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 conflict, thus, consequently gunshot-related injuries and mortalities are common [10]. Conflicts 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 firearm 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 firearm 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 findings 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 findings 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 fixation 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 significantly 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 fixation 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 firearm 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 first 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 findings 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].