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Eur J Cardiothorac Surg 2003;23:888-893
© 2003 Elsevier Science NL

Thoracic firearm injuries in children: management and analysis of prognostic factors

Department of Thoracic and Cardiovascular Surgery, Dicle University School of Medicine, 21280 Diyarbakir, Turkey

Received 16 October 2002; received in revised form 25 February 2003; accepted 27 February 2003.

^* Corresponding author. Akkoyunlu 3. sok Altunbay 3 apt no: 7, 21100 Diyarbakir, Turkey. Tel.: +90-412-248-8001; fax: +90-412-248-8440
e-mail: sevval{at}dicle.edu.tr

	Abstract

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion References

 
Objective: Thoracic firearm injuries (TFI) have become increasingly prevalent in children. Our purpose is to assess the injury pattern, Injury Severity Score (ISS), length of hospital stay (LOS), management and outcome of children with TFI with respect to the type of injury and to evaluate the value of ISS for predicting injury severity and the eventual need for thoracotomy, as well as the rate of morbidity and mortality. Methods: Between January 1987 and June 2002, 110 children (88 boys and 22 girls) ≤16 years of age with firearm injuries to the chest were evaluated. The children were divided in four groups according to cause of injury. An ISS was calculated for each child. Those children who died before admission were excluded from the study. The relationship between ISS and prognostic factors was analyzed in all four groups. Results: The mean age was 11.1±3.0 (range 3–16) years. Eighty-eight (80%) were male and 22 (20%) were female. The causes of firearm injuries were high-velocity gunshot wounds (HVGSW) in 52 (47.2%), low-velocity gunshot wounds (LVGSW) in 23 (20.9%), shotgun wounds (SGW) in 18 (16.3%), and explosives wounds (EW) in 17 (15.4%). Lung injury occurred in 72 (65.5%) patients. Tube thoracostomy was sufficient in 76.3% (84 of 110) for thoracic injury. The morbidity rate was 16.3% (18/110) and the mortality rate was 4.5% (5/110). Mean ISS was 16.62±8.2 (range 4–48). Fifty-eight patients (52.7%) had an ISS ≤16, while 31 (28.2%) had a score between 17 and 25, and 21 (19.1%) had a score greater than 25. The need for thoracotomy, as well as the rate of morbidity and mortality were significantly higher in children for those with an ISS >25. SGW and EW groups had a significantly higher ISS. The mean LOS was 10.84±4.7 days (range 4–42). The value of LOS was significantly higher in children with SGW and EW. Conclusion: The majority of TFI in children can be treated successfully by tube thoracostomy if there are no gross pulmonary lacerations and airway injuries. SGW and EW were commonly associated with higher ISS and LOS. The ISS was found to be an independent predictor of the need for thoracotomy, as well as for rates of morbidity and mortality.

Key Words: Thoracic firearm injuries • Children • Injury severity score

	1. Introduction

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion References

 
Over the past 15 years there has been a significant increase in the incidence of penetrating thoracic firearm injuries in children [1–4], with firearms now being responsible for 77% of teenage homicides in the United States [1]. Of children injured by firearms, 10–15% suffer intrathoracic penetration [5,6]. The availability and access to firearms coupled with the psychosocial and socioeconomic difficulties of childhood and adolescence are suggested risk factors for the rise in penetrating trauma injuries [5,7]. Despite increases in pediatric firearm injuries, issues related to thoracic firearm injuries have received little attention in the literature. Thoracic firearm injuries are generally mentioned as a subset in pediatric thoracic trauma reviews [1]. There has been no recent study analyzing the specific experience of firearm injuries exclusively to the thorax in children.

Most studies from a non-military environment continue to support the use of chest tube thoracostomy as the primary treatment for non-mediastinal chest injury, with a low incidence of thoracotomy being reported [8–11]. The present report reviews the characteristics of thoracic firearm injuries, the injury patterns, management, correlation between Injury Severity Score (ISS) and morbidity, mortality, need for surgery and length of hospital stay (LOS). Herein, we report our experiences with thoracic firearm injuries in children from southeastern Turkey over the last 15 years.

	2. Materials and methods

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion References

 
Dicle University Medical School Research Hospital serves as a referral hospital for eleven cities throughout the southeast and eastern regions of Turkey. Approximately 60% of this population is under 20 years of age. The majority of trauma patients are transferred to this center for final diagnosis and treatment.

