Outcomes of very elderly trauma ICU PATIENTS: Results from the Spanish trauma ICU registry / Desenlace de los pacientes traumáticos muy ancianos en la unidad de cuidados intensivos. Resultados del Registro Español de Trauma en las UCI

OBJECTIVE: To analyze outcomes and factors related to mortality among very elderly trauma patients admitted to intensive care units (ICUs) participating in the Spanish trauma ICU registry. DESIGN: A multicenter nationwide registry. Retrospective analysis. November 2012-May 2017. SETTING: Participating ICUs. PATIENTS: Trauma patients aged ≥ 80 years. INTERVENTIONS: None. Main variables of interest: The outcomes and influence of limitation of life sustaining therapy (LLST) were analyzed.comparisons were established using the Wilcoxon test, Chi-squared test or Fisher's exact test as appropriate. Multiple logistic regression analysis was performed to analyze variables related to mortality. A p-value < 0.05 was considered statistically significant. RESULTS: The mean patient age was 83.4 ± 3.3 years; 281 males (60.4%). Low-energy falls were the mechanisms of injury in 256 patients (55.1%). The mean ISS was 20.5 ± 11.1, with a mean ICU stay of 7.45 ± 9.9 days. The probability of survival based on the TRISS methodology was 69.8 ± 29.7%. The ICU mortality rate was 15.5%, with an in-hospital mortality rate of 19.2%. The main cause of mortality was intracranial hypertension (42.7%). The ISS, the need for first- and second-tier measures to control intracranial pressure, and being admitted to the ICU for organ donation were independent mortality predictors. LLST was applied in 128 patients (27.9%). Patients who received LLST were older, with more severe trauma, and with more severe brain injury. CONCLUSIONS: Very elderly trauma ICU patients presented mortality rates lower than predicted on the basis of the severity of injury

OBJETIVO: Analizar el desenlace y los factores relacionados con la mortalidad de los pacientes traumáticos muy ancianos ingresados en las Unidades de Cuidados Intensivos (UCI) participantes en el Registro Español de Trauma en las UCI (RETRAUCI). DISEÑO: Registro multicéntrico nacional. Análisis retrospectivo. Noviembre de 2012-mayo de 2017. Ámbito: Las UCI participantes. Pacientes o PARTICIPANTES: Pacientes traumáticos con edad ≥ 80 años. INTERVENCIONES: Ninguna. Variables de interés principales: Analizamos el desenlace y la influencia de la limitación de los tratamientos de soporte vital (LLST). Las comparaciones entre grupos se realizaron mediante la prueba de Wilcoxon, la prueba de Chi-cuadrado y la prueba exacta de Fisher según estuviera indicado. Se realizó un análisis multivariante mediante regresión logística para analizar las variables asociadas a la mortalidad. Un valor de p < 0,05 se consideró el límite de la significación estadística. RESULTADOS: La edad media fue de 83,4 ± 3,3 años. Varones 281 (60,4%). La causa principal del traumatismo fueron las caídas de baja energía en 256 pacientes (55,1%). El Injury Severity Score (ISS) medio fue de 20,5 ± 11,1. La estancia media en las UCI fue de 7,45 ± 9,9 días. La probabilidad de supervivencia, de acuerdo con la metodología TRISS fue de 69,8 ± 29,7%. La mortalidad en las UCI fue del 15,5%. La mortalidad hospitalaria fue del 19,2%. La causa principal fue la hipertensión intracraneal (42,7%). El ISS, la necesidad de medidas de primer o segundo nivel para controlar la presión intracraneal y el ingreso en las UCI orientado a la donación de órganos fueron predictores independientes de mortalidad. Se documentó la LLST en 128 pacientes (27,9%). Los pacientes con LLST fueron mayores, con una mayor gravedad lesional y un traumatismo craneoencefálico más grave. CONCLUSIONES: Los pacientes traumáticos muy ancianos en las UCI presentaron menor mortalidad de la predicha por la gravedad del traumatismo

Fatal Penetrating Head Injuries Caused by Projectile Tear Gas Canisters.

