Are Facial Gunshot Wounds More Fatal When They Are Self-Inflicted or Other-Inflicted?
1
Division of Oral and Maxillofacial Surgery, NewYork-Presbyterian/Columbia University Irving Medical Center, 630 West 168th Street, New York, NY 10032, USA
2
Department of Oral and Maxillofacial Surgery, New York University, Langone Medical Center and Bellevue Hospital Center, New York, NY, USA
3
Department of Oral and Maxillofacial Surgery, School of Dental Medicine, University of Pennsylvania, Philadelphia, PA, USA
4
Private Practice, Brockton Oral and Maxillofacial Surgery Inc., Brockton, MA, USA
5
Department of Oral and Maxillofacial Surgery, Good Samaritan Medical Center, Brockton, MA, USA
6
Department of Oral and Maxillofacial Surgery, School of Dentistry, Kaohsiung Medical University, Kaohsiung, Taiwan
*
Author to whom correspondence should be addressed.
Craniomaxillofac. Trauma Reconstr. 2022, 15(4), 275-281; https://doi.org/10.1177/19433875211039919
Submission received: 1 November 2020
/
Revised: 1 December 2020
/
Accepted: 1 January 2021
/
Published: 17 August 2021
Abstract
:Abstract: Study Design: This was a retrospective cohort study of the 2014 Nationwide Emergency Department Sample (NEDS). Objective: Intraoral and submental projectile entry points may be less fatal than other facial entry points due to the indirect access to the intracranial structures and the protection offered by the intervening maxillofacial complex. Because intraoral and submental trajectories are almost always present in the setting of attempted suicide, this study sought to determine if intent (self-harm versus other-harm) influenced mortality in facial gunshot wound (GSW) patients. Methods: All patients with a diagnosis of a facial fracture secondary to firearm injury were included in the study sample. The primary predictor was self-harm. Secondary predictors were derived from patient, injury, and hospitalization characteristics. The study outcome was death. Univariate time to event analyses were conducted for all study predictors. A multivariate regression model for mortality was created using all relevant predictors. Results: The final sample included 668 facial GSW injuries, of which 19.3% were attributed to self-harm. Self-inflicted GSWs were more likely to involve the mandible (58.9 vs 46.0%, P < 0.01), ZMC/maxilla (47.3 vs 32.5%, P < 0.01), and intracranial cavity (48.1 vs 22.6%, P < 0.01). The overall mortality rate was 7.3%, and the mean time to death was 2.2 days. After controlling for pertinent covariates, the risk of mortality was independently decreased with mandibular injury (HR = 0.36, P = 0.03). However, mortality was increased by self-harm intent (HR = 3.94, P < 0.01) and intracranial involvement (HR = 11.24, P < 0.01). Conclusions: Consistent with a pattern of intraoral and submental entry points, self-inflicted facial GSWs demonstrated higher rates of mandibular injury. Despite this finding, self-harm injuries still carried a higher incidence of intracranial injury and a greater independent risk of mortality. Our results refute any notion that the mechanism and trajectory of self-inflicted GSWs is less fatal.
