Analysis of 107 civilian craniocerebral gunshot wounds

In this study, we present a retrospective analysis of 107 cases due to civilian craniocerebral gunshot wounds that were treated by the medical faculty of Dicle University during a period of 7 years (January 1993 to January 2000). Twenty patients died at the hospital, and the deaths were determined to result from direct effects of brain damage. Coma was the best prognostic guideline. Diffuse brain damage and ventricular injury, particularly infections, were associated with poor outcome. Electronic Publication     

Civilian craniocerebral gunshot wounds

Experience with 120 patients who incurred a gunshot wound to the head with dural penetration is presented. All of the patients were managed by a standard resuscitation protocol and assigned a clinical grade based on their level of consciousness both at the time of presentation and at 2 to 4 months after injury. Fifty patients (42%) underwent surgery. Twenty-eight patients (23%) had a good recovery, 19 (16%) were moderately disabled, 6 (5%) were severely disabled, and 67 (56%) died. All patients who were alert and awake with a normal or near normal neurological examination at the time of admission survived with a good outcome. All but 4 patients who were comatose at the time of admission died. Nine patients, however, who were not comatose at the time of admission died from potentially preventable causes. In 3 of these patients, a more aggressive diagnostic approach (including cerebral angiography) may have altered their ultimate outcome. An expeditious approach to the trauma victim with a comprehensive management scheme after injury may have altered the course in the remainder of these patients.     

Surgical management of craniocerebral gunshot wounds

Thirty-nine cases operated on because of gunshot wounds in our clinics the years 1976–1986 have been investigated. Factors contributing to mortality and out-come were evaluated. All the principles of emergency medical care and of surgical treatment of penetrating wounds should be applied to those patients with craniocerebral gunshot wounds in whom sugery is indicated.     

Penetrating craniocerebral gunshot wounds in civilians

Summary In spite of speedy transfer, only 18 percent of patients with penetrating craniocerebral gunshot wounds survived long enough to reach a neurosurgeon; the mortality among these was 79 percent. Mortality was 22 percent in patients conscious on admission, but 93 percent in patients unconscious on admission. True mortality from penetrating craniocerebral gunshot wounds in civilians seems to be extremely high; in this catchment area it was about 97 percent.     

Treatment of civilian gunshot wounds to the head

Gunshot wounds to the head are a common problem in the United States. A review of the literature and a survey of neurosurgeons suggests some differences of opinion regarding treatment. But the series upon which these opinions are based may be quite different. Disseminated intravascular coagulation can be a major problem. CT scanning is important for surgical decision making. Angiography should be used in cases in which bullets have passed near major vessels. We suggest an aggressive approach, with evacuation of clots and monitoring of intracranial pressure and treatment of elevations, as well as the routine use of anticonvulsants and antibiotics. Vocational rehabilitation is also important.     

Rectal gunshot wounds. Management of civilian injuries

The diagnosis and operative management of 43 consecutive low velocity wounds of the rectum were evaluated with regard to postoperative morbidity and mortality. Rectal and proctoscopic examinations, although frequently positive (80% and 91%, respectively), were not uniformly reliable in making the preoperative diagnosis. Diversion of the fecal stream by colostomy occupies a key role in operative management. Loop colostomy appears not only as efficacious as end colostomy and mucus fistula, but also requires less time to perform and subsequently close. Distal rectal washout is an important adjunct which reduces the incidence of rectal and intra-abdominal infectious complications. Civilian and military wounds of the rectum appear to differ in terms of the postoperative complications, mortality rate, and management techniques.     

The early prognosis of craniocerebral gunshot wounds in civilian practice as an aid to the choice of treatment

Summary The authors report a series of 56 cases of craniocerebral lesions secondary to missile injuries studied by means of CT scan. CT scans demonstrate the track of the missile, destruction of deep cerebral parenchyma, dissection of the white matter (intracerebral air) and reactive oedema. The prognostic incidence of CT is discussed. The CT scan helps to choose the best therapeutic management with respect to each particular case.     

Pyogenic osteomyelitis of axial bones following civilian gunshot wounds.