BACKGROUND: Since their advent in the 1920s, tear gas canisters (TGCs) have been frequently used in crowd control. Few reports have documented nonpenetrating injuries attributed directly to TGCs. In this study, we report a case series of fatal penetrating head injuries caused by TGCs. METHODS: We conducted a retrospective chart review of all the patients who were admitted to the Neurosurgery Teaching Hospital in Baghdad, Iraq, since the start of the antigovernment protests (October 2019). All patients who suffered penetrating head trauma caused by TGCs were included in our study. We collected patient demographics, wound location, neurologic examination, computed tomography (CT) scan findings, surgical management, and clinical outcomes. RESULTS: We found 10 cases of penetrating head trauma caused by TGCs. All victims were men, with a mean age of 16 years (range, 14-19 years). The mean Glasgow Coma Scale score was 7 (range, 3-10). The neurologic examination revealed unilateral hemiplegia/hemiparesis and pupillary abnormality in 40% (n = 4) and 50% (n = 5) of the patients, respectively. CT scans revealed an extensive pattern of brain damage. Surgical intervention was done in 80% of cases (n = 8), which included removal of the TGC, wound debridement, and hemostasis. The in-hospital mortality rate was 100% (N = 10), with all fatalities occurring within 1-3 days of admission. CONCLUSIONS: TGCs have the potential to cause lethal penetrating head injuries, calling for a reevaluation of their safety and methods of use in terms of human health.

Craniofacial injuries by firearms projectiles: An analysis of 868 deaths in the five regions of Brazil.

Firearms injuries have a legal and medico-legal importance, and are especially lethal when they reach the craniofacial regions of the victim. The present study aims to identify the characteristics of craniofacial lesions resulting from firearm projectiles, to register the most affected craniofacial regions by this type of injury and to verify the demographic profile of the victims. A retrospective study was carried out on the autopsy records produced in the first semester of 2015, in five Institutes of Legal Medicine in Porto Velho, situated in the cities of João Pessoa, Vitória, Porto Alegre and Brasília. Data extracted included sex, skin color and age of the victim, craniofacial region reached, shooting distance, shape and size of the injuries and manner of death (homicide, suicide or accident). Based on the 868 reports analyzed, it was possible to observe 1700 entrance lesions of firearm projectiles in craniofacial regions. Among cases of known manner of death, homicides were the most frequent (97.0%). It was observed a higher frequency of male victims (93.3%), mixed race (62.0%), between the ages of 12 and 29 years (59.4%). In all cases considered as suicide or accident there was only one entrance wound, but in 82.8% of the homicides there were multiple gunshot wounds. The craniofacial most affected regions were temporal (25.2%) and occipital (19.8%). The most common sites of projectiles exit were the temporal (25.3%) and parietal (16.1%). All cases of suicide were related to contact shot (69.2%) or close-range shot (30.8%), and among the homicides the distant range shots were more frequent (54.0%). The shape of entrance wounds was mostly circular (56.8%) and oval (31.3%), and among the exit injuries, the lesions were irregular (43.3%) and starry (24.1%). The entrance wounds showed smaller sizes than the exit lesions (p < 0.0001). The data obtained are useful for guiding research that takes into account craniofacial trauma caused by firearm projectiles, makes it possible to compare this data with those of other countries and can base investigative conclusions based on the analyzes discussed in the present work.

Prognostic performance of computerized tomography scoring systems in civilian penetrating traumatic brain injury: an observational study.

BACKGROUND: The prognosis of penetrating traumatic brain injury (pTBI) is poor yet highly variable. Current computerized tomography (CT) severity scores are commonly not used for pTBI prognostication but may provide important clinical information in these cohorts. METHODS: All consecutive pTBI patients from two large neurotrauma databases (Helsinki 1999-2015, Stockholm 2005-2014) were included. Outcome measures were 6-month mortality and unfavorable outcome (Glasgow Outcome Scale 1-3). Admission head CT scans were assessed according to the following: Marshall CT classification, Rotterdam CT score, Stockholm CT score, and Helsinki CT score. The discrimination (area under the receiver operating curve, AUC) and explanatory variance (pseudo-R2) of the CT scores were assessed individually and in addition to a base model including age, motor response, and pupil responsiveness. RESULTS: Altogether, 75 patients were included. Overall 6-month mortality and unfavorable outcome were 45% and 61% for all patients, and 31% and 51% for actively treated patients. The CT scores' AUCs and pseudo-R2s varied between 0.77-0.90 and 0.35-0.60 for mortality prediction and between 0.85-0.89 and 0.50-0.57 for unfavorable outcome prediction. The base model showed excellent performance for mortality (AUC 0.94, pseudo-R2 0.71) and unfavorable outcome (AUC 0.89, pseudo-R2 0.53) prediction. None of the CT scores increased the base model's AUC (p > 0.05) yet increased its pseudo-R2 (0.09-0.15) for unfavorable outcome prediction. CONCLUSION: Existing head CT scores demonstrate good-to-excellent performance in 6-month outcome prediction in pTBI patients. However, they do not add independent information to known outcome predictors, indicating that a unique score capturing the intracranial severity in pTBI may be warranted.