Introduction
Suicide is the leading cause of nonaccidental death in young adults, and firearms are both the most common and the most lethal method of suicide.[1] It is well-known that intracranial involvement portends a poor prognosis.[2,3] Specifically, bihemispheric injuries that violate the midline brain structures are generally not salvageable even with aggressive surgical approaches.[4] Likewise, transection of vital posterior brainstem structures is almost uniformly fatal. Compared to other mechanisms, self-inflicted gunshot wounds (GSWs) are thought to result in higher case fatality rates because of the closer range of energy transfer and the greater incidence of cranial involvement.[3]
Roughly 15% of all GSWs affect the head or face,[2] however when self-harm is implicated this figure increases to 75%.[5] Compared to GSWs from assault, self-inflicted GSWs follow a more predictable and stereotyped pattern of injury. Solitary GSWs are more common in attempted suicide, and multiple entry points are more indicative of assault or homicide.[5] During self-inflicted GSWs to the face, the gun is typically held in the dominant hand and oriented to point either intraorally, under the chin, at the side of the head, or directly at the forehead.[5,6] Fortunately, fewer than half of patients with facial GSWs have concomitant brain injuries.[7] Therefore, most facial GSWs are survivable.[8] A lateral (coronal) or frontal (sagittal) gun orientation pointing directly at the brain almost certainly causes neurologic devastation or death, however in such cases the face is usually spared as most civilian firearms are low-velocity and do not cause large cavitation or avulsion.[9,10] Self-inflicted facial GSWs are typically incurred through either a transoral (sagittal) or a submental (axial) entry site.[6,9] Paradoxically, although the intent of these approaches is to inflict maximal damage, they may carry lower than expected rates of intracranial injury and death. It is difficult to aim superiorly toward the neurocranium with a transoral trajectory.[9] Similarly, with a submental trajectory, both the mandible and midface may absorb and dissipate projectile forces before they reach the cranial base. Neck extension, performed to accommodate the barrel of the gun, may additionally displace the cranium away from the path of the projectile. Given the low rates of polytrauma and intracranial involvement, it is theoretically plausible that patients presenting with self-inflicted facial GSWs may in fact be more likely to survive their injuries than victims of interpersonal gun violence despite the massive collateral tissue damage from contact-range fire.
A prior study evaluating penetrating cranial trauma found no significant survival differences between GSWs intended for either self-harm or assault.[11] To date, no studies have compared the survival of self-versus otherinflicted facial GSWs. The purpose of this study was to investigate the severity of self-inflicted facial GSWs. Our aim was to determine if the intent of injury was associated with mortality in facially-injured GSW patients. To achieve our aim, we queried and analyzed a nationally representative administrative database.
Materials and Methods
This is a 1-year retrospective observational cohort study derived from the 2014 Nationwide Emergency Department Sample (NEDS). The NEDS is provided through the Healthcare Cost and Utilization Project (HCUP) and approximates a 20% stratified sample of all hospital-owned emergency department (ED) discharges. The ICD9-CM diagnosis and procedure codes used in this study are presented in Table 1. The NEDS database was searched from January 1 through December 31, 2014. All records documenting a facial fracture secondary to firearm use were included in the study sample.
Data was obtained regarding patient, injury, and hospitalization characteristics. Patient characteristics included age, gender, insurance, income quartile, and psychiatric diagnosis. Injury characteristics included injury intention (self-harm or other-harm), date of ED presentation (weekend or weekday), season, trauma center level, trauma center region, injury severity score (ISS), firearm type (handgun, shotgun, or rifle), facial fracture location(s), presence of intracranial injury, and mechanical ventilation, and tracheostomy requirements. The ISS is an established 75-point scale that integrates information from 6 body regions (head and neck, face, chest, abdomen and pelvis, extremities, external) to quantify trauma severity. An ISS score greater than 15 indicates a major trauma or polytrauma.[12] Hospitalization characteristics included ED disposition and charges as well as inpatient disposition, inpatient length of stay (LOS), and total charges for admitted patients. Patients leaving against medical advice were considered to have a home disposition. Patients expiring in the ED were assumed to have a LOS of 0 days.
Statistical Analysis
The primary study predictor was self-harm status. Secondary predictors were composed of the aforementioned patient, injury, and hospitalization characteristics. The study outcome was hospital mortality. Characteristics were compared between self- and other-harm injuries using chisquared and independent two-sample t-tests. Kaplan-Meier estimator curves were used to plot survival and estimate 48-hour mortality rates. Univariate time to event analyses were conducted for mortality using log-rank tests to identify survival differences within both primary and secondary predictor variables. Univariate predictor variables with P < 0.10 were included in the multivariate Cox proportional hazards regression model. Hazard ratios (HRs) were calculated and their significance was determined using the Wald chi-square test. Statistical significance was defined as a P < 0.05, and all analyses were performed with SAS 9.4 (SAS Institute, Cary, NC). As per Columbia University Irving Medical Center policy, research involving the analysis of de-identified data from publicly-available datasets does not require IRB review.
