Factors Associated with Discharge to Skilled Nursing Facility Following Gunshot Wounds.

INTRODUCTION: Firearm injury is a public health crisis. Most victims are minorities in underserved neighborhoods. Measuring firearm injury by mortality underestimates its impact, as most victims survive to discharge. This study was done to determine if race and insurance status are associated with discharge disposition for gunshot wound (GSW)-related trauma. METHODS: Using the 2019 Trauma Quality Improvement Program database, we identified GSW patients with Abbreviated Injury Scale (AIS) = 1-3. Exclusion criteria included patients who died in hospital and routine home discharge. We compared discharge patterns of patients based on demographics (age, gender, race, ethnicity, payor, AIS, hospital designation, and length of stay [LOS]) and injury severity. Multivariable logistic regression models identified factors associated with discharge disposition. RESULTS: Our sample included 2437 patients with GSWs. On univariable analysis, Black patients were more likely to discharge to home with home health (64.1% Black versus 34.7% White; P < 0.001). White patients were more likely to discharge to skilled nursing facility (SNF) (51.4% White versus 44.6% Black; P < 0.001). Controlling for age, race, Latin ethnicity, primary payor, LOS, AIS severity, and injury severity score factors independently associated with discharge to SNF included age (0.0462, P < 0.001), Medicaid (1.136, P < 0.0003), Medicare (1.452, P < 0.001), and LOS (0.03745, P < 0.001). CONCLUSIONS: Postacute care following traumatic injuries is essential to recovery. Black GSW victims are more likely to be discharged to home health than White patients, who are more likely to be discharged to SNF. Targeted programs to reduce barriers to appropriate aftercare are necessary to eliminate this bias and improve the care of underserved populations.

Identifying mental health outcomes and evidence-based psychological interventions for supporting pediatric gunshot wound patients: A systematic review and proposed conceptual model.

BACKGROUND: Accidental and assault gunshot wounds (GSWs) are the second leading cause of injury in the United States for youth ages 1- to 17-years-old, resulting in significant negative effects on pediatric patients' mental health functioning. Despite the critical implications of GSWs, there has yet to be a systematic review synthesizing trends in mental health outcomes for pediatric patients; a gap the present review fills. Additionally, this review identifies evidence-based psychological interventions shown to be effective in the treatment of subclinical symptoms of psychological disorders in the general population. METHODS: A comprehensive search was conducted using five databases: American Psychological Association (APA) PsycInfo, APA PsycArticles, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Education Resource Information Center (ERIC), and Medical Literature Analysis and Retrieval Systems Online (MEDLINE). Twenty-two articles met inclusion criteria. RESULTS: Findings suggest pediatric GSW patients are at a significantly elevated risk for mental health disorders when compared to other- (e.g., motor vehicle collision) and non-injured youth. Disorders include post-traumatic stress, disruptive behavior, anxiety, depression, and substance use. Hospital-based violence intervention programs, cultivating supportive relationships with adults in one's community, and trauma-focused outpatient services were identified as effective interventions for treating subclinical psychological symptoms. CONCLUSIONS: Depicted in the proposed conceptual model, the present study delineates a direct association between pediatric GSWs and subsequent onset of mental health disorders. This relation is buffered by evidence-based psychological interventions targeting subclinical symptoms. Results suggest brief psychological interventions can help treat mental health challenges, minimizing risk for significant long-term concerns. Cultural adaptations to enhance the utility and accessibility of interventions for all patients are recommended.

Shots fired: evaluation of vascular injury, compartment syndrome, and transfusion rates among civilian ballistic orthopaedic fracture patients presenting to two Level I trauma centres.

