Gunshot Wounds to the Head in an Urban Setting

Syndemic Profiles for HIV, Hepatitis C, and Sextually Transmitted Infections Among Mexican American Women Formerly Affiliated with Youth Street Gangs

We examine syndemic profiles of intimate partner violence, mental health, drug use, incarceration, and infectious diseases (HIV, HCV, and STIs) among a sample of adult Mexican American women who were affiliated with youth street gangs during adolescence through their relationships to boys and men. Latent class analysis included multiple factors along the following dimensions: intimate partner violence, drug use, mental illness, and incarceration. Five unique syndemic profiles were found with varying associations to HIV, HCV, and STI: (1) no syndemic, (2) intimate partner violence, no syndemic, (3) drug use, mental health, and incarceration syndemic, (4) intimate partner violence, drug use (without injection drug use), and mental health syndemic, and (5) intimate partner violence, drug use with injection drug use, mental health, and incarceration syndemic. To successfully prevent HIV, HCV, and STI among gang-involved girls and women, it is necessary to address syndemic factors.

Pediatric intracranial gunshot wounds: the Memphis experience

OBJECTIVE Penetrating brain injury in civilians is much less common than blunt brain injury but is more severe overall. Gunshot wounds (GSWs) cause high morbidity and mortality related to penetrating brain injury; however, there are few reports on the management and outcome of intracranial GSWs in children. The goals of this study were to identify clinical and radiological factors predictive for death in children and to externally validate a recently proposed pediatric prognostic scale. METHODS The authors conducted a retrospective review of penetrating, isolated GSWs sustained in children whose ages ranged from birth to 18 years and who were treated at 2 major metropolitan Level 1 trauma centers from 1996 through 2013. Several standard clinical, laboratory, and radiological factors were analyzed for their ability to predict death in these patients. The authors then applied the St. Louis Scale for Pediatric Gunshot Wounds to the Head, a scoring algorithm that was designed to provide rapid prognostic information for emergency management decisions. The scale's sensitivity, specificity, and positive and negative predictability were determined, with death as the primary outcome. RESULTS Seventy-one children (57 male, 14 female) had a mean age of 14 years (range 19 months to 18 years). Overall mortality among these children was 47.9%, with 81% of survivors attaining a favorable clinical outcome (Glasgow Outcome Scale score ≥ 4). A number of predictors of mortality were identified (all p < 0.05): 1) bilateral fixed pupils; 2) deep nuclear injury; 3) transventricular projectile trajectory; 4) bihemispheric injury; 5) injury to ≥ 3 lobes; 6) systolic blood pressure < 100 mm Hg; 7) anemia (hematocrit < 30%); 8) Glasgow Coma Scale score ≤ 5; and 9) a blood base deficit < -5 mEq/L. Patient age, when converted to a categorical variable (0-9 or 10-18 years), was not predictive. Based on data from the 71 patients in this study, the positive predictive value of the St. Louis scale in predicting death (score ≥ 5) was 78%. CONCLUSIONS This series of pediatric cranial GSWs underscores the importance of the initial clinical exam and CT studies along with adequate resuscitation to make the appropriate management decision(s). Based on our population, the St. Louis Scale seems to be more useful as a predictor of who will survive than who will succumb to their injury.

Predictors of outcome in civilian gunshot wounds to the head

Object

Civilian gunshot wounds to the head (GSWH) are often deadly, but some patients with open cranial wounds need medical and surgical management and are potentially good candidates for acceptable functional recovery. The authors analyzed predictors of favorable clinical outcome (Glasgow Outcome Scale scores of 4 and 5) after GSWH over a 24-month period.

Methods

The authors posited 2 questions: First, what percentage of civilians with GSWH died in the state of Maryland in a given period of time? Second, what were the predictors of favorable outcome after GSWH? The authors examined demographic, clinical, imaging, and acute care data for 786 civilians who sustained GSWH. Univariate and logistic regression analyses were used to analyze the data.

