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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.

Antibiotics

The early use of prophylactic antibiotics is recommended in the treatment of penetrating brain injury.38 Although there are no randomized controlled studies comparing the use of antibiotics to nonuse of antibiotics, comparison of infection rates from the preantibiotics era suggest that antibiotics are effective. From military literature, it appears that antibiotics have been routinely used in penetrating head injuries since 1946.43 Prophylactic antibiotics are used by the majority of neurosurgeons during even minor neurosurgical procedures.44 In addition, prophylactic antibiotics have been shown to reduce infection during clean neurosurgical procedures.45 It is therefore reasonable to conclude that antibiotics are indicated in penetrating head injury.

No studies exist to demonstrate the best antibiotic choice in penetrating injury. In 1991, a survey of neurosurgical care was performed, which indicated that cephalosporins were the preferred antibiotics for penetrating head injury.46 No current United States guidelines exist to direct antibiotic choice in penetrating brain injury. Current British guidelines recommend IV cefuroxime plus IV metronidazole as a first-line antibiotic regimen.47 Other experts recommend a combination of IV ceftriaxone, metronidazole, and vancomycin in penetrating brain injuries.47 Antibiotics should be chosen in conjunction with the consulting neurosurgeon; however, early initiation of a broad-spectrum antibiotic with good cerebral penetration (such as ceftriaxone) is recommended.

Antiepileptic Drugs

The use of antiepileptic drugs (AEDs) to control posttraumatic seizures remains controversial. Of primary interest in the ED is the control of early (< 1 week) posttraumatic seizures. Current recommendations from the American Academy of Neurology support the use of phenytoin for the prevention of early posttraumatic seizures.48 This recommendation is supported by a large blinded randomized trial showing successful reduction in seizures with phenytoin in the first week after severe head trauma.49 However, a later study in children demonstrated a very low posttraumatic seizure rate in the first 48 hours and no reduction of seizures with the addition of phenytoin.50 More-recent studies have looked at other AEDs, as compared to phenytoin, and show varying results.51-54 There are no good studies that provide recommendations for the new-generation AEDs over the standard phenytoin therapy.

Elevated Intracranial Pressure Control

Patients with penetrating brain injury are at risk for acute neurological deterioration due to elevated intracranial pressure (ICP) from brain edema resulting from the trauma. Though debated, use of additional premedications during rapid sequence intubation (RSI) — so-called “neuroprotective RSI” — may help blunt a rise in ICP during intubation and can be considered. (See Clinical Pathway For The Management Of Gunshot Wounds To The Head.) In addition, mannitol has traditionally been used to acutely reduce intracranial edema through osmotic pressure. More recently, hypertonic solutions of saline or crystalloids have been investigated for ICP reduction. Vialet et al studied 7.5% saline compared to 20% mannitol in 20 patients with TBI and persistent coma. This randomized trial showed fewer episodes of intracranial hypertension and a lower failure rate in the hypertonic saline group as compared to the mannitol group.55 Similarly, Ichai et al performed a randomized trial comparing mannitol to a sodium lactate solution of similar osmolarity in 34 patients with severe TBI. They also found that the sodium lactate solution was more effective in intracranial pressure reduction than mannitol.56 Unfortunately, no consistent recommendations exist for the concentration or dosage of hypertonic saline. Concentrations of hypertonic saline range from 3% to 23.4%.55,57 The current literature suggests, however, that hypertonic saline is likely more effective than mannitol for the reduction of intracranial pressure.58 For clinicians not experienced in administration of hypertonic saline, a reasonable initial dose (as demonstrated by Vialet et al) is 2 mL/kg of 7.5% saline solution.56

A simple, noninvasive method to help decrease ICP is to raise the head of the bed 30° above parallel. This maneuver has been demonstrated to lower ICP without adversely affecting cerebral perfusion pressure or cerebral oxygenation, and it is recommended to be started within the first 24 hours after injury.59 Hyperventilation is no longer recommended as an ICP reduction strategy except in preherniation states. Current Brain Trauma Foundation guidelines can be found online at https://www.braintrauma.org/ coma-guidelines/. They are summarized in Table 6 and are relevant for both blunt and penetrating head trauma. These differ from some of the newest data and earlier discussion, reflecting existing controversies and areas of needed research.

 
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Last Modified: 07/19/2018
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