Results
A total of 668 patient records fulfilled the study inclusion criteria. The mean age was 33.6 years (SD: 14.6), and nearly all patients were male (88.0%). 47.4% of patients had either Medicaid or Medicare, while 28.3% of patients were uninsured. Over half of patients (50.9%) resided in zip codes representing the lowest income quartile, and over half of treating hospitals (50.8%) were located in the South. Injuries were most often performed with handguns (82.6%) followed by shotguns (13.3%) and rifles (4.1%). The mean ISS score was 14.2 (SD: 9.6). Over a quarter of injuries had a concomitant intracranial injury (27.5%), and nearly half of patients required mechanical ventilation (41.9%).
Characteristics of Self-Harm Injuries
129 (19.3%) records docu mented self-harm. Patients who engaged in self-harm were significantly older (45.0 vs 30.8y, P < 0.01) and more likely to have private insurance (36.5 vs 21.4%, P < 0.01) (Table 2). They were also more likely to have a documented comorbid psychiatric illness (72.1 vs 29.1%, P < 0.01) and less likely to present on the weekend (26.4 vs 37.8%, P < 0.01). There were also higher rates of injury to the mandible (58.9 vs 46.0%, P < 0.01), ZMC/maxilla (47.3 vs 32.5%, P < 0.01), and cranial contents (48.1 vs 22.6%, P < 0.01). With respect to injury severity, self-harm was associated with greater mean ISS scores (16.2 vs 13.7, P < 0.01) and mechanical ventilation requirement (62.0 vs 37.1%, P < 0.01). There were no differences in the type of gun used (P = 0.60).
Survival
Overall, 49 (7.3%) patients died either in the ED or after admission. Among those who expired from their injuries, the mean time to death was 2.2 days with 73.9% passing away during the first 48-hours. In contrast, those who survived ultimately had a significantly longer LOS (11.7 vs 2.2 days, P < 0.01). In the univariate analyses, mortality over time was significantly greater with self-harm intent (P < 0.01), older age (P < 0.01), higher income (P < 0.01), intracranial injury (P < 0.01), and mechanical ventilation (P < 0.01) (Table 3). Higher rates of survival were observed in patients with a documented psychiatric illness (P < 0.01), a concomitant mandible fracture, and those who went on to obtain a tracheostomy (P < 0.01). After controlling for other relevant predictors, self-harm intent (HR = 3.94, P < 0.01), intracranial injury (HR = 11.24, P < 0.01), and mechanical ventilation requirement (HR = 5.19, P < 0.01) each independently increased the risk of mortality (Table 4). Mandible fractures (HR = 0.36, P = 0.03) and tracheostomy (HR = 0.05, P < 0.01) were found to independently increase the probability of survival.
Discussion
This study sought to determine if self-inflicted facial GSWs were more fatal than other-inflicted GSWs with facial involvement. Our results found that despite increased rates of mandibular and ZMC/maxilla involvement, which are suggestive of submental and intraoral entry points, self-inflicted mechanisms still carried triple the risk of mortality over time. Furthermore, patients sustaining selfinflicted GSWs had higher rates of intracranial injury, higher ISS, and were more likely to require mechanical ventilation. Taken together, this data argues against the notion that self-inflicted GSWs could be less damaging.
Intuitively, multiple bullet wounds from a homicide attempt should carry a higher mortality risk than a single bullet wound from a suicide attempt. However, Cripps et al found that, among patients who sustained both head and body GSWs, each additional GSW did not increase mortality or affect ISS.[13] Suicides more often involve close range and contact shots whereas homicides more frequently involve distant range shots.[5,14,15] Indeed, the distance traveled by the bullet between firearm and victim inversely correlated with the size of the entry wound and the amount of tissue destruction in histologic and radiographic analyses.[16,17] The close range of self-inflicted GSWs also allows for more precise aiming of the firearm muzzle directly into the head’s vital structures while distant projectiles are more likely to land off target, resulting in more superficial grazing injuries.
