Management of 3794 gunshot wounds of head at disaster scale, who presented to our emergency room in groups continuously over a period of 20 years, by the Department of Neurosurgery at Sher-I-Kashmir Institute of Medical Sciences (SKIMS) Kashmir, India, from September 1988 to November 2008, revealed an overall mortality of 87.69% (3327 out of 3794). Patients were triaged in emergency CT-room. Most of the victims were males. Most of the deaths 79.14% (2633 out of 3327) occurred within 30 minutes of the patient's arrival to the hospital and only 694 patients lived beyond one hour of arrival. Out Of total (3327) deaths, 2844 patients had admission GCS score of 3 and all of these died. No deaths occurred in the group of patients with GCS score 9-15. Poor and delayed mode of transportation accounted for 89.2% (2133 out of 2391) deaths. Elderly patients above 41 years of age in both sexes had poor outcome. 45 Children (below 18 years) were injured with a mortality of 42.2% (19 out of 45), attributing 0.57% (19 out of 3327) to total deaths. Surgical mortality was 30.9% (181 out of 585) and un-operative patients had 42.2% (46 out of 109) mortality. About 65.87% (276 out of 419) patients with admission-GCS score 4 to 8 were surgically salvageable. Predictors of poor outcome were low admission GCS score, fixed and dilated pupils, poor and delayed mode of transportation, hemodynamic instability, abnormal breathing at admission, coagulopathy and disseminated intravascular coagulation (DIC), CT visualisation of subarachnoid hemorrhage (SAH), ventricular hemorrhage, midline shift, bihemispheric and multilobar injuries and scalp wounds at occipital, temporal and frontal areas. However retained missile and bone fragments were less harmful than retained wooden (pulped mulberry stem) and cardboard wads and pneumocephalus in causing infections, cortical atrophy and seizures in the long run.

We studied the comparative outcome related to 694 non-metallic and metallic craniocerebral missile injuries who lived at 2 hours and beyond the time of injury in a retrospective and prospective analysis in the Department of Neurosurgery at Sher-I-Kashmir Institute of Medical Sciences (SKIMS) Kashmir, India, over a period of 21 years from September 1988 to March, 2010. The study revealed an overall mortality of 32.70% (227 out of 694). A total of 664 adults and 30 children (mostly teenagers) were studied. The 79.1% (549 out of 694) patients were metallic missile injuries whereas 20.8% (145 out of 694) patients were non-metallic missile injuries. The non-metallic missile injury group mostly (72.4% i.e.; 105 out of 145) had low GCS score and overall worse prognosis with zero good-recovery, 47.5% disabilities and 52.4% mortality as compared to the metallic missile injury group. The non-metallic group comprised of 60% (18 out of 30) children with one death. Non-metallic missile injuries accounted for 10.95% (76 out of 694 patients) of total deaths. Predictors of poor outcome were low admission GCS score, non-metallic penetrating injury due to tear-gas cartridges, rubber bullets and stone-bullets, perforating metallic missile injuries and delayed and maltransportation. Most complications in non-metallic missile injuries were infective and had poor outcome. The common non-metallic missiles used were stone bullets (balls) fired by Gulail (modified catapult) or slingshot, red rubber bullets, plastic tear gas shells and cartridges, wooden (pulped mulberry stem) and card-board wads used in shotguns. The stone pelting, throwing stone projectiles (stone-bullets) by Gulail and manually has become a common way to inflict head injuries in Kashmir. The non-metallic missiles are not less-lethal and have high disabling, killing and infective potential.

Background The missile injuries of the cranium and brain in the modern era have shifted from soldiers to the civilians and from the battle grounds to the populated zones due to increase in the terrorist and military strikes. The management of the victims depends on the resuscitation at the site of injury and the distance and transportation to the tertiary care centre. This article presents the details of the missile injuries to the brain, the third-world problems and the management. Material and methods A retrospective analysis of 3794 craniocerebral missile injuries, managed by the Department of Neurosurgery at Sher-I-Kashmir Institute of Medical Sciences (SKIMS) Kashmir, India, over a period of more than 21 years from September 1988 to September 2009. Patients were triaged in emergency CT-room, resuscitated and operated. Statistical software programme SPSS 11.5 was used to derive the numerical significance. Results Revealed an overall mortality of 87.69% (3327 out of 3794). Most of the deaths 79.14% (2633 out of 3327) occurred within 30 minutes of the patient's arrival to the hospital and only 694 patients lived beyond one hour of arrival. Conclusion Presently the quantum of outcome i.e, survival and good recovery in craniocerebral missile injuries appears a meager heap compared to the huge amount of death and disability. And the situation will continue to be so unless tertiary care hospitals are set up within and around the armed and conflict zones, war torn areas and battle fields, rather than risking transportation, time of resuscitation, intervention and the results.

Background The missile injuries of the cranium and brain in the modern era have shifted from soldiers to the civilians and from the battle grounds to the populated zones due to increase in the terrorist and military strikes. The management of the victims depends on the resuscitation at the site of injury and the distance and transportation to the tertiary care centre. This article presents the details of the missile injuries to the brain, the third-world problems and the management. Material and methods A retrospective analysis of 3794 craniocerebral missile injuries, managed by the Department of Neurosurgery at Sher-I-Kashmir Institute of Medical Sciences (SKIMS) Kashmir, India, over a period of more than 21 years from September 1988 to September 2009. Patients were triaged in emergency CT-room, resuscitated and operated. Statistical software programme SPSS 11.5 was used to derive the numerical significance. Results Revealed an overall mortality of 87.69% (3327 out of 3794). Most of the deaths 79.14% (2633 out of 3327) occurred within 30 minutes of the patient's arrival to the hospital and only 694 patients lived beyond one hour of arrival. Conclusion Presently the quantum of outcome i.e, survival and good recovery in craniocerebral missile injuries appears a meager heap compared to the huge amount of death and disability. And the situation will continue to be so unless tertiary care hospitals are set up within and around the armed and conflict zones, war torn areas and battle fields, rather than risking transportation, time of resuscitation, intervention and the results.