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Stray Bullet Injuries in a Tertiary Care Center

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Stray Bullet Injuries in a Tertiary Care Center SIGNA VITAE 2016; 12(1): 106-110 Stray bullet injuries in a tertiary care center NICHOLAS BATLEY, RINAD BAKHTI, RANA BACHIR, AFIF MUFARRIJ Department of Emergency Medicine, American University of Beirut Medical Center, Beirut, Lebanon Corresponding author: Aff Mufarrij Department of Emergency Medicine American University of Beirut Medical Center P.O.Box - 11-0236 Riad El Solh Beirut 1107 2020 Phone: +961-1-350000 Ext: 6636 E-mail: [email protected] ABSTRACT and the region to document cases of stray will fall at its terminal or free fall velocity bullet injuries presenting to the ED. Bet- based on bullet characteristics like weight Background. A stray bullet injury is de- ter laws and educational policies need to and shape, its kinetic energy, and whether fned as an accidental frearm injury oc- be implemented to help discourage this it lands base or nose frst. (5) Te degree curring outdoors by an anonymous at- practice. of tissue damage also varies based on the tacker. Stray bullet injuries are rare, but not size of the organ or tissue and the resist- uncommon in certain parts of the world. Key words: stray bullets, emergency depart- ance of the tissue to strain. (6) A bullet that In Pakistan, 165 patients with stray bullet ment, injured body part, consequences of hits ‘nose frst’ will have the highest termi- injuries were recorded between 2006 and stray bullets, hospital admissions, severity of nal velocity and might cause more damage. 2010. injury, surgical intervention, Lebanon (5) Tis can occur from both handguns and rifes. With an AK47 rife, the veloc- Objectives. In Lebanon, gunshots may oc- ity of a bullet is 2,330 feet per second (fps) cur during politicians’ speeches, funerals INTRODUCTION with a bullet weight of 7.9 grams, while an and afer exam results are published. No M16 has a velocity of 3,250 fps and a bul- studies to date have looked at the details A 38-year-old female presented to the let weight of 3.6 grams. (7) Te maximum and consequences of these gunshot inju- Emergency Department (ED) at the Amer- range of an AK47 and an M16 is 2300 ries. ican University of Beirut Medical Center meters and 2700 meters, respectively. (8) (AUBMC). She was having dinner on the Bullets with a caliber of 0.30 may have a Methods. A retrospective chart review of veranda of a seaside restaurant in Bei- terminal velocity of 300 fps, whereas larger patients presenting to an emergency de- rut when she developed a sudden, severe bullets of 0.50 caliber may have a velocity partment (ED) in Beirut, Lebanon, from right-sided headache and bleeding from of 500 fps. (9) 2010 to 2015, with clear stray bullet inju- a scalp wound. Te patient underwent a ries was conducted. Variables included: computed tomography (CT) scan of the Te trajectory of a bullet, called “horizon- demographics, injured body part, admis- brain, which revealed a bullet lodged in the tal projectile motion,” will continue to ac- sion to hospital, number of days in hospi- scalp with no skull fracture or intracranial celerate when shot in the air until it arrives tal, length of stay in the ED, mortality, past injury (fgure 1). Te bullet was removed at a point where its weight is equal to the medical history, emergency severity index, without complication, the scalp was su- resistance of the air. Although when fall- and consequences of injury including sur- tured and the patient discharged home in ing, these bullets are not at optimum veloc- gery. a stable condition. ity, they might still reach 600 fps while fall- ing down. A speed of 148 fps is sufcient Results. Out of 154 bullet injuries, 12 stray Te International Classifcation of Dis- for a bullet to penetrate the skin whereas bullet injuries were recorded. Injuries of eases defnes a stray bullet injury as an ac- a bullet at 200 fps can potentially pierce the lower extremity were most common, cidental frearm injury occurring outdoors through bone structures and enter the followed by the head, shoulder/thorax, by an anonymous attacker. (1) Although skull. (10) When a bullet is shot at a high abdomen/pelvis and upper extremity. Sur- stray bullet injuries are generally rare, but non-vertical angle, it is more likely to gery was needed in 7 patients (58.3%). Te they are not entirely uncommon in certain be potentially fatal on return. (5) With median length of stay was 3.08 hours in the parts of the world. (2) Falling bullets may most cases of stray bullet injuries, the bul- ED and 4.78 days in hospital. Tere were hit people, more commonly in populated let is stuck in subcutaneous regions with no recorded deaths. Consequences of each areas like cities, cause injury