Utilization of Ophthalmic Management in Patients with Head-and-Neck Trauma Secondary to Firearms

Introduction

This retrospective cohort study presents the epidemiology of severe firearm-related ophthalmic injury and the level of ophthalmology involvement in the multidisciplinary management of head-and-neck gunshot injuries.

Methods

A retrospective study identified 207 patients with firearm-related injuries involving the head and neck treated at an Academic Tertiary Care Institution from 2010 to 2020.

Results

Ophthalmology consulted on 29% of patients with head-and-neck firearm injuries. At least one of the services managing facial trauma (plastic surgery and otolaryngology) consulted on 71.5% of cases (P < 0.001). Of patients evaluated by ophthalmology, 93.3% survived to discharge; 78.2% of patients who were not evaluated survived to discharge (P = 0.009). Ophthalmology consulted on all patients with open globe injury (10.6%) (P < 0.001), all of which were evaluated by the facial trauma service (P = 0.002), 77.3% by otolaryngology (P = 0.42), 50% by neurosurgery, 36.4% by plastic surgery, 13.6% by orthopedic surgery, and 4.5% by vascular surgery. Ophthalmology consulted on 76.5% of patients with orbital fracture (32.9%) (P < 0.001); 83.8% were evaluated by the facial trauma service (P = 0.006), 69.1% by otolaryngology (P = 0.014), 54.4% by neurosurgery, 27.9% by plastic surgery, 10.3% by orthopedic surgery, and 2.9% by vascular surgery. For patients with orbital fractures, 92.3% survived when ophthalmology was consulted (P = 0.698); 43.8% survived when not consulted (P = 0.001).

Conclusions

Firearm-related injuries of the head and neck frequently involve ocular and orbital structures, often causing serious vision-threatening injuries. Multispecialty management is common and early ophthalmology specialist evaluation and co-management are indicated to best identify ophthalmic injuries.

Prognosis and futility in neurosurgical emergencies: A review

A patient with a life-threatening intracranial insult presents a difficult situation to the neurosurgeon. In a few short minutes the neurosurgeon must assess the patient's neurologic status, imaging, and medical condition then confer with the patient's proxy regarding treatment. This assessment ideally includes recognition of situations where aggressive care is futile and therefore such treatments should not be offered. The proxy discussion must involve surgical and nonsurgical management options and the impact of these options on survival and residual disability. Surgical decision-making is frequently difficult, even for designated proxies armed with advance directives, as these documents are usually vague with regard to acceptable functional outcomes. To complicate things further, when emergencies are off-hours, housestaff or physician extenders may need to represent the medical team in these discussions so that surgical treatment, if desired, can be arranged expeditiously. These difficulties sometimes lead to the performance of emergent surgical procedures in situations where poor outcome is certain, with deleterious effects to the patient, family, and healthcare system. It is clear then that neurosurgeons as well as their housestaff and extenders should have working knowledge of prognostic information relating to intracranial insults and familiarity with the complex ethical concept of medical futility. In this paper we review the relevant literature and our goal is to juxtapose these topics so as to provide a framework for decision making in that critical time.

Tendencia de los años perdidos de vida potencial por trauma en Colombia: análisis de un periodo de nueve años