PURPOSE: This study investigates baseline patient demographics and predictors of vascular injury, blood transfusion, and compartment syndrome in patients with orthopaedic fractures secondary to GSWs at two high-volume Level I trauma centres. METHODS: A retrospective chart review of all GSW-related trauma patients at two Level I trauma centres between July 2019 and September 2021 was conducted. Chi-squared and two-tailed independent t tests were used for data analysis, and logistic regression with odds ratios (OR) determined predictors of primary outcomes. RESULTS: Among 478 GSW patients, 94 (19.7%) sustained 130 orthopaedic fractures, most commonly at the lower extremity (77.7%). Orthopaedic fracture patients showed significantly higher rates of vascular injury (29.8 vs. 4.7%, p < 0.001), transfusion (27.7 vs. 12.8%, p = 0.006), and compartment syndrome (3.2 vs. 0.3%, p = 0.011) compared to non-orthopaedic injury patients. Univariable analysis identified ankle (OR = 47.50, p < 0.001) and hip/femur fractures (OR = 5.31, p < 0.001) as predictors of vascular injury. Multivariable logistic regression revealed lower extremity vascular injury (OR = 54.69, p = 0.006) and anatomic fracture sites of the humerus (OR = 15.17, p = 0.008), clavicle/scapula (OR = 11.30, p = 0.009), and acetabulum/pelvis (OR = 7.17, p = 0.025) as predictors of blood transfusion. Univariable analysis showed lower extremity vascular injury (OR = 30.14, p = 0.007) as a predictor of compartment syndrome. CONCLUSION: These findings underscore the importance of diagnosing and managing vascular injuries and compartment syndrome in GSW-related orthopaedic fractures, emphasizing the necessity for targeted transfusion strategies in such cases.

Disparities in Care Among Gunshot Victims: A Nationwide Analysis.

INTRODUCTION: Given the well-known healthcare disparities most pronounced in racial and ethnic minorities, trauma healthcare in underrepresented patients should be examined, as in-hospital bias may influence the care rendered to patients. This study seeks to examine racial differences in outcomes and resource utilization among victims of gunshot wounds in the United States. METHODS: This is a retrospective review of the National Trauma Data Bank (NTDB) conducted from 2007 to 2017. The NTDB was queried for patients who suffered a gunshot wound not related to accidental injury or suicide. Patients were stratified according to race. The primary outcome for this study was mortality. Secondary outcomes included racial differences in resource utilization including air transport and discharge to rehabilitation centers. Univariate and multivariate analyses were used to compare differences in outcomes between the groups. RESULTS: A total of 250,675 patients were included in the analysis. After regression analysis, Black patients were noted to have greater odds of death compared to White patients (odds ratio [OR] 1.14, confidence interval [CI] 1.037-1.244; P = 0.006) and decreased odds of admission to the intensive care unit (ICU) (OR 0.76, CI 0.732-0.794; P < 0.001). Hispanic patients were significantly less likely to be discharged to rehabilitation centers (Hispanic: 0.78, CI 0.715-0.856; P < 0.001). Black patients had the shortest time to death (median time in minutes: White 49 interquartile range [IQR] [9-437] versus Black 24 IQR [7-205] versus Hispanic 39 IQR [8-379] versus Asian 60 [9-753], P < 0.001). CONCLUSIONS: As society carefully examines major institutions for implicit bias, healthcare should not be exempt. Greater mortality among Black patients, along with differences in other important outcome measures, demonstrate disparities that encourage further analysis of causes and solutions to these issues.

Adolescent Gun Violence Shows an Age Group to Focus Trauma Prevention.

INTRODUCTION: Gun violence continues to escalate in America's urban areas. Peer groups of gun wound victims are potential targets for violence prevention initiatives; identification of this cohort is pivotal to efficient deployment strategies. We hypothesize a specific age at which the incidence of penetrating trauma increases significantly in adolescence, below which should be the focus on future trauma prevention. METHODS: Adolescent trauma patients with gunshot wounds seen from July 2011 through June 2021 at a well-established, urban, academic level 1 trauma center were reviewed retrospectively and grouped by age. A linear regression and repeated measured analysis of variance evaluated the change in gunshot wound victims over this time, grouped by age. Demographics were extrapolated, and standard statistical analysis was performed. RESULTS: A total of 1304 adolescent trauma patients were included. Those aged 15 y and under had an unchanged incidence of gunshot wounds. However, those aged 16 y and more experienced the majority of increased gun violence; 92% were Black and 90% were male with a mortality of 12%. Adolescents aged 15 y and below were 95% Black and 84% male, with a mortality of 18%. CONCLUSIONS: Primary prevention efforts to mitigate gun violence should be focused on adolescents below 16 y of age. Prevention of gun violence should include community outreach efforts directed toward middle school-aged children and younger, hoping to decrease the incidence of injury due to gun violence in older adolescents in the future.

Antibiotic Duration Following Abdominal Gunshot Injuries With Associated Pelvis or Spine Involvement: A 20-Year Single-Center Experience.

