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AbstractGunshot wounds are traumatic events

that emergency departments around the

country treat on a daily basis. An increas-

ing number of these wounds are being

caused by air rifles that shoot ball bearings

(ie, BB guns) and, although uncommon,

the results can be fatal. The general public

and most practitioners may not realize the

damage these “toys” can inflict. This article

highlights an unfortunate event involving

a BB gun accidentally discharged at close

range and the consequences. Data from

recent and older studies are discussed re-

garding the firepower of these guns and

their potential for injury.

Air rifles that shoot ball bear-ings (ie, BB guns) have been in production for decades and are

considered by most to be not much more than a toy. This leads to the perception that these guns may be safe for children to use unsupervised; however, modern-ization has made BB guns into weapons with potentially lethal power. Accidental injuries from BBs can cause a wide va-riety of complications because of their ability to penetrate the skin, eyes, skull, thorax, and abdomen. This article pres-ents a case of a BB gun-related traumat-ic brain injury and further discusses BB gun injuries and their prevention.

CASE REPORTA 10-year-old boy was shooting his

BB gun at targets in the backyard with his 12-year-old brother when they ran out of BBs. Assuming that the gun was empty, the older brother pointed it to-ward the victim and discharged it ap-proximately one foot away from his head. Unfortunately, there was one BB left in the gun and it struck the 10-year-old brother above his right ear. The mother was summoned immediately by the older brother and they found the younger brother lying on the ground, un-conscious, unresponsive, and with ago-nal breaths. Emergency medical services arrived, intubated him, and flew him via helicopter to the emergency department (ED).

Initial examination in the ED re-vealed a small entrance wound over the right temporal region and above the ear. After sedation was discontinued, the pa-tient was unresponsive with 4-mm reac-tive pupils, decerebrate positioning, and hypertonic reflexes. A head computed tomography (CT) exam without con-trast revealed bone fragments displaced into the right temporal lobe, extensive parenchymal, intraventricular, and sub-arachnoid hemorrhages. The scan also showed a projectile tract traversing from the right to left temporal lobe with pos-sible Circle of Willis involvement, and a metallic BB in the left temporal lobe (Figures 1 and 2). A cerebral angiogram showed no evidence of vascular injury.

The neurosurgery department was consulted and the patient was taken to the operating room (OR) for a right temporal craniectomy with debridement of bone fragments and placement of an intracranial pressure monitor. Immedi-ately after, a left frontal burr hole with placement of a ventricular drain was completed. The patient was admitted to the pediatric intensive care unit (PICU) for further management. His intracranial pressures (ICPs) and cerebral perfusion pressures (CPPs) were managed with temperature regulation, hyperosmotic therapy, low-normocarbia, sedation, paralytics, head of bed elevated to 30 degrees, minimal stimulation, and even-tually a pentobarbital coma. Repeat head

Air Rifles Are More than Toys: BB Gun-Related Traumatic Brain InjuryBlaine Klopotek, PA-C; Richard Weibley, MD; and Rene Chapados, MD

Blaine Klopotek, PA-C, is a Certified Physician

Assistant at St. Joseph’s Children’s Hospital of

Tampa. Richard Weibley, MD, is a Clinical Profes-

sor of Pediatrics, University of South Florida Mor-

sani College of Medicine; and a Pediatric Critical

Care Physician at Tampa General Hospital and St.

Joseph’s Children’s Hospital of Tampa. Rene Cha-

pados, MD, is a Clinical Professor of Pediatrics,

University of South Florida Morsani College of

Medicine; and a Pediatric Critical Care Physician

at Tampa General Hospital and St. Joseph’s Chil-

dren’s Hospital of Tampa.

Address correspondence to Blaine Klopotek,

PA-C, St. Joseph’s Hospital, Pediatric ICU, 3001 W.

Dr. Martin Luther King Jr. Boulevard, Tampa, FL

33607; email: blaineblaine@hotmail.com.

Disclosure: The authors have no relevant fi-

nancial relationships to disclose.

doi: 10.3928/00904481-20141124-12

PEDIATRIC ANNALS • Vol. 43, No. 12, 2014 495

FEATURE

CT scan without contrast showed a simi-lar presentation as before, with increasing brain ischemia. Four days after his arrival, due to his deteriorating clinical exam and difficulty controlling his ICPs and CPPs, the patient was taken back to the OR for a bifrontal and bitemporal decompressive craniectomy. Ongoing neurological ex-ams never improved, but rather worsened to no gag reflex, pupils at 2 mm and fixed, no spontaneous movements, and a mini-mal, ineffective respiratory effort.

After a PICU hospital course of 1 week, the patient’s family changed his medical status to “do not resuscitate” and ultimately decided to have his body sent for organ procurement.

