Outcome and rational management of civilian gunshot injuries to the brain-retrospective analysis of patients treated at the Helsinki University Hospital from 2000 to 2012.

BACKGROUND: Treatment of gunshot wounds of the brain (GSWB) remains controversial and there is high variation in reported survival rates (from < 10 to > 90%) depending on the etiology and country. We retrospectively analyzed the outcome of a series of consecutive GSWB patients admitted alive to a level 1 trauma center in a safe high-income welfare country with a low rate of homicidal gun violence. METHODS: Patients admitted due to a GSWB to the HUS Helsinki University Hospital during 2000-2012 were identified from hospital discharge registry and log books of the emergency room and ICU. CT scans and medical records of these patients were reviewed. Univariate analysis and backward logistic regression were performed, and their results compared with that of a systematic literature review of factors related to the outcome of GSWB patients. RESULTS: Sixty-four patients admitted alive after GSWB were identified. Eighty percent had self-inflicted GSWB, 81% were contact shots, and 70% were caused by handguns. In-hospital mortality was 72%. Factors associated with mortality in our series were low GCS (≤ 8) at admission, transventricular bullet trajectory, and associated damage to deep brain structures, as reported before in the literature. Of the 64 patients admitted alive, 42% (27/64) were admitted to ICU, 34% (22/64) underwent surgery, and in 25% (16/64), craniotomy and hematoma evacuation was performed. Mortality in the surgically treated group was 32% but near 100% without surgery and ICU treatment. Median GOS in the surgically treated patients was 3 (range 1-5). CONCLUSIONS: GSWB caused by contact shot from handguns has a high mortality rate, but can be survived with reasonable outcome if limited to lobar injury without significant damage to deep brain structures or brain stem. In such GSWB patients, initial aggressive resuscitation, ICU admission, and surgery seem indicated.

Gunshot wounds in Finland.

On average 200 gunshot wounds are treated in Finland annually. Half of them are caused by firearm accidents, whereas the great majority of fatal wounds are self-inflicted. Physicians treating trauma patients should be familiar with the basics of ballistics. In practice, however, a distinction between gunshot wounds caused by handguns and those caused by rifles or shotguns is generally sufficient. Generally accepted guidelines for treating trauma patients are followed, and imaging is used for nearly all patients. Removal of bullets is generally not necessary. Most patients require operative treatment, but in certain cases a non-operative approach may be considered. In severe gunshot wounds rapidly administered antibiotics and a sufficiently radical debridement remain the mainstays of treatment.