Introducción. El trauma es reconocido como una epidemia global que varía según las regiones donde se presenta. Una parte de la carga de la enfermedad está determinada por los años perdidos de vida potencial, la cual es una estimación de amplio uso para la vigilancia en salud pública; sin embargo, existe poca información disponible en relación a esto. El objetivo de este estudio fue determinar la tendencia de los años perdidos de vida potencial por el trauma en un período de nueve años. Métodos. La información se obtuvo del Instituto Nacional de Medicina Legal y Ciencias Forenses en un período de nueve años (2007-2015). La población de referencia se determinó con base en las proyecciones del Departamento Administrativo Nacional de Estadística, que indicaron una expectativa de vida de 75 años. Resultados. En el 2015, a las lesiones por traumatismos en Colombia les correspondieron 1.920,7 años perdidos de vida potencial por cada 100.000 personas. Durante el período de estudio, las principales causas fueron los homicidios (rango, 51 a 68 %) y los accidentes de tránsito (rango, 19 a 28 %); la relación entre hombres y mujeres fue de 7:1, y la tendencia estadística fue hacia la disminución de los años perdidos de vida potencial. Conclusiones. Los homicidios siguen aportando el mayor número de lesiones por trauma y años perdidos de vida potencial. Los hombres jóvenes continuaron siendo la población mayormente afectada. Se conceptúa la necesidad de incrementar los esfuerzos para mejorar la vigilancia en salud pública y ahondar en las intervenciones oportunas relacionadas con el trauma.

Prognostic performance of computerized tomography scoring systems in civilian penetrating traumatic brain injury: an observational study

Background

The prognosis of penetrating traumatic brain injury (pTBI) is poor yet highly variable. Current computerized tomography (CT) severity scores are commonly not used for pTBI prognostication but may provide important clinical information in these cohorts.

Methods

All consecutive pTBI patients from two large neurotrauma databases (Helsinki 1999–2015, Stockholm 2005–2014) were included. Outcome measures were 6-month mortality and unfavorable outcome (Glasgow Outcome Scale 1–3). Admission head CT scans were assessed according to the following: Marshall CT classification, Rotterdam CT score, Stockholm CT score, and Helsinki CT score. The discrimination (area under the receiver operating curve, AUC) and explanatory variance (pseudo-R²) of the CT scores were assessed individually and in addition to a base model including age, motor response, and pupil responsiveness.

Results

Altogether, 75 patients were included. Overall 6-month mortality and unfavorable outcome were 45% and 61% for all patients, and 31% and 51% for actively treated patients. The CT scores’ AUCs and pseudo-R²s varied between 0.77–0.90 and 0.35–0.60 for mortality prediction and between 0.85–0.89 and 0.50–0.57 for unfavorable outcome prediction. The base model showed excellent performance for mortality (AUC 0.94, pseudo-R² 0.71) and unfavorable outcome (AUC 0.89, pseudo-R² 0.53) prediction. None of the CT scores increased the base model’s AUC (p > 0.05) yet increased its pseudo-R² (0.09–0.15) for unfavorable outcome prediction.

Conclusion

Existing head CT scores demonstrate good-to-excellent performance in 6-month outcome prediction in pTBI patients. However, they do not add independent information to known outcome predictors, indicating that a unique score capturing the intracranial severity in pTBI may be warranted.

Electronic supplementary material

The online version of this article (10.1007/s00701-019-04074-1) contains supplementary material, which is available to authorized users.

Successful Surgical Treatment of Severe Perforating Diametric Craniocerebral Gunshot Wound Sustained during Combat: A Case Report

Many researchers classify perforating diametric craniocerebral gunshot wounds as fatal because mortality exceeds 96% and the majority of patients with such injuries die before hospitalization. A 23-year-old Ukrainian male soldier was admitted to a regional hospital with a severe perforating craniocerebral wound in a comatose state (Glasgow Coma Scale score, 5). Following brain helical computed tomography, the patient underwent primary treatment of the cerebral wound with primary duraplasty and inflow/outflow drainage. After 18 days of treatment in the intensive care unit, he was transferred to a military hospital for further rehabilitation. This report details our unusual case of successful treatment of a perforating diametric craniocerebral gunshot wound.

Outcomes of tibia shaft fractures caused by low energy gunshot wounds

BACKGROUND

The purpose of this project was to compare the rates of infections, nonunions, malunions, and secondary operations in tibia fractures resultant from low energy GSWs versus those seen in open and closed tibia fractures resultant from blunt trauma. A secondary objective was to assess the utility of using the traditional Gustilo-Anderson classification system for open fractures to describe fractures secondary to low energy GSW.

