Gunshot Injuries: Patterns, Presentations, and Outcomes of Civilian Hospital Experiences in a Developing Country Setting

Abstract

.Gunshot injuries can be classi ed anatomically according to the site of body affected. Such common sites include the head, neck, pelvis, limbs or multiple regions combined, which has high morbidity and mortality rates.
In USA approximately 30,000 patients are hospitalized for gunshot injuries yearly, and 2500 of them die in the hospital. Firearm homicides are 19 times more prevalent in the USA than other higher income countries [6]. In Africa, rearm injuries represent a major health problem. South Africa is an example of a country that faces this problem, which creates a huge burden on the healthcare resources [7]. Firearm injuries were estimated to amount to almost 55,000 in 2012 in South Africa [8].
In Sudan the incidence of injuries for different cause was 82.0/1000 person per year, with low socioeconomic status population placed at an increased risk. There is a lack of reliable resources documenting injury-related deaths [2]. Regarding gunshot injuries in Sudan, there is no study which we know that has documents and report the incidence, causes or the outcome. So, we look for Evidencebased data to plan and promote management and prevention protocol. This study was conducted to investigate the pattern of gunshot injuries and its impact on case management, along with patient morbidity and mortality.

Study design
This is retrospective, hospital-based study was conducted between January 2015 and December 2019 in Elobeid teaching hospital, to review the clinical presentation and case management outcomes of gunshot injuries. All the patients' records were reviewed during the study period.

Setting
Emergency and trauma patients were referred to Elobeid Teaching hospital emergency department to receive the urgent care. Elobeid Teaching hospital is the oldest and biggest hospital in the Kordofan Region and is owned and operated by the North Kordofan state. Patients included in this study have been referred to the hospital from the states of Kordofan and Darfur. The hospital is comprised of an accident and emergency department, radiological department, Laboratory center with a blood bank, surgical specialty department, Medical specialty department as well as an operation complex with an intensive care department.

Inclusion and exclusion criteria
We include all patient presented to the hospital with Gunshot injuries, resulting from civilian altercations, during the study period and received treatment in the hospital. Any patients that were dead at time of presentation or died within the rst 6 hours were excluded from the study population.

Clinical assessment
Primary assessment was done for all patients presented to the emergency department through the Advanced Trauma Life Support protocol. The emergency team checked each patient's airways, breaching, circulation and disability. Following the primary assessment, a primary investigation was done after the stabilization of the patients. Emergency procedure like chest tube insertions and surgical toilets and explorations of abdominal wounds, under local anaesthesia, were done in the emergency department. Lastly, the patients were categorized, according to their condition, to receive further treatment by the General Surgery or Orthopedic Units for any additional necessary surgeries or follow up.

Operative treatments
Operative surgeries such as laparotomy are urgently performed in cases of abdominal injury or internal bleeding. Orthopaedic operations are typically done within the 3-5 days. Optimization of patients was done preoperatively (to replace the blood loss) and reviewed review by anesthetist and request the relevant investigations. Following the optimization, patients will be followed by the responsible units, which will assess the patients in the outpatient clinic in intervals of 2 weeks, 1 month, 3 month, six months and 1 year depending on their condition.

Data collection and analysis
Flowchart sheets were used to collect the baseline characteristics of the patients. Age, sex, residence, education, occupation and causes of the quarrel were checked. Information regarding the site of bullet, condition at the time of presentation, diagnosis, complications and outcomes were determined. Types of operation and intervention done were determined based on each individual case. The data collected were entered and analyzed using SPSS version 21 statistical software (IBM Corporation, Chicago, IL). Results were tabulated and presented as frequencies and percentages, accordingly. For each test, P < .05 was considered statistically signi cant (95% CI).

Results
The total number of patients who were diagnosed with gunshot injuries and included in the study is 157. The mean age of patients is 27.7 years old, ranging between 1 to 65 years old. The most common age group is 21-30 years. All patients' characteristics are shown in Table 1. Most of the patients in this study were males 87.9% and 46.2% of them are married. Twenty ve percent of the patients were residents of Elobeid city while the rest were from outside the city. About two thirds of patients were either illiterate (36.1%) or primary school level education 37.3% and their jobs are farmer or labeler in 36.1 and 28.5 percent respectively. Table 2 demonstrates the anatomical site of gunshot wounds, diagnosis, and treatment done for the patients. The anatomical site of the wounds was found mainly in the lower limbs and upper limbs in 65 patients (41.4%) and 36 patients (22.9%) respective. Additionally, the least common wound site is perineum among with only 3 (1.9%) patients being affected. The most common diagnosis among patients in this study were limb fractures and soft tissue injuries among 78 (49.7%) and 45 (28.7%) patients respectively. There were three patients diagnose with a head injury. Speci c treatments in this study included wound debridement which was done for 91 (58.0%) patients. Other treatments included bone xation, laparotomy and chest tube insertion which were done for the rest of the patients.
More than 120 (75%) of patients were cured and discharged in a good condition and 27 (17.2%) patients were referred to specialized center for further treatment. Diagnosis of referred patients is shown in Fig. 1. Five (3.2%) patients were discharge against medical advice and 5 (3.2%) additional patients died. There is signi cant correlation (p value less than 0.05) between nal management outcome and site of gunshot (Table 2). Hospital stay is was demonstrated in Table 3 and it was affected by diagnosis and treatment. A signi cant correlation (p value less than < 0.05) was found between hospital stay and treatment.

