Injury Patterns and Treatment Strategies in Civilian and Military Isolated Abdominal Gunshot Wounds.

BACKGROUND: Combat-related gunshot wounds (GSW) may differ from those found in civilian trauma centers. Missile velocity, resources, logistics, and body armor may affect injury patterns and management strategies. This study compares injury patterns, management, and outcomes in isolated abdominal GSW between military (MIL) and civilian (CIV) populations. METHODS: The Department of Defense Trauma Registry (DoDTR) and TQIP databases were queried for patients with isolated abdominal GSW from 2013 to 2016. MIL patients were propensity score matched 1:3 based on age, sex, and extraabdominal AIS. Injury patterns and in-hospital outcomes were compared. Initial operative management strategies, including selective nonoperative management (SNOM) for isolated solid organ injuries, were also compared. RESULTS: Of the 6435 patients with isolated abdominal GSW, 183 (3%) MIL were identified and matched with 549 CIV patients. The MIL group had more hollow viscus injuries (84% vs. 66%) while the CIV group had more vascular injuries (10% vs. 21%) (p < .05 for both). Operative strategy differed, with more MIL patients undergoing exploratory laparotomy (95% vs. 82%) and colectomy (72% vs. 52%) (p < .05 for both). However, no difference in ostomy creation was appreciated. More SNOM for isolated solid organ injuries was performed in the CIV group (34.1% vs. 12.5%; p < 0.05). In-hospital outcomes, including mortality, were similar between groups. CONCLUSIONS: MIL abdominal GSW lead to higher rates of hollow viscus injuries compared to CIV GSW. MIL GSW are more frequently treated with resection but with similar ostomy creation compared to civilian GSW. SNOM of solid organ injuries is infrequently performed following MIL GSW.

An unplanned complex suicide with 6 mm Flobert revolver and train crash: a case report.

A complex suicide defines a combination of multiple suicidal methods the victim successively or concurrently carries out. We present a case of a 72-year old man found dead on the railtrack, seemingly committing simple train-related suicide. Flobert revolver - a small caliber handgun was found nearby. Herein, we emphasize the significance of a thorough external examination, stress the fact that victim can act after low-energy projectile trauma and match our case to a similar complex suicide.

[Distribution features of gunshot residue from hunting Steyr Mannlicher AUG-Z3 carbine on targets]. / Osobennosti raspredeleniya na mishenyakh produktov vystrela iz okhotnich'ego karabina Steyr Mannlicher AUG-Z3.

OBJECTIVE: To study the morphology of distribution of shot factors on white targets made of coarse calico at different distances. MATERIAL AND METHODS: The study was conducted on 57 experimental damages of targets made of cotton fabric, caused by shots from hunting self-loading Steyr Mannlicher AUG-Z3 carbine of.223 Rem caliber. The number of experimental firings equal 19 was done by 3 shots at the distance from close range to 250 cm. The examination of shot targets was carried out using the visual, metric, stereoscopic (Leica 125M microscope) methods, in ultraviolet rays (LUMATEC SUPERLITE M Series light). RESULTS: The nature and morphology of distribution of gunshot residue on targets' surfaces made it possible to establish close range firing zones. The nature in which soot is deposited during shot under the conditions of point-blank range and in the first zone of close range (up to 8 cm) allows to establish the position of weapon's transverse plane relative to the target basing on a specific blowout of a gas-powder jet from special design of flame arrestor. The performed experimental shooting from hunting self-loading Steyr Mannlicher AUG-Z3 carbine made it possible to determine the metric and morphological characteristics of the close range firing zones: 1 zone is equal a distance up to 8 cm; 2 zone - up to 30 cm; 3 zone - up to 100 cm from muzzle of weapon. The design features of Steyr Mannlicher AUG-Z3 carbine's flame arrestor allow to identify the type of weapon according to the morphological pattern of target's damage. The complex of obtained data makes it possible to determine the firing distance with high accuracy.

[Main milestones of forensic ballistics history in Russia]. / Osnovnye vekhi istorii sudebno-meditsinskoi ballistiki v Rossii.

The purpose of the scientific work is to outline the main stages of the development of forensic examination of gunshot injuries in Russia. The analysis of the special literature from 1865 to the present time has demonstrated that the issue of forensic examination of gunshot injuries has been analyzed quite deeply by Russian forensic specialists. Meanwhile, expert practice sets forth tasks that are associated with the emergence of new firearm samples and new methods of laboratory and instrumental diagnosis.

