A 38 y.o. male was found down in cardiac arrest after a gsw to the head. He was brought to the ED with a pulse
What are his chances for survival?
extensive pneumocephaly was noted with a “mount fuji” sign over the frontal lobes.
The posterior skull was fractured
Our patient had a severe gunshot wound to the head. What criteria are available to predict survival and meaningful outcome?
Civilian gunshot wounds to the head are the deadliest of all gun injuries. The survival rate is only 9%. Each year 20,000 persons have gunshot wounds to the head. The severity of injury depends on the velocity of the bullet; with high velocity rounds delivered from military weapons causing the most severe injuries.
cavitation in ballistic gel
https://www.youtube.com/watch?v=NvYWWwylz-I cavitation from blast is shown here.
Bullets cause damage to the brain in several ways: direct injury such as laceration and crushing, cavitation and shock waves. After the primary insult, a secondary set of injuries follows with a biochemical cascade producing enzymes, phospholipids and excitatory neurotransmitters such as glutamate. Free radicals propagate further damage.
Poor prognostic findings include older age and penetration all the way through the skull. In the Iran –Iraq war a poor outcome occurred in 50% of patients treated for a bullet passing all the way through the skull and only 20% fatality was noted in those with a bullet retained inside the skull. Presumably this is due to the higher energy of the bullet.
The BAYLOR CRANIAL GUNSHOT PROGNOSIS SCORE is a useful tool. It predicts in- hospital survival and outcomes six months after injury.
One point is assigned for age greater than 35.
On point is assigned for unreactive pupils
One point is assigned for initial GCS of 3 or 4.
Two points are assigned for a trajectory through both hemispheres or the posterior fossa.
The score has been validated at other sites and is a reasonable indicator of prognosis in discussions The score ranges from 0 to 5.
In discussions with family members it can serve to avoid a substantial use of resources which may only lead to prolonging life in an undesirable state.
Our patient had arrested at the scene. He arrived with a pulse and spontaneous though inadequate respirations. He received a Baylor score of 3 and was admitted to ICU for comfort care. He became hypotensive and expired in 12 hours.
Gressot L, Chamoun R, Patel A. et al. Predictors of outcome in civilains with gunshot wounds to the head upon presentation J Neurosurg. 2014;121(3):645-652.
Yengo-Kahn A, Patel P et al. The value of simplicity : externally validating the Baylor cranial gunshot wound prognosis score. Journal of Neurosuregery published a head of print, March 9,2021. DOI: 10.31712020.9JNS201891.
Qi H, Li K. Civilian gunshot wounds to the head: a case report, clinical management and literature review. Chinese Neurosurgical Journal 2021;7:12.
Bizhan A, Mossop C, Aarabi J. Surgical management of civilian gunshot wounds to the head. Handb Clin Neruol 2015 127: 181-93.
Aarabi B. History of the management of craniocerebral wounds. Aarabi B, Kaufman et al eds. Missile Wounds of the Head and Neck. Park Ridge Ill. American Association of Neurological Surgeons. 1999 vol 1281:2929.e