Epidemiology of firearm injuries in a Scandinavian trauma center

This is the largest epidemiology study of firearm injuries in Sweden over a 12-year period at an urban major trauma center. There was a significant increase in number of firearm injuries over the years. During the study period, the percentage of penetrating trauma increased from 5.3% 2005 to 12% 2016, and the percentage of firearm injuries of all penetrating trauma increased from 16% 2005 to 36% 2016. Young age and men were dominating. The lower extremity was the most common injury location over the years and the femoral artery was the dominating vascular injury. 17% of patients had major vascular injuries which significantly increased over the years. More than one-tenth of patients died; the majority within 24 h mainly due to injuries to the head and neck area and the chest.

There have been relatively few studies published on epidemiology of civilian firearm injuries in European countries most likely explained by the low frequency of these injuries in most high-income countries. The Trauma Audit Research Network (TARN) database was used to examine adult persons hospitalized for penetrating trauma injury in England and Wales between 2000 and 2005, showing that stabbing was the most common type of injury (73%) followed by shooting (19%) [11]. Davies et al. showed that deaths and serious injuries from firearms remained rare in the civilian population of England and Wales although an upward trend has been described [7]. From an urbanized German region, a total of 121 patients sustained penetrating injuries by interpersonal violence or attempted suicide, 23 (19%) of them by firearms [6]. The experience from Southwest Finland between 1997 and 2011 reported 130 penetrating trauma including 16 with a gun [12]. From the United States, using data from the National Inpatient Sample (NIS) during a 10-year period (2004–2013), the annual rate of hospitalizations for GSW was reported to remain stable at 80 per 100,000 hospital admissions [3]. From our data we clearly had an increasing trend of firearm injury admissions in recent years. The majority of patients were young males which has previously been reported [3, 6, 12‐14].

Several factors such as wound ballistics, tissue structure, and anatomical relationships determine the extent of injury after firearms [15]. The most common anatomical location of injury was the lower extremities and the femoral artery was the most common injured vessel in this study. A review of the National Trauma Databank showed that the extremities are the most commonly injured anatomic region in nonfatal firearm trauma and are associated with high rates of vascular and bony injury [16]. Vascular injury, with or without fracture, was here the biggest predictor of local complications. The vascular trauma experience from a British trauma center showed that stab wounds were the most frequent cause of vascular injuries; five times more common than gunshot wounds [17]. Meskey et al. studied 650 patients with 938 fractures resulting from firearms where the femur (30%) was the dominating fracture [18]. Ballistic fractures of the fibula and tibia were at increased risk for development of compartment syndrome.

We were somewhat surprised that only 53% of our study population underwent one or more surgical procedures. Livingstone et al. reported in a retrospective registry review of patients treated for GSW at an urban major trauma center in the US that 75% of patients admitted to hospital needed at least one surgical procedure during hospitalization [13]. Non-operative management and exclusion of minor surgery such as wound debridement, wound exploration, and wound closure may explain some of these differences. Almost three-quarter of patients with GSW to the chest had surgical interventions including chest tube, thoracotomy or laparotomy.

The 30-day mortality after firearm injury was 12.8% in this study. The majority of these patients died within 24 h and some was more or less dead on arrival. The most common lethal injuries were distributed to the chest and the head and neck area. Gunshot wounds to the head carry a high mortality rate. Aarabi et al. showed that 76% of patients with civilian gunshot wounds to the head died at the scene of accident, and 61% of the patients who were admitted to hospital died [19]. Recent data from the American College of Surgeons (ACS) National Trauma Data Bank showed that firearm injuries have the highest case fatality rates in every age group with a mortality rate of 15.3% for GSWs [20].

There are some inherent limitations to this retrospective study based on registry data from two trauma registries Some of the study variables existed only in one registry. However, there are few missing data in the registries and patient charts could be used to control and complete data. Only patients admitted to the trauma center in the region were included in the study which may exclude patients with less severe injuries that may have been admitted to other hospitals. Also patients with firearm injuries that were already dead at the scene and did not reach the hospital were not included.

Firearm injuries cause significant morbidity and mortality and are an important medical and public health problem. In a Scandinavian trauma center there has been an increase of firearm injuries in recent years. The lower extremities followed by the abdomen are dominating injured regions and there has been an increase in associated vascular injuries. Most fatalities occur within 24 h due to injuries to the head and neck or chest. Additional studies and education on all levels of trauma care are necessary to further improve the management of patients with firearm injuries.