Discussion
Gunshot injuries represent a major health problem health worldwide with direct burdens to health service and economy [9]. Sudan is considered one of the sub-Saharan countries affected by internal con ict, thus, consequently gunshot-related injuries and mortalities are common [10]. Con icts tend to arise due to different tribes and ethnic groups competing for basic resources in one place. Poverty, increased intolerance in the community and armed robberies are all considered to be important factors leading to increased gunshot violence in different parts of the country [5]. To the best of our knowledge there were no studies that determine the extent of rearm injuries in Sudan. In this study, we reviewed the data (clinical presentation, treatments and management outcome) of 157 patients presented to the hospital with gunshot wounds due to various causes in the period of January 2014 to January 2019 to assess the pattern, causes, management and the outcome. The total number of patients reviewed in this study is same or slightly higher than some an available national and international [6,11,12] data but still less than reported number from USA and South Africa [8,13,14].
Gunshot injuries affects all age groups at different stages of life, but are more prevalent in younger age groups [14] The most common age group affected by gunshot injury in this study is the younger age which is in line with what has been previously reported by other studies [5,14,15]. However, 18% of the study's participant is comprised of the pediatrics age group. This outcome is unusual and is considered to be high compared to a study done in Nigeria [15]. Interestingly, our numbers, with regards to gunshot injuries in pediatric patients, are similar to a report from South Africa [13]. Like other previous studies [5,9,12,14,16,17], our data revealed that males were disproportionately affected, and this could explained by their outdoors presence most of the time because of societal gender roles.
The most common anatomical site of the body affected by nonfatal rearm injuries are the upper or lower limbs extremities including soft tissue as well as bone tissue [6]. In this study the lower limb followed by the upper limb are the most common sites injured (65%). Conversely, the perineum was found to be the least affected site (2%). These ndings are like those reported in previous literature [6,8,13]. However, results from a study done in Sudan, during the period of civil demonstrations, showed only one patient with a gunshot wound in the lower extremity hip bone [18]. The extent of injury and tissue damage following gunshots depends on several factors such as wound ballistics, tissue structure and the respective anatomical relationships [19]. Our data showed limbs fracture with local soft tissue injuries as the most common presenting diagnosis, followed by visceral perforations, rib fractures and head injuries. These ndings are like studies conducted previously [8,13,14].
Furthermore, a study done by Livingstone et al in a major trauma center USA showed that 75% of patients admitted with gunshot wounds underwent at least one surgical intervention procedure [20]. Almost all our study's patients underwent one or more surgical intervention(s) ranging from minor wound debridement to exploratory laparotomy. Other surgical procedures included bone internal, external xation or both, and chest tube insertion. However some other report showed only 53% of the patients required a surgical intervention [6]. The economic aspect of prolonged hospital stays and their burden on the health care system was addressed. About half of the patients in our study stayed in the hospital for more than 20 days. This is considered to be a signi cantly long hospitalization period in comparison to other studies [17,21]. However, this long stay can be explained by the presence of open limb fractures which usually need external xation and frequent wound debridement and dressing. The overall outcome of the patient in our data was good, where 75% of patients were cured and discharged in a good condition. About 17% of patients were referred to specialized center for further management that are not a available at our medical center.
Firearm injuries have the highest case fatality rate in every age group, with a mortality rate of 15.3% for gunshot wounds in according to a report from the American College of Surgeons (ACS) National Trauma Data Bank [6]. Another study done in the Scandinavian Trauma Center revealed mortality rate of 12.8% for rearm injuries. Study done by Mansor et al showed mortality rates of 7.7% in civilian gunshot injuries and 10% for stray bullets [17]. In our data the mortality rate was 3.1%, which is comparable data reported from the London Major Trauma Center. [12]. The deaths in our study population occurred within the rst and second weeks of injury. All 5 deceased patients had gunshots to the abdomen, which are known carry high morbidity and mortality rate according to a national and international studies [5,22,23].
Laparotomy was done for those patients with ndings of internal organs injuries. One patient underwent chest tube insertion in addition to laparotomy due associated chest injury. However study done in Nigeria showed no mortality rate. [15].

Conclusion
Most of the patient in this study were young males. Upper and lower limb fractures are the most common presentations. Wound debridement, bone xation and laparotomy are the most common treatments with signi cant success rates, despite prolonged hospital stay.

Declarations
Authors' contributions  Patients who are cured or referred related to diagnosis