[Historical aspects, current state and problematic issues of forensic medical examination of a gunshot blunt trauma]. / Istoricheskie aspekty, sovremennoe sostoyanie i problemnye voprosy sudebno-meditsinskoi ekspertizy zapregradnoi ognestrel'noi travmy.

The data of the world literature characterizing the forensic aspects of blunt trauma are generalized and systematized. The issues related to the morphology of damage caused after overcoming an obstacle made of various materials by a bullet, the trajectory of a firearm projectile after overcoming an obstacle, the deformation of a bullet, the transfer of fragments of an obstacle by a bullet, the determination of the distance to the target located behind the damaged barrier, the study of the strength properties of individual human armor protection, the nature of the release of particles of an obstacle. The current state of forensic medical examination of blunt trauma is considered, problems and promising directions of their solution are identified. The importance of using knowledge in the field of theoretical mechanics of deformed solid bodies and high-speed impact interaction of solid bodies is noted.

[Variability of input gunshot injuries of clothing fabrics]. / Variabel'nost' vkhodnykh ognestrel'nykh povrezhdenii tkanei odezhdy.

One of the main components of a gunshot injury is the entrance hole. Its characteristic features: round shape, size, the presence of a central tissue defect, abrasion collar (contamination, metallization), are differential diagnostic signs of an entrance gunshot injury. Under the conditions of the conducted experiments, the peculiarities of the variability of the described signs of the entrance holes on the clothing fabrics were studied, depending on the nature of the objects to be subjected and the contact velocity of the firearm projectile. The identified features must be taken into account when examining gunshot injuries, as well as planning and conducting experimental studies with firearms.

[Impact of projectile incidence angle with obstacle during ricochet on the damage characteristics formed in smoothbore weapon shot]. / Vliyanie ugla vstrechi puli s pregradoi pri rikoshete na kharakteristiku povrezhdenii, obrazuyushchikhsya pri vystrele iz gladkostvol'nogo oruzhiya.

The aim of this study was to establish the degree of projectile incidence angle with obstacle on forensic medical characteristic of gunshot injuries arising from smoothbore weapon fire and bullet ricochet. Based on the comprehensive forensic study results of experimental entry gunshot injuries, statistically significant differences in the following morphological signs were found for two ranges of incidence angle values (10-20° and 30-50°): «Number of MD¼, «Length 1 MD¼, «Length 2 MD¼, «Width 1 MD¼, «Orientation of AD to the conventional clock face relative to MD 1 or to the group of largest MD (max. value)¼. The medians and limits of 99% confidence intervals of these features values were observed depending on the range of incidence angle values. The revealed patterns can be used in expert practice during forensic medical examination of gunshot injuries formed as a result of a projectile ricochet after smoothbore weapon fire, as well as to develop a methodology for conducting a forensic study of this gunshot injury type.

A Prospective Audit of 805 Consecutive Patients With Penetrating Abdominal Trauma: Evolving Beyond Injury Mechanism Dictating Management.

BACKGROUND: Global trends of penetrating abdominal trauma (PAT) have seen a shift toward a selectively conservative management strategy. However, its widespread adoption for gunshot injuries has been sluggish. The purpose of this study is to compare the injury mechanisms of gunshot (GSW) and stab wounds (SW) to the abdomen in presentation, management, and outcomes. METHODS: Prospective cohort study, set in Cape Town, South Africa, over 2 years. All patients presenting to the center with PAT during this time were included. Presentation, management, and outcomes were compared by injury mechanism, with a focus on the operative strategy (operative vs nonoperative). RESULTS: During the study period, 805 patients (SW 37.6%; GSW 62.4%) with PAT were managed. Immediate laparotomies were performed in 119 (39.3%) SW and 355 (70.7%) GSW, with a therapeutic laparotomy rate of 85.7% and 91.8% for SW and GSW, respectively. Nonoperative management (NOM) was implemented in 184 SW (60.7%) and 147 GSW (29.3%) (P < 0.001), with a 92.9% and 92.5% success rate for SW and GSW, respectively. The therapeutic laparotomy rate for the delayed laparotomies (DOM) was 69.2% for SW, and 90.9% for GSW. The accuracy of clinical assessment (with adjuncts) in determining the need for laparotomy was: GSW-92% and SW-91%. Univariate analysis revealed the mechanism not to be associated with DOM. The overall mortality rate was 7.2%, and nonfatal morbidities 22.2%. CONCLUSION: Although GSW is a more morbid and often fatal injury, the general principles of selective conservatism hold true for both GSW and SW, equally.