DISCUSSIONBB guns are classified as nonpowder

guns but they can still cause serious in-jury. Each year, nearly 14,000 shootings occur, with the large majority (roughly 67%), occurring in persons aged 19 years or younger.1,2 The highest incidence oc-

curs in children aged 10 to 14 years, and predominantly in males.3 Because of ad-vancements in gun safety, these injury rates have declined substantially since the early 1990s; however, they still pose a significant threat of morbidity and mor-tality.4-6 Of note, most incidents are of un-intentional nature and occur within close proximity to the victim’s home.3

Most people underestimate the fire-power of modern BB guns. Actual fire-arms and BB guns have a mechanism of action that is very similar, and some BB guns can produce muzzle velocities that are faster than many low-velocity handguns and rifles.5 For example, a .38 caliber Smith & Wesson revolver fires at a velocity of 234 m/sec, but 50% of BB guns sold in the United States fire with a muzzle velocity of 152 to 282 m/sec.4,5 Recent studies state the muzzle velocity in some BB guns can be 364 m/sec.6 Giv-en these numbers, BBs possess enough kinetic energy to penetrate skin and, de-pending on the body region, to fracture

bone.7,8 The extent of injury is due largely in part to the distance from which the BB is fired.9 This patient was fired upon at close range, resulting in the BB entering his temporal bone.

Treatment and management should be determined on a case-by-case basis, with surgical intervention potentially prevent-ing further complications. As with other medical conditions, prevention is better than a cure. Efforts have been focused on passing legislation regulating the power of BB guns, informing owners of their potential, and encouraging manufacturers to promote safety measures.10 Most im-portantly, adult supervision of activities associated with BB gun use may be the best option. Although the past two de-cades have seen a reduction in the num-ber of injuries, the potential for and the incidence of them still remains.

CONCLUSIONBB guns should be considered more

than toys. The ongoing number of fa-

Figure 1. The red arrow points to the entrance wound, bone fragments, subarachnoid/parenchymal hemorrhages, and projectile tract. The yellow arrow points to a metallic BB in the left temporal lobe of the patient.

Figure 2. The green arrows point to intraventricular hemorrhages and early intracranial pressure changes.

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FEATURE

talities raises concern about the amount that may occur in the future. With any type of gun, tragedy can strike at any moment, with the sequelae being detri-mental and sometimes fatal. Although the extent of injury is closely depen-dent on the power and type of BB gun used, certain precautions should be taken to prevent harm. Parents, super-vising adults, and clinicians need to be cognizant of the facts and continuously encourage safe practice. Ultimately, in-juries associated with BB guns should receive prompt medical attention and management similar to that of other firearm-related injuries.

REFERENCES 1. National Center for Injury Prevention and

Control, U.S. Centers for Disease Con-trol and Prevention (2010) Web-based In-jury Statistics Query and Reporting System (WISQARS) Nonfatal Injury Reports 2010. http://www.cdc.gov/injury/wisqars/. Ac-cessed November 19, 2014.

2. Centers for Disease Control and Prevention. BB and pellet gun-related injuries—United States, June 1992-May 1994. MMWR Morb Mortal Wkly Rep. 1995;44(49):909-913.

3. Nguyen MH, Annest JL, Mercy JA, Ryan GW, Fingerhut LA.Trends in BB/pellet gun injuries in children and teenagers in the Unit-ed States, 1985-99. Inj Prev. 2002;8(3):185-191.

4. McNeill AM, Annest JL. The ongoing hazard of BB and pellet gun-related inju-ries in the United States. Ann Emerg Med. 1995;187:191-192.

5. Naude GP, Bongard FS. From deadly weapon to toy and back again: the danger of air rifles. J Trauma. 1996;41(6):1039-1043.

6. Laraque D; Committee on Injury, Violence, and Poison Prevention. Injury Risk of non-powder guns. Pediatrics. 2004;114(5):1357-1361.

7. Tsui CL, Tsui KL, Tang YH. Ball bearing (BB) gun injuries. Hong Kong J Emerg Med. 2010;17:488-491.

8. Miner ME, Cabrera JA, Ford E, Ewing-Cobbs L, Amling J. Intracranial penetration due to BB air rifle injuries. Neurosurgery. 1986;19(6):952-954.

9. Grocock C, McCarthy R, Williams DJ. Ball Bearing (BB) guns, ease of purchase and po-tential for significant injury. Ann R Coll Surg Engl. 2006;88:402-404.

10. Bond SJ, Schnier GC, Miller FB. Air-pow-ered guns: too much firepower to be a toy. J Trauma. 1996;41(4):674-678.

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