Survival following Self-Inflicted Gunshots to the Face.

BACKGROUND: Self-inflicted gunshot wounds involving the face are highly morbid. However, there is a paucity of objective estimates of mortality. This study aims to provide prognostic guidance to clinicians that encounter this uncommon injury. METHODS: A retrospective review of patients presenting to R Adams Cowley Shock Trauma Center (a Level I trauma center) with self-inflicted gunshot wounds to the face from 2007 to 2016. Isolated gunshot wounds to the calvaria or neck were excluded. The data were analyzed to determine predictors of survival. RESULTS: Of the 69 patients that met inclusion criteria, 90 percent were male and 80 percent were Caucasian, with an age range of 21 to 85 years. The most frequently seen injury patterns showed submental (57 percent), intraoral (22 percent), and temporal (12 percent) entry sites. Fewer than half (41 percent) of the cohort sustained penetrative brain injury. Overall, there were 18 deaths (overall mortality, 26 percent), 17 of which were secondary to brain injury. Independent predictors of death included penetrative brain injury (OR, 17; p < 0.0001) and age. Mortality was 17 percent among patients younger than 65 years, compared with 73 percent for those aged 65 years or older (p = 0.0001). Gastrostomy placement was independently associated with 25 percent reduction in length of hospitalization (p = 0.0003). CONCLUSIONS: Despite tremendous morbidity, the overwhelming majority of patients who present with facial self-inflicted gunshot wounds will survive, especially if they are young and have no penetrative brain injury. These findings should help guide clinical decisions for this devastating injury. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

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.

Outcome of Craniocerebral Penetrating Injuries: Experience from the Syrian War.

OBJECTIVES: Gunshot wounds to the brain are the most fatal of all firearm injuries. The aim of this study was to evaluate mortality and morbidity in patients with penetrating craniocerebral gunshot injuries and to identify risk factors that affect the outcome. PATIENTS AND METHODS: A retrospective review from June 2012 to November 2013 of 44 Syrian patients with gunshot wound to the head was performed. A thorough physical examination and computed tomography (CT) of the brain was obtained for all patients at the time of admission. Associated systemic injuries were found in 19 patients (43%). Surgical intervention was performed in 25 patients (57%); the remaining patients were managed conservatively. The patients were followed for a period of 1 to 15 months (range: 6 ± 2 months). Univariate analysis of patient age, sex, type of penetrating object, Glasgow Coma Scale (GCS) score and pupil size on admission, brain CT findings, presence of systemic injuries, and surgical intervention on the patient outcome was performed. RESULTS: Eleven patients (25%) had a bullet injury; the remaining 33 (75%) patients had blast injuries. Initial brain CT revealed different types of skull fractures, intracerebral hemorrhage, and brain edema in all patients. The mortality rate during the follow-up period was 25%. Of the survivors, 25 patients (76%) had a good recovery, eight patients (24%) had a mild disability, and none had a severe disability. The significant factors determining outcome in this series were GCS on admission (p < 0.005) and positive pupil reaction to light (p < 0.05). The patient age, sex, CT findings, systemic injuries, neurosurgical intervention, and hospital length of stay were not significant prognostic factors (p > 0.05). CONCLUSIONS: Among various variables, GCS and pupil reactivity were the outcome predictors in patients with penetrating craniocerebral injuries. Age, sex, type of penetrating object, CT findings, and surgical intervention did not have a significant effect on survival for these kinds of injuries.

Multicenter Validation of the Survival After Acute Civilian Penetrating Brain Injuries (SPIN) Score.

