Predictors of mortality in severely head-injured patients with civilian gunshot wounds: A report from the nih traumatic coma data bank

doi:10.1016/0090-3019(92)90109-Z

Surgical Neurology

Volume 38, Issue 6, December 1992, Pages 418-423

https://doi.org/10.1016/0090-3019(92)90109-Z Get rights and content

Abstract

Predictors of outcome were examined in this prospective study of 151 patients severely injured by civilian gunshot wounds. Of the 151 patients, 133 (88%) died. Of the 123 patients with an initial Glasgow Coma Scale score of 3–5, 116 (94%) died, whereas of the 20 with an initial Glasgow Coma Scale score of 6–8, 14 (70%) died. There were no good outcomes, and only three moderate recoveries in patients who had initial scores of 8 or less.

In those patients who survived long enough for intracranial pressure monitoring, intracranial hypertension predicted a very poor outcome. Computed tomographic scan characteristics such as midline shift, compression or obliteration of the mesencephalic cisterns, the presence of subarachnoid blood, intraventricular hemorrhage, and the presence of hyperdense or mixed-density lesions greater than 15 mL, either bilateral or unilateral, were all associated with a poor outcome. However, neither the caliber of gun nor the distance of the gun from the head significantly affected the risk of dying.

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Cited by (117)

