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Research Letters |

Firearm Injuries of Children and Adolescents in 2 Colorado Trauma Centers: 2000-2008 FREE

Angela Sauaia, MD, PhD; Joshua I. Miller, MPH; Ernest E. Moore, MD; David Partrick, MD
[+] Author Affiliations

Author Affiliations: University of Colorado School of Public Health, Denver (Dr Sauaia and Mr Miller) (angela.sauaia@ucdenver.edu); Denver Health Medical Center, Denver, Colorado (Dr Moore); and Children's Hospital Colorado, Denver (Dr Partrick).


Letters Section Editor: Jody W. Zylke, MD, Senior Editor.

More Author Information
JAMA. 2013;309(16):1683-1685. doi:10.1001/jama.2013.3354.
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Published online

To the Editor: Given recent firearm-related fatalities combined with declining gun research funding,1 it is important to monitor firearm injuries in youths. Injury death rates are available but provide an incomplete picture of these potentially preventable injuries.2

Investigations on temporal trends of both fatal and nonfatal firearm injuries remain scarce.35 Our objective was to investigate temporal trends of both fatal and nonfatal firearm injuries in children and adolescents presenting to 2 Colorado urban trauma centers.

We queried the trauma registries of 2 level 1 trauma centers in Denver and Aurora, Colorado, from 2000 to 2008 for all injuries occurring in children and adolescents aged 4 to 17 years (hereafter referred to as youth). Trauma registries are mandated in Colorado and include all level 1 trauma center patients with 1 or more of the following criteria: in-hospital death (deaths at scene are not included), admission to hospital unit, highest level trauma team activation, longer than 12 hours of observation, or Injury Severity Score6 (ISS; range, 0-75) greater than 9.

Variables reported had complete data, except for race/ethnicity (2.8% missing) and ISS (1% missing). Missing values were not associated with other variables, suggesting random missingness. Injury was classified as self-inflicted if there was unequivocal information that the patient injured himself or herself purposefully or by accident. Intention is not consistently reported and was not assessed.

The Colorado Multiple Institutional Review Board considered the study exempt and did not require informed consent.

We compared firearm injuries with other injuries regarding patient characteristics (age, sex, race/ethnicity [white non-Latino vs others], injury self-infliction, ISS, mortality, and intensive care requirement). We analyzed temporal trends regarding patient and injury characteristics as well as outcomes among fatal and nonfatal firearm injuries.

Wilcoxon or Spearman rank correlation tests were used for continuous variables and χ2 or Fisher exact tests were used for proportions. The categorical outcomes were adjusted for age, sex, white non-Latino race/ethnicity, ISS, and temporal trends through logistic regression; and goodness of fit was assessed with C statistics. Variables are reported by triennials for simplicity but annual data were used for analysis.

Statistical analyses were performed using SAS version 9.3 (SAS Institute Inc). Tests were 2-sided, with significance established at a P value of .05.

Overall, 6920 youths were injured. Firearms caused the injury in 129 of these youths (1.9%) (2.1% in 2000-2002; 1.9% in 2003-2005; 1.6% in 2006-2008). Firearm-wounded patients were more likely to be adolescent males, and their injuries were more often self-inflicted compared with youths with other injuries (Table 1). Sixty-five patients (50.4%) with firearm injuries required intensive care vs 1311 patients (19.3%) with other trauma; 17 patients (13.2%) with firearm injuries died vs 116 (1.7%) with other trauma.

Table Graphic Jump LocationTable 1. Demographic and Injury Characteristics of Children and Adolescents Presenting to 2 Urban Level 1 Trauma Centers, 2000-2008

Firearm injury severity significantly increased over time (ISS of 9 in 2000-2002; 10 in 2003-2005; 15 in 2006-2008; Spearman test, P = .048), whereas no significant changes were detected over time by age, sex, race/ethnicity, case fatality, or intensive care requirement. Multivariable analysis for firearm injuries yielded an odds ratio for intensive care of 2.35 (95% CI, 1.40-3.93) and 9.93 (95% CI, 4.30-22.92) for death compared with those with other injuries (Table 2).

Table Graphic Jump LocationTable 2. Multiple Logistic Regression Analysis of the Independent Effect of Firearm Injuries on Death and Requirement for Intensive Care

Firearms were an important mechanism of injury in the youth in this study. Compared with other serious injuries, firearm injuries were more severe, more often required intensive care, and claimed more lives, justifying focusing on pediatric firearm injuries as a prevention priority.