INTRODUCTION: Optimal antimicrobial prophylaxis duration following gunshot wounds (GSW) to the abdomen with an associated orthopedic fracture is unknown. This study evaluated the safety and efficacy of short versus long courses of prophylactic antibiotics following penetrating hollow viscus injury with communicating orthopedic fracture. METHODS: This retrospective study included adult patients admitted to the trauma service over a 20-y period who sustained an abdominal GSW with hollow viscus injury and communicating spine or pelvic fractures. Patients were stratified into cohorts based on prophylactic antibiotic duration: short course (SC, ≤48 h) and long course (>48 h). The primary outcome was the incidence of osteomyelitis and meningitis up to 1-y postinjury. Secondary outcomes included hospital length of stay and the incidence of multidrug-resistant organisms and Clostridioides difficile infections. Risk factors for osteomyelitis and meningitis were determined. RESULTS: A total of 125 patients were included with 45 (36%) in the SC group. Median prophylactic antibiotic durations were SC, 1 (interquartile range [IQR], 1-2) versus long course, 7 (IQR, 5-7) d (P < 0.001). There was no difference in osteomyelitis and meningitis incidence (2 [4.4%] versus 4 [5%], P = 0.77). Median hospital length of stay (7 [IQR, 6-11] versus 9 [IQR, 6-15] d, P = 0.072) and incidence of multidrug-resistant organisms (6 [13.3%] versus 13 [16.3%], P = 0.86) and Clostridioides difficile infections (0 [0%] versus 1 [1.3%], P = 0.77) were similar between groups. There were no independent risk factors identified for osteomyelitis or meningitis. CONCLUSIONS: A shorter course of antibiotic prophylaxis ≤48 h may be adequate following abdominal GSW that traverses a hollow viscus and results in pelvic fracture or spinal column injury.

Gunshot residues found at the exit wound: a case report.

Gunshot residues (GSRs) play an important role in forensic investigations of gun-related violence. The presence of GSRs has been described to help to identify the bullet entry area, as it was supposed not to be found at exit wounds. This report details the suicidal headshot of an 84-year-old male where unburned tube-like, cuboid and flake-formed powder particles have been found not only at the inside of the muzzle but also circular around the exit wound. With very short-barrelled weapons, it must be expected that part of the propellant charge leaves the barrel unburned behind the bullet. In contrast to that, the barrel length of the used weapon should lead to a complete burn-up of powder particles. The surprisingly large number of unburned powder particles present at the exit wound of the injury gave reason for further investigation to understand the underlying ballistic aspects and outlines the importance of having a close look at incidence scene photos during an investigation.

Wandering projectile, a rare cause of acute urinary retention.

BACKGROUND: Urethral obstruction due to retained projectile migrating into the genitourinary system has rarely been reported. The literature describes two main methods of retained projectile removal from the genitourinary system: (1) spontaneous expulsion during voiding and (2) manual extraction due to urethral obstruction causing acute urinary retention. CLINICAL PRESENTATION: We present a case in which a 23-year-old man presented with acute urinary retention four days after suffering a gunshot wound to the right distal posterolateral thigh. A retained projectile eroded through the posterior wall (slightly to the right) of the bulbar urethra at the bulb, migrated through the urethra, and eventually became lodged in the external urethral meatus, causing obstruction and acute urinary retention. Subsequently, the foreign body was removed with manual extraction along with gentle external pressure under sedation and the patient was discharged with a 16 Fr transurethral catheter in situ to be kept for 1 week and removed after a week. CONCLUSION: The absences of signs do not always effectively rule out urethral or bladder injury. Urethral foreign bodies are not commonly encountered when they do the entry is usually the urethral meatus. However, the treating physician must that other mechanisms also exist especially in those with bullet injury to flank, abdomen, pelvis and even the distal thigh like our case.

Pediatric craniocerebral firearm injuries: literature review, best practices in medical and surgical management, and case report.