Between January 1987 and June 2002, 110 children ≤16 years of age with firearm injuries to the chest were hospitalized at the Dicle University Medical School, Department of Thoracic and Cardiovascular Surgery. After the initial physical examination and stabilization of vital signs, chest radiographs were obtained for all patients. Computerized tomography (CT) or/and perfusion scintigraphy scans of the lungs were obtained to distinguish between, where necessary, pulmonary contusion with or without lacerations and pulmonary hematoma that might be undetectable on chest X-ray. Bronchoscopy was performed in patients suspected of having major bronchus injuries or lung lacerations. Consultations with other surgical departments were undertaken if required. Tube thoracostomy, if indicated, was performed in the emergency department. Prophylactic antibiotics were used in all patients.

The hospital records of these patients were reviewed retrospectively. Clinical data included age, sex, type of injury, associated injuries, management, LOS, morbidity and mortality. In order to assess the type of injury caused by a firearm, as well as its width, force and management the children were divided into four groups according to injury cause. Gunshot wounds were divided into two groups: high-velocity gunshot wounds (HVGSW) and low-velocity gunshot wounds (LVGSW). Other injury types included shotgun wounds (SGW) and explosives wounds (EW, composed of land mines, grenades and explosives). An ISS [12] was calculated for each child. Children who died before admission were excluded from the study. The relations between the ISS and LOS, morbidity, mortality, need for thoracotomy, and type of injury were evaluated.

To compare the four groups, one-way analysis of variance and the Post-Hoc Tukey's HSD test were performed. Each of the two independent groups were compared by using Student's t-test. The morbidity and mortality of all four groups were analyzed by the Chi-square test. The relationship between the ISS and need for thoracotomy as well as the rate of morbidity and mortality in all four groups were also analyzed by the Chi-square test. A P value less than 0.05 was considered statistically significant.

	3. Results

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion References

 
The average age was 11.1±3.0 (range 3–16 years). Eighty-eight patients (80%) were male and 22 (20%) were female. The causes of firearm injuries were HVGSW in 52 patients (47.2%), LVGSW in 23 (20.9%), SGW in 18 (16.3%), and EW in 17 (15.4%). In our subjects, the general characteristics of injury type were as follows: HVGSW: Causes severe tissue damage beyond the tract of penetration. In general, there is more extensive damage at the exit point of the bullet. HVGSW in the chest wall, lungs and in the surrounding tissue produce more intense and evident cavitation, laceration and contusion. LVGSW: In general, the bullet entry and exit wounds exhibit limited minimal chest wall trauma and in some patients minimal lacerations and contusions to the lungs. SGW: Multiple pellet entries are scattered over a wide area. In some patients defects in the chest wall and widespread lung contusions can result. SGW have a tendency to cause multi-organ injuries. EW: Affects a wide area of the body and can cause multi-system trauma. The effects of the blast have a tendency to destroy tissue under the surface of the skin. There is little damage caused to the chest wall.

Most of the injuries in our study occurred in children between the ages of 11 and 16. Pulmonary injury was present in 72 patients (65.5%) (Table 1). Pulmonary contusion (n:47) was the most common thoracic injury, followed by hemothorax (n:38) and hemopneumothorax (n:29). Sixty-six patients (60%) had isolated thoracic injuries. Twelve of these had a secondary thoracic injury. Of the remaining 44 patients (40%), 21 had one associated injury, 14 had two, seven had three, and two had four. Orthopedic injuries were the most common associated injuries (Table 2). Neurologic sequelae were present in 12 patients: paraplegia in four, quadriplegia in one, and brachial plexus injury in seven patients. Four patients required mechanical ventilation, two due to extensive pulmonary contusion and the others as a result of cerebral pathology.

Tube thoracostomy was the most common treatment modality in this series, which was sufficient alone in 84 patients (76.3%) for thoracic injury (Table 3). Chest wall repair was performed in 13 patients without requirement thoracotomy. In these patients, 11 had HVGSW and two had SGW. Thoracotomy was performed in 14 patients (ten immediate, four delayed) (Table 3). Of the four delayed thoracotomies, two were due to intrathoracic hematoma that resulted from inappropriate chest tube drainage. In the remaining two patients, decortication was performed because of empyema thoracis. Immediate thoracotomy was performed in ten patients. All patients who underwent immediate thoracotomy had excessive bleeding or vital and hemodynamic instability. The most common reason for the use of thoracotomy was HVGSW (7/14, 50%) in our study. Other thoracotomies recorded include those for SGW in four patients (4/14, 28.6%), LVGSW in two patients (2/14, 14.3%) and EW in one patient (1/14, 7.1%). Primary repair of lung lacerations were the most common surgical treatments (Table 4). Observation alone was accomplished in ten patients (9.1%). In four of the observed patients, the follow-up chest X-rays appeared completely normal. In these patients, pulmonary contusion was identified by CT or pulmonary perfusion scintigraphy. In three of the ten observed patients (30%), delayed hemothorax or hemopneumothorax developed between 12 and 48 h after admittance. Chest tube drainage was sufficient for successful treatment in these patients. In order to determine those suspected of major bronchial wounds or lacerations to the lungs with major bronchial wounds, in four patients rigid or flexible bronchoscopy was required. Major bronchial injury was determined in one patient as a result of this method.