BACKGROUND: Civilian penetrating traumatic brain injury (pTBI) is a serious public health problem in the United States, but predictors of outcome remain largely understudied. We previously developed the Survival After Acute Civilian Penetrating Brain Injuries (SPIN) score, a logistic, regression-based risk stratification scale for estimating in-hospital and 6-mo survival after civilian pTBI with excellent discrimination (area under the receiver operating curve [AUC-ROC = 0.96]) and calibration, but it has not been validated. OBJECTIVE: To validate the SPIN score in a multicenter cohort. METHODS: We identified pTBI patients from 3 United States level-1 trauma centers. The SPIN score variables (motor Glasgow Coma Scale [mGCS], sex, admission pupillary reactivity, self-inflicted pTBI, transfer status, injury severity score, and admission international normalized ratio [INR]) were retrospectively collected from local trauma registries and chart review. Using the original SPIN score multivariable logistic regression model, AUC-ROC analysis and Hosmer-Lemeshow goodness of fit testing were performed to determine discrimination and calibration. RESULTS: Of 362 pTBI patients available for analysis, 105 patients were lacking INR, leaving 257 patients for the full SPIN model validation. Discrimination (AUC-ROC = 0.88) and calibration (Hosmer-Lemeshow goodness of fit, P value = .58) were excellent. In a post hoc sensitivity analysis, we removed INR from the SPIN model to include all 362 patients (SPINNo-INR), still resulting in very good discrimination (AUC-ROC = 0.82), but reduced calibration (Hosmer-Lemeshow goodness of fit, P value = .04). CONCLUSION: This multicenter pTBI study confirmed that the full SPIN score predicts survival after civilian pTBI with excellent discrimination and calibration. Admission INR significantly adds to the prediction model discrimination and should be routinely measured in pTBI patients.

Trends in civilian penetrating brain injury: A review of 26,871 patients.

INTRODUCTION: 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). METHODS: We performed a 5-year-analysis of all trauma patients diagnosed with pTBI in the TQIP. Our outcome measures were trends of pTBI. RESULTS: A total of 26,871 had penetrating brain injury over the 5-year period. Mean age was 36.2 ±â€¯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. CONCLUSIONS: 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.

INTRODUCTION: 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. METHODS: 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. RESULTS: 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). CONCLUSION: 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.

Civilian Gunshot Wounds to the Head: Prognostic Factors Affecting Mortality: Meta-Analysis of 1774 Patients.

Civilian gunshot wounds to the head (cGSWH) are devastating, but there is no consensus regarding prognosis and management. Therefore, we conducted a meta-analysis to identify prognostic factors associated with mortality. PubMed, EMBASE, Scopus, Web of Science, and Cochrane Library were queried for retrospective cohort studies of isolated cGSWH reporting mortality prognostic factors. Meta-Analysis Of Observational Studies in Epidemiology (MOOSE) guidelines were followed. Study quality was assessed using the Newcastle-Ottawa scale. Primary outcome was mortality. Pooled estimates of odds ratios (ORs) and 95% confidence intervals (CIs) were derived using random-effects models. Seventeen (17) observational studies (1774 patients) were identified and included. Factors associated with mortality were: age >40 years (OR, 3.44; 95% CI [1.71-6.91]), suicide attempt (5.78; [3.07-10.87]), Glasgow Coma Scale (GCS) 3-8 compared with 9-15 (38.02; [21.98-65.77]), GCS 3-5 versus 6-8 (15.38; [6.72-35.23], bilateral fixed and dilated pupils versus normal (67.12; [16.67-270.22]), and versus unilateral fixed and dilated pupil (25.35; [5.82-110.41]), dural penetration (29.07; [4.30-196.53]) and bihemispheric (4.23; [2.32-7.68]), and multi-lobar injuries (6.53; [1.99-21.42]). Selection for operative management, according to expert neurosurgical opinion, was protective (0.06; [0.01-0.22]). This is the first meta-analysis on cGSWH mortality prognostic factors. Increasing age, suicide attempt, lower GCS, bilateral mydriasis, dural penetration, and bihemispheric and multi-lobar injury are associated with increased mortality. This study can serve as a guide to clinicians and will provide directions for future research to develop evidence-based management algorithms.

Mortality Following Hospital Admission for US Active Duty Service Members Diagnosed With Penetrating Traumatic Brain Injury, 2004-2014.

