Objective. To describe the epidemiology of air gun injuries to children that required hospitalization.
Design. A consecutive series of children with air gun injuries.
Setting. Urban pediatric teaching hospitals in Cincinnati, OH; Kansas City, MO; and Seattle, WA.
Methods. A retrospective chart review.
Results. A total of 101 children were studied: 81% were male; 80% were white, 18% were black, and 2% were other races. The median age was 10.9 years (range, 0.5 to 18.8). Victims were most commonly shot by a friend (30%) or sibling (21%). A total of 34% occurred at the victim's home, and 36% occurred at the home of a friend or relative. Although 71% of shootings were unintentional, 5% were assaults, and 1% were suicides.
The median hospital stay was 3 days (range, 1 to 17 days). Fifteen children (15%) required treatment in intensive care. A total of 56% required at least one surgical procedure. Forty-nine had injuries to the head, including 38 with injuries to the eye, 10 with intracranial injuries, and 1 with a skull injury. Fourteen children were shot in the neck; 15 were shot in the chest, with 2 patients sustaining lacerations of the pericardium and 1 having a right ventricular foreign body. Another child had a laceration of the innominate artery. Nineteen had abdominal injuries, including laceration of the stomach (N = 3), small bowel (N = 4), colon (N = 2), and liver (N = 3).
Three of 10 children with intracranial injuries died. Two had long-term neurologic deficits. Of children with eye injuries, 25 (66%) had permanent visual loss and 15 (39%) of these were blind.
Conclusion. Air guns are associated with serious and fatal injuries. Families should be counseled that air guns may cause serious injuries and even death. Furthermore, pediatric care givers should advocate for increased regulation of air guns and expansion of safety standards.
Air guns are nonpowder firearms that use air or another compressed gas to propel a projectile such as a “BB” or pellet. Nonpowder guns or air guns are often considered toys in American society. Approximately 2 to 2.5 million nonpowder firearms are sold annually in the United States.1 Although no national studies have estimated household air gun ownership, a Chicago area survey reported that 6% of families that included at least one 3-year-old child owned an air gun.2 Family use increased to 11% in families with a boy between the ages of 10 and 14 years.
More is known about the prevalence of air gun injuries. The Centers for Disease Control and Prevention has estimated that ∼33 000 people, or 12.9 per 100 000 population, are treated for such injuries in hospital emergency departments in the United States each year.3 The group at highest risk is boys between 10 and 14 years of age, in whom the rate of injuries requiring emergency care is 121.1 per 100 000 population. However, the true incidence is probably higher, because air gun injuries can be recorded as a nonspecific gunshot wound rather than an air gun injury.4
Although ocular trauma with long-term visual loss associated with air gun injury is well-recognized,5-7 many parents, children, and physicians have not appreciated that air guns can inflict other serious penetrating injuries. We recently cared for several children with severe injuries to the brain, chest, or abdomen from air gun wounds, prompting us to review all cases of air gun injures admitted to our institutions.
We reviewed the charts of all patients <19 years of age admitted to the hospital with an air gun injury between January 1988 and January 1996 at the Children's Hospital Medical Center (Cincinnati, OH), Children's Hospital and Medical Center (Seattle, WA), and Harborview Medical Center (Seattle, WA); and between January 1989 and September 1996 at Children's Mercy Hospital (Kansas City, Missouri). Cases were identified through the trauma registry of all hospitals except Children's Hospital and Medical Center, Seattle, WA, where cases were identified by medical records review of International Classification of Diseases, 9th revision code E 917.9.
Charts were reviewed for patient demographic data and the following items when they were recorded: type of gun (pellet or BB), circumstances of shooting, victim–shooter relationship, intent of shooting, gun ownership, and location of incident. Total hospital length of stay, need for intensive care, nature and extent of injuries, procedures performed, complications, and outcome were also reviewed.
Data are reported as median and range unless otherwise specified.
A total of 191 cases were identified: 53 children from Cincinnati, 27 children from Kansas City, 9 children from Harborview Medical Center, and 12 children from Children's Hospital and Medical Center. Males made up 81%, and the median age was 10.9 years (range, 0.5 to 18.8). Of the children, 80% were white, 18% were black, 1% was Asian or Native American. A total of 58 children (57%) had commercial insurance, 23 (23%) had Medicaid, and 18 (18%) were self-insured; insurance information was missing on 2 subjects.
Characteristics of the Air Gun Shooting
Pellet guns were recorded as the offending weapon in 26 cases (26%), whereas BB guns accounted for the remaining 75 shootings (74%) (Table 1). The victim was most frequently shot by a friend (N = 30, 30%) or sibling (N = 21, 21%). In 24 cases (24%), the medical record did not identify the shooter. Most of the shootings were identified as unintentional (N = 72, 71%); however, five victims (5%) were assaulted, and one (1%) committed suicide. Intent was not recorded in 23 cases (23%).