Interestingly, the presence of a documented psychiatric diagnosis independently reduced the risk of mortality. On the surface, this seems counterintuitive as an overwhelming majority of self-inflicted GSWs occurred in patients with a psychiatric diagnosis. Other authors analyzing their institutional cohorts have found a similar protective benefit of psychiatric illness.[9,18] This observation has been attributed to more impulsive behavior among depressed patients with less conviction in the suicide attempt and less preparation prior to discharging the firearm. Logistically, it may also be the consequence of poor record keeping. It is less imperative to obtain collateral information pertaining to mental health history in the acute trauma setting, especially after a patient succumbs to their injuries. In our sample, poor records may not have played a large role since the majority (72%) of self-harm patients had psychiatric diagnoses on file, which was far greater than the incidence of psychiatric comorbidity (18%) identified in a review of the National Trauma Data Standard.[19]
The demographics of self-inflicted GSW patients in our study were consistent with that in the existing literature. As in our data, multiple studies have found that over 80% of self-inflicted gunshot wounds have occurred in males.[11,20,21] There was also a common pattern of selfharm risk and mortality rates increasing with age.[7,22] This could be attributed to older patients having more comorbid medical conditions such as diabetes or peripheral vascular disease that could complicate wound healing. Other studies reported comparable rates of pre-existing mood and substance-related disorders,[22,23] and those with selfinflicted GSWs were also more likely to possess private insurance[24] and survive if they were insured.[11]
There are several limitations to this study that are inherent to the data source used. First, we were unable to include patients who were pronounced dead at the scene or who expired prior to ED arrival. Consequently, we may be underestimating some of the mortality rates associated with our predictor variables. Second, our study relies on accurate and consistent ICD coding of diagnoses and procedures by hospital providers. Unfortunately, ICD codes sometimes cannot fully capture the details of a hospital course, and the prevalence of facial GSWs and related interventions may be underreported due to coding errors and use of similar or related codes that were outside the inclusion criteria. Finally, the location and extent of penetrative brain injury was not specified and therefore could not be correlated with outcomes.
In conclusion, self-inflicted facial GSWs had higher rates of mandibular injury, consistent with intraoral and submental entry, but carried a higher incidence of intracranial injury and a greater independent risk of mortality. Self-inflicted GSWs were often associated with psychiatric disorders, which have become increasingly prevalent in recent years.[25] Increased screening and treatment for psychiatric disorders may reduce the future healthcare burden of self-inflicted GSWs. Craniomaxillofacial trauma surgeons must dispel the notion that self-inflicted GSWs are less dangerous due to their trajectory.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