METHODS

A retrospective review of 327 patients with tibia shaft fractures was conducted at our level I trauma center. Patients underwent a variety of interventions depending on their injury. Standard fixation techniques were utilized. Outcome measures include: mechanism of injury, rates of superficial and deep infection, nonunion, malunion, and secondary operations.

RESULTS

Deep infection after low energy GSW tibia fractures was uncommon and seen in only 2.3% of patients. Rates of infection after low energy GSWs were similar to low and high energy closed tibia fractures resultant from blunt trauma, but significantly less than that seen in open type II (25%, p < 0.05), type IIIA (19.5%, p < 0.05), and type IIIB fractures (47%, p < 0.01). There were no nonunions following GSW fractures, versus 3.7% after closed tibia fractures from blunt trauma (p = 0.2). Nonunions were more common after open fractures from blunt trauma (11%, p < 0.05) versus GSWs. Differences in infection and nonunion were associated with more secondary operations (18%, p < 0.01) in the open tibia fracture group compared with GSWs (2.3%) and closed fractures (7.9% p = 0.19).

CONCLUSIONS

While GSWs are traditionally thought of as open injuries, low energy GSW tibia fractures had a low rate of infection and no nonunions, and resulted in a reoperation rate similar to closed blunt tibia shaft fractures and significantly lower than open tibia fractures.

The intracranial number of foreign bodies as a predictor of mortality after penetrating brain injury

INTRODUCTION

Penetrating brain injury (PBI) is the most lethal form of traumatic brain injury, which is a leading cause of mortality. PBI has a mortality rate of 23%-93% and 87%-100% with poor neurological status. Despite the use of various prognostic factors there is still a need for a specific prognostic factor for early prediction of mortality in PBI to reduce mortality and provide good outcomes with cost-effective surgical treatments. The aim of this study was to investigate the predictive value of the number of intracranial foreign bodies (FBs) on mortality in PBI in the Emergency Department.

METHODS

The study included 95 patients admitted with PBI caused by barrel bomb explosion. The intracranial number of FB was examined by brain computed tomography. Logistic regression was used to assess the association of the intracranial number of FB on mortality. Correlation analyses were performed to investigate the association of Glasgow Coma Scale (GCS) with intracranial number of FB.

RESULTS

The optimal cut-off value of the intracranial number of FB calculated for mortality was 2, which was effective for predicting mortality (p < .001). In patients with >2 intracranial FB, the mortality rate was statistically significantly 51-fold higher than those with ≤2 (p < .001). A statistically significant negative correlation was determined between GCS and number FB (r = -0.697; p < .001).

CONCLUSION

When the intracranial number of FB was >2, mortality significantly increased in patients with PBI. The intracranial number of FBs may be considered as a novel prognostic factor for the prediction of mortality in PBI.

Developing a simplified clinical prediction score for mortality in patients with cerebral gunshot wounds: The Maritzburg Score

Introduction Cerebral gunshot wounds are highly lethal and literature on the clinical scores for mortality prediction is limited. Materials and methods A retrospective study was undertaken over a 5-year period at the Pietermaritzburg Metropolitan Trauma Service in South Africa. A simplified clinical prediction score was developed based on clinical and/or physiological variables readily available in the resuscitation room. Results A total of 102 patients were included; 92% (94/102) were male and the mean age was 29 years; 22% (22/102) died during the admission. The presence of visible brain matter (odds ratio 12.4, P = 0.003) and motor score less than 5 (odds ratio 89.6, P  < 0.001) allows the prediction success of 92% (sensitivity 73% and specificity 98%). The area under the receiver operating characteristic curve was 94% (95% confidence interval 88-100%, P  < 0.001). Conclusions The presence of visible brain matter, together with a motor score of less than 5, allows accurate identification of non-survivors of cerebral gunshot wounds. Further study is required to validate this score.

