODS

After constructing a list of U.S. physician professional associations, we located position statements by consulting association websites, conducting a PubMed search, and reviewing the citations of identified statements. Once unique statements were identified (N = 32), two reviewers independently coded content such as major events, pediatric focus, firearm type, and policy recommendations.

RESULTS

Recent statements appear to be timed following mass casualty events such as the Sandy Hook and Parkland school shootings. Associations have increasingly adopted public health framing over time. Nine statements focused on the pediatric population, while an additional 13 made reference to the pediatric population. The most common recommendations include increased gun violence research or research funding (84%), freedom of physician counseling (75%), mandatory background checks (72%), and safe storage (72%).

CONCLUSION

Based on this analysis, recent statement volume appears to be tied to current events rather than keeping daily gun violence against children continuously on the agenda. Mentions of "gun control" have receded over time and have been replaced by public health framing that places advocacy for firearm injury prevention in the physician's domain.

LEVEL OF EVIDENCE

III/IV.

Comparison of cost and resource utilization between firearm injuries and motor vehicle collisions at pediatric hospitals

BACKGROUND/OBJECTIVES

Firearm injuries are converging with motor vehicle collisions (MVC) as the number one cause of death for children in the United States. Thus we examine differences in hospital cost and hospital resource utilization between motor vehicle and firearm injury.

METHODS

This retrospective, cross-sectional study compares hospital costs and resource utilization of motor vehicle and firearm-injured children aged 0 to 19 years of age over a 5-year time frame (January 1, 2013-December 31, 2017) in 35 freestanding children's hospitals that submitted data to the Pediatric Health Information System. The primary outcome was hospital-adjusted comparative cost per patient presentation. Generalized linear mixed models were used to quantify the relationship between the type of injury and each outcome, adjusting for patient characteristics and hospital.

RESULTS

There were 89,133 emergency department (ED) visits attributed to MVCs and 3,235 for firearm injury. Of the youths who presented for firearm injury, 49% were hospitalized versus 14% of youths presenting with MVC (adjusted odds ratio [aOR] = 6.6, 95% confidence interval [CI] = 6.1 to 7.2). Youths with firearm injury were more likely to be admitted to an intensive care unit (aOR = 6.7, 95% CI = 5.9 to 7.7) and had longer lengths of stays (aOR = 2.2, 95% CI = 1.9 to 2.6) compared to their MVC counterparts. Children admitted for firearm injury had more imaging and ED return visits, along with subsequent inpatient admission within 3 days (aOR = 3.4, 95% CI = 2.1 to 5.5) and 1 year (aOR = 2.5, 95% CI = 2.1 to 2.9). The mean relative per-patient costs were nearly fivefold higher for the firearm-injured group.

CONCLUSIONS

Hospital costs and markers of resource utilization were higher for youths with firearm injury compared to MVC. High medical resource utilization is one of several important reasons to advocate for a comparable national focus and funding on firearm-related injury prevention.

Mortality After Adolescent Firearm Injury: Effect of Trauma Center Designation

PURPOSE

To determine the incidence and outcomes of firearm injuries in adolescents and the effect of trauma center (TC) designation on their mortality.

METHODS

The National Trauma Data Bank (2010-2016) was queried for all encounters involving adolescents aged 13-16 years with firearm injuries. Multivariable logistic regression was employed to determine the association of covariates with mortality (α = .05). Propensity score matching was also used to explore the relationship between TC designation and mortality.

RESULTS

A total of 9,029 adolescents met inclusion criteria. Patients aged 15 and 16 years compromised 77.8% of the cohort and were more often male (87.9% vs. 80.6%, p < .001), black (63.8% vs. 56.1%, p < .001), injured in the abdomen (25.4% vs. 22.4%, p = .007) or extremities (62.3% vs. 56.7%, p < .001), and incurred severe injuries (54.5% vs. 50.9%, p = .004) versus 13- and 14-year-old patients. Younger patients were more often injured in the head/neck (23.8% vs. 20.5%, p = .001). Multivariable logistic regression demonstrated no difference in mortality between age groups. Poor neurologic presentation, severe injury, abdominal, chest, and head injuries were all associated with an increased odds of death. Odds of mortality were 2.88 times higher at adult TCs compared to pediatric TCs (CI: 1.55-5.36, p = .001). However, using a 1:1 propensity score matching model, no difference in mortality was found between TC types (p = NS).

CONCLUSIONS

Variability exists in outcomes for adolescents after firearm injuries. Understanding and identifying the potential differences between pediatric and adult TCs managing adolescent firearm victims may improve survival in all treatment venues, but these data support patients being treated at the closest available TC.

United States trends in healthcare charges for pediatric firearm injuries

BACKGROUND

From 2009 to 2016, >21,000 children died and an estimated 118,000 suffered non-fatal injuries from firearms in the United States. Limited data is available on resource utilization by injury intent. We use hospital charges as a proxy for resource use and sought to: 1) estimate mean charges for initial ED and inpatient care for acute firearm injuries among children in the U.S.; 2) compare differences in charges by firearm injury intent among children; and 3) evaluate trends in charges for pediatric firearm injuries over time, including within intent subgroups.

METHODS

In this repeated cross-sectional analysis of the 2009-2016 Nationwide Emergency Department Sample, we identified firearm injury cases among children aged ≤19 years using ICD-9-CM and ICD-10-CM external cause of injury codes (e-codes). Injury intent was categorized using e-codes as unintentional, assault-related, self-inflicted, or undetermined. Linear regressions utilizing survey weighting were used to examine associations between injury intent and healthcare charges, and to evaluate trends in mean charges over time.

RESULTS

Among 21,951 unweighted cases representing 102,072 pediatric firearm-related injuries, mean age was 16.6 years, and a majority were male (88.2%) and publicly insured (51.5%). Injuries were 53.9% assault-related, 37.7% unintentional, 1.8% self-inflicted, and 6.7% undetermined. Self-inflicted injuries had higher mean charges ($98,988) than assault-related ($52,496) and unintentional ($28,618) injuries (p < 0.001). Self-inflicted injuries remained associated with higher mean charges relative to unintentional injuries, after adjusting for patient demographics, hospital characteristics, and injury severity (p = 0.015). Mean charges for assault-related injuries also remained significantly higher than charges for unintentional injuries in multivariable models (p < 0.001). After adjusting for inflation, mean charges for pediatric firearm-related injuries increased over time (p-trend = 0.018) and were 23.1% higher in 2016 versus 2009. Mean charges increased over time among unintentional injuries (p-trend = 0.002), but not among cases with assault-related or self-inflicted injuries.

CONCLUSIONS

Self-inflicted and assault-related firearm injuries are associated with higher mean healthcare charges than unintentional firearm injuries among children. Mean charges for pediatric firearm injuries have also increased over time. These findings can help guide prevention interventions aimed at reducing the substantial burden of firearm injuries among children.