Documentation of Firearm Safety Screening During Emergency Department Visits for Assault-Related Injury.

Assault-injured youth have an increased risk of future violence. Identifying firearm access among youth in the emergency department (ED) creates an opportunity for interventions aimed at reducing future violent events. We performed this study to determine the extent to which children with assault-related injuries are screened for access to firearms in the ED. We performed a retrospective chart review of all medical records from adolescent ED visits to an academic, tertiary care pediatric hospital in Washington DC with ICD-10 codes related to assault in a 3-month period. We found that among 252 assault-related encounters, none had any documentation of firearm access in the provider note, social work note, or psychiatry consultant note. Therefore, we concluded that firearm access screening is rarely documented in ED visits among patients who present for an assault, highlighting an important missed opportunity for firearm access screening among this high-risk group.

[Treatment of victims with mine-explosive injuries]. / Rezul'taty lecheniya ranenykh s minno-vzryvnoi travmoi.

OBJECTIVE: To study the incidence and structure of combat gunshot surgical trauma received during the 2nd Karabakh War and to analyze the results of treatment of these victims. MATERIAL AND METHODS: We analyzed surgical treatment of 60 victims with combat gunshot surgical trauma received during the 2nd Karabakh war. In 25 (41.7%) victims, injury occurred as a result of mine-explosive trauma. These victims were divided into 3 groups depending on mechanism of mine-explosive injury. The 1st group included 7 (28%) patients who received mine-explosive injury due to indirect (propelling) effect of blast wave. The 2nd group included 14 (56%) victims in whom mine-explosive injury was caused by non-contact (distant) impact of mine fragments. The 3rd group consisted of 4 (16%) patients whose mine-explosive injuries were caused by direct impact of explosion factors on various anatomical areas. Patients were also ranked into 3 groups depending on the nature and severity of mine-explosive injury: wounded with isolated injuries (n=16, 64%), wounded with concomitant injuries (n=2.8%), wounded with combined and multiple injuries (n=7, 28%). RESULTS: Most patients underwent organ-sparing procedures. Resections were performed only in 4 cases (splenectomy - 3, nephrectomy - 1). Postoperative complications developed in 23 (38.3%) wounded (suppuration of postoperative wounds - 13, post-traumatic pleuritis - 5, clotted hemothorax - 2, subphrenic abscess - 1, phlegmon of perineum and perianal region - 2). Mortality rate was 1.7%. CONCLUSION: Timely sorting and evacuation of victims, early qualified surgical care and correct postoperative management with monitoring of vital functions can improve the results of treatment of victims with mine-explosive trauma. Autologous skin grafting for extensive defects and closure of colostomy with restoration of colon continuity were essential in rehabilitation of these patients.

[Diagnostic difficulties in a patient with a combined gunshot injury involving non-penetrating abdominal wound and injury of superficial femoral artery]. / Sochetannaya ognestrel'naya travma bedrennoi arterii i nepronikayushchego raneniya zhivota.

Non-penetrating gunshot abdominal wounds are rare in peacetime and mainly caused by firearm traumatic weapons. The main therapeutic measure in this case is primary surgical debridement with adequate drainage. At the same time, such injuries may be accompanied by damage to internal organs. Timely diagnosis of these lesions may be difficult, and surgical treatment may be necessary. We report a patient with combined gunshot injury, damage to superficial femoral artery and non-penetrating abdominal wound followed by contusion and necrosis of small bowel. When providing medical care in patients with non-penetrating gunshot abdominal wounds, one should remember possible damage to internal organs due to high kinetic energy of the wounding projectile resulting contusion-induced necrosis.

[Possibility of determining «Paradox¼ and «Lancaster¼ barrel boring type by human body gunshot wounds morphology and clothing defects]. / O vozmozhnosti sudebno-meditsinskoi diagnostiki tipa sverlovki kanala stvola «Paradox¼ i «Lancaster¼ po morfologii ognestrel'nykh ranenii tela cheloveka i povrezhdenii odezhdy.