Civilian cerebral gunshot wounds: a South African experience

BACKGROUND

Cerebral gunshot wounds represent one of the most lethal forms of traumatic brain injury, but there is a paucity of literature on the topic, especially from the developing world. We reviewed our experience and describe the spectrum and outcome of civilian cerebral gunshot wounds in a major metropolitan trauma centre in South Africa.

METHODS

This was a retrospective study of all patients with isolated cerebral gunshot wounds managed by the Pietermaritzburg Metropolitan Trauma Service over a 5-year period from 2010 to 2014.

RESULTS

One hundred and two patients were included, 92% (94/102) were male and the mean age was 29 years. Fifty-four per cent (55/102) of all patients were from urban areas. The mean time from injury to arrival was 6 h (standard deviation: 5) for urban patients and 15 h (standard deviation: 5.2) for rural patients (P < 0.001). Ninety-four per cent (94/102) of all injuries were related to interpersonal violence and involved low velocity firearms. Twenty per cent of all patients (20/102) had a Glasgow Coma Scale 3-8, 20% (20/102) 9-12 and 61% (61/102) 12-15. All 102 patients underwent computed tomography scans. Thirty per cent (31/102) required neurosurgical interventions. The overall mortality rate was 22% (22/102). There was a significant difference in mortality between urban and rural patients (9% versus 36%, P < 0.001).

CONCLUSIONS

Cerebral gunshot wounds are associated with significant mortality and protracted delay to definitive care is common in our setting. Those who survive the delayed transfer to definitive care generally do well and have reasonably good clinical outcomes.

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.

Racial Disparities in Cranial Gunshot Wounds: Intent and Survival

BACKGROUND

Gunshot wounds (GSW) to the head are associated with the highest mortality of all gun-related injuries, with assault reported as the leading cause of penetrating GSW. Several studies have explored factors and trends related to assault and self-inflicted GSW separately. The aim of this study was to investigate epidemiological characteristics and racial differences collectively in patients with GSW to the head by examining associations to injury intent and survival.

METHOD

A retrospective study was performed by accessing the hospital trauma registry at our regional Level 1 Trauma Center. A query of neurosurgery consults with penetrating trauma was completed from January 2008 to October 2013. Patients with penetrating intracranial GSW were included in the study. A chi-square test was used to evaluate association between patients' characteristics and intent of injury. Logistic regression analyses predicting intent of injury and survival were also conducted.

RESULTS

Of 111 patients, the majority were male (87.4 %). Most were African American (57.7 %) and Caucasian (35.1 %). Compared to African Americans, Caucasian patients were more likely to inflict self-harm (odds ratio (OR) 16.369 (95 % confidence interval (CI) 5.633-47.571), p < 0.0001), while African Americans (OR 26.413 (95 % CI 8.957-77.890), p < 0.0001) were more likely to be victims of assault. Race and other demographic variables did not predict survival nor did intent of injury (p = 0.368).

CONCLUSION

This study reports that there are racial disparities between assault GSW and self-inflicted GSW. However, neither race nor intent is a predictor of survival outcome. Targeted efforts are needed to reduce occurrence of cranial GSW events in order to decrease associated morbidity and mortality.

Management of Craniocerebral Gunshot Injuries: A Review

Craniocerebral gunshot injuries (CGI) are increasingly encountered by neurosurgeons in civilian and urban settings. Unfortunately this is a prevalent condition in developing countries, with major armed conflicts which is not very likely to achieve a high rate of prevention. Management goals should focus on early aggressive, vigorous resuscitation and correction of coagulopathy; those with stable vital signs undergo brain computed tomography scan. Neuroimaging is vital for surgical purposes, especially for determine type surgery, size and location of the approach, route of extraction of the foreign body; however not always surgical management is indicated, there is also the not uncommon decision to choose non-surgical management. The treatment consist of immediate life salvage, through control of persistent bleeding and cerebral decompression; prevention of infection, through extensive debridement of all contaminated, macerated or ischemic tissues; preservation of nervous tissue, through preventing meningocerebral scars; and restoration of anatomic structures through the hermetic seal of dura and scalp. There have been few recent studies involving penetrating craniocerebral injuries, and most studies have been restricted to small numbers of patients; classic studies in military and civil environment have identified that this is a highly lethal or devastating violent condition, able to leave marked consequences for the affected individual, the family and the health system itself. Various measures have been aimed to lower the incidence of CGI, especially in civilians. It is necessarily urgent to promote research in a neurocritical topic such as CGI, looking impact positively the quality of life for those who survive.