	4. Discussion

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion References

The severity of and approach to thoracic firearm injuries depends on the offending weapon and the energy involved [13]. In our series, the SGW and EW groups had a higher ISS, and as a result a higher rate of morbidity and LOS in hospital. Injuries caused by explosives or shotguns affect a larger area of the body and for that reason the effects of such injuries are more severe [14,15]. In such cases, multisystem injuries are generally observed. Additionally, explosive injuries have significant blast force impact. When the blasting force is closer than 20 feet, however, air bearing structures such as the lungs and the gastrointestinal tract are frequently injured [15]. Moreover, because the vital structures in children are concentrated within a smaller space, more vital organs can be injured. For example, SGW can produce relatively greater rates of morbidity [14] and this observation was borne out in our series as SGW had the highest rate of morbidity (23.5%). We found that although there was no statistically significant difference in morbidity among the four groups of patients, those patients who sustained EW and SGW had a significantly greater morbidity rate than those of the other groups. While morbidity was 6.9% in the group with an ISS ≤16, this ratio increased to 38.1% when an ISS greater than 25 was present. The ISS is found to be a significant independent predictor of morbidity in our patients. Patients in the HVGSW and LVGSW groups were generally shot by one bullet and had at most one to two sites on the body that were of concern. Small-caliber handgun injuries are characterized by much less primary tissue destruction than wounds caused by hunting or military weapons [13]. HVGSW involve the transfer of a higher amount of kinetic energy via a missile. The destruction of tissue is directly proportional to the velocity and energy of the missile. Doubling the velocity quadruples the energy. Low-velocity guns do not transfer a large amount of energy to the surrounding tissue. The HVGSW group had more cavitation damage and contusions in the lungs than did the LVGSW group [15]. The HVGSW group had a significantly higher rate of contusion in the lung (29/52, 55.7%) than did the LVGSW group (3/23, 13%). Additionally, 11 patients required chest wall repair who had HVGSW while did not in patients with LVGSW. Pulmonary contusion can often result in alveolar atelectasis, parenchymal consolidation, or interstitial derangement [16]. These changes result in ventilation/perfusion mismatching, intrapulmonary shunting, and decreased lung compliance. Pulmonary contusion may progress to ARDS and concomitant extrathoracic injuries that give rise to an increased mortality rate [15]. Pulmonary contusion was present in 42.7% of our patients. However, most of these contusions were present in only a limited area of the lung and contributed little to patient morbidity. Pulmonary contusions usually appear on initial chest radiographs. However, some contusions may not able to be distinguished from pulmonary hematoma or lacerations using chest radiography. At times these lesions may be in the same time and may not be distinguishable by chest X-ray. In patients we suspected of having such injuries we used CT scanning. The increased use of CT scanning has improved sensitivity and made diagnosis easier than using X-rays alone. Pulmonary hematoma may be difficult to differentiate from pulmonary contusion because of surrounding intraparenchymal hemorrhaging. However 24–48 h after the injury, a hematoma typically develops into a discrete mass with distinct margins. CT scans can be helpful in distinguishing between contusion and hematoma. Additionally, CT has led to the finding that pulmonary lacerations are frequently associated with pulmonary contusions [15]. Only three patients required mechanical ventilation due to extensive contusions or cerebral pathology. Two of these patients died due to ARDS and cerebral herniation. These two patients also had concomitant extrathoracic wounds.

