Despite the Increasing Use of Nonoperative Management of Firearm Trauma, Shotgun Injuries Still Require Aggressive Operative Management

Results We evaluated 2833 patients injured by firearms; of these 61 had shotgun wounds (2.2%). The remainder sustained gunshot wounds. Mortality between shotgun and gunshot trauma patients was similar (7% versus 9%, respectively, P = 0.8). There was no difference in the mean Injury Severity Score (ISS) (13.7 ± 1.6 versus 12.9 ± 0.2; P = 0.6). Overall, 61% of patients underwent operative intervention after shotgun injuries versus 36% of patients with gunshot wounds ( P < 0.0001). Patients surviving shotgun injuries had a longer length of stay (10.1 ± 2.0 d versus 5.9 ± 0.21, P < 0.05). Conclusions Although the injury severity was similar, injuries from shotguns required more operations and resource utilization. Shotgun blasts can create impressive superficial injuries as well as significant deep organ damage. An aggressive operative approach to managing shotgun trauma is advantageous. Key Words penetrating trauma shotgun Introduction The energy dissipation of gunshot and shotgun blasts is very different [1] . Injuries from shotgun blasts vary depending on the distance of the victim from the shooter as well as the choke of the shotgun, which controls the shot pattern [2] . The pellet load and wad of the ammunition also vary [3, 4] . These variables lead to a range of injuries with point blank blasts being very destructive, and longer range blasts rarely causing significant deep tissue damage [1, 5] . Shotgun blasts also have the potential to effect multiple systems [6] . The management of penetrating trauma has evolved considerably over the 20th century. Penetrating trauma, including firearm injuries, is increasingly managed nonoperatively [7–10] . Although there have been multiple attempts to develop a scoring system for shotgun wounds [5, 11, 12] , no scoring system has proven to be successful in predicting the need for emergency operative management. Clinical judgment remains the most reliable guide when assessing the need for operative intervention [11, 13] . Additionally, improved outcomes after shotgun injury have been attributed to aggressive operative management [1, 14] . We postulated that gunshot and shotgun blasts create different injury patterns that require different management protocols. Although many injuries from gunshot wounds can be managed nonoperatively, wounds from shotgun blasts continue to require aggressive operative management. The specific aims of this study were: (1) to determine the difference in injury severity between shotgun and gunshot trauma patients, (2) to determine the difference in operative management between shotgun and gunshot trauma injuries, and (3) to determine the difference in hospital resource utilization between shotgun and gunshot trauma patients. Methods We retrospectively reviewed the trauma records at our university-based, urban trauma center. All gunshot trauma activations from January 1998 to December 2007 were analyzed. Patients were grouped by trauma mechanism (shotgun or other gunshot). Severity of injury was measured using the Injury Severity Scale (ISS) and the Revised Trauma Score (RTS). Patients were grouped as having a mild (1–8), moderate (9–15), severe (16–24), or most severe (>24) injury based on the ISS. The RTS was calculated from the first set of vitals obtained and analyzed in continuum. Patients who were deceased on arrival (DOA) to the trauma bay were excluded from the study. DOA patients had an RTS of 0 and were declared deceased before ever leaving the trauma bay. Trauma records were used to determine ICU admission, radiology examinations, and operative procedure. ICU admission was any stay in the ICU during hospitalization. Radiology was any ultrasound, CT scan, or MRI obtained during hospitalization. An operation was any procedure performed in the operative suite during hospitalization. Significant injury (AIS > 2) to head, chest, and other regions were also analyzed. Means were compared using the t -test, and percentages were compared using Fisher's test. A logistic regression was used to determine the odds ratio for in-hospital death while correcting for any confounding effects of race, gender, age, and injury severity. A similar regression was used to determine the odds ratio for hospital resource utilization, i.e., operation, ICU admission, and radiology. The reference group for multivariate analysis was