A total of 42 shootings occurred either outside the victim's home (N = 19, 19%) or outside the home of a friend or relative (N = 22, 22%), whereas 22 shootings occurred inside either the victim's house (N = 15, 15%) or the house of a friend or relative (N = 7, 7%). The location of the shooting was not stated in 37 cases (37%). The median distance from which the gun was fired was 5 feet (range, 0 to 70 feet); however, this information was not estimated in 42 cases (42%). Gun ownership and gun brand were not recorded in the majority of cases.
Injury and Hospitalization Data
The median hospital stay was 3 days (range, 1 to 17). Fifteen children required initial treatment in the intensive care unit. The most common site of injury was the eye or orbit (N = 38, 38%) (Table 2). Common ocular injuries included hyphemas (55%), open globes (38%), and vitreous hemorrhages (26%). Eleven (11%) children sustained cranial injuries (Table3). Eight of these children had intracerebral hemorrhages. The projectiles were lodged in the following brain structures: the occipital lobe (N = 3), cerebral peduncle (N = 1), thalamus (N = 1), temporal lobe (N = 1), parietal lobe (N = 1), and lateral ventricle (N = 1). In four children, the projectile crossed the midline of the brain causing damage to both hemispheres, and in one the projectile traversed through the sphenoid bone to the occipital lobe.
Fourteen children had injuries to the neck, 15 suffered injuries within the thorax, including laceration of the innominate artery, a pericardial foreign body, and an intracardiac (right ventricular) foreign body. Eighteen children had injuries within the abdomen, including laceration of a hollow viscus in 8, and liver lacerations in 3 (Table 3).
A total of 56 (55%) children required at least one surgical procedure during the initial hospital admission. Of the 11 children with intracranial injuries, 2 had craniotomes for wound debridement and dural repair, and 1 had a ventriculostomy placed to monitor intracranial pressure and remove cerebrospinal fluid. Eleven of 14 children with wounds to the neck had exploration of the neck and removal of the foreign body. Seventeen of 19 children with intraabdominal injuries required an exploratory laparotomy. Six children with thoracic injuries had invasive procedures. The child with an epicardial foreign body had a pericardiocentesis followed by open surgical removal of the foreign body. The laceration of the innominate artery required emergency repair and resuscitation from hemorrhagic shock. The child with the right ventricular foreign body had two cardiac catheterizations to attempt removal that were unsuccessful, and the BB remained in the ventricle. Three others required chest tube placement. All children with extremity injuries required surgical removal of the foreign body.
Three (3%) children with intracerebral injuries died. One of these was an adolescent suicide, whereas two other children, 2 and 7 years of age, died of unintentional injuries. One child with an intracranial injury developed a cerebrospinal fluid leak that resolved without surgical intervention. Another child had dizziness that resolved several weeks after injury. Two children had residual neurologic deficits: one with a hemiparesis, and one with loss of cognitive function. Both of these children required inpatient rehabilitation. Two children with neck injuries suffered nerve paresis acutely, but recovered fully after discharge. One child shot in the hand had numbness of a finger acutely and was lost to follow-up.
Of 38 children with ocular injuries, 25 (66%) suffered permanent visual impairment, and 15 (39%) suffered complete blindness in the affected eye. Children shot in the eye at closer ranges tended to have a greater risk of visual loss or complete blindness; however, this was not statistically significant. Among the children in whom the distance was estimated in the chart (N = 18), 13 children were shot from <20 feet, 8 were blinded, and 2 suffered partial visual loss. Of 3 children shot from >20 feet, 1 suffered partial visual loss and none were blinded. The muzzle velocity of the guns used was not available from the chart.
Children with injuries to the thorax, abdomen, and extremities recovered without significant disabilities.
Air guns can cause disabling and fatal injuries in children. Eye injuries were the most common injury in this series; however, injuries to the brain, chest, and abdomen were not infrequent. This may seem surprising for a supposed “toy.” As in previous series,3,5,6 we found that young adolescent boys were the most common victims of air gun injuries. Furthermore, most children suffered unintentional injuries, either in their homes or in other familiar surroundings, and they were most likely to be shot by a friend or family member. Our series suggests that the majority of severe air gun injuries that require hospitalization occur in the child's usual environment. Certainly the children do not appreciate the potential of air guns to cause serious injuries. It is unknown whether their care givers fail to understand the ability of air guns to penetrate tissues and organs, inflicting significant injuries to children or whether they simply overestimate the child's ability to safely handle the air gun.