Thoracotomy is required infrequently in children [3,17]. The indications for the procedure are well known and include massive bleeding, massive air leakage and cardiac tamponade, tracheobronchial injury, esophageal perforation, cardiac or major vessel injury, and post-traumatic empyema [15]. However, in our series about half of the injuries were due to HVGSW combined with a low incidence of operative management. This is attributable to the absence or limited number of major vessel, tracheobrochial, esophageal and cardiac injuries. We believe that patients with such injuries die at the incident scene or en route to hospital. Thoracotomy was required in 12.7% of our patients. Of those undergoing thoracotomy, 64.3% had an ISS greater than 25, whereas only one patient required thoracotomy in the group with an ISS ≤16. As a predictor of surgical requirement, the ISS was found to be a significant independent factor [P<0.001]. Reinhorn et al. [7] reported that among gunshot wound victims, 46% of those requiring surgical intervention had an ISS greater than 25. The incidence of patients with penetrating chest injuries requiring thoracotomy constitutes 3–71% of those in the literature [1,3,8,17–21]. In another study similar to our own that only covered thoracic firearm injuries in children, the rate of thoractomy ranged from 17.7 to 35.3% [1]; this ratio is even greater than our own. The difference probably stems from the fact that the number of patients in Nance's series who had injuries requiring urgent thoractomy was higher as a result of the short time taken to reach the hospital prior to death.

Most penetrating chest wounds can be treated with tube thoracostomy and supportive measures if there are no gross pulmonary lacerations and/or airway injuries. The procedure has been used for 53.9–92% of patients in various studies [8,10,19,22–25]. In our series, tube thoracostomy alone was sufficient for thoracic injury in 73.9% of the patients. Observation was accomplished in ten patients (9.1%). In three of the ten observed patients, delayed hemothorax or hemopneumothorax developed after 12 and 48 h of observation. Meller et al. [17] have recommended expectantly observation especially with penetrating chest trauma, even for those without air or fluid accumulation in the chest. They suggested the use of 2 days as a conservative guideline [17]. In a thoracic gunshot wound series, Ordog et al. [6] suggested treatment as outpatients after 4 h of observation in patients who have normal vital signs and normal chest X-ray findings. In our experience, the observation period should be at least 48 h for a child who has thoracic firearm injury with normal vital signs and normal radiographic findings.

The mean LOS was significantly longer for those patients sustaining SGW and EW than for those sustaining HVGSW and LVGSW. The ISS was significantly higher in the SGW and EW groups. Higher ISS was found to increase the LOS.

The mortality rate regards children with firearm injuries has received little attention. In general, the mortality rate connected with penetration of the thorax includes injuries caused by stab wounds and firearms combined, while in some studies the statistics for children and adults are combined. The mortality rates reported for children with firearms-related thoracic injuries was 11.8% [1] and 31% [7]. Mortality rates often depend on the population studied and whether or not patients who die in an emergency room are included [3]. The overall mortality rate we experienced was 4.5%. The reasons why the mortality rate in our study was lower than in others are that most of the injured patients came from rural areas where poor or inadequate first aid was provided and that the transport used to get them to hospital was either poor or it brought them to the hospital late; thus, badly wounded patients did not reach the hospital in time for treatment. In addition, children are more susceptible to blood loss than adults are. Overall, the patients that reached our hospital were in a better overall state. The transportation system and initial management on the way to hospital are not as well developed as in other countries, especially in our region. Four of the five mortalities occurred in patients who had an ISS greater than 25 in our study. In all four cases, two or more body systems were affected. The ISS was found to be a reliable indicator of mortality (P<0.001) as well as of morbidity and the need for surgery. The ISS developed by Baker et al. [12] can be used to better predict patients carrying a higher risk of mortality as well as those in need of more immediate care.

In conclusion, children who are the victims of shotgun wounds or explosive wounds have a higher ISS rating and LOS in hospital, as well as increased rates of morbidity. Therefore, those with such an injury should be retained for a longer period in an intensive care unit. The ISS is an independent predictor of the need for thoracotomy, as well as for the rate of morbidity and mortality. The majority of firearm injuries in children can be treated successfully by tube thoracostomy alone if there are no gross pulmonary lacerations and airway injuries. The death and complication rates from thoracic firearms injuries would be greatly reduced if better first aid and speedier transportation were provided.

	Footnotes

 
Presented in part at the 5th Congress of Trauma and Emergency Surgery, Istanbul Convention and Exhibition Center (ICEC), Istanbul, Turkey, October 1–5, 2002.

	References

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion References

 

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Eren, S. Articles by Eren, M. N. Search for Related Content PubMed PubMed Citation Articles by Eren, S. Articles by Eren, M. N. Related Collections Lung - other Minimally invasive surgery Chest wall