Results

Of the 786 patients in this series, 712 (91%) died and 74 (9%) completed acute care in 9 trauma centers. Of the 69 patients admitted to one Maryland center, 46 (67%) eventually died. In 48 patients who were resuscitated, the Injury Severity Score was 26.2, Glasgow Coma Scale (GCS) score was 7.8, and an abnormal pupillary response (APR) to light was present in 41% of patients. Computed tomography indicated midline shift in 17%, obliteration of basal cisterns in 41.3%, intracranial hematomas in 34.8%, and intraventricular hemorrhage in 49% of cases. When analyzed for trajectory, 57.5% of bullet slugs crossed midcoronal, midsagittal, or both planes. Two subsets of admissions were studied: 27 patients (65%) who had poor outcome (25 patients who died and 2 who had severe disability) and 15 patients (35%) who had a favorable outcome when followed for a mean period of 40.6 months. Six patients were lost to follow-up.

Univariate analysis indicated that admission GCS score (p < 0.001), missile trajectory (p < 0.001), surgery (p < 0.001), APR to light (p = 0.002), patency of basal cisterns (p = 0.01), age (p = 0.01), and intraventricular bleed (p = 0.03) had a significant relationship to outcome. Multivariable logistic regression analysis indicated that GCS score and patency of the basal cistern were significant determinants of outcome. Exclusion of GCS score from the regression models indicated missile trajectory and APR to light were significant in determining outcome.

Conclusions

Admission GCS score, trajectory of the missile track, APR to light, and patency of basal cisterns were significant determinants of outcome in civilian GSWH.

Gunshot wounds to the spine in post-Katrina New Orleans

BACKGROUND

Gunshot wounds (GSW) to the spine represent a major health concern within today's society. Our study assessed the epidemiologic characteristics of patients with GSW to the spine treated in New Orleans.

PATIENTS AND METHODS

A retrospective chart review was performed from January 2007 through November 2011 on all the patients who were seen in the emergency room and diagnosed with a gunshot wound to the spine. Epidemiologic factors, as well as the results of admission toxicology screening, were noted. Outcome analysis was performed on patients undergoing conservative versus operative management for their injuries. Clinical outcomes were assessed using the ASIA classification system. Complications related to initial injury, neurosurgical procedures, and hospital stay were noted.

RESULTS

A total of 147 patients were enrolled. Of those diagnosed with a GSW to the spine, 88 (59.8%) received an admission toxicology screen. Seventy-three (83%) patients out of those tested had a positive screen, with the most common substances detected being cannabis, cocaine, and alcohol. In regards to management, 127 (87%) patients were treated conservatively and only one (0.7%) patient improved clinically from ASIA D to E. Of the 20 patients who underwent surgery, one (5%) patient had clinical improvement post-operatively from ASIA C to D.

CONCLUSIONS

This study evaluates the largest number of patients with GSW to the spine per year treated in a single centre, illustrating the violent nature of New Orleans. In this urban population, there was a clear correlation between drug use and suffering a GSW to the spine. Surgical intervention was seldom indicated in these patients and was predominately used for fixation of unstable fractures and decompression of compressive injuries, particularly below T11. Minimally invasive techniques were used successfully at our institution to minimize the risk of post-operative CSF leak.

Violence-Related Traumatic Brain Injury: A Population-Based Study

BACKGROUND

Most studies of traumatic brain injury (TBI) and violence are small, focus on one violent mechanism only, and are nonrepresentative. This large, population-based effort examines characteristics, circumstances of injury, treatment pathways, and outcomes of persons with TBI as a result of all types of violence, compares them with other TBI survivors, identifies a risk profile, and examines how a violent cause impacts later outcomes.

METHODS

This study involved medical record abstraction and telephone survey at 1 year postinjury of a weighted sample of 2,771 Coloradans hospitalized with TBI between January 1, 1996, and June 30, 1999.

RESULTS

People with violently incurred TBI are more likely to be young, male, members of minority groups, single, and premorbid alcohol abusers than other TBI survivors. At 1 year postinjury, they report less community integration and more headaches, confusion, and sensory and attentional disturbances. Predictors of these outcomes included age, gender, injury severity, and employment status.

CONCLUSION

It appears that essentially the same factors that increase risk of sustaining a violent TBI negatively impact later outcomes as well.