OBJECTIVE: To examine mortality among active duty US military service members (SMs) with the diagnosis of penetrating traumatic brain injury (PTBI) and a hospital admission between 2004 and 2014. DESIGN: Data on SMs with PTBI and an admission to a military or civilian hospital were obtained from the 2004 to 2014 Military Health System data repository. After applying exclusion criteria, data on 1226 SMs were analyzed. MAIN MEASURES: The number of observed deaths per 100 identified patients with PTBI and time to death from admission were used as main measures. RESULTS: Approximately 25% of the 1226 patients with PTBI included in this study died following admission, with 44.6% of the all deaths occurring within a day following hospital admission and 75% occurring within the first week. Severe comorbid conditions and intentionally self-inflicted injuries are associated with higher mortality rate. SMs' gender, age, year of hospital admission, and service were significantly associated with likelihood of death following PTBI hospitalization. Males had a higher likelihood of dying following hospital admission compared with females (odds ratio = 2.7, confidence interval = 1.03-7.9). SMs in the 35- to 44-year-old and 45- to 64-year-old groups had up to a 2.6 times higher odds of death following their admission compared with the 25- to 34-year-old group. Age, admission year, service, and rank were significantly associated with SMs' time to death from hospitalization. Patients between the ages of 45 and 64 years were significantly more likely to die earlier than other age groups. Furthermore, cases in the Navy Afloat group had a higher fatality rate and were more likely to die earlier than patients in other services. PTBI comorbid conditions and injury type did not significantly affect time to death. CONCLUSION: This study quantifies case fatality rate among hospitalized US SMs with the diagnosis of PTBI. We report a 23.1% crude case fatality rate among the current cohort. Early intensive care for these patients may be the key to improving survival rates.

Developing a simplified clinical prediction score for mortality in patients with cerebral gunshot wounds: The Maritzburg Score.

Introduction Cerebral gunshot wounds are highly lethal and literature on the clinical scores for mortality prediction is limited. Materials and methods A retrospective study was undertaken over a 5-year period at the Pietermaritzburg Metropolitan Trauma Service in South Africa. A simplified clinical prediction score was developed based on clinical and/or physiological variables readily available in the resuscitation room. Results A total of 102 patients were included; 92% (94/102) were male and the mean age was 29 years; 22% (22/102) died during the admission. The presence of visible brain matter (odds ratio 12.4, P = 0.003) and motor score less than 5 (odds ratio 89.6, P  < 0.001) allows the prediction success of 92% (sensitivity 73% and specificity 98%). The area under the receiver operating characteristic curve was 94% (95% confidence interval 88-100%, P  < 0.001). Conclusions The presence of visible brain matter, together with a motor score of less than 5, allows accurate identification of non-survivors of cerebral gunshot wounds. Further study is required to validate this score.

Coagulopathy as a predictor of mortality after penetrating traumatic brain injury.

STUDY HYPOTHESIS: Traumatic brain injury (TBI) is a leading cause of mortality with penetrating TBI (p-TBI) patients having worse outcomes. These patients are more likely to be coagulopathic than blunt TBI (b-TBI) patients, thus we hypothesize that coagulopathy would be an early predictor of mortality. METHODS: We identified highest-level trauma activation patients who underwent an admission head CT and had ICU admission orders from August 2009-May 2013, excluding those with polytrauma and anticoagulant use. Rapid thrombelastography (rTEG) was obtained after emergency department (ED) arrival and coagulopathy was defined as follows: ACT≥128s, KT≥2.5s, angle≤56°, MA≤55mm, LY-30≥3.0% or platelet count≤150,000/µL. Regression modeling was used to assess the association of coagulopathy on mortality. RESULTS: 1086 patients with head CT scans performed and ICU admission orders were reviewed. After exclusion criteria were met, 347 patients with isolated TBI were analyzed-99 (29%) with p-TBI and 248 (71%) with b-TBI. Patients with p-TBI had a higher mortality (41% vs. 10%, p<0.0001) and a greater incidence of coagulopathy (64% vs. 51%, p<0.003). After dichotomizing p-TBI patients by mortality, patients who died were younger and were more coagulopathic. When adjusting for factors available on ED arrival, coagulopathy was found to be an early predictor of mortality (OR 3.99, 95% CI 1.37, 11.72, p-value=0.012). CONCLUSIONS: This study demonstrates that p-TBI patients with significant coagulopathy have a poor prognosis. Coagulopathy, in conjunction with other factors, can be used to earlier identify p-TBI patients with worse outcomes and represents a possible area for intervention.

