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, 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 the same or slightly higher than some available national and international [6, 11, 12] data but still less than the reported number from the USA and South Africa [8, 13, 14].
Gunshot injuries affect 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 be 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 is is the extremities of upper or lower limbs including soft tissue as well as bone tissue [6]. In this study, the lower limb followed by the upper limb is the most common site 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 limb 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 reports 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 good condition. About 17% of patients were referred to specialized centers for further management that are not available at our medical center.
Suicidal attempts are the commonest cause in developed countries[22]. However, published data from Nigeria and some other African countries, armed robbery attacks were found to be the commonest cause of gunshot injuries[15, 22]. In this study, our findings are not in agreement with the previous studies showing that personal enmity to be the more common causes of gunshot injuries. This could be explained by the presence of many interpersonal conflicts in these regions mostly due to different social reasons.
Firearm injuries have the highest case fatality rate in every age group, with a mortality rate ranging between 15.3% to 5.5 according to reports from developed countries.[6, 12, 23]. Furthermore Studies done in Libya, Nigeria, Tanzania, and South Africa showed gunshot mortality rate from 4.5% up to 8.3%.[8, 17, 22, 24] In our data the mortality rate was 3.2%, which is comparable to the lower limit of these data. This could be explained by the fact that we include only the deaths that occur following the patient admission to the hospital and we exclude any deaths occurring with the arrival or shortly after that which could tell us into survival bias. However, study done in Nigeria showed no mortality rate. [15]. 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 to carry high morbidity and mortality rate according to national and international studies [5, 25, 26]. Laparotomy was done for those patients with findings of internal organs injuries. One patient underwent chest tube insertion in addition to laparotomy to associated chest injury.