INTRODUCTION: Civilian craniocerebral firearm injuries are extremely lethal. Management includes aggressive resuscitation, early surgical intervention when indicated, and management of intracranial pressure. Patient neurological status and imaging features should be used to guide management and the degree of intervention. Pediatric craniocerebral firearm injuries have a higher survival rate, but are much rarer, especially in children under 15 years old. This paucity of data underscores the importance of reviewing pediatric craniocerebral firearm injuries to determine best practices in surgical and medical management. CASE PRESENTATION: A 2-year-old female was admitted after suffering a gunshot wound to the left frontal lobe. Upon initial evaluation, the patient displayed agonal breathing and fixed pupils with a GCS score of 3. CT imaging showed a retained ballistic projectile in the right temporal-parietal region with bifrontal hemorrhages, subarachnoid blood, and a 5-mm midline shift. The injury was deemed nonsurvivable and non-operable; thus, treatment was primarily supportive. Upon removal of the endotracheal tube, the patient began breathing spontaneously and improved clinically to a GCS score of 10-12. On hospital day 8, she underwent cranial reconstruction with neurosurgery. Her neurological status continued to improve, and she was able to communicate and follow commands but retained notable left-sided hemiplegia with some left-sided movement. On hospital day 15, she was deemed safe for discharge to acute rehabilitation.

Risk of Infection Following Gunshot Wound Fractures to the Foot and Ankle: A Multicenter Retrospective Study.

The purpose of this multicenter retrospective chart review was to describe demographics, fracture and wound characteristics, and treatments for foot and/or ankle fractures caused by gunshot wounds (GSWs) and identify factors that increase risk of infection in adults treated at 5 urban level 1 trauma centers in South and Midwest regions of the United States. A total of 244 patients sustained GSW-related fractures of the foot/ankle during 2007-2017, of whom 179 had ≥30 days of follow-up data after the initial injury. Most patients were male (95.1%; 232/244) with an average age of 31.2 years. On average, patients sustained 1.3 GSWs (range 1-5) to the foot/ankle. Most GSWs were categorized as low energy (85.1%; 171/201) and the majority (58.2%; 142/244) had retained bullet fragments. Antibiotics were administered at initial presentation to 78.7% (192/244) of patients and 41.8% (102/244) were managed operatively at the time of initial injury. Nerve injury, vascular injury, and infection were documented in, respectively, 8.6% (21/243), 6.6% (16/243), and 17.2% (42/244) of all cases. Multivariable analysis revealed that high-energy injuries and retained bullet fragments increased the risk of infection by 3-fold (odds ratio 3.09, 95% confidence interval 1.16-8.27, p = .025) and 3.5-fold (OR 3.48, 95% CI1.40-8.67; p = .008), respectively. Side of injury, primary injury region, and vascular injury were not significant predictors of infection risk. Further research should examine whether retained bullet fragments are directly associated with infection risk and support the development of guidelines regarding the management of patients with GSW-related fractures to the ankle/foot.

GUNSHOT SHRAPNEL WOUND OF THE THIGH WITH DAMAGE TO THE SUPERFICIAL FEMORAL ARTERY (FEATURES OF CLINICAL MANIFESTATIONS, DEVELOPMENT OF COMPLICATIONS WITH LATE MEDICAL CARE AND PRESERVATION OF THE LIMB).

OBJECTIVE: The aim: To demonstrate the features of clinical manifestations and complications that occur with delayed medical treatment in cases of gunshot shrapnel through a wound of the thigh with damage to the superficial femoral artery. PATIENTS AND METHODS: Materials and methods: The wounded individual, S., was 52 years old and had sustained a gunshot wound through a shrapnel wound of the left thigh with damage to the superficial femoral artery and soft tissue defect. Medical assistance was provided during the stages of medical evacuation. RESULTS: Results: The soldier sustained a gunshot wound through the upper third of the left thigh, resulting in damage to the vascular-nerve bundle and a soft tissue defect. First aid was provided at the scene, and surgical procedures were performed during the stages of medical evacuation, including primary surgical treatment of wounds in the upper third of the left thigh. On the second day following the injury, the wounded man was transferred to the Vinnytsia Military Medical Clinical Center and admitted to the vascular surgery department. After an ultrasound examination and repeated surgical treatment of the wound on the left thigh, damage to the superficial femoral artery was identified. CONCLUSION: Conclusions: The presence of features of blood circulation in gunshot wounds of the main vessels of the lower limbs can favorably affect the possibility of saving the limb, as evidenced by the case presented.

PROSPECTS OF THE HIGH-SPEED MULTIMEDIA DATA TRANSMISSION TECHNOLOGIES USE IN THE STRUCTURE OF THE SYSTEM FOR PROVIDING AID TO INJURED PERSONS HAVING A GUNSHOT DEFECT OF SOFT TISSUES.