The effect of brain tomography findings on mortality in sniper shot head injuries.

OBJECTIVES: Penetrating gunshot head injuries have a poor prognosis and require prompt care. Brain CT is a routine component of the standard evaluation of head wounds and suspected brain injury. We aimed to investigate the effect of brain CT findings on mortality in gunshot head injury patients who were admitted to our emergency department (ED) from the Syrian Civil War. METHODS: The study group comprised patients who were admitted to the ED with gunshot brain injury. Patients' GCS scores, prehospital intubations and brain CT findings were examined. RESULTS: 104 patients were included (92% male, mean age 25 years). Pneumocephalus, midline shift, penetrating head injury, patients with GCS scores ≤6 and patients who had to be intubated in the prehospital period were associated with higher mortality (p<0.05). DISCUSSION: The results of this study demonstrated that pneumocephalus, midline shift, a penetrating head injury, GCS scores ≤6 and prehospital intubation are associated with high mortality, whereas patients with temporal bone fracture, perforating or single cerebral lobe head injury had a higher survival rates. The temporal bone has a relatively thin and smooth shape compared with the other skull bones so a bullet is less fragmented when it has penetrated the temporal bone, which could be a reason for the reduced cavitation effect. In perforating head injury, the bullet makes a second hole and so will have deposited less energy than a retained bullet with a consequent reduction in intracranial injury and mortality. Further studies are required to reach definitive conclusions.

Coagulopathy and transfusion requirements in war related penetrating traumatic brain injury. A single centre study in a French role 3 medical treatment facility in Afghanistan.

INTRODUCTION: Traumatic brain injury associated coagulopathy is frequent, either in isolated traumatic brain injury in civilian practice and in combat traumatic brain injury. In war zone, it is a matter of concern because head and neck are the second most frequent site of wartime casualty burden. Data focusing on transfusion requirements in patients with war related TBI coagulopathy are limited. MATERIALS AND METHODS: A descriptive analysis was conducted of 77 penetrating traumatic brain injuries referred to a French role 3 medical treatment facility in Kabul, Afghanistan, deployed on the Kabul International Airport (KaIA), over a 30 months period. RESULTS: On 77 patients, 23 died during the prehospital phase and were not included in the study. Severe traumatic brain injury represented 50% of patients. Explosions were the most common injury mechanism. Extracranial injuries were present in 72% of patients. Traumatic brain injury coagulopathy was diagnosed in 67% of patients at role 3 admission. Red blood cell units (RBCu) were transfused in 39 (72%) patients, French lyophilized plasma (FLYP) in 41 (76%), and fresh whole blood (FWB) in 17 (31%). CONCLUSION: The results of this study support previous observations of coagulopathy as a frequent complication of traumatic brain injury. The majority of patients with war related penetrating traumatic brain injury presented with extracranial lesions. Most of them required a high level of transfusion capacity.

Pediatric intracranial gunshot wounds: the Memphis experience.

OBJECTIVE Penetrating brain injury in civilians is much less common than blunt brain injury but is more severe overall. Gunshot wounds (GSWs) cause high morbidity and mortality related to penetrating brain injury; however, there are few reports on the management and outcome of intracranial GSWs in children. The goals of this study were to identify clinical and radiological factors predictive for death in children and to externally validate a recently proposed pediatric prognostic scale. METHODS The authors conducted a retrospective review of penetrating, isolated GSWs sustained in children whose ages ranged from birth to 18 years and who were treated at 2 major metropolitan Level 1 trauma centers from 1996 through 2013. Several standard clinical, laboratory, and radiological factors were analyzed for their ability to predict death in these patients. The authors then applied the St. Louis Scale for Pediatric Gunshot Wounds to the Head, a scoring algorithm that was designed to provide rapid prognostic information for emergency management decisions. The scale's sensitivity, specificity, and positive and negative predictability were determined, with death as the primary outcome. RESULTS Seventy-one children (57 male, 14 female) had a mean age of 14 years (range 19 months to 18 years). Overall mortality among these children was 47.9%, with 81% of survivors attaining a favorable clinical outcome (Glasgow Outcome Scale score ≥ 4). A number of predictors of mortality were identified (all p < 0.05): 1) bilateral fixed pupils; 2) deep nuclear injury; 3) transventricular projectile trajectory; 4) bihemispheric injury; 5) injury to ≥ 3 lobes; 6) systolic blood pressure < 100 mm Hg; 7) anemia (hematocrit < 30%); 8) Glasgow Coma Scale score ≤ 5; and 9) a blood base deficit < -5 mEq/L. Patient age, when converted to a categorical variable (0-9 or 10-18 years), was not predictive. Based on data from the 71 patients in this study, the positive predictive value of the St. Louis scale in predicting death (score ≥ 5) was 78%. CONCLUSIONS This series of pediatric cranial GSWs underscores the importance of the initial clinical exam and CT studies along with adequate resuscitation to make the appropriate management decision(s). Based on our population, the St. Louis Scale seems to be more useful as a predictor of who will survive than who will succumb to their injury.