white, male gunshot patients with mild injuries. StatView (SAS Institute, Cary, NC) was used for statistical analysis. Values are listed as a percentage or mean ± SEM. Results There were 3075 patients who presented to our institution after firearm trauma from 1998 to 2007. Of these, 242 were DOA and excluded. Of the 2833 patients meeting our inclusion criteria, 61 (2%) were injured by a shotgun blast ( Fig. 1 ). Mortality rates were 7% for shotgun victims and 9% for gunshot victims ( P = 0.8). Of the shotgun patients who died, all sustained the most severe of injuries (ISS > 24). Ninety-three percent of the gunshot victims who died suffered the most severe of injuries. Mortality remained similar after adjusting for race, gender, age, and injury severity score in the logistic regression. Only patients with complete data for all variables were included in the regression. Seven percent (198) of patients were missing data. The sample size for the regression was therefore 2635. The odds ratio of mortality for shotgun patients was 0.79 (95% CI 0.16–3.84) after logistic regression. There was no difference in injury severity between the shotgun and gunshot groups. Mean ISS for shotgun victims was 13.7 ± 1.6 versus 12.9 ± 0.2 for gunshot victims ( P = 0.6). Mean RTS for shotgun victims was 7.4 ± 0.2 versus 7.3 ± 0.1 for gunshot victims ( P = 0.5). The pattern of injury severity was similar between the shotgun and gunshot groups ( Fig. 2 ), although shotgun victims had more moderate (ISS 9–15) injuries (30% versus 19%, P < 0.05). There was no difference in the number of patients who suffered mild injuries (ISS 0–8, P = 0.09), severe injuries (ISS 16–24, P = 0.7), or the most severe injuries (ISS > 24, P = 1) between the groups. Shotgun victims required more operations than gunshot victims. After injury, 61% (37) of patients underwent operative intervention after shotgun injuries versus 36% (1001) of patients with gunshot wounds ( P < 0.0001) ( Fig. 3 ). After adjusting for age, race, gender, and injury severity scores in the logistic regression, the odds ratio for requiring an operation after shotgun injury was 3.4 (95% CI 1.6–7.3) compared with the reference odds ratio of 1.0 for gunshot injury. A total of 129 operative procedures were performed on the 37 shotgun victims who required operative management, which averaged over three procedures per patient. The majority of these procedures involved extremity wounds (48%) and abdominal wounds (32%) ( Fig. 4 ). Of the 61 shotgun victims, 40 (66%) suffered multiple injuries. Twenty-four patients (39%) suffered injuries in multiple anatomical regions (i.e., head and neck, chest, abdomen, or extremity). Seventeen shotgun victims suffered thoracic trauma (28%), 13 with major wounds (AIS > 2). Of the patients with thoracic trauma, four underwent thoracotomies, resulting in two lobectomies and one pneumonectomy. There were four deaths in the shotgun group, all suffered major thoracic wounds, and three of these required a thoracotomy. Thirteen shotgun victims suffered abdominal trauma (21%). Eleven patients with abdominal trauma underwent exploratory laparotomy. The two patients with abdominal trauma who were treated nonoperatively had isolated liver injuries. There were two negative laparotomies. No patient with abdominal trauma died. Fifty-two shotgun victims (85%) suffered extremity trauma, of which 29 required operations. There were 20 extremity fractures and 10 extremity vascular injuries. Operative management of extremity wounds accounted for 48% of all the operative procedures among shotgun patients. Shotgun victims utilized more resources in their hospital course than gunshot victims. Of patients surviving to hospital discharge, those with shotgun injuries had longer ICU stays (2.8 ± 0.9 versus 1.4 ± 0.1 d, P = 0.03) and longer total hospitalizations (10.1 ± 2.0 d versus 5.9 ± 0.2, P = 0.003) ( Fig. 5 ). There was no difference in the need for CT scans (43% versus 49%, P = 0.4) or consultations (26% versus 19%, P = 0.2). Conclusions Shotgun injuries and gunshot injuries are ballistically different and therefore require different clinical approaches [1, 2] . Shotgun wounds range from injuries with point blank blasts being very destructive, and longer range blasts rarely causing significant deep tissue damage [1, 5] . Shotgun blasts also have the potential to affect multiple systems [6] . Although injuries from gunshot wounds are increasingly managed nonoperatively [7–10] , we hypothesized