Gunshot wounds to the head

Although regional differences exist, the incidence of civilian gunshot wounds, including gunshot wounds to the head, is increasing in most urban areas. The role of surgery in selected cases is to decrease secondary brain injury and thereby increase the quality of outcome. Debridement and removal of accessible fragments and watertight closure for patients with GCS scores of 6 to 15 is appropriate, as is evacuation of large hematomas causing significant mass effect. A difference of opinion exists in how to manage patients with GCS scores of 3 to 5. Levyetal (1994) showed that these patients are not likely to benefit from surgical intervention, although a subgroup of patients who have reactive pupils and no evidence of subarachnoid hemorrhage, ventricular involvement, or fragmentation deserve close follow-up.

Stone eta/ (1995) treated patients with GCS scores of 3 with surgery if they had reactive pupils, and patients with GCS scores of 4 to 7 if they had some motor response, even with non-reactive pupils. Two patients with GCS scores of 3 had good outcomes.

Cranial stab wounds are much less common, but have the highest incidence of vascular lesions including traumatic aneurysms. Therefore angiography should be performed for all patients with cranial stab wounds. The weapon should remain in the head until it can be taken out in the operating room where any adverse consequences can be adequately controlled. Patients should receive broad-spectrum antibiotics for 10 days, and supratentorial stab wounds should receive prophylactic anticonvulsants.

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