Outcomes and demostration of cranial firearm injuries: A multicenter retrospective study.

BACKGROUND: Cranial firearm injuries (CFAI) are associated with significant morbidity and mortality.This study was aimed to determine the factors affecting mortality of CFAI cases managed in our institution by a retrospective analysis of CT scans and clinical data. METHODS: This multicenter retrospective study examined two hundred and nineteen patients presenting to neurosurgery clinics after CFAI between January 2012 and November 2014. Age, sex, Glasgow Coma Score (GCS), CT findings, and mortality and morbidity rates of the patients were analyzed to determine the factors affecting mortality. RESULTS: Mean age of the study population was 24.19±12.25 years, 85.8% of them were male. The most common CT findings were fracture (100%), intracranial hemorrhage (61.2%), and an intracranially located foreign body (44.3%). A cranial operation was performed in 64.8% of the victims. Mean GCS on admission was 8±3.9, which increased in survivors (p<0.05). CONCLUSION: CFAIs are associated with increased mortality and morbidity. We determined that many factors affected morbidity and mortality rates, and patient age, presence of intracranial hemorrhage, GCS, and treatment protocols were significantly associated with mortality.

[Methodological aspects of surgical approach in victims with severe multiple craniofacial trauma in consideration of severity of traumatic injury].

It is important to improve the medical care system and treatment of victims, introduce new methods of treatment and attract the multidisciplinary specialists in the cases of multitrauma. An integrated approach is required for the identification of different character and severity of multiple craniofacial injuries and the development of rational surgical strategy on this base. Different scales such as AIS, CRIS, ISS, PTS, TRISS, TRISSCAN, CRAMS et.al, were created abroad. Another approach to medical strategy was developed in the department of military surgery of Kirov Military Academy in the late nineties. It was based on investigating of possibilities of surgical strategy optimization by application of objective evaluation of the severity of injuries (military surgery--SP, SG, SS). Given treatment strategy of victims with multiple craniofacial trauma resulted in double reduction of quantity of suppurative and septic complications (from 10.5% to 4.1%). It gave the possibility to reduce the lethality from 6.4% to 4.0%. At the same time a hospital stay was shortened and the strategy allowed obtaining satisfactory functional results of treatment and avoiding reinterventions for removal of posttraumatic facial deformations.

Characteristics of a rat model of an open craniocerebral injury at simulated high altitude.

To establish a rat model of an open craniocerebral injury at simulated high altitude and to examine the characteristics of this model. Rats were divided randomly into a normobaric group and a high-altitude group and their corresponding control groups. A rat model of an open craniocerebral injury was established with a nail gun shot. Simulated high-altitude conditions were established with a hypobaric chamber at 0.6 ATA to mimic pressure at an altitude of 4000 m. Mortality, brain water content (BWC), Evans blue content, pathology, regional cerebral blood flow (rCBF), partial pressure of brain tissue oxygen (PbtO2), and brainstem auditory-evoked potential were observed after injury. The mortality of the high-altitude group was significantly greater than that of the normobaric group within 72 h after injury (P<0.05). BWC and Evans blue content increased by 48 h after injury (P<0.05); pathological changes in damaged brains were more serious. In contrast, rCBF and PbtO2 had decreased markedly by 72 h (P<0.01); brainstem auditory-evoked potential values were significantly prolonged (P<0.05). Moreover, an inverse correlation between rCBF and BWC and a positive correlation between rCBF and PbtO2 were found. The rat model of an open craniocerebral injury at simulated high altitude can be established successfully using a nail gun shot and a hypobaric chamber. The injury characteristics at high altitude were more serious, rapid, and prolonged than those in the normobaric group.