OBJECTIVE: The aim: To improve the results of providing medical care in the conditions of a full-scale war in Ukraine due to the use of medical technologies. PATIENTS AND METHODS: Materials and methods: From the first days, the Military Medical Clinical Center of the Southern Region provided medical assistance to the persons wounded as a result of the Russian Federation's armed aggression. The presented multidisciplinary observation includes data received from 24.02.22 to 26.05.22. During this term, the multidisciplinary team assisted by the Teladoc Health system (the connection between the Charite Clinic, Berlin, and the MMCC of the Southern Region, Ukraine) performed 39 reconstructive and remedial operations in the MMCC of the Southern Region (Department of Surgical Infection). RESULTS: Results: It has been found that the implementation of differentiated surgical tactics (developed in cooperation between Charite clinics, Berlin, and MMCC of the Southern Region, Ukraine, using the Teladoc health system) in wounded patients with gunshot defects of soft tissues at the III and IV levels of medical care improves functional results, increases indicators of satisfactory from 46.9 % to 53.7 %, reducing the relative number of unsatisfactory from 18.8 % to 11.6 %. CONCLUSION: Conclusions: The information exchange in the Teladoc Health system is performed in telephone mode through protected communication channels. It enabled real-time treatment strategy recommendations and improved functional outcomes, increasing the satisfactory rate from 46.9 % to 53.7 %, and reducing the relative unsatisfactory rate from 18.8 % to 11.6 %.

Gunshot-related lower extremity nerve injuries.

OBJECTIVE: The purpose of this study was to describe the frequency of nerve injury associated with lower extremity ballistic trauma, the associated skeletal and soft tissue injuries, and the rate of neurologic recovery. DESIGN AND SETTING: A retrospective review of an institutional trauma database was completed at a single level 1 trauma academic medical center. PATIENTS: This was an institutional review board approved retrospective cohort study of patients over 16 years of age presenting with ballistic-related traumatic injury to the lower extremities between May 2018 and May 2019. All patients identified with lower extremity ballistic trauma were included in this study. The rate of nerve palsy, associated skeletal injury, and operative fixation were recorded for each anatomic zone. Rates of associated concomitant vascular injury, fracture, and compartment syndrome were collected through a review of the electronic medical records. Chart review was performed to evaluate outcomes and nerve recovery. RESULTS: Twenty-one patients (21 extremities, 21/148, 14%) were diagnosed by attending physicians, fellowship-trained in orthopedic trauma, as having ballistic-related nerve injuries. Seventy-three percent of patients with a documented neurologic injury (11/15) demonstrated complete nerve recovery as measured by the MRC and sensory scale assessment at most recent follow-up, while the rest demonstrated no improvement in their neurologic deficits from presentation. The rate of associated vascular injury in patients with lower extremity nerve palsies was 38% (8/21). While the rate of vascular injury in the absence of neurologic injury was 3% (4/127). CONCLUSIONS: This series of lower extremity nerve injuries in a large sample of urban lower extremity ballistic trauma noted a high rate of concomitant nerve injuries. An associated diagnosis of a vascular injury appears to portend a higher risk of neurologic injury. Treating surgeons should have a high index of suspicion for associated vascular injury in patients presenting with a ballistic lower extremity nerve palsy.

Retained lumbar intradural bullet fragment with neurological recovery after delayed removal of bullet: Case report and literature review.

Civilian gunshot wound (GSW) to the spine is expected to increase in our environment due to the recent surge in violence and firearm attacks in the society either by herdsmen, bandits, unknown gunmen, or from exchange of gun fire with security personnel in response to insecurity issues. The management of GSW in the spine remains controversial, with no clear recommendations for surgical intervention by spine surgeons. In light of this, we report a case of civilian GSW to the lumbar spine in a 47-year-old female with resultant immediate paraplegia. Neuroradiological studies revealed a large bullet lodged in the left L2/3 spinal canal. There was a 4-week wait for consent for surgery to be obtained, with no improvement in motor function during the period. She underwent laminectomy and duratomy with removal of the bullet. Motor function returned 3 weeks after the surgery, and she was discharged home 8 weeks after the surgery, actively mobilizing on a Zimmer frame. The case report demonstrates the beneficial role of surgical intervention in properly selected patients, with resultant satisfactory functional neurological recovery.

[Bullet embolism of internal carotid artery. (A case report and literature review)]. / Pulevaya emboliya vnutrennei sonnoi arterii. (Klinicheskoe nablyudenie i obzor literatury).

