Vascular trauma and haemorrhage after firearm injuries

Firearm injuries are an increasing global health problem resulting in deaths and disabilities among its victims as well as an immense burden both for the society as well as the health care system. Vascular injuries and haemorrhage are particularly lethal after gun violence. The aim of this thesis was to investigate management strategies and patient outcomes of vascular injuries and haemorrhage after firearm injuries. Paper I was a systematic review characterising injuries and mortality after CPMSs focusing on in-hospital management of haemorrhage and vascular injuries. The paper showed an overall high mortality after CPMSs with injuries mainly located to the extremities (35%), abdomen (20%) and thorax (19%) with approximately one quarter of deaths being related to haemorrhage involving central large vessel injuries. 47% (97/206) of all hospitalised patients required a surgical procedure. Paper II was a retrospective nationwide epidemiological study including all patients with firearm injuries between 2011 and 2019 (n=1010). The most common injury location was lower extremity (30%) followed by upper extremity (14%), abdomen (14%), and thorax (13%). The head was the most severely injured body region. It showed an annual increase of firearm-related injuries and fatalities (P <0.001) and 17% succumbed from their injuries within 30-days with most deaths occurring within 24-hours of admission. It also showed an association between 24-hour mortality and NISS, SBP <90 mmHg and head injury with AIS ≥ 3. Paper III was also a retrospective nationwide epidemiological study from 2011 and 2019 (n=162), showing that firearm-related vascular injuries increased annually (P<0.005). The lower extremity (42%) was the most common injury location followed by abdomen (19%) and thorax (19%), with vascular injuries to thorax and abdomen being most lethal. Most deaths (80%) were within 24-hours of injury and there was an association between 24-hour mortality and vascular injury to thorax, abdomen, thoracic aorta or femoral artery. Paper IV was a retrospective nationwide observational study investigating pre-hospital and hospital mortality after firearm injuries between 2012 and 2023 (n=519). There was an annual increase in deaths (P<0.001). Fifty-eight percent of all deaths occurred pre-hospital and 42% in-hospital. Haemorrhage was the most common cause of in-hospital death (49%) but constituted only of 24% in the pre-hospital setting. 50% of all patients had vascular injuries. Injury to head (OR 1.75, 95% CI 1.28-2.40, P=0.001), neck (OR 3.30, 95% CI 1.75-6.23, P<0.001) and thorax (OR 2.87, 95% CI 1.93-4.26, P<0.001) were associated with an earlier death as well as injury to thoracic aorta (OR 2.45, 95% CI 1.52–3.97, P<0.001) and the pulmonary artery (OR 2.39, 95% CI 1.11–5.13, P=0.026). In conclusion, this thesis showed that firearm injuries increased in Sweden and that firearm-related vascular injuries and haemorrhage caused significant morbidity and mortality. It underscores the need for early haemorrhage control strategies and better preparedness in the health care system to improve outcomes following future incidents of gun violence. List of scientific papers This thesis is based on the following papers, which are referred to in the text by their Roman numerals. I. Nyberger K, Strömmer L, Wahlgren CM. A systematic review of haemorrhage and vascular injuries in civilian public mass shootings. Scand J Trauma Resusc Emerg Med. 2023 Jun 19;31(1):30. https://doi.org/10.1186/s13049-023-01093-x II. Nyberger K, Caragounis EC, Djerf P, Wahlgren CM. Epidemiology of firearm injuries in Sweden. Eur J Trauma Emerg Surg. 2022 Jun;48(3):2349-2357. https://doi.org/10.1007/s00068-021-01735-8 III. Nyberger K, Caragounis EC, Djerf P, Wahlgren CM. Management and outcomes of firearm-related vascular injuries. Scand J Trauma Resusc Emerg Med. 2023 Jul 7;31(1):35. https://doi.org/10.1186/s13049-023-01098-6 IV. Nyberger K, Kahn L, Rezaie A, Strömmer L, Wahlgren CM. Injury patterns in fatal gun violence - time to death and cause of death. [Submitted] All previously published papers were reproduced under the terms of the Creative Commons CC BY license.