Study limitations include trauma registry deficiencies (such as inconsistent capturing of intentionality and exclusion of deaths at scene, which is a significant fraction of firearm-related deaths); and data restricted to 2 trauma centers, which may not generalize to other regions. In addition, data were available only until 2008; however, there has been no substantial decline in published firearm death rates in Colorado since 2008 (2.2 per 100 000 persons aged 4-17 years in 2000, 1.9 in 2009, and 2.8 in 2011).

More recent data from other areas with detail on the circumstances of the firearm injury are needed.

Author Contributions: Dr Sauaia had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Sauaia.

Acquisition of data: Sauaia, Miller.

Analysis and interpretation of data: Sauaia, Miller, Moore, Partrick.

Drafting of the manuscript: Sauaia, Moore.

Critical revision of the manuscript for important intellectual content: Sauaia, Miller, Moore, Partrick.

Statistical analysis: Sauaia, Miller.

Administrative, technical, or material support: Sauaia, Partrick.

Study supervision: Sauaia, Moore.

Conflict of Interest Disclosures: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

This article was corrected for errors on April 26, 2013.

Kellermann AL, Rivara FP. Silencing the science on gun research.  JAMA. 2013;309(6):549-550
PubMed   |  Link to Article
Annest JL, Mercy JA, Gibson DR, Ryan GW. National estimates of nonfatal firearm-related injuries: beyond the tip of the iceberg.  JAMA. 1995;273(22):1749-1754
PubMed   |  Link to Article
Senger C, Keijzer R, Smith G, Muensterer OJ. Pediatric firearm injuries: a 10-year single-center experience of 194 patients.  J Pediatr Surg. 2011;46(5):927-932
PubMed   |  Link to Article
Eber GB, Annest JL, Mercy JA, Ryan GW. Nonfatal and fatal firearm-related injuries among children aged 14 years and younger: United States, 1993-2000.  Pediatrics. 2004;113(6):1686-1692
PubMed   |  Link to Article
Dowd MD, Sege RD.Council on Injury, Violence, and Poison Prevention Executive Committee; American Academy of Pediatrics.  Firearm-related injuries affecting the pediatric population.  Pediatrics. 2012;130(5):e1416-e1423
PubMed   |  Link to Article
Baker SP, O’Neill B, Haddon W Jr, Long WB. The Injury Severity Score: a method for describing patients with multiple injuries and evaluating emergency care.  J Trauma. 1974;14(3):187-196
PubMed   |  Link to Article

Figures

Tables

Table Graphic Jump LocationTable 1. Demographic and Injury Characteristics of Children and Adolescents Presenting to 2 Urban Level 1 Trauma Centers, 2000-2008
Table Graphic Jump LocationTable 2. Multiple Logistic Regression Analysis of the Independent Effect of Firearm Injuries on Death and Requirement for Intensive Care

References

Kellermann AL, Rivara FP. Silencing the science on gun research.  JAMA. 2013;309(6):549-550
PubMed   |  Link to Article
Annest JL, Mercy JA, Gibson DR, Ryan GW. National estimates of nonfatal firearm-related injuries: beyond the tip of the iceberg.  JAMA. 1995;273(22):1749-1754
PubMed   |  Link to Article
Senger C, Keijzer R, Smith G, Muensterer OJ. Pediatric firearm injuries: a 10-year single-center experience of 194 patients.  J Pediatr Surg. 2011;46(5):927-932
PubMed   |  Link to Article
Eber GB, Annest JL, Mercy JA, Ryan GW. Nonfatal and fatal firearm-related injuries among children aged 14 years and younger: United States, 1993-2000.  Pediatrics. 2004;113(6):1686-1692
PubMed   |  Link to Article
Dowd MD, Sege RD.Council on Injury, Violence, and Poison Prevention Executive Committee; American Academy of Pediatrics.  Firearm-related injuries affecting the pediatric population.  Pediatrics. 2012;130(5):e1416-e1423
PubMed   |  Link to Article
Baker SP, O’Neill B, Haddon W Jr, Long WB. The Injury Severity Score: a method for describing patients with multiple injuries and evaluating emergency care.  J Trauma. 1974;14(3):187-196
PubMed   |  Link to Article
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