In the specialized forensic medical literature there is no data that allow to reliably and objectively confirm application «Paradox¼ or «Lancaster¼ boring firearms to cause injury. This study analyzes the literature in order to determine the possibility of diagnosing these types of weapon's barrel boring by the morphology of injury. The results of the analysis demonstrate a high probability of barrel boring type distinctive features existing. In addition, has been found the opportunity to determine the type of bullet in the cartridge used to damage. Concluded that it is necessary to do an additional experimental research of the specified conditions for causing firearm injuries.

A systematic review and individual patient data meta-analysis of heart failure as a rare complication of traumatic arteriovenous fistulas.

OBJECTIVE: Traumatic arteriovenous fistulas (AVFs) are rare. The vast majority occur secondary to penetrating injuries. High-output cardiac failure is a well-recognized serious complication of AVFs, associated with high morbidity and mortality. The objective of the present study was to identify predictors of heart failure (HF) in patients with traumatic AVF. METHODS: Both PubMed/MEDLINE (Ovid) and CINAHL were searched (up to June 2019) for studies reporting individual patient data on the clinical and demographic characteristics of patients with AVF secondary to penetrating trauma. Exclusion criteria were age <18 years, no specification of symptoms, a cranial, spinal, or cardiac AVF location, and an iatrogenic mechanism of injury. The present study was performed in accordance with the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines. RESULTS: A total of 274 AVF patients from 15 case series and 177 case reports were included. The median age at presentation was 32 years (interquartile range, 24-43 years), 90% were men. The most frequent mechanisms of injury were stab wounds (43%) and gunshot wounds (32%). The AVF location was the abdomen (n = 86; 31%), lower limb (n = 79; 29%), neck (n = 61; 22%), thorax (n = 38; 14%), and upper limb (n = 10; 4%). Of the 274 patients, 35 (13%) had presented with HF and 239 (87%) with other symptoms. The risk of HF increased with an increased feeding artery diameter (P < .001). On univariate analysis, HF was significantly associated with a longer median time from injury to presentation with AVF (11.2 years vs 0.1 years; P < .001), older median age at presentation (43 years vs 31 years; P = .002), involvement of a large feeding artery (ie, aorta, pulmonary artery, subclavian artery, external iliac artery; 40% vs 13%; P < .001), shrapnel injuries (11% vs 2%; P = .011), and injuries to the trunk or lower limb (94% vs 71%; P = .004). After adjusting for clinical and demographic patient characteristics, involvement of a large feeding artery (odds ratio, 3.25; 95% confidence interval, 1.26-8.42; P = .015) and every 6 years of delay to presentation (odds ratio, 1.30; 95% confidence interval, 1.03-1.63; P = .026) remained independent predictors for HF. CONCLUSIONS: HF occurs in a small but important fraction of traumatic AVF patients and develops after highly variable latency periods. Large feeding arteries and delayed presentation independently predicted HF in this cohort.

A systematic review of clinical and laboratory findings of lead poisoning: lessons from case reports.

Lead is one of the most toxic heavy metals in the environment. The present review aimed to highlight hazardous pollution sources, management, and review symptoms of lead poisonings in various parts of the world. The present study summarized the information available from case reports and case series studies from 2009 to March 2020 on the lead pollution sources and clinical symptoms. All are along with detoxification methods in infants, children, and adults. Our literature compilation includes results from 126 studies on lead poisoning. We found that traditional medication, occupational exposure, and substance abuse are as common as previously reported sources of lead exposure for children and adults. Ayurvedic medications and gunshot wounds have been identified as the most common source of exposure in the United States. However, opium and occupational exposure to the batteries were primarily seen in Iran and India. Furthermore, neurological, gastrointestinal, and hematological disorders were the most frequently occurring symptoms in lead-poisoned patients. As for therapeutic strategies, our findings confirm the safety and efficacy of chelating agents, even for infants. Our results suggest that treatment with chelating agents combined with the prevention of environmental exposure may be an excellent strategy to reduce the rate of lead poisoning. Besides, more clinical studies and long-term follow-ups are necessary to address all questions about lead poisoning management.

Selective Nonoperative Management of Abdominal Shotgun Wounds.