Bullet vascular embolism is a rare complication of gunshot wounds with risk of dire consequences and even death. Bullet embolism of internal carotid artery is extremely rare. Therefore, there is no uniform approach to the treatment of these patients. Nevertheless, removal of embolus through available surgical approach and arterial reconstruction with restoration of blood flow seems optimal. The authors present a 14-year-old patient with a wound to the left half of the chest from pneumatic gun complicated by bullet migration to the right ICA. Surgical intervention made it possible to remove the bullet from the artery and eliminate the risk of thrombosis and embolism. This case demonstrates the possibilities of open reconstructive surgery of supra-aortic vessels.

A comparison of clinical characteristics, radiographic findings, and outcomes of bihemispheric versus unihemispheric gunshot wounds to the head.

INTRODUCTION: Unihemispheric head gunshot wound (HGSW) are associated with improved survival; however, specific clinical and radiographic characteristics associated with survival have not been clearly defined. To further guide prognosis estimates and care discussions, this study aims to identify unihemispheric HGSWs injury patterns; comparing them to bihemispheric HGSWs characterizing factors associated with improved clinical outcomes and survival. METHODS: Patients presenting to our Level 1 trauma center from January 2013 through May 2019 with HGSW injury were reviewed. Patients were grouped into those with unihemispheric versus bihemispheric HGSWs and survivors versus non-survivors. Clinical variables and head computed tomography (CT) features were compared using comparative statistics. RESULTS: 62 HGSW patients met study criteria (unihemispheric = 33, bihemispheric = 29). Regardless of injury type, avoidance of injury to multiple lobes, temporal, parietal and basal ganglia brain regions and intracranial vascular injury were also associated with survival (p < 0.05). Lower admission GCS score and lower motor GCS score was associated with reduced survival in unihemispheric HGSW injury (p < 0.05). Unihemispheric HGSW survivors demonstrated improved clinical outcomes, with reduced hospital length of stay (5 days vs. 47 days, p = 0.014) and intensive care unit length of stay (3 days vs. 20 days, p = 0.021) and more favorable disposition location. CONCLUSION: We found presenting clinical features and CT imaging patterns previously associated with improved survival in HGSW patients is similar in unihemispheric specific injuries. Importantly, a more favorable admission GCS score may portend survivability in unihemsipheric HGSW. Furthermore, unihemispheric HGSW survivors may have improved clinical outcomes, length of stay and disposition location.

Clinical complications of surviving gunshot wounds to the head in children and adolescents: the Miami experience.

BACKGROUND: Gunshot wounds (GSWs) to the head in the pediatric population are both rare and devastating, with the clinical course of pediatric survivors poorly understood. Correspondingly, the aim of this study was to summarize the clinical complications clinicians can expect of survivors of GSW to the head in children and adolescents in hospital and after discharge. METHODS: A retrospective review of our Level 1 trauma center database between 2011 and 2021 was performed. Clinical data was extracted for those patients aged ≤ 18 years old who survived initial hospitalization with at least one documented follow-up. Categorical data were then compared using Chi-squared test. RESULTS: A total of 19 pediatric survivors of GSW to the head satisfied all selection criteria with an average age was 15.3 years. The majority of cases were isolated head injuries (63%), with an average Glasgow Coma Score (GCS) of 11.9. Bullet trajectory was intraparenchymal in 11 (58%) cases and extraparenchymal in 8 (42%) cases, with 15 (79%) patients treated by surgical intervention. A total of 13 (68%) patients experienced a complication during their hospitalization, with the most common being sympathetic hypertension and endocrinologic salt wasting, each occurring in 5 (26%) patients. With respect to complication categories, the intraparenchymal patients experienced statistically more complications than extraparenchymal patients that were infectious (54% vs 0%, P = 0.01) and sympathetic (45% vs 0%, P = 0.03) in nature. However, with respect to overall neurologic (P = 0.24), endocrinologic (P = 0.24), and traumatic (P = 0.24) complications, their incidences were statistically comparable. All patients were successfully discharged on average post-injury day 22 with an average GCS of 14.0. Mean follow-up for the cohort was 42.6 months, with an average GCS of 14.3. A total of 6 (32%) patients experienced a complication relatable to their initial GSW injury after discharge. The most common individual complication was new-onset seizures in 3 (16%) patients. CONCLUSIONS: Survivors of pediatric GSW to the head can experience multi-systemic complications during both initial hospitalization and afterwards, and bullet trajectory involving the parenchyma may be associated with specific complications more than others. Dedicated inpatient management and outpatient follow-up involving surveillance for complications across all systems, not just neurological, are recommended to ensure patients receive the best care possible.