Gunshot injury to the head and spine

The principles of management of civilian gunshot wounds (GSWs) to the head and spine have evolved directly from the experience gained in war by military neurosurgeons. The type of craniocerebral wounds being produced in urban gang warfare and suicide at tempts using handguns or rifles at close range vary considerably from the lower velocity fragment injuries which are common in modern warfare. Civilian craniocerebral GSWs are often devastating. The in-hospital mortality for civilians with penetrating craniocerebral injury is 52-95% depending on the proportion of suicide victims in the series. The most important predictive factor is the post-resuscitation Glasgow Coma Score (GCS). Many civilian victims (47%) present with GCS 3-5 and only approximately 8.1% survive. Of these survivors, 1.4% will have nil, mild or moderate disability without surgery and 4.8% with surgery. Higher post-resuscitation GCS is associated with a significantly improved survival: GCS 6-8, 35.6% and GCS 9-15, 90.5%. A selective treatment policy is recommended for the patients with GCS 3-5. There are many clinical and radiological correlates with poor outcome that help the neurosurgeon decide on operative versus supportive treatment. Early aggressive resuscitation, surgery and vigorous control of intracranial pressure offers the best chance of achieving a satisfactory outcome. Spinal GSWs are uncommon and the neurosurgeon should be aware of the principles of management and prognosis. The indication for acute spinal cord decompression is deteriorating neurological status. Steroids are not indicated for these injuries. Neurosurgeons should take an active role in formulating and supporting public policy which aims to reduce possession and usage of firearms and therefore the prevalence of gunshot injuries.

Intracranial hemorrhage associated with tangential gunshot wounds to the head

Tangential gunshot wounds (TGSWs) to the head are gunshot wounds in which the bullet or bullet fragments do not penetrate the inner table of the skull.

OBJECTIVES

To determine the occurrence of intracranial hemorrhage (ICH) associated with TGSW to the head and to assess the ability of selected clinical criteria to predict ICH in this patient population.

METHODS

A retrospective chart review of patients diagnosed as having TGSWs to the head presenting to the ED of Los Angeles County + University of Southern California Medical Center from October 1, 1993, to May 31, 1996.

RESULTS

Four hundred twenty patients with gunshot wounds to the head presented to the ED. CT confirmed the diagnosis of TGSWs in 154 patients (36.7%). Head CT of patients with TGSWs revealed 25 (16.2%) skull fractures and 37 (24.0%) ICHs. Fourteen (56.0%) skull fractures were depressed. Of patients with a CT-documented TGSW to the head, 23 (16.1%) had a history of a loss of consciousness (LOC), 129 (84.3%) had a normal neurologic examination in the ED, 17 (11.1%) had a Glasgow Coma Scale score (GCS) < 15, and 75 (48.7%) had retained extracranial bullets or bullet fragments. Of all patients with TGSWs to the head, 113 had a GCS of 15 with no LOC and a normal neurologic examination, with 17 of these 113 patients (15.0%) having ICH. One patient died while hospitalized. Fifty-six (36.6%) patients were released home directly from the ED. Five clinical criteria (history of LOC, GCS < 15 on ED presentation, skull fracture, location of TGSW on the skull, and presence of extracranial bullet fragments) were examined to determine their ability to predict ICH. None of these criteria either alone or in combination were adequately predictive of ICH.

CONCLUSION

In this series, 1 in 4 patients with a TGSW to the head had an ICH. All patients with TGSWs to the head should undergo head CT to rule out depressed skull fractures and ICH.

Firearm suicides and homicides in the United States: regional variations and patterns of gun ownership

Among industrialized countries, the United States has the highest rates of firearm suicide and homicide, as well as the highest rate of gun ownership. The present study compares the differential impact of gun availability on firearm suicides and homicides in the U.S. Using data from the NCHS Mortality Detail Files (1989-1991), the 1990 U.S. census population estimates, and the General Social Surveys (1989-1991) for nine geographic divisions, we computed rates of firearm and non-firearm suicides and homicides as well as rates of gun ownership for four gender-race groups. We tested the strength of the associations between gun availability and firearm suicide and homicide rates by computing the Spearman correlation coefficients. To help elucidate the role of method substitution, we conducted similar analyses on non-firearm suicide and homicide. The results show that gun ownership has a stronger impact on firearm suicides than homicides. These findings held up after stratifying by gender and race. The study suggests that reducing the aggregate level of gun availability may decrease the risk of firearm-related deaths.