A series of forty-five patients with low velocity gunshot wounds to the spine and pelvis were followed up for at least eight weeks to determine the incidence of pyogenic osteomyelitis and the role of debridement and fragment removal in its prevention. Four cases of osteomyelitis were found, and although debridement was not frequently done, the incidence of osteomyelitis was higher following debridement than it was without debridement. The most important cause appeared to be spread of contiguous intraabdominal abscesses into the injured paravertebral muscles and spine. If an intraabdominal abscess did not develop, the presence of gastrointestinal injury did not predispose the patient to osteomyelitis. Based on this study, we can conclude that debridement and fragment removal of the spine and pelvic bones are unnecessary for low velocity missile wounds.     

Pattern of civilian gunshot wounds in Durban,South Africa

Abstract  

To evaluate the pattern, demographics, circumstances behind events and patient outcome of civilian gunshot wounds (GSWs), we conducted a prospective review in a surgical department in Durban, South Africa over a period of 9 months.     

An evaluation of hemodilution as therapy for craniocerebral gunshot wounds

Using a model of a craniocerebral gunshot wound, isovolemic hemodilution was found to reduce mortality rate from 100% to 40% in monkeys given similar injuries. While blood pressure, intracranial pressure, respiration, and EEG were also followed, it was the carotid blood flow that served as the most significant harbinger of death. It had previously been shown, in this model, that if the 3-minute carotid blood flow was 23% of baseline or less the animal would die in less than 1 hour. The present investigation demonstrated that isovolemic hemodilution, applied to those animals whose flow at 3 minutes was thus compromised, resulted in a 60% survival with an increase in carotid flow being shown in the survivors. It is presumed that this resulted from lowering the blood viscosity and counteracting increased vascular resistance.     

Civilian craniocerebral gunshot wounds: an update in predicting outcomes

Given the high mortality in patients sustaining intracranial injury secondary to gunshot wounds (GSWs), predictors to identify patients at increased risk of death are needed to assist clinicians early in determining optimal treatment. There have been few recent studies involving penetrating craniocerebral injuries, and most studies have been restricted to small numbers of patients, which do not allow for adequate prediction of mortality. A retrospective chart review of 298 patients who sustained GSWs to the head between 1992 and 2003 was conducted at a level 1 trauma center. Demographics, bullet trajectory, admitting Glasgow Coma Scale (GCS), head Abbreviated Injury Score (AIS), as well as admission blood pressure and respiratory rate were evaluated. Univariate testing followed by multivariate logistic regression was performed to identify independent predictors of death. In-hospital mortality for patients with intracranial injury secondary to GSW was 51 per cent. A GCS <5 on admission and a high Injury Severity Score (ISS >25) was associated with mortality as compared with survivors (P < 0.05). Of those patients presenting with a GCS of 3, there were seven survivors to discharge. Logistic regression identified the following variables as predictors of death: respiratory arrest on admission, hypotension on admission, transhemispheric and transventricular GSW. Identification of those patients at the highest risk of death secondary to a craniocerebral GSW allows clinicians to better predict outcome and prognosis. This is not only important in determining treatment algorithms for physicians but also for appropriate counseling of family members to educate them with regard to patients' outcomes.     

Similarities between civilian gunshot wounds to the head and nongunshot head injuries

BACKGROUND: This investigation compared the cerebral pathophysiologic status of gunshot wounds to the head (GSWH) with that of severe head injury of other causes (non-GSWH). METHODS: Data were collected prospectively from 71 GSWH and 541 non-GSWH patients. The two groups had similar demographic characteristics and injury severities. Cerebral metabolic parameters for each patient were averaged for the entire period of monitoring. These per-patient averages were compared between GSWH and non-GSWH groups. RESULTS: Median intracranial pressure was 21.4 mm Hg in GSWH patients vs. 16.7 mm Hg in non-GSWH patients (p < 0.001). Mean arterial pressures were similar, but the higher intracranial pressure in GSWH patients produced a lower median cerebral perfusion pressure. Cerebral blood flow, cerebrovascular resistance, cerebral metabolic rate of oxygen, average jugular venous oxygen saturation, and number of jugular venous desaturations did not differ significantly between the groups. Three-month outcome was death in 43% of GSWH patients and 32% of non-GSWH patients, persistent vegetative state or severe disability in 33% and 32%, respectively, and moderate disability or good recovery in 24% and 36%, respectively. These outcomes were not significantly different (p = 0.11). CONCLUSION: GSWH patients suffer global cerebral metabolic disturbances that are at least as severe as those seen in non-GSWH patients with injuries of comparable severity. This selected population of GSWH patients may enjoy outcomes comparable to those of non-GSWH patients if they are treated by the same aggressive protocols.     