Evaluation of follow-up and long-term outcomes of gunshot and stab wounds in a French civilian population.

PURPOSE: The data concerning long-term follow-up and outcomes of penetrating trauma are poorly detailed in the literature. The main objective of our study was to analyze the hospital and extra-hospital follow-up of penetrating trauma victims and to evaluate the late complications and long-term consequences of these traumas. METHODS: This work was a retrospective longitudinal monocentric observational study conducted at Laveran Military Hospital, from January 2007 to January 2017. All patients hospitalized for gunshot wound or stab wound management during this period were identified via a retrospective systematic query in the hospital information system using the ICD-10 codes. Epidemiological data, traumatism characteristics, hospital management, follow-up and traumatism consequences (i.e., persistent disability) were analyzed. To improve evaluation of traumatism long-term consequences, extra-hospital follow-up data from general physicians (GP) were collected by phone call. During this interview, 9 closed questions were asked to the GP. The survey evaluated: the date of the last consultation related to injury with the GP, the specific follow-up carried out by the GP, traumatism consequences, and recurrence of traumatism. Descriptive, univariate and multivariate with regression analysis were used for statistical analysis. RESULTS: A total number of 165 patients were included. Median (Q1, Q3) of hospital follow-up was 28 (4, 66) days. One hundred one patients (61.2%) went to their one-month consultation at hospital. GP follow-up was achieved for 76 patients (55.2%). Median (Q1, Q3) of GP follow-up was 47 (21, 75) months. Twenty-four patients (14.5%) have been totally lost to follow up. The overall follow-up identified 54 patients (32.7%) with long-term consequences, 20 being psychiatric disorders and 30 organic injuries. Organic consequences were mainly peripheral nerve damages (n = 20; 12.1%). Most of the psychiatric consequences were diagnosed during GP follow-up (n = 14; 70%). Seventeen cases (10.3%) of recurrence were found and late mortality occurred in 4 patients (2.4%). High injury severity score, older age and gunshot wound were significantly linked to long-term consequences. Data collection and analysis were carried out in accordance with MR004 reference methodology. CONCLUSION: This study showed a high rate of long-term consequences among patients managed for penetrating injury. If all organic lesions are diagnosed during hospital follow-up and jointly managed by hospital and extra-hospital physicians, most socio-psychiatric consequences were detected and followed by extra-hospital workers. However, for half of the patients, the extra-hospital follow-up could not be assessed. Thus, these consequences are very probably underestimated. It appears imperative to strengthen the compliance and adherence of these patients to the care network. Awareness and involvement of medical, paramedical teams and GP role seems essential to screen and manage these consequences.

Ballistic trauma caused by military rifles: experimental study based on synthetic skull proxies.

Rifles are often involved in violent deaths such as homicide and suicide. Consequently, expert knowledge and experimental forensic investigations are important to clarify the nature of ballistic trauma when applied to the human head and neurocranium. This study investigated differences in entrance wound morphology with Synbone® spheres which are described as being comparable to human flat bones. A series of ballistic experiments were conducted using two different rifle calibers (5.56 × 45 mm and 7.62 × 39 mm Full Metal Jacket (FMJ)). Synbone® spheres were used for close-range 0.3 m simulated executions as well as at 25 m and 35 m to simulate urban and military engagements. Results were compared with previously published experimental studies using similar military ammunition. In our study, entry wound morphology closely resembles real forensic cases compared to exit wound and overall shape morphology independently of the distance and the caliber. Circumferential delamination was clearly visible with full metal jacket (FMJ) rounds, yielding similar damage pattern morphology to the human crania. This study documented the presence of hydraulic burst or shock in all ten rounds from all three distances. Krönlein shots were also observed in some cases. Synbone® spheres constitute an acceptable synthetic surrogate for ballistic experiments. The present study offers new initial data on the behavior of Synbone® proxies in ballistic testing of military ammunitions; FMJ gunshot injuries to the human head, for distances that have not previously been published, suggesting that efficient tests can take place under these conditions. Further research on experimental ballistics with a larger number of controlled factors and multiple repetitions is recommended to verify the results of this pilot study before applied in forensic simulations.

[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.