Lancia, Massimo MD; Rosati, Valentina MD; Gioia, Sara MD; Conforti, Federica MD; Suadoni, Fabio MD
The death of a 3-year-old child is a tragic event, especially when occurring in an unexpected and violent manner.
The authors report a case of an accidental death of a 3-year-old child who unintentionally shot himself while he was handling his father’s handgun.
The peculiarity of the observed injury makes the case particularly interesting, along with the fact that, in Italy, unintentional firearm-related deaths are rather uncommon among children and adolescents.
In the United States, firearm-related injuries are the second cause of injury death.1 However, if nonfatal, unintentional injuries are often self-inflicted, involve a handgun, and occur during ordinary gun-related practices such as cleaning, loading/unloading, handling, or carrying the gun, as Sinauer et al2 demonstrated in their study.
The case involved a 3-year-old boy who unintentionally shot himself with his father’s handgun (semiautomatic, 9-mm caliber).
The father worked as a security guard and left his handgun in the house, charged and unlocked, within range of the child. The latter found the gun and accidentally shot himself to the head with a consequent immediate death.
The main external findings were as follows (Figs. 1, 2):
- - diffuse blood stains on the face and on the right parietal-occipital part of the head and hair;
- - black point-shaped excoriations all over the face, mainly on the nose, right part of the middle face, right eyelid, right cheek, and lips;
- - right periorbital hematoma;
- - excoriation of the right nostril, the diameter of which was increased compared with the left one;
- - lacerated wound on the right parietal-occipital region of the head, with an irregular shape and separated, ragged edges (2.6 × 1.8 cm); and
- - 3 small bruises on the right palm.
Because of the presence of only 1 bullet hole on the parietal-occipital region, radiological cranial examinations were performed before proceeding with the autopsy: the x-ray image showed no bullet inside the skull; computed tomographic scans (Figs. 3–5) showed a wide fracture of the right parietal-occipital skull with a bone defect and external extruded bone fragments as well as a fracture of the right maxillary bone, right orbit floor, and right ethmoid and sphenoid bones with bone fragments strewn in the brain parenchyma. Computed tomographic scans showed a linear cavity within the right cerebral hemisphere, originating from the skull-base fracture (sphenoid and ethmoid) and ending at the parietal-occipital fracture.
During the autopsy, the main findings were as follows:
- - an irregularly round-shaped bone loss (diameter, 1.8 cm), with the underlying cerebral tissue exposed, in the right parietal-occipital skull, from which 3 fracture lines extended anteriorly, posteriorly, and medially;
- - an area of bone loss in the sphenoid to the ethmoid bone, associated with several fractures of the skull base, involving the right orbit, the right temporal pyramid, and the occipital bone; and
- - blood in the ventricular system.
Thus, in the imaging and autopsy findings, the reconstruction of the shot trajectory showed that, after being fired into the right nostril, the bullet passed through the right nasal cavity, fracturing the maxillary and orbital bones, and then perforated the skull base via the sphenoid and ethmoid bones.
The right cerebral hemisphere was perforated and the exit wound was localized at the right parietal-occipital skull.
It is compatible with a self-inflicted gunshot. Computed tomographic scans were useful to confirm the entrance site of the bullet and, especially, to establish the trajectory with the whole spectrum of fractures.
The case shows a fatal cranial injury with an unusual entrance site of the bullet, as a result of curiosity of a 3-year-old child in the presence of an unsupervised handgun.
The peculiarity of the case is mainly based on the extremely unusual gunshot entry wound through the nose. In the English literature, nasal entry wounds are only described for suicide cases3,4 and accidental shootings are not mentioned.
Although the exit wound in the parietal-occipital region of the head had the typical aspects (such as the irregular shape, everted skin margins, no abrasion collar, beveling of the outer table of the skull), the right nostril, where the bullet entered the body, was only excoriated and larger than the left one.
In addition, the periorbital hematoma was mild.
The 1 distinctive feature of a gunshot entry wound was the presence of black point-shaped excoriations involving most of the face.
The evidence that resulted from autopsy and imaging findings, especially the direction and trajectory of the gunshot as well as the bruises on the child’s right hand, led to the conclusion that the gunshot was self-inflicted.
Indeed, the evidence collected by the police confirmed the presence of gunpowder residues on the child’s hands but not on his relatives’, who were at home at the same time the shooting happened. In fact, according to witness statements, the child was alone on the upper floor of the house while the rest of his family was having dinner downstairs.
Concerning the context of curiosity of a 3-year-old child with an unsafely stored handgun, it is to say that unintentional deaths, especially among children and adolescents, often occur in a domestic environment.5–7
Therefore, in some cases, these deaths could be preventable by safer firearm storage.
Zavoski et al8 showed in their study that 6% of the firearm deaths in the population examined were unintentional and that handguns were responsible for a large number of those unintentional shootings compared with other types of firearms. Regardless of circumstances and intent, unintentional shootings were associated with an easy access to firearms for children.
The reported case shows how inappropriate the storage of a handgun is in a house with a 3-year-old child. In fact, the easy access to a firearm for a child and the resemblance to toys might have contributed to the unintentional shooting.
Many studies demonstrate that unintentional firearm-related injuries and deaths often occur while the victim is playing with the gun.7,9
Hemenway et al9 have shown, in their study, how most of the deaths among children aged 0 to 14 years were inflicted by others, which is the contrary of the described case. In the same study, the authors stated that most of the deaths occurred in the context of someone playing with the gun or hunting and, in these circumstances, were again inflicted by others.
Moreover, a statistically significant association has been demonstrated between gun availability and unintentional firearm deaths.10
Prevention of unintentional shootings must begin with removing guns from the homes of young children. If, as in the reported case, work-related necessities force a person to keep the firearm in a house with children, safer storage is mandatory to reduce the children’s risk for injury.11
Therefore, limiting the access to handguns and the practice of keeping the household firearm locked, unloaded, and separated from the ammunition are protective measures for unintentional shootings and deaths and, in general, in the prevention of firearm-related morbidity and mortality.8,12
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