Improving survival rates after civilian gunshot wounds to the brain.
BACKGROUND
Gunshot wounds to the brain are the most lethal of all firearm injuries, with reported survival rates of 10% to 15%. The aim of this study was to determine outcomes in patients with gunshot wounds to the brain, presenting to our institution over time. We hypothesized that aggressive management can increase survival and the rate of organ donation in patients with gunshot wounds to the brain.


METHODS
We analyzed all patients with gunshot wounds to the brain presenting to our level 1 trauma center over a 5-year period. Aggressive management was defined as resuscitation with blood products, hyperosmolar therapy, and/or prothrombin complex concentrate (PCC). The primary outcome was survival and the secondary outcome was organ donation.


RESULTS
There were 132 patients with gunshot wounds to the brain, and the survival rates increased incrementally every year, from 10% in 2008 to 46% in 2011, with the adoption of aggressive management. Among survivors, 40% (16 of 40) of the patients had bi-hemispheric injuries. Aggressive management with blood products (p = 0.02) and hyperosmolar therapy (p = 0.01) was independently associated with survival. Of the survivors, 20% had a Glasgow Coma Scale score ≥ 13 at hospital discharge. In patients who died (n = 92), 56% patients were eligible for organ donation, and they donated 60 organs.


CONCLUSIONS
Aggressive management is associated with significant improvement in survival and organ procurement in patients with gunshot wounds to the brain. The bias of resource use can no longer be used to preclude trauma surgeons from abandoning aggressive attempts to save patients with gunshot wound to the brain.
Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, University of Arizona, Tucson, AZ. Electronic address: bjoseph@surgery.arizona.edu.
Bellal
B
Joseph
Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, University of Arizona, Tucson, AZ.
Hassan
H
Aziz
Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, University of Arizona, Tucson, AZ.
Viraj
V
Pandit
Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, University of Arizona, Tucson, AZ.
Narong
N
Kulvatunyou
Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, University of Arizona, Tucson, AZ.
Terence
T
O'Keeffe
Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, University of Arizona, Tucson, AZ.
Julie
J
Wynne
Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, University of Arizona, Tucson, AZ.
Andrew
A
Tang
Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, University of Arizona, Tucson, AZ.
Randall S
RS
Friese
Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, University of Arizona, Tucson, AZ.
Peter
P
Rhee
D000293:Adolescent; D000328:Adult; D001779:Blood Coagulation Factors / Q000627:therapeutic use; D016913:Blood Component Transfusion; D003131:Combined Modality Therapy; D005260:Female; D005440:Fluid Therapy; D020197:Head Injuries, Penetrating / Q000401:mortality / Q000628:therapy*; D006401:Hematologic Agents / Q000627:therapeutic use; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D012151:Resuscitation / Q000379:methods; D012189:Retrospective Studies; D015996:Survival Rate; D009927:Tissue and Organ Procurement / Q000706:statistics & numerical data; D014193:Trauma Centers; D016896:Treatment Outcome; D014948:Wounds, Gunshot / Q000401:mortality / Q000628:therapy*; D055815:Young Adult
D001779:Blood Coagulation Factors; D006401:Hematologic Agents; C025667:prothrombin complex concentrates
AIS; Abbreviated Injury Scale; GCS; Glasgow Coma Scale; INR; PCC; SBP; international normalized ratio; prothrombin complex concentrate; systolic blood pressure