Nonpowder Firearm Injuries to Children Treated in Emergency Departments

Discussion

There were an estimated 364 133 children with nonpowder firearm injuries treated in US EDs from 1990 through 2016, averaging 13 486 annually. Consistent with previous studies, the head and neck were the most commonly injured body region, with frequent involvement of the eyes.^4,6,19,24 The overall number and rate of nonpowder firearm injuries decreased significantly during the study period by 47.8% and 54.5%, respectively. However, eye injuries associated with nonpowder firearms demonstrated the opposite trend, with the number and rate increasing significantly by 49.5% and 30.3%, respectively. This is in agreement with previous reports.^6,24

Nonpowder firearms should be regarded as potentially lethal weapons. Most fire projectiles in excess of the minimum velocity to penetrate human skin, which is ∼70 m per second (230 ft per second) with an energy/area of presentation of ∼2.1 m-kg per cm,^3,25 and many achieve a muzzle velocity similar to a handgun.^26,27 Fatal injuries from nonpowder firearms have been reported and most often are associated with penetrating wounds to the head, neck, or chest.^10,12,13 Although there were no deaths reported in our study, the NEISS does not adequately capture fatalities because deaths are not consistently transported to the ED and those that occur after admission to the hospital are missed when only the ED medical record is reviewed.

There were an estimated 53 994 eye injuries in our study, accounting for 14.8% of all nonpowder firearm injuries. These injuries were often serious with 22.2% requiring admission to the hospital. The rate of eye injuries increased by 30.3% during the study period. These findings agree with previous studies, which emphasize that eye injuries are commonly reported in association with nonpowder firearms and can result in serious adverse outcomes, including partial or complete vision loss.^4,6,7,11 Indeed, nonpowder firearms account for most pediatric eye injuries that are admitted to the hospital.⁶ Educational efforts to prevent nonpowder firearm eye injuries often focus on the use of appropriate eye protective equipment, with 1 study estimating that eye protection was absent in >98% of eye injuries.⁶ Voluntary safety standards exist for eye protective equipment for paintball and airsoft guns.^28,29 A policy statement by the American Academy of Pediatrics provides specific recommendations for protective eyewear for children participating in various sports and recreational activities, including use of nonpowder firearms.³⁰

Unlike powder firearms, which fall under the oversight of the Bureau of Alcohol, Tobacco, Firearms, and Explosives within the US Department of Justice, the CPSC has federal jurisdiction over nonpowder firearms. Although the CPSC has no mandatory safety regulations for nonpowder firearms, 2 voluntary safety standards have been adopted, American Society for Testing and Materials (ASTM) F589 Standard Consumer Safety Specification for Non-Powder Guns and ASTM F590 Standard Consumer Safety Specification for Non-Powder Gun Projectiles and Propellants.^8,13 Manufacturers are extensively involved in the development of ASTM voluntary standards and generally comply with the safety specifications included in the standards.

Despite the lack of federal mandatory safety standards for nonpowder firearms, 23 states and the District of Columbia have adopted laws to address the safety concerns of these products. In addition, local jurisdictions such as New York City, have passed their own ordinances.⁵ The 4 major categories of state regulations include (1) defining nonpowder firearms as firearms (New Jersey and Rhode Island), (2) defining certain high-power or large caliber nonpowder firearms as firearms (Illinois and Michigan), or (3) defining nonpowder firearms as dangerous weapons (Connecticut, Delaware, and North Dakota). Each of these definitions carry restrictions on the purchase, transfer, possession, or use of the nonpowder firearm, which vary by state. The fourth category of state regulation restricts access by children. Most state regulations fall into this last category, vary greatly by state, and frequently can easily be circumvented with parental consent or adult supervision. Variability includes the age cutoff for these regulations, some applying to children <18 years of age and others applying to those as young as <12 years of age.⁵

This study has several limitations. The number of nonpowder firearm injuries is underestimated by the NEISS because it only includes individuals treated in EDs and not in other health care settings, such as urgent care facilities and private physician offices. Individuals treated in EDs also may not be representative of the entire spectrum of individuals with these injuries. NEISS case narratives may not consistently provide information about the user of the firearm, whether the injury was intentional or unintentional, and other details of the injury incident; however, all narratives were individually reviewed to ensure, to the best of our ability, that each case was categorized appropriately. There were no fatalities in this study; however, the NEISS does not capture fatal injuries well, so we are unable to comment on fatal injuries associated with nonpowder firearms on the basis of this database. We did not have access to pediatric nonpowder firearm exposure data; therefore, US population data were used to calculate injury rates. Despite these limitations, this study provides a comprehensive epidemiological investigation of pediatric nonpowder firearm injuries over a 26-year study period by using a nationally representative sample.