Surgical management of civilian gunshot wounds to the head

Each year close to 20000 Americans are involved in gunshot wounds to the head (GSWH). Over 90% of the victims of GSWH eventually fail to survive and only a meager 5% of the patients have a chance to continue with a useful life. One of the fundamental jobs of providers is to realize who the best candidate for the best possible management is. Recent evidence indicates that a good Glasgow Coma Scale (GCS) score at the time of admission puts such patients at high priority for management. Lack of abnormal pupillary response to light, trajectory of slug away for central gray, and visibility of basal cisterns upgrade the need for utmost care for such a victim. Surgical management is careful attention to involvement of air sinuses and repair of base dura. Patients with diffuse injury should have intraventricular intracranial pressure (ICP) monitoring and if needed a timely decompressive craniectomy. Since close to 2% of patients with penetrating brain injury may harbor a vascular injury, subjects with injuries close to the Sylvian fissure and those with the fragment crossing two dural compartments should have computed tomography angiography and if needed digital subtraction angiography to rule out traumatic intracranial aneurysms. In case of a positive study, these patients should have endovascular management of their vascular injuries in order to prevent catastrophic intracerebral hematomas and permanent deficit. Although supported by class III data, subjects of GSWH need to be on broad spectrum antibiotics for a period of 3-5 days. If cerebrospinal fluid (CSF) fistulas are observed at any time during the patient's hospital course, they should be taken very seriously and appropriate management is needed to prevent deep intracranial infections.

Predictors of outcome in civilians with gunshot wounds to the head upon presentation

OBJECT

Prediction of outcome from initial presentation after a gunshot wound to the head (GSWH) is essential to further clinical decision making. The authors' goals are to report the survival and functional outcomes of these patients, to identify prognostic factors, and to propose a scoring system that can predict their outcome.

METHODS

The records of 199 patients admitted with a GSWH with dural penetration between 1990 and 2008 were retrospectively reviewed. The inclusion criterion was a CT scan available for review. Patients declared brain dead on presentation were excluded, which yielded a series of 119 patients. Statistical analysis was performed using a logistic regression model.

RESULTS

Fifty-eight (49%) of the 119 patients died. Twenty-three patients (19%) had a favorable outcome defined as a 6-month Glasgow Outcome Scale (GOS) score of moderate disability or good recovery, 35 (29%) had a poor outcome (GOS of persistent vegetative state or severe disability), and 3 (3%) were lost to follow-up. Significant prognostic factors for mortality were age older than 35 years, nonreactive pupils, bullet trajectory of bihemispheric (excluding bifrontal), and posterior fossa involvement compared with unihemispheric and bifrontal. Factors that were moderately associated with higher mortality included intracranial pressure (ICP) above 20 mm Hg and Glasgow Coma Scale (GCS) score at presentation of 3 or 4. Upon multivariate analysis, the significant factors for mortality were bullet trajectory and pupillary response. Variables found to be significant for good functional outcome were admission GCS score greater than or equal to 5, pupillary reactivity, and bullet trajectory of unihemispheric or bifrontal. Factors moderately associated with good outcome included age of 35 years or younger, initial ICP 20 mm Hg or lower, and lack of transventricular trajectory. In the multivariate analysis, significant factors for good functional outcome were bullet trajectory and pupillary response, with age moderately associated with improved functional outcomes. The authors also propose a scoring system to estimate survival and functional outcome.