that since the energy dissipation is different between gunshot and shotgun wounds, their injury patterns and treatment options should also be different. The goals of this study were: (1) to determine the difference in injury severity between shotgun and gunshot trauma patients, (2) to determine the difference in operative management between shotgun and gunshot trauma injuries, and (3) to determine the difference in hospital resource utilization between shotgun and gunshot trauma patients. We found that (1) the injury severity between shotgun and gunshot trauma patients was similar, (2) shotgun patients required a greater number of operations than gunshot patients, and (3) shotgun patients utilized more hospital resources than gunshot patients. To our knowledge, this is the first study to directly compare the mortality, injury severity, and management of shotgun injuries to gunshot injuries. We practice in the age of selective nonoperative management, where fewer and fewer injuries mandate operative care. The success of selective nonoperative management of firearm trauma depends on due diligence in determining which patients require operative care. A selected subset of patients can be successfully managed nonoperatively after firearm trauma. Our findings suggest that shotgun injuries are less likely than gunshot wounds to be successfully managed nonoperatively. Operative treatment is needed for the significant tissue damage caused by the shotgun blast. Although the injury severity and mortality from shotgun and gunshot trauma was similar, shotgun victims required greater operative care. This aggressive treatment approach resulted in a longer overall hospital stay after shotgun trauma. The difference in the pattern of tissue damage between gunshot and shotgun blast has been recognized for several decades [5] . High mortality and morbidity have been observed from shotgun wounds even with low trauma scores [11] . Several scoring systems have been developed in an attempt to guide the care of shotgun injuries [5, 12, 13] . None of these scoring systems have proven to be more reliable than clinical judgment [11, 13] . Our data supports other investigators, who have also recommend aggressive operative management of these wounds [1, 14] . There was no difference in injury severity, as measured by Injury Severity Score or Revised Trauma Score, between patients injured by shotgun blasts or gunshots in our study. Shotgun injuries may have required greater amounts of resources due to the operative debridement and wound care needs of the significant soft tissue damage caused by the shotgun blast. The Injury Severity Score may underestimate the effects of multiple injuries [15, 16] , often seen with shotgun blasts. Of the 61 shotgun victims, 40 (66%) suffered multiple injuries. Twenty-four patients (39%) suffered injuries in multiple anatomic regions (i.e., head and neck, chest, abdomen, or extremity). The ISS is calculated by scoring the worst injury from each body system, and may underestimate multiple injuries to the same body system [16] . The New Injury Severity Score is calculated by scoring the worst injuries regardless of body system. Some studies have demonstrated better outcomes prediction with the New Injury Severity Score [15] , but its superiority over the ISS in penetrating trauma is debated [16, 17] . Our study was limited by the amount of shotgun trauma seen at our institution. Our urban trauma center only received 63 shotgun trauma activations from January 1998 to December 2007. This obviously affected the statistical significance of our findings. Despite this, there were real differences in the operative care and resource needs of shotgun victims compared with gunshot victims. Even with similar injury severity injuries from shotgun require more operative intervention and resource utilization than gunshot injuries. The difference in the need for operative care of shotgun injuries is likely related to the difference in the ballistics of shotgun wounds. Shotgun blasts can create impressive superficial injuries as well as significant deep organ damage. An aggressive operative approach to managing shotgun trauma is advantageous. References 1 E.A. Deitch W.R. Grimes Experience with 112 shotgun wounds of the extremities J Trauma 24 1984 600 2 G.J. Ordog J. Wasserberger S. Balasubramaniam Shotgun wound ballistics J Trauma 28 1988 624 3 C.A. Davis T.H. Cogbill P.J. 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