Conflicts of Interest
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
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Table 1.
ICD-9 Codes Definitions for Diagnoses and Procedures.
| ICD-9 diagnosis code | |
| Facial fracture | |
| Nasal | 802.0, 802.1 |
| Mandible | 802.20-29, 802.30-39 |
| ZMC/Maxilla | 802.4, 802.5, 802.7 |
| Orbital floor | 802.6 |
| Other | 802.8, 802.9 |
| Intracranial injury | 800.10-49, 800.60-99, 801.10-49, 801.60-99, 803.10-49, 803.60-99, 804.10-49, 804.60-99, 850.0-9, 851.00-99, 852.00-59, 853.00-19, 854.00-19, 907.0, V15.52 |
| Psychiatric diagnosis | |
| Substance related disorder | 291.0-5, 291.81-89, 291.9, 292.0, 292.11-12, 292.2, 292.81-89, 292.9, 303.00-03, 303.90-93, 304.00-93, 305.00-03, 305.20-93, 357.5, 425.5, 535.30-31, 571.0-3, 648.30-34, 655.50-53, 760.71-73, 760.75, 779.5, 965.00-09, 980.0, V65.42 |
| Mood disorder | 293.83, 296.00-06, 296.10-16, 296.20-26, 296.30-36, 296.40-46, 296.50-56, 296.60-66, 296.7, 296.80-89, 296.90, 296.99, 300.4, 311 |
| Anxiety disorder | 293.84, 300.00-09, 300.10, 300.20-29, 300.3, 300.5, 300.89, 300.9, 308.0-9, 309.81, 313.0-1, 313.21-22, 313.3, 313.82, 313.83 |
| Cognitive disorder | 290.0, 290.10-13, 290.20-21, 290.3, 290.40-43, 290.8-9, 293.0-1, 294.0, 294.10-11, 294.20-21, 294.8-9, 310.0, 310.2, 310.81-89, 310.9, 331.0, 331.11-19, 331.2, 331.82, 797 |
| Schizophrenia or other psychotic disorder | 293.81-82, 295.00-05, 295.10-15, 295.20-25, 295.30-35, 295.40-45, 295.50-55, 295.60-65, 295.70-75, 295.80-85, 295.90-95, 297.0-9, 298.0-9 |
| Conduct disorder | 312.30-39 |
| Developmental disorder | 299.00-01, 299.10-11, 299.80-81, 299.90-91, 307.0, 307.20-23, 307.3, 307.6, 307.7, 307.9, 309.21, 313.23 313.89 313.9, 315.00-09, 315.1-2, 315.31-39, 315.4-9, 317, 318.0-2, 319, V40.0, V40.1 |
| Personality disorder | 301.0, 301.10-13, 301.20-22, 301.3-4, 301.50-59, 301.6-7, 301.81-89, 301.9 |
| Adjustment disorder | 309.0-1, 309.22-29, 309.3-4, 309.82-89, 309.9 |
| ICD-9 procedure code | |
| Tracheostomy | 31.1, 31.21-29 |
| Mechanical ventilation | 93.90, 93.92, 96.01-05, 96.70-72 |
Table 2.
Emergency Department Characteristics Stratified by Injury Intent.
| Other-inflicted, n (%) | Self-inflicted, n (%) | P value | |
| Age, years# | 30.8 [29.8, 31.9] | 45.0 [42.1, 47.9] | <0.01* |
| Male | 472 (87.6%) | 116 (89.9%) | 0.46 |
| Insurance | <0.01* | ||
| Public | 234 (46.9%) | 57 (49.6%) | |
| Private | 107 (21.4%) | 42 (36.5%) | |
| Uninsured | 158 (31.7%) | 16 (13.9%) | |
| Income quartile, percentile | <0.01* | ||
| 0 to 25th | 296 (56.4%) | 34 (27.4%) | |
| 26 to 50th | 130 (24.8%) | 43 (34.7%) | |
| 51st to 75th | 61 (11.6%) | 28 (22.6%) | |
| 76th to 100th | 38 (7.2%) | 19 (15.3%) | |
| Psychiatric illness | 157 (29.1%) | 93 (72.1%) | <0.01* |