CONCLUSIONS

Age, pupils, GCS score, and bullet trajectory on CT scan can be used to determine likelihood of survival and good functional outcome. The authors advocate assessing patients based on these parameters rather than pronouncing a poor prognosis and withholding aggressive resuscitation based upon low GCS score alone.

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 and blast injuries to the face are associated with significant morbidity and mortality: results of an 11-year multi-institutional study of 720 patients

BACKGROUND

Gunshot wounds and blast injuries to the face (GSWBIFs) produce complex wounds requiring management by multiple surgical specialties. Previous work is limited to single institution reports with little information on processes of care or outcome. We sought to determine those factors associated with hospital complications and mortality.

METHODS

We performed an 11-year multicenter retrospective cohort analysis of patients sustaining GSWBIF. The face, defined as the area anterior to the external auditory meatuses from the top of the forehead to the chin, was categorized into three zones: I, the chin to the base of the nose; II, the base of the nose to the eyebrows; III, above the brows. We analyzed the effect of multiple factors on outcome.

RESULTS

From January 1, 2000, to December 31, 2010, we treated 720 patients with GSWBIF (539 males, 75%), with a median age of 29 years. The wounding agent was handgun in 41%, explosive (shotgun and blast) in 20%, rifle in 6%, and unknown in 33%. Prehospital or resuscitative phase airway was required in 236 patients (33%). Definitive care was rendered by multiple specialties in 271 patients (38%). Overall, 185 patients died (26%), 146 (79%) within 48 hours. Of the 481 patients hospitalized greater than 48 hours, 184 had at least one complication (38%). Factors significantly associated with any of a total of 207 complications were total number of operations (p < 0.001), Revised Trauma Score (RTS, p < 0.001), and head Abbreviated Injury Scale (AIS) score (p < 0.05). Factors significantly associated with mortality were RTS (p < 0.001), head AIS score (p < 0.001), total number of operations (p < 0.001), and age (p < 0.05). An injury located in Zone III was independently associated with mortality (p < 0.001).

CONCLUSION

GSWBIFs have high mortality and are associated with significant morbidity. The multispecialty involvement required for definitive care necessitates triage to a trauma center and underscores the need for an organized approach and the development of effective guidelines.

LEVEL OF EVIDENCE

Therapeutic/care management, level III.

Statistical validity and clinical merits of a new civilian gunshot injury classification

BACKGROUND

Despite the high prevalence of civilian gunshot injuries (GSIs) in the United States, no universally accepted classification currently exists. Recently, two of us (ZG, RWL) proposed a GSI classification based on energy transferred, vital structure damage, wound characteristics, fracture, and degree of contamination. This classification has not been validated in a clinical setting.

QUESTIONS/PURPOSES

We determined the feasibility, internal consistency, and predictive accuracy of this classification.

METHODS

We reviewed the medical records of 216 patients with 264 GSIs treated at a Level I trauma center. Feasibility was determined by the investigators' ability to retrospectively complete the classification system based on patient information routinely collected in medical records. Internal consistency was determined using Cronbach's coefficient alpha. Predictive accuracy was constructed and interpreted in a receiver operating characteristic (ROC) curve using all the classification components to predict GSI severity. The clinical management/outcome (deceased, hospitalization versus nonadmission, and surgical versus nonsurgical treatment) was used as a proxy measure of GSI severity.

RESULTS

We were able to apply the classification to 82% of charts we reviewed. The classification components appeared to be internally consistent (Cronbach's alpha was 0.69 and was increased to 0.78 after exclusion of contamination). Each component was associated with clinical management. GSI classified as high energy, worse vital structure, and high contamination had higher rates of surgery (84%, 84%, and 100%, respectively). The area under the ROC curve was 0.80, suggesting the classification can accurately describe GSI severity.

CONCLUSIONS

Our results suggest this new civilian GSI classification is statistically valid and has clinical merits warranting further investigation in the setting of a prospective trial.