BACKGROUND: Selective nonoperative management (SNOM) of abdominal gunshot wounds (GSWs) has not been specifically examined after shotgun injuries. Because of the unpredictable nature of shotgun pellets, it is unclear if SNOM after shotgun wounds is safe. The study objective was to examine outcomes after SNOM for shotgun wounds to the abdomen. METHODS: Patients with isolated abdominal shotgun wounds were identified from the National Trauma Data Bank (2007-2017). Transfers, arrival without signs of life, death in the emergency department, severe (Abbreviated Injury Scale ≥3) extra-abdominal injuries, abdominal Abbreviated Injury Scale = 6, and missing data were exclusion criteria. Patients with abdominal handgun wounds (GSWs) were used for comparison. Study groups of shotgun-injured patients were defined by management strategy: operative management (OM) (exploratory laparotomy ≤4h) versus SNOM (no exploratory laparotomy ≤4h). Outcomes were compared by mechanism of injury (shotgun versus GSW) and management strategy (OM versus SNOM) using univariate and multivariate analyses. RESULTS: After exclusions, 1425 patients injured by abdominal shotgun wounds were included. Shotgun-injured patients underwent SNOM more frequently than GSW patients (42% versus 34%, P < 0.001). On multivariate analysis, injury by shotgun was independently associated with SNOM (OR 1.443, P = 0.040). Shotgun injuries were significantly more likely to fail SNOM (OR 2.401, P = 0.018). Failure of SNOM occurred earlier among shotgun-than GSW-injured patients (15 versus 24h, P = 0.011). SNOM after shotgun injury was associated with lower mortality than OM, even when patients failed SNOM (P < 0.001). Complications were uniformly higher after OM than SNOM, even when SNOM failed (P < 0.05). CONCLUSIONS: SNOM was utilized more commonly after shotgun wounds than GSWs. However, SNOM was more likely to fail after shotgun injury and tended to occur earlier after admission. SNOM after shotgun injury was associated with improved mortality and decreased complication rates when compared with OM, even when patients failed SNOM. SNOM appears to be a safe and beneficial management strategy after shotgun wounds to the abdomen.

Fake gunshot wounds in the skull-post-mortem artifact caused by steel probe during police search for a missing body.

The paper presents a case of a forensic autopsy of a young woman who was murdered and her dismembered body was hidden in soil and water. In the skull of the deceased, in the temporal and occipital regions, the autopsy revealed 3 round, almost identical holes, which looked like small caliber gunshot wounds. Doubts about the cause of these injuries were raised by the fact that despite the decomposition of the body, the continuity of the dura at the site of these holes remained undamaged and the absence of any trace of a bullet's wound track in the brain, the absence of a foreign body in the cranial cavity, as well as the absence of wounds on the opposite side of the skull that could be exit wounds. A thorough analysis of the investigation and the activities carried out during the search for the missing body allowed to adopt and finally confirm the hypothesis that the above mentioned skull damage occurred during the search for the cut-off head of the deceased in shallow water by means of special tapered conical steel probes used by the rescue/search teams. Due to the structure of such a spike, i.e., a sharp end and then a wide cone, only a superficial puncture of the steel probe tip three times into the skull had taken place, which caused regular, rounded bone damage without damaging the dura and brain. The presented case indicates that sometimes post-mortem artifacts may suggest a completely different origin of wounds, which emphasizes the need for a comprehensive analysis of all possible causes of their occurrence, particularly data concerning the handling of the corpse before it is delivered to the morgue, so as not to make a diagnostic error during autopsy.

[Comprehensive treatment of a victim with gunshot injury of the head complicated by infection]. / Kompleksnoe lechenie postradavshego s infektsionno oslozhnennym ognestrel'nym povrezhdeniem golovy. Vybor effektivnoi taktiki lecheniya.

Gunshot head injuries make up 35% of all injuries. Brain injuries are diagnosed in 42.2% of cases, maxillofacial region - 35.7%, eye - 13.9%, outer and inner ear - 3.2%. These damages account 14.8%, 12.5%, 4.9% and 2.9% of the total number of injuries, respectively. In our opinion, primary surgical treatment of gunshot wounds should be carried out in a strict system of multiple-stage surgical management in accordance with the principles of treating wounds from high-speed weapons.

[Problems of expert assessment in gunshot injuries caused by shots from special weapon]. / Problemy ekspertnoi otsenki ognestrel'nykh povrezhdenii, prichinennykh vystrelami iz oruzhiya spetsial'nogo naznacheniya.