Increased Incidence and Mortality of Civilian Penetrating Traumatic Brain Injury in Sweden: A Single-Center Registry-Based Study
2024, World Neurosurgery
Penetrating trauma to the head and neck has increased during the past decade in Sweden. The aim of this study was to characterize these injuries and evaluate the outcomes for patients treated at a tertiary trauma center.
Swedish trauma registry data were extracted on patients with head and neck injuries admitted to Karolinska University Hospital (Stockholm, Sweden) between 2011 and 2019. Outcome information was extracted from hospital records, with the primary endpoints focusing on the physiological outcome measures and the secondary endpoints on the surgical and radiological outcomes.
Of 1436 patients with penetrating trauma, 329 with penetrating head and neck injuries were identified. Of the 329 patients, 66 (20%) had suffered a gunshot wound (GSW), 240 (73%) a stab wound (SW), and 23 (7%) an injury from other trauma mechanisms (OTMs). The median age for the corresponding 3 groups of patients was 25, 33, and 21 years, respectively. Assault was the primary intent, with 54 patients experiencing GSWs (81.8%) and 158 SWs (65.8%). Patients with GSWs had more severe injuries, worse admission Glasgow coma scale, motor, scores, and a higher intubation rate at the injury site. Most GSW patients underwent major surgery (59.1%) as the initial procedure and were more likely to have intracranial hemorrhage (21.2%). The 30-day mortality was 45.5% (n = 30) for GSWs, 5.4% (n = 13) for SWs, and 0% (n = 0) for OTMs. There was an annual increase in the incidence and mortality for GSWs and SWs.
Between 2011 and 2019, an increasing annual trend was found in the incidence and mortality from penetrating head and neck trauma in Stockholm, Sweden. GSW patients experienced more severe injuries and intracranial hemorrhage and underwent more surgical interventions compared with patients with SWs and OTMs.
Management of Penetrating Traumatic Brain Injury: Operative versus Non-Operative Intervention
2021, Journal of Surgical Research
Citation Excerpt :
Among pTBI patients who reach the emergency department, Aarabi et al.15 found a 61% mortality rate with the remainder having a “good” outcome at 3 y. Despite this, many providers question the use of aggressive management in this population.16-18 Furthermore, several studies have shown that victims of pTBI who present with a GCS ≥6 have a high incidence of survival and reasonable chance of a meaningful outcome.14,19,20 Current data are limited that assesses mortality in pTBI patients with varying GCS scores stratified by intervention method.
Penetrating traumatic brain injury (pTBI) is the most lethal form of TBI, with mortality rates as high as 90%. This high mortality rate leads many providers to feel that the treatment of pTBI is futile. Contrary to this point of view, several studies have shown that victims of pTBI who present with a Glasgow Coma Scale (GCS) ≥6 have a reasonable chance of a meaningful outcome. This study sought to investigate outcomes of pTBI patients based on GCS score who underwent neurosurgical intervention (craniotomy or craniectomy) and compare them with patients who did not undergo surgical intervention.
The study represents a secondary analysis of the data that were collected from 2006 to 2016 from 17 institutions as part of a multi-center study, investigating clinical outcomes for adult patients sustaining pTBI and surviving >72 h. Patients were divided into those with GCS 3-5 and those with GCS ≥6. Within these groups, patients were stratified by whether they received surgical intervention, compared with standard non-surgical care. Patient level data (age and gender), clinical data (Injury Severity Score and Abbreviated Injury Score), GCS on admission, post-op infection rates, and outcomes data (mortality, length of stay [LOS], intensive care unit LOS) were collected. Both groups were compared using independent sample t-test or chi-squared test.
Seven hundred twenty patients with pTBI were identified over 11 y, out of which 336 (46.7%) underwent surgery. The mean Injury Severity Score and Abbreviated Injury Score on admission were higher in the surgical intervention group than their non-surgical counterpart in patients with a GCS ≥6 (P < 0.0001). Patients with GCS of 3-5 with surgical intervention demonstrated a higher survival rate than non-surgical patients (P < 0.0001). In the GCS ≥6 group, surgical intervention did not impact near-term mortality. Intensive care unit LOS was significantly longer in the surgical intervention group in patients with GCS ≥ 6 (P < 0.0001) and GCS of 3-5 (P < 0.0001), as was total hospital LOS (P < 0.0001). Patients with a GCS 3-5 and ≥6 who underwent surgical intervention were more likely to develop a central nervous system infection (P = 0.016; P = 0.017).
Surgical intervention in pTBI patients with GCS 3-5 results in improved mortality but comes at a cost of increased resource utilization in the form of longer LOS and higher infection rate. On the other hand, in patients with GCS ≥6, surgery does not provide significant benefits in patient survival. Future prospective studies providing insight as to the impact of surgery on the resource utilization and quality of survival would be beneficial in determining the need for surgical intervention in this population.
Prognosis and futility in neurosurgical emergencies: A review
2020, Clinical Neurology and Neurosurgery
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.
Management of civilians with penetrating brain injury: A systematic review
2020, Journal of Critical Care
There has been a dramatic increase in penetrating gunshot-inflicted civilian penetrating brain injuries (cvPBI). We undertook a systematic review with exclusive focus on the management of cvPBI.
We explored: (1) cervical spine immobilization, (2) seizure incidence and prophylaxis, (3) infection incidence and antibiotic prophylaxis, (4) coagulopathy (5) vascular complications, and (6) surgical management. We searched PubMed, EMBASE, and Cochrane (1985–2019). The PRISMA guidelines were followed. The Newcastle-Ottawa Scale was employed for qualitative assessment; risk of bias was evaluated based upon the RTI item bank. The full protocol was registered to PROSPERO (CRD42019118877).
The literature is scant, and of overall low quality and high risk of bias. Incidence of c-spine injury with no direct trauma is low; incidence of seizures does not appear to be different from non-penetrating mechanisms; there is no robust data for prophylactic antibiotics; coagulopathy is prevalent and has been independently associated with outcome; there is a high incidence of vascular injuries with traumatic intracranial aneurysms the most common sequelae; neurosurgical decision-making appears largely influenced by operator's assessment of salvageability. Surgery has been associated with decreased mortality.
Limited amount of published work is clinically meaningful; this systematic review identified key knowledge gaps.
Trends in civilian penetrating brain injury: A review of 26,871 patients
2019, American Journal of Surgery
Citation Excerpt :
Additionally, suicide attempts carry high mortality because of the close-range injury.5 Aldrich et al. analyzed the role of early hypotension in patients with pTBI.27 They reported that 84% of those with early hypotension died compared to 76% of patients with no hypotension.
The aim of our study is to analyze the 5 years' trends, mortality rate, and factors that influence mortality after civilian penetrating traumatic brain injury (pTBI).
We performed a 5-year-analysis of all trauma patients diagnosed with pTBI in the TQIP. Our outcome measures were trends of pTBI.
A total of 26,871 had penetrating brain injury over the 5-year period. Mean age was 36.2 ± 18 years. Overall 55% of the patients had severe TBI and mortality rate was 43.8%. There was an increase in the rate of pTBI from 3042/100,000 (2010) to 7578/100,000 trauma admissions (2014) (p < 0.001). The mortality rate has increased from 35% (2010) to 48% (2011) (p < 0.001) followed by a linear decrease in mortality to 40% (2014). Independent predictors of mortality were age, pre-hospital intubation, suicide attempt, and craniotomy/craniectomy.
Incidence and mortality for patients who are brought to hospitals following pTBI have gradually increased over the five-year period. Self-inflicted injury and prehospital intubation were the two most significant predictors of mortality.
The intracranial number of foreign bodies as a predictor of mortality after penetrating brain injury
2019, American Journal of Emergency Medicine
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.
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.
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).
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.

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^☆: This work was supported by the Traumatic Coma Data Bank (TCDB) under Contracts N01-NS-3-2339, N01-NS-3-2340, N01-NS-3-2341, N01-NS-3-2342, N01-NS-6-2305 from the National Institute of Neurological Disorders and Stroke (NINDS). The TCDB Manual of Operations, which includes the TCDB data forms, is available from the National Technical Information Service (NTIS), U.S. Department of Commerce, 5285 Port Royal Road, Springfield, VA 22161 (NTIS Accession No. PB87 228060/AS).

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Predictors of mortality in severely head-injured patients with civilian gunshot wounds: A report from the nih traumatic coma data bank☆

Abstract

Analysis of 76 civilian craniocerebral gunshot wounds

J Neurosurg

Civilian gunshot wounds to the head: A prospective study

Neurosurgery

Initial CT findings in 753 patients with severe head injury

Penetrating craniocerebral wounds in civilians

Acta Neurochir (Wien)

Assessment of outcome after severe brain damage

Lancet

Civilian gunshot wounds: the limits of salvageability

Acta Neurochir (Wien)