Civilian craniocerebral gunshot injuries in a developing country: presentation, injury characteristics, prognostic indicators, and complications

BACKGROUND

Civilian craniocerebral gunshot injuries (CGIs) are rare but increasing in incidence in the developing world and there is scare literature on presentation, injury characteristics, prognostic indicators, and complications of brain trauma due to projectiles.

METHODS

A retrospective review of 51 civilian patients with CGI who presented to the Aga Khan University Hospital between 1998 and 2011 was carried out. Presentation, injury characteristics, and complications were analyzed with emphasis on outcomes and prognostic indicators.

RESULTS

There were 43 male and 8 female patients with an average age of 28.92 (±12.33) years. Twenty-three patients had a Glasgow Coma Scale (GCS) score of 13-15, 6 patients had a GCS score of 9-12, and 22 patients had a GCS score of 3-8 on admission. The overall mortality rate was 22% (n = 11). The most common postoperative neurologic deficits were motor deficits (19 patients) followed by aphasias (11 patients). On univariate analysis, admission GCS score and bi- or multilobar injuries were found to be highly predictive of neurologic outcome. There was no difference in outcomes between penetrating and perforating injuries. We also failed to find a statistically significant correlation between ventricular injury and outcomes in our patients.

CONCLUSION

Admission GCS and number of lobes involved are highly prognostic of outcome. Patients with a GCS score ≥9 and unilobar injury on computed tomographic scans may benefit the most from surgical management.

Management of pediatric intracranial gunshot wounds: predictors of favorable clinical outcome and a new proposed treatment paradigm

OBJECT

There has been an increase in civilian gun violence since the late 1980s, with a disproportionately high increase occurring within the pediatric population. To date, no definite treatment paradigm exists for the management of these patients, nor is there a full understanding of the predictors of favorable clinical outcome in this population.

METHODS

The authors completed a retrospective review of all victims of intracranial gunshot injury from birth to age 18 years at a major metropolitan Level 1 trauma center (n = 48) from 2002 to 2011. The predictive values of widely accepted adult clinical and radiographic factors for poor prognosis were investigated.

RESULTS

Eight statistically significant factors (p < 0.05) for favorable outcome were identified. These factors include single hemispheric involvement, absence of a transventricular trajectory, < 3 lobes involved, ≥ 1 reactive pupil on arrival, systolic blood pressure > 100 mm Hg on arrival, absence of deep nuclei and/or third ventricular involvement, initial ICP < 30 mm Hg when monitored, and absence of midline shift. Of these 8 factors, 5 were strong predictors of favorable clinical outcome as defined by Glasgow Outcome Scale score of 4 or 5. These predictive factors included absence of a transventricular trajectory, < 3 lobes involved, ≥ 1 reactive pupil on arrival, absence of deep nuclei and/or third ventricular involvement, and initial ICP < 30 mm Hg. These findings form the basis of the St. Louis Scale for Pediatric Gunshot Wounds to the Head, a novel metric to inform treatment decisions for pediatric patients who sustain these devastating injuries.

CONCLUSIONS

The pediatric population tends to demonstrate more favorable outcomes following intracranial gunshot injury when compared with the adult population; therefore some patients may benefit from more aggressive treatment than is considered for adults. The St. Louis Scale for Pediatric Gunshot Wounds to the Head may provide critical data toward evidence-based guidelines for clinical decision making.

External validation of a prognostic model for early mortality after traumatic brain injury

BACKGROUND

Traumatic brain injury (TBI) is a major cause of lost disability-adjusted life years, and a valid model allowing prediction of outcome would be welcome. For a clinical prediction model to be valid, generalization to other populations must be possible. The aim of this study was to externally validate a model for in-hospital mortality in patients with TBI, which was recently development at the University of Southern California (USC).