and in some no exit wounds. stray bullet injury are presented. cases, result in death. (3) In a sample of 284 cases, 81% of those injured were unaware In Lebanon, gunshots are frequently heard Conclusion. Stray bullet injuries are com- of the causes or events of the shooting. (4) during politicians’ speeches, funerals and monly reported on in news and media afer exam results are published. (11) No outlets. Tis is the frst study in Lebanon Generally, a bullet that is fred vertically studies to date have looked at the conse- 106 | SIGNA VITAE quences of these gunshots. Te purpose of Statistical analyses were carried out using and posterior chest (50%). Of the 2% of the current work is to better defne stray SPSS 23 (Statistical Package for Social Sci- bullets hitting the chest, only a fraction bullet-induced pathology and its conse- ences). In the univariate analyses, descrip- had injured the heart. Some consequences quences. tive statistics and frequency distributions included seizures, neurologic defcits and were presented whereas the continuous joint immobility. variables were analyzed as means, standard MATERIALS AND METHODS deviations, ranges and percentiles. Between 2006 and 2010, 165 patients with stray bullet injuries were detected in the Te present paper summarizes the data on Sind province of Pakistan. (14) Te ma- stray bullet injuries presenting to the ED of RESULTS jority (61.8%) presented with peritonitis, AUBMC in Beirut, Lebanon, from January followed by haemothorax/ pneumothorax 2010 to November 2015. Te study was ap- Out of a total of 154 bullet injuries, 12 in 11% of cases. Additionally, 55% un- proved by the Institutional Review Board cases were found to be stray bullet injuries. derwent laparotomy, whereas the rest had at AUBMC. AUBMC is the largest tertiary Socio-demographic and clinical character- chest tubes inserted and other procedures care center in Lebanon, receiving approxi- istics are presented in table 1 (Appendix done. In terms of consequences of injury, mately 49,000 patient visits per year. Te A). Te sample was composed of 5 males nine people sufered permanent disabili- ED is divided into three levels: a high acu- (41.7%) and 7 females (58.3%), with a me- ties and 13 died. In a similar study from ity section (ED1), low acuity section (ED2) dian age of 25.5 years. Four were married Pakistan, 144 injuries from stray bullets and a pediatrics section (ED3). Triage is (33.3%) and the remaining were single were assessed; marriage ceremony celebra- conducted according to the Emergency (66.7%). A total of 7 were self-paying pa- tions were the most common cause. (3) Of Severity Index (ESI) scoring system, as- tients (58.3%). Five patients (55.6%) had the 144 cases, 102 were considered a trivial signing severity scores to patients. (12) ESI received an ESI of 2 while four (44.4%) had injury, while the rest required surgical in- consists of fve levels used to assess patient an ESI of 3 at triage. Only two reported tervention. Te mean hospital stay was 13 acuity from level 1 (most urgent) to level 5 having any past medical history (16.7%). days and the surgical interventions con- (least resource intensive). During the study Almost all patients were admitted to the ducted were: chest intubation, wound tract period, 288,361 patients were admitted to hospital except for one (91.7%). Injuries exploration to retrieve the bullet, and lapa- the ED. Te ESI distribution of those seen of the lower extremity were most com- rotomy to manage intra-abdominal injury, was 0.4%, 7%, 67.7%, 22.7%, and 2.2% for mon with 5 cases (41.7%), followed by the with no recorded deaths. ESI 1, 2, 3, 4, and 5, respectively. Payment head with 3 cases (25%), shoulder/thorax, was covered though private insurance in 2 cases (16.7%), one case of abdominal/ According to the Centers for Disease Con- 72.5% of cases, 25% out-of-pocket and pelvic injury (8.3%) and one case of an trol and Prevention, 2 people die and 25 2.5% through governmental insurance. injured upper extremity (8.3%). Surgery people are injured annually on New Year’s was required for 7 patients (58.3%). Te Eve in Puerto Rico. (15) Te most common A retrospective chart review of patients median length of stay during their visit site of injury is the head (36%), followed by of all ages presenting to the ED in Beirut, was found to be 3.08 hours in the ED and the foot (26%) and then shoulder (16%). Lebanon, in these fve years with clear stray 4.78 days in the hospital. Tere were no bullet injuries, was conducted. Stray bullet recorded deaths. Each case, along with the In some countries in the Middle East, gun- cases were defned as unintentional injuries consequences of injury, is presented in Ap- fre ofen occurs during weddings, gradu- resulting from an unknown shooter.
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