| Substance-related disorder | 101 (18.7%) | 51 (39.5%) | <0.01* |
| Schizophrenia | 6 (1.1%) | 4 (3.1%) | 0.09 |
| Mood disorder | 25 (4.6%) | 67 (51.9%) | <0.01* |
| Anxiety disorder | 41 (7.6%) | 22 (17.1%) | <0.01* |
| Adjustment disorder | 6 (1.1%) | 4 (3.1%) | 0.09 |
| Weekend presentation | 204 (37.9%) | 34 (26.4%) | 0.01* |
| Season | 0.09 | ||
| Winter | 113 (23.7%) | 40 (35.4%) | |
| Spring | 123 (25.8%) | 25 (22.1%) | |
| Summer | 126 (26.5%) | 26 (23.0%) | |
| Fall | 114 (24.0%) | 22 (19.5%) | |
| Trauma center | <0.01* | ||
| Level 1 | 352 (69.2%) | 84 (73.0%) | |
| Level 2 | 76 (14.9%) | 27 (23.5%) | |
| Level 3 | 31 (6.1%) | 3 (2.6%) | |
| Non-trauma | 50 (9.8%) | 1 (0.9%) | |
| Hospital region | 0.69 | ||
| Northeast | 38 (7.1%) | 11 (8.5%) | |
| Midwest | 133 (24.7%) | 36 (27.9%) | |
| South | 275 (51.0%) | 64 (49.6%) | |
| West | 93 (17.3%) | 18 (14.0%) | |
| Injury severity score# | 13.7 [12.8, 14.5] | 16.2 [14.7, 17.8] | <0.01* |
| Gun | 0.60 | ||
| Handgun | 168 (84.0%) | 74 (79.6%) | |
| Shotgun | 25 (12.5%) | 14 (15.1%) | |
| Rifle | 7 (3.5%) | 5 (5.4%) | |
| Fracture location(s) | |||
| Orbit | 91 (16.9%) | 22 (17.1%) | 0.96 |
| ZMC/Maxilla | 175 (32.5%) | 61 (47.3%) | <0.01* |
| Nasal | 121 (22.5%) | 33 (25.6%) | 0.45 |
| Mandible | 248 (46.0%) | 76 (58.9%) | <0.01* |
| Intracranial injury | 122 (22.6%) | 62 (48.1%) | <0.01* |
| Mechanical ventilation | 200 (37.1%) | 80 (62.0%) | <0.01* |
| Tracheostomy | 102 (18.9%) | 48 (37.2%) | <0.01* |
| ED disposition | <0.01* | ||
| Home | 119 (22.1%) | 2 (1.6%) | |
| Admission | 385 (71.4%) | 117 (90.7%) | |
| Transfer | 34 (6.3%) | 8 (6.2%) | |
| Death | 1 (0.2%) | 2 (1.6%) | |
| ED charges, USD# | 5,468.20 [4,774.10, 6,162.30] | 5,994.40 [3,936.60, 8,052.30] | 0.55 |
| IP disposition | <0.01* | ||
| Home | 284 (73.8%) | 36 (30.8%) | |
| Transfer | 74 (19.2%) | 62 (53.0%) | |
| Death | 27 (7.0%) | 19 (16.2%) | |
| IP LOS, days# | 9.8 [8.7, 10.8] | 14.3 [11.7, 16.9] | <0.01* |
| IP + ED charges, USD# | 174,514.00 [151,007.00, 198,021.00] | 186,282.00 [152,097.00, 220,467.00] | 0.62 |
*, P < 0.05. #, mean [95% CI].
Table 3.
Univariate Analyses for Mortality.
| 48-hour mortality rate [95% CI] | P value | ||
| Self-harm | <0.01* | ||
| Y | 13.6% [7.4, 19.8] | ||
| N | 5.5% [3.2, 7.9] | ||
| Age, y | <0.01* | ||
| <18 | 8.7 [—2.8, 20.2] | ||
| 18 to 65 | 6.5% [4.2, 8.8] | ||
| ≥65 | 23.1% [6.9, 39.3] | ||
| Gender | 0.99 | ||
| Male | 7.3 [4.9, 9.8] | ||
| Female | 8.7% [1.4, 15.9] | ||
| Season | 0.93 | ||
| Winter | 8.6% [3.5, 13.7] | ||
| Spring | 8.6% [3.2, 13.9] | ||
| Summer | 4.7% [0.7, 8.7] | ||
| Fall | 8.0% [2.7, 13.3] | ||
| Weekend presentation | 0.42 | ||
| Y | 8.5% [4.2, 12.7] | ||
| N | 7.0% [4.2, 9.7] | ||
| Income quartile, percentile | 0.03* | ||
| 0 to 25th | 6.2% [3.2, 9.2] | ||
| 26 to 50th | 9.8% [4.5, 15.1] | ||
| 51st to 75th | 2.7% [—1.0, 6.4] | ||
| 76th to 100th | 14.4% [3.7, 25.1] | ||
| Insurance | 0.06 | ||
| Public | 5.7% [2.7, 8.7] | ||
| Private | 6.1% [1.7, 10.6] | ||
| Uninsured | 13.8% [7.3, 20.2] | ||
