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Analysis of the factors increasing the mortality in emergency department following firearm injuries

Firearm injuries (FAI) can be observed in all the societies. However, they are more common in underdeveloped societies, especially where acts of violence are prominent. The influencing factors in the prevalence of mortality due to firearm injuries are sociocultural factors, socioeconomic state, insufficient legal regulation, immigration, mafia, and acts of terror (1,2). However, FAIs are considerably common in countries where the firearm usage is enabled through legislation, such as the United States of America. FAIs are the second most common cause of death among 15-19 year-olds (3). The rates of homicide in the US are seven times higher compared to the other developed countries. Only in the year 2014, 33.700 people were killed due to FAIs, and approximately 81.000 people received non-fatal injuries (4) . Recent studies indicate that the mortality rates due to FAIs are high (5,6). FAIs still cause a considerable number of deaths and disabilities in Turkey. In Turkey, about 3.000 people die due to firearm injuries every year. According to the autopsy reports of the Forensic Medicine Institution, the rate of FAI range between 8 to 13% (7). The main reason why the incidences of FAIs are high is because the acts of terror resume in this region and the local population react violently to these incidents. The extent of the damage that occurred within the organs and the subsequent results are closely associated with the area of injury and the properties of the firearm/bullet. If the vital organs or blood vessels are damaged, the patients usually die before they can reach the healthcare center. In the cases of the patients that come to the emergency rooms, the morbidity and mortality values indicate lifethreatening injuries (depending on the region of the injury). Mortality rates are very high in vital organ injuries. The injuries can cause health and labor force losses for the patients that recover from death, together with important health problems. Our purpose is to determine the factors that influence morbidity and mortality in FAIs and to provide suggestions for preventive measures to decrease mortality rates.


Introduction
Firearm injuries (FAI) can be observed in all the societies. However, they are more common in underdeveloped societies, especially where acts of violence are prominent. The influencing factors in the prevalence of mortality due to firearm injuries are sociocultural factors, socioeconomic state, insufficient legal regulation, immigration, mafia, and acts of terror (1,2). However, FAIs are considerably common in countries where the firearm usage is enabled through legislation, such as the United States of America. FAIs are the second most common cause of death among [15][16][17][18][19] year-olds (3). The rates of homicide in the US are seven times higher compared to the other developed countries. Only in the year 2014, 33.700 people were killed due to FAIs, and approximately 81.000 people received non-fatal injuries (4) . Recent studies indicate that the mortality rates due to FAIs are high (5,6). FAIs still cause a considerable number of deaths and disabilities in Turkey. In Turkey, about 3.000 people die due to firearm injuries every year. According to the autopsy reports of the Forensic Medicine Institution, the rate of FAI range between 8 to 13% (7). The main reason why the incidences of FAIs are high is because the acts of terror resume in this region and the local population react violently to these incidents. The extent of the damage that occurred within the organs and the subsequent results are closely associated with the area of injury and the properties of the firearm/bullet. If the vital organs or blood vessels are damaged, the patients usually die before they can reach the healthcare center. In the cases of the patients that come to the emergency rooms, the morbidity and mortality values indicate lifethreatening injuries (depending on the region of the injury). Mortality rates are very high in vital organ injuries. The injuries can cause health and labor force losses for the patients that recover from death, together with important health problems. Our purpose is to determine the factors that influence morbidity and mortality in FAIs and to provide suggestions for preventive measures to decrease mortality rates.

Materials and Methods
All patients admitted to the emergency department (ED) with gunshot wounds were included in the study. This study was analyzed retrospectively. The files of the patients who applied to Van Yüzüncü Yıl University Dursun Odabaş Medical Center between January 2010 and January 2014 were taken from hospital information system. All kinds of injuries due to firearm injuries were included in the study. There were a total of 246 patients. Data obtained from patients (age, sex, distribution of cases by month and year, wound localization and accompanying organ injuries, GCS and Hb levels, length of stay in the ED were analyzed. For data analysis, the anatomical region was categorized as head and neck, trunk (chest, abdomen and pelvis), upper extremity, lower extremity and multiple (injury involving ≥2 regions). The effects of these factors on mortality were investigated. Most of the patients with gunshot wounds were brought to our emergency clinic by "112" emergency ambulance. Other injured patients were referred to ED by their relatives and a small number of them were referred from other medical centers. Patients who died outside the hospital were excluded from the study. In addition, chi-square test was performed to determine the relationship between categorical variables. Statistical significance level was considered as 5% and SPSS (ver: 21) statistical program was used for all statistical computations.

Discussion
Firearm injuries are a global public health problem. Non-fatal firearm injuries have different rates compared to fatal ones. On average, two out of every seven firearm injuries consist of fatal and five nonfatal injuries (8). The FAIs are an independent risk factor with high morbidity and mortality rates. Most of the injured patients either died at the scene or transferred to the hospital or died at ED in the first minutes of treatment (5). The most important finding of our study was that low GCS and Hb levels, length of stay in the ED had an impact on mortality and mortality rates were higher. There was a significant relationship between low GCS and death (p<0.001).
The neurological examination findings are defined as determinants of prognosis in the literature. It is known that GCS results play a part in mortality. This scale is a simple and useful method for evaluating the morbidity and mortality of the patient. It is positively and hemothorax (27%). They also found that the most common reason of mortality was injury to major blood vessels (18). Oymacı et al. have determined that the most frequent intra-abdominal injuries were located in the colon, the small intestine, the liver and the biliary ducts respectively (19). Eriş et al. have indicated that 16.8% of abdominal injuries resulted in mortality. The most commonly injured organs were determined to be the small and large intestines (12). Limitation(s): It is a limitation of our study that the infections are not investigated, as they are an important risk factor for mortality. Also, the reason for low mortality rates in the ED may be due to the successful initial treatment or because the patient is urgently hospitalized due to the urgency of their situation.
The most important finding of our study was that low GCS and Hb levels, length of stay in the ED had an impact on mortality and mortality rates were higher. In particular, intracranial hemorrhages, main vessel injuries, abdominal injuries, high mortality rate can be. FAIs should be treated with the work of the interdisciplinary trauma team. Initial treatment should be performed as specified in the Advanced Trauma Life Support protocol.