VIOLENCE
intellectual effort has traditionally been focused on Non-Accidental
Trauma (NAT). While the term is broad in scope, it typically refers
to a child who is injured deliberately, usually by blunt mechanism.
At the governmental and provider levels, a tremendous amount of
effort has been directed at the identification, treatment and preven-
tion of these types of violent injuries. Providers are required by law
to report suspected cases of NAT to local Child Protective Services
(CPS), so that an appropriate investigation can be undertaken to
determine the safety of the child’s living environment. Court orders
can be obtained through those investigations to remove the child
from unsafe situations. Forensics experts are increasingly available
in major children’s hospitals, and use their expertise in patterns of
deliberate injury to assist with both the CPS investigation and direct
treatment of the child’s injuries. Within our institution, educational
videos for new parents - now legally required in Kentucky prior
to the baby’s discharge - explain to them the devastating effects of
Shaken Baby Syndrome.
Pediatric firearm injuries have historically received less attention
and effort from our health care system than have other forms of
violent trauma. This may be due to the perception these injuries
don’t occur with the same frequency or severity as seen in adults.
It may also be because other forms of violent trauma are more per-
vasive in our patient population. However, a review of our trauma
registry data at Norton Children’s Hospital demonstrates that gun
related injury is a significant and increasing issue for children in
our community. In the last eight years, 113 patients have been
treated here, with an average of 10 per year between 2010-2014, but
more than 20 per year since 2015 - without a change in the overall
number of trauma admissions. Average victim age has been stable
at just over nine years. Overall mortality from these injuries has
been 13.7 percent over the entire time period; in almost all cases,
devastating traumatic brain injury is the cause. This mortality rate
far eclipses that for any other type of injury seen by our institution,
with the exception of severe traumatic brain injury from NAT in
the neonatal and infant population.
While the majority of adult gunshot wound victims are injured
with intent, this has largely not been the case in our pediatric pop-
ulation. For all patients treated at our institution during the years
2010-2107, 75.2 percent (85/115) were injured unintentionally.
When considering patients 12 years of age or younger, this percent-
age increased to 95.3 percent (48/51). Common mechanisms for
unintentional gun injury included self-inflicted injuries sustained
when a small child picked up a gun in the house, one child acciden-
tally shooting another while playing with an adult’s gun, injuries
sustained with adults while hunting or cleaning a gun, and injuries
sustained from proximity to a violent confrontation. Unfortunately,
the tendency towards unintentional injury in younger children does
not equate to decreased severity of injury or any survival advantage.
The average age of the patients who died during the reviewed time
period was nine years (age range 1-16). Of the 15 patients who died,
67 percent were under the age of 10, and all of these patients were
injured without intent.
Among the intentional gunshot wounds treated at our institution,
almost all were single or group related violence events in which the
victim was either a participant or the intended target. This type of
injury was nearly exclusively limited to our adolescent population.
Interestingly, the mortality rate was actually significantly lower in
this group of patients (2.7 percent) than in the group overall. These
injuries tended to be non-fatal extremity or superficial chest wounds
in our population. Many were discharged from the emergency de-
partment after being evaluated. There were two suicide attempts,
both in adolescent, both of whom died from their injuries.
Children have a remarkable ability to tolerate and recover from
injury. It is not surprising that of the 98 patients who ultimately
survived to discharge, only two required inpatient rehabilitation
before going home. An additional two had brain injuries severe
enough that they did not qualify for inpatient rehabilitation, and
were ultimately sent to long-term care facilities. The overwhelming
majority of patients who survived were discharged in good condition
to home, and made complete recoveries.
Although historically perceived as isolated, relatively rare events,
gunshot wounds cause significant morbidity and mortality in our
pediatric population. As care providers for children, we are seeing
more of these events over time. This is not a problem limited to
violent adolescents. These injuries are occurring in infants and small
children, they are occurring accidentally due to careless handling of
guns, and they are causing deaths. Although pediatric survivors of
gunshot wounds typically recover well, they can have hospital stays
which are physically and psychologically difficult for them, and ex-
tremely stressful for their parents. It cannot be stressed enough that
the majority of these injuries are both unintentional and preventable.
More effort needs to be directed toward education regarding the
handling and storage of firearms in households where children
are present, and the support of legislation that would directly or
indirectly restrict the access of children to guns.
Dr. Foley is a practicing Associate Professor of Surgery and Pediatrics for
the UofL School of Medicine as well as the Medical Director of Trauma
and Burn Care and Norton Children’s Hospital.
AUGUST 2018
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