Missile injury to the pediatric brain in conflict zones

Abstract

<jats:sec> <jats:title>Object</jats:title> <jats:p>This study was conducted both prospectively and retrospectively at one center over a period of 8 years. The population consisted of all patients with both an age 18 years or younger and a diagnosed penetrating missile injury (PMI) during the study interval. The authors analyzed factors determining outcome and demographic trends in this population, and they compared them with those in the more developed world</jats:p></jats:sec> <jats:sec> <jats:title>Methods</jats:title> <jats:p>Fifty-one patients were the victims of armed conflict, although no one was directly a party to any battle. This mechanism of injury is in strong opposition to data in the literature from developed countries, in which most missile injuries are the result of suicide or homicide or are even sports related. Moreover, all previous studies on the pediatric population have considered only injuries from gunshots, but authors of the current study have included injuries from other penetrating missiles as well.</jats:p></jats:sec> <jats:sec> <jats:title>Results</jats:title> <jats:p>On cross tabulation analysis using the chi-square test, the factors shown to correlate with outcome included the Glasgow Coma Scale (