Disaster management of civilian gunshot head wounds in north Indian state

Abstract

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.

Factors affecting dural penetration and prognosis in patients admitted to emergency department with cranial gunshot wound

“…In a study by Mansuco et al [11] in 40 subjects with CGW, 16 died and 3 survived among subjects with a GCS ≤8, whereas all subjects with a GCS score greater than 8 survived. Studies in CGW have shown that admission GCS is the cornerstone for the determination of prognosis and mortality in CGWs, and mortality increases as GCS decreases [10,14,17,20,26]. Our results were in accordance with the literature data.…”

“…İntraventricular hemorrhage, SAH, shift, and edema on CT are predictive of poor prognosis and increased mortality in penetrating CGWs [17,18,20,26]. The same CT findings were also correlated to poor prognosis and high mortality in our study.…”

“…Previous studies have shown the relationship of multilobar injuries with increased mortality and worse prognosis compared to unilobar injuries [23][24][25][26]. Bihemispheric lesions have also been demonstrated to correlate to increased mortality [13,17,18,26].…”

“…Bihemispheric lesions have also been demonstrated to correlate to increased mortality [13,17,18,26]. Studies examining bullet trajectory have shown that a lateral trajectory is associated with a higher mortality and worse prognosis than an anterolateral trajectory [14,27].…”

Non-metallic and metallic craniocerebral missile injuries: Varied outcome

“…In fact the non-metallic plastic, rubber, wax, stones and wooden missiles have proved more dangerous and fatal to control mobs and protesters 3,4,5,6,7 . Gunshot wounds of head are common in military personnel in war zones but for the past few decades civilian population around the world has become vulnerable to such injuries due to civil wars, regional conflicts, militancy, terrorism and military-related operations 8 . The rubber bullets were first used in 1970 by British Forces in Northern Ireland and were replaced by plastic bullets in 1972 by the British authorities.…”