The management of civilian ureteral gunshot wounds: a review of 8 patients

Ureteral injury is a rare consequence of abdominal gunshot wounds. We recently treated 8 patients with ureteral injuries. Failure to diagnose ureteral injury at presentation led to postoperative complications, necessitating additional operative procedures in 4 patients. However, in all 8 patients renal salvage was achieved.     

Treatment of thoracoabdominal gunshot wounds in civilian practice. Experience with forty-four cases

Forty-four acute cases of thoracoabdominal injuries in civilian practice are presented. Injury to multiple abdominal organs occurred in 50 per cent. The mortality in those with multiple organ injuries was 33 per cent whereas among those with injury to a solitary organ it was 4.5 per cent. The liver was injured in 61 per cent of cases. Although intercostal tube drainage (50 per cent) usually suffices in the management of the chest injury, thoracotomy was indicated in a number of cases. We advocate preservation of the thoracoabdominal barrier, by making a separate thoracic and abdominal wound, to prevent thoracic contamination, diaphragmatic hernia, and to achieve a thorough abdominal exploration. The total complication rate is 25 per cent. There were nine deaths (20 per cent) in the entire series, eight of which were directly related to the thoracoabdominal injury, yielding a corrected mortality of 18 per cent. One patient died from a separate gunshot wound to the brain.     

The role of early surgical intervention in civilian gunshot wounds to the head.

Surgical management of gunshot wounds of the head has remained a controversial issue in the care of civilian patients. In an attempt to determine who might benefit from aggressive surgical intervention, we examined 89 patients over a 3-year period who had suffered cranial gunshot wounds and had at least one computed tomographic scan of the head after admission. Patients were divided into those receiving early (less than 24 hours) surgical intervention (ES, n = 27), late (greater than 24 hours) surgical intervention (LS, n = 6) or no surgical intervention (NS, n = 56). Overall mortality was 63%. Ten of 27 patients (37%) in the ES group died compared with 46 of 56 patients (82%) in the NS group (p less than 0.0001). Glasgow Coma Scale (GCS) scores in the ES group averaged 7.86 +/- 4.72 and in the NS group 5.59 +/- 4.42 (p less than 0.05). The GCS scores in the LS group (all of whom survived) were significantly higher than those of the other two groups, 12.17 +/- 4.10. The number of patients with GCS scores of 3 or 4 on admission was significantly less in the ES (41%) than in the NS group (66%, p = 0.035) and survival was better with surgery (36%) than without (3%, p = 0.007). Patients with mass lesions (clot, ventricular blood) were more often found in the ES group (17/27) than in the NS group (18/56) (p = 0.008). Patients with bihemispheric injuries fared better with surgery (7 of 14 survivors) than without (2 of 33 survivors, p = 0.0003). Only one infectious complication (brain abscess) was encountered in the LS group. No delayed intracranial complications in survivors in the NS group were seen.(ABSTRACT TRUNCATED AT 250 WORDS)     

Penetrating gunshot wounds of the chest in civilian practice: experience with 250 consecutive cases

Our experience indicates a continued rising incidence of gunshot wounds of the chest in the United States. During the past 4 1/2 years, 250 consecutive cases were treated at the King-Drew Medical Center in Los Angeles. Ninety per cent presented with a haemothorax or haemopneumothorax. Pneumothorax alone was present in only 3 per cent of cases. Twenty per cent had associated intra-abdominal injuries, involving mostly the diaphragm, liver, spleen and the gastrointestinal tract. Eighty per cent were treated with tube thoracostomy and among these there were 2 deaths, neither being related to the chest injury. About 16 per cent underwent thoracotomy with a mortality of 12.8 per cent, all the deaths being caused by severe cardiac wounds. The overall mortality was 2.8 per cent. The complication rate was 5.3 per cent, most complications occurring in patients with associated intra-abdominal and spinal cord injuries. The average period of hospitalization was 6.5 days. The management plan and the indications for the two courses of therapy are discussed.     

Cranial gunshot wounds

Cranial gunshot wounds frequently produce devastating injuries to central nervous system structures. This article reviews pertinent principles of ballistics to explain several mechanisms of injury to the brain. A series of 21 consecutive cases of cranial gunshot wounds is presented outlining a protocol for management and identifying factors of prognostic significance.