METHODS

The validation cohort was derived from a hospital-based, prospectively collected trauma registry in Oslo, Norway. We included patients admitted with a head injury without hypotension, severe thoracic, or abdominal injury (n = 3,136). We calculated the probability of death according to the USC model. The performance of the model was evaluated using measures of calibration and discrimination in the total sample and subgroups according to initial Glasgow Coma Scale (GCS) score.

RESULTS

The USC model provided excellent discrimination (area under the receiver operating characteristic curve, AUC = 0.93), but unsatisfactory calibration (p < 0.001) for the total sample (GCS 3-15). In the GCS 4-8 subgroup we found good discrimination (AUC = 0.89) but poor calibration (Hosmer-Lemeshow test, p < 0.001).

CONCLUSION

The findings question the external validity of the USC model, suggesting that it should not be implemented as a tool for short-term mortality prediction in our TBI population.

Role of Selective Management of Penetrating Injuries in Mass Casualty Incidents

Terrorist violence has emerged as an increasingly common cause of mass casualty incidents (MCI) due to the sequelae of explosive devices and shooting massacres. A proper emergency medical system disaster plan for dealing with an MCI is of paramount importance to salvage lives. Because the number of casualties following a MCI is likely to exceed the medical resources of the receiving health care facilities, patients must be appropriately sorted to establish treatment priorities. By necessity, clinical signs are likely to prove cornerstones of triage during MCI. An appropriate and effective application of experiences learned from the use of selective nonoperative management (SNOM) techniques may prove essential in this triage process. The present appraisal of the available literature strongly supports that the appropriate utilization of these clinical indicators to identify patients appropriate for SNOM is essential, critical, and readily applicable. We also review the initial emergent triage priorities for penetrating injuries to the head, neck, torso, and extremities in a mass casualty setting.

Gastric Injury Increases Infections in Trauma Patients

Some physicians feel gastric injury is not a significant contributing factor to the adverse outcome of trauma patients, but rather a marker of epigastric injury. We hypothesized the addition of a gastric injury to multiple injured trauma patients would increase infection rate. We conducted a retrospective study comparing 450 consecutive patients with full-thickness gastric injury with 983 patients without gastric injury during the same time period. Infection rate in patients with gastric injury was 44 per cent (200 of 455) and significantly higher than 36 per cent (357 of 983) seen without gastric injury (P = 0.006). Logistic regression revealed gastric injury was an independent risk factor for infection controlling for age, Injury Severity Scale, gender, mechanism of injury, shock, and associated injuries (P = 0.047). Requiring a transfusion, Injury Severity Scale, colon injury, age, pancreas injury, and emergency department shock were also independent risk factors for developing an infection. The addition of a gastric injury to a trauma patient appears to increase the risk for infection.

Endonasal transsphenoidal endoscopy-assisted removal of a shotgun pellet in the sphenoid sinus: a case report

BACKGROUND

Gunshot accidents are not uncommon in Taiwan, but involvement limited to the ocular region and sphenoid sinus is rare. Minimal invasive treatment by endonasal transsphenoidal endoscopy-assisted procedure should be considered if there are no additional injuries in the craniocerebral region.

CASE DESCRIPTION

A 39-year-old man had severe pain in the left eye with resulting blindness after being accidentally hit in the left eye by a gunshot pellet while walking in a wooded area. He was referred from another hospital with the impression of left eyeball rupture. There was no severe neurologic deficit except for blindness of the left eye when he arrived at the emergency department of our hospital. Brain and orbits CT scans showed a round metallic foreign body at the right sphenoid sinus without predominant damages of brain parenchyma. Endonasal transsphenoidal endoscopy-assisted procedure was used to remove the shotgun pellet, and the patient had good clinical outcomes.

CONCLUSION

Herein we present this rare case to show the possibility of a shotgun pellet injury remaining in the sphenoid sinus. The role of radiological studies such as CT scans and intraoperative C-arm fluoroscope plain films in diagnosis and management of this case is affirmed. The strategy of minimally invasive treatment by endonasal transsphenoidal endoscopy-assisted procedure for those limited injuries is a good choice for treatment.