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<< Ballistic Injuries In The Emergency Department (Trauma CME)

Management Of Gunshot Wounds To The Head

The mortality associated with penetrating ballistic brain injury is high. Zafonte et al performed a 7-year prospective study and found that 36% of patients with gunshot wounds to the head were dead on arrival to the ED or expired in the ED. Of those who survived to hospital admission, 41% expired in the first 48 hours, an overall 77% mortality in the first 48 hours.36 Before 2001, no standardized guidelines existed for the care of the patient with penetrating head injury. In 2001, the Eastern Association for the Surgery of Trauma (EAST) introduced a set of guidelines directed specifically to the care of the patient with penetrating brain injury.37 These guidelines provide some important direction for both initial resuscitation and surgical care of these patients.

Early and appropriate resuscitation is imperative for the victim of penetrating head trauma. A single episode of hypotension is associated with worse outcomes for the severely brain-injured patient. While early and aggressive resuscitation is standard, the selection of the appropriate resuscitation fluid is a subject of much debate.

Albumin administration has been associated with worse outcomes in severe TBI patients and is not used in trauma resuscitation.38 However, the advent of modern synthetic colloid solutions may lead to changes in the current resuscitation algorithms. Although potentially promising experimental data exist, no large randomized controlled trials show a mortality benefit to synthetic colloid solutions.39

Hypertonic saline resuscitation continues to be a subject of much research and interest. Prehospital studies using hypertonic saline in severe TBI patients show no benefit over isotonic solutions.40 Potential benefits of hypertonic saline resuscitation include lower fluid volumes, limited edema formation, and reduced inflammation.42 However, no current large trials exist that show a survival benefit of hypertonic saline over conventional trauma resuscitation. With the current literature not identifying a clearly superior resuscitation fluid, it is prudent to recommend using the fluid that the emergency clinician’s center is most comfortable with to ensure safe and rapid resuscitation. For a more complete discussion of fluid management in traumatic hemorrhagic shock, see the November 2011 issue of Emergency Medicine Practice, “Traumatic Hemorrhagic Shock: Advances In Fluid Management.

Neuroimaging

Noncontrast computed tomography (CT) scan is the imaging modality of choice for penetrating brain injury.37 Cranial x-rays provide no additional information and are not recommended as an initial or additional study in penetrating brain injury. Due to the metal content of many ballistics, magnetic resonance imaging is currently not a prudent choice for the initial evaluation of these patients.

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