Forensic examination of a gunshot injury is the most difficult problem of domestic and foreign forensic medicine. A large amount of knowledge and practical observations on damage from standard samples of handguns has been accumulated. The emergence of new unique samples of special-purpose weapons requires forensic physicians and forensic experts to conduct a complex of morphological, spectral, forensic chemical, medico-forensic, radiological and other special laboratory studies of damage caused by such weapons. The article presents a case of forensic medical examination commission with the issue solution of differential diagnosis of causing a mortal fire wound injuries by a specific sample of special-purpose handgun.

Lower extremity vascular injuries caused by firearms have a higher risk of amputation and death compared with non-firearm penetrating trauma.

OBJECTIVE: Firearm injuries have traditionally been associated with worse outcomes compared with other types of penetrating trauma. Lower extremity trauma with vascular injury is a common presentation at many centers. Our goal was to compare firearm and non-firearm lower extremity penetrating injuries requiring vascular repair. METHODS: We analyzed the National Inpatient Sample from 2010 to 2014 for all penetrating lower extremity injuries requiring vascular repair based on International Classification of Diseases, Ninth Revision codes. Our primary outcomes were in-hospital lower extremity amputation and death. RESULTS: We identified 19,494 patients with lower extremity penetrating injuries requiring vascular repair-15,727 (80.7%) firearm injuries and 3767 (19.3%) non-firearm injuries. The majority of patients were male (91%), and intent was most often assault/legal intervention (64.3%). In all penetrating injuries requiring vascular repair, the majority (72.9%) had an arterial injury and 43.8% had a venous injury. Location of vascular injury included iliac (19.3%), femoral-popliteal (60%), and tibial (13.2%) vascular segments. Interventions included direct vascular repair (52.1%), ligation (22.1%), bypass (19.4%), and endovascular procedures (3.6%). Patients with firearm injuries were more frequently younger, black, male, and on Medicaid, with lower household income, intent of assault or legal action, and two most severe injuries in the same body region (P < .0001 for all). Firearm injuries compared with non-firearm injuries were more often reported to be arterial (75.5% vs 61.9%), to involve iliac (20.6% vs 13.7%) and femoral-popliteal vessels (64.7% vs 39.9%), to undergo endovascular repair (4% vs 2.1%), and to have a bypass (22.5% vs 6.5%; P < .05 for all). Firearm-related in-hospital major amputation (3.3% vs 0.8%; P = .001) and mortality (7.6% vs 4.2%; P = .001) were higher compared with non-firearm penetrating trauma. Multivariable analysis showed that injury by a firearm source was independently associated with postoperative major amputation (odds ratio, 4.78; 95% confidence interval, 2.07-11.01; P < .0001) and mortality (odds ratio, 1.74; 95% confidence interval, 1.14-2.65; P = .01). CONCLUSIONS: Firearm injury is associated with a higher rate of amputation and mortality compared with non-firearm injuries of the lower extremity requiring vascular repair. These data can continue to guide public health discussions about morbidity and mortality from firearm injury.

Trends in Firearm Injuries Among Children and Teenagers in the United States.

BACKGROUND: Gun violence among children and teenagers in the United States occurs at a magnitude many times that of other industrialized countries. The trends of injury in this age group relative to the adult population are not well studied. This study seeks to measure trends in pediatric firearm injuries in the United States. METHODS: Data from the National Trauma Data Bank (2010-2016) were used in selecting patients evaluated for firearm injury. Patients were classified as children and teenagers (<20 y) or adults (≥20 y). Changes in the proportion of firearm injuries among children and teenagers relative to the overall population (pediatric component) were determined using trend analyses. RESULTS: There were 240,510 firearm injuries with children and teenagers accounting for 45,075 of these injuries (pediatric component of 18.7%). Pediatric firearm injury was mostly among males (87.4%), Blacks (60.7%), and victims of assault (76.0%). The pediatric component of firearm injuries decreased from 21.7% in 2010 to 18.2% in 2016 (P-trend < 0.001). Although there was a decrease from 22.7% to 17.6% in the pediatric component of assault (P-trend < 0.001), there was an increase from 8.7% to 10.1% in the pediatric component of self-inflicted injuries (P-trend = 0.028). Substratification by race/ethnicity showed decrease in the pediatric component of firearm injuries among all groups (P-trend < 0.001) except Whites (P-trend = 0.847). CONCLUSIONS: Despite reductions in the pediatric component of firearm injuries, there remains a significant burden of injury in this group. Continued public health efforts are necessary to ensure safety and reduce firearm injuries among children and teenagers in the United States.