The ability of any gun to injure is related to the energy imparted to the tissues, which is proportional to both the velocity (squared) and the mass of the projectile. The injury potential of air guns is most closely related to muzzle velocity, because the mass of the projectile is small. Muzzle velocity varies by the mechanism of air propulsion. Today's air guns use one of three systems: a pneumatic spring, a pumping device that allows repeated manual compression of air, or a pressurized gas canister. The traditional spring-loaded piston device usually generates a muzzle velocity of 250 to 350 feet/second, although some new models have velocities of up to 900 feet/second.8,9 Manual compression guns allow the level of pressurized air to increase through multiple pumps and can generate velocities of up to 900 feet/second,10 which is in the same range of muzzle velocities for some lower caliber pistols and revolvers.3 Pressurized carbon dioxide-powered guns have muzzle velocities of 400 to 450 feet/second.11 Because the mass of the pellet or BB is low, they rapidly lose velocity because of wind resistance and gravity compared with conventional firearms. However, at closer range serious injuries can be anticipated.12
The impact velocity required to penetrate the human eye is 130 feet/second,13 whereas the velocity required to penetrate skin is 290 feet/second and for passage through the skin and into soft tissues is >330 feet/second with a .177-caliber air gun.14Therefore, it is not surprising that air guns with higher muzzle velocities fired at close range are capable of causing life-threatening injuries to vital organs such as the brain, heart, and major blood vessels.
Three children died from air gun injuries to the brain. The air guns had sufficient power to cause bilateral intracranial injuries. However, it is not surprising that even among hospitalized children with air gun wounds to the thorax and heart to the chest, there was a better outcome than among children with powder gun wounds. A recent report of pediatric thoracic gunshot wounds reported a mortality of 14%,15 whereas gunshot wounds to the heart result in an extremely poor prognosis, with an overall survival of only 7%.16 Air gun wounds to the abdomen are associated with a high rate of visceral injury (61%) in this series. The rate of visceral injury in this small series seems to be slightly lower than the rate of visceral injury attributable to powder gunshot wounds to the abdomen, which is ∼90%.17 This suggests that a conservative surgical approach with an exploratory celiotomy is appropriate for most air gun injuries that penetrate the abdominal wall.
This series of hospitalized children is similar in many ways to a series of hospitalized New Zealand children18 and to a series of children who required treatment in the emergency department reported by McNeill et al.3 However, the majority of children treated in the emergency department for air gun injuries (55%) and children with air gun injuries hospitalized in New Zealand (57%) had injuries to their extremities, compared with only 6% of similar injuries in our series. This difference may reflect a lower threshold to admit injured children with less severe injuries to the hospital in New Zealand or may be attributable to other unidentified factors. Conversely, a greater percentage of our patients suffered injuries to the trunk (32% vs 14%) than patients treated in the emergency department. Finally, ocular injuries were more common in our patients (37%) than in the other two series (6% and 18%). McNeill3 reported that almost 31% of victims treated in the emergency department shot themselves, which was more than twice the rate in our series.
This study is a case series and therefore is subject to many limitations. The data were collected retrospectively, and we could not determine complete information on the circumstances of the shooting or the types of air guns used. We described children admitted to pediatric teaching hospitals in three cities, and thus our findings cannot be generalized to the entire US population. Furthermore, we cannot estimate the prevalence of air gun injuries in children who require hospitalization or differences in risk associated with demographic features such as age, race, or gender. Nevertheless, the intent of this series was to highlight the potential danger of significant air gun injuries and to describe the children we have treated and their injuries.
Pediatricians should be aware that no national regulations have been developed for air guns, despite gun designs that generate high muzzle velocities. Voluntary standards have existed since 1978; however, they do not include standards for maximum velocity, specifications for projectile tip, impact force, or use of protective eye wear.5 The industry does make a voluntary statement that air guns should be used under adult supervision if the child is <16 years of age. Fourteen states have some regulation regarding air gun use; however, these do not include Ohio, Washington, or Missouri. Most simply restrict the purchase by minors without the permission of a parent.3
This series demonstrates that air guns pose a significant risk of severe injury, permanent disability, and even death. Furthermore, they can be used as instruments of assault or suicide. The American Academy of Pediatrics Committee on Accident and Poison Prevention has recommended that federal regulations and safety standards be enacted, such that the velocity of air guns be regulated to levels below those that penetrate the skin or eyes, that safety glasses be advocated during air gun use, and that multiple-pump air rifles be regulated in a manner similar to that for firearms.5 We support these recommendations and additional research to evaluate methods to limit pediatric exposure to air guns and to prevent air gun injuries. Public service messages regarding air gun injuries and safety measures such as protective glasses and limited muzzle velocity would provide important information to families.
- Received October 25, 1996.
- Accepted March 4, 1997.
Reprint requests to (S.L.B.) Children's Hospital and Medical Center, Box 5371, Seattle, WA 98105.
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- Committee on Accident and Poison Prevention
- ↵American Academy of Ophthalmology. BB and Pellet Guns are a Major Cause of Devastating Ocular Injuries in Children. San Francisco, CA: Public Health Note KK-PH01-92; Feb 15, 1992
- ↵Daisy Manufacturing Company. Airguns, Ammo and Accessories. Rogers, AK: Daisy Manufacturing Company; 1994
- ↵Marksman Products. Marksman Just Took Three Shots at Creating the Perfect Air Rifle. Huntington Beach, CA: S/R Industries; 1994
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- Copyright © 1997 American Academy of Pediatrics