| Hospital region | 0.62 | ||
| Northeast | 5.4% [—1.9, 12.7] | ||
| Midwest | 8.0% [3.3, 12.8] | ||
| South | 6.8% [3.7, 9.8] | ||
| West | 9.7% [3.3, 16.1] | ||
| Trauma center | 0.24 | ||
| Level 1 | 6.8% [4.2, 9.3] | ||
| Level 2 | 12.1% [4.7, 19.6] | ||
| Level 3 | 7.1% [—6.3, 20.6] | ||
| Non-trauma | 0.0% [n/a] | ||
| Psychiatric illness | <0.01* | ||
| Y | 4.1 [1.5, 6.7] | ||
| N | 10.2% [6.6, 13.8] | ||
| Gun | 0.96 | ||
| Handgun | 9.1% [4.7, 13.6] | ||
| Shotgun | 9.6% [—0.7, 19.9] | ||
| Rifle | 10.0% [—8.6, 28.6] | ||
| Orbit | 0.24 | ||
| Y | 4.4% [0.2, 8.6] | ||
| N | 8.2% [5.5, 10.8] | ||
| ZMC/Maxilla | 0.28 | ||
| Y | 5.5% [2.2, 8.8] | ||
| N | 8.7% [5.5, 11.8] | ||
| Nasal | 0.10 | ||
| Y | 3.3% [—0.4, 6.9] | ||
| N | 8.4% [5.7, 11.2] | ||
| Mandible | <0.01* | ||
| Y | 2.6% [0.7, 4.5] | ||
| N | 13.3% [8.9, 17.7] | ||
| Intracranial injury | <0.01* | ||
| Y | 21.4% [15.2, 27.6] | ||
| N | 0.3% [—0.3, 1.0] | ||
| Mechanical ventilation | <0.01* | ||
| Y | 11.8% [7.9, 15.6] | ||
| N | 2.2% [0.3, 4.0] | ||
| Tracheostomy | <0.01* | ||
| Y | 0.7% [—0.6, 2.0] | ||
| N | 10.5% [7.2, 13.7] | ||
*, P < 0.05.
Table 4.
Cox Proportions Hazards Regression Model for Mortality.
| Mortality | ||
| HR [95% CI] | P value | |
| Self-harm | 3.94 [1.70, 9.17] | <0.01* |
| Age, y | ||
| <18 | Ref | — |
| 18 to 65 | 0.56 [0.16, 1.97] | 0.36 |
| ≥65 | 1.22 [0.26, 5.75] | 0.80 |
| Income quartile, percentile | ||
| 0 to 25th | Ref | — |
| 26 to 50th | 1.32 [0.63, 2.78] | 0.46 |
| 51st to 75th | 0.43 [0.11, 1.65] | 0.22 |
| 76th to 100th | 2.42 [0.82, 7.14] | 0.11 |
| Insurance | ||
| Public | Ref | — |
| Private | 0.66 [0.24, 1.81] | 0.42 |
| Uninsured | 2.07 [0.98, 4.39] | 0.06 |
| Psychiatric illness | 0.15 [0.06, 0.35] | <0.01* |
| Intracranial injury | 11.24 [3.25, 8.46] | <0.01* |
| Mandible | 0.36 [0.14, 0.90] | 0.03* |
| Mechanical ventilation | 5.19 [2.10, 12.82] | <0.01* |
| Tracheostomy | 0.05 [0.01, 0.35] | <0.01* |
Ref, reference value. *, P < 0.05.
© 2021 by the author. The Author(s) 2021.
Share and Cite
MDPI and ACS Style
Lee, K.C.; Wu, B.W.; Chuang, S.-K. Are Facial Gunshot Wounds More Fatal When They Are Self-Inflicted or Other-Inflicted? Craniomaxillofac. Trauma Reconstr. 2022, 15, 275-281. https://doi.org/10.1177/19433875211039919
AMA Style
Lee KC, Wu BW, Chuang S-K. Are Facial Gunshot Wounds More Fatal When They Are Self-Inflicted or Other-Inflicted? Craniomaxillofacial Trauma & Reconstruction. 2022; 15(4):275-281. https://doi.org/10.1177/19433875211039919
Chicago/Turabian StyleLee, Kevin C., Brendan W. Wu, and Sung-Kiang Chuang. 2022. "Are Facial Gunshot Wounds More Fatal When They Are Self-Inflicted or Other-Inflicted?" Craniomaxillofacial Trauma & Reconstruction 15, no. 4: 275-281. https://doi.org/10.1177/19433875211039919
APA StyleLee, K. C., Wu, B. W., & Chuang, S.-K. (2022). Are Facial Gunshot Wounds More Fatal When They Are Self-Inflicted or Other-Inflicted? Craniomaxillofacial Trauma & Reconstruction, 15(4), 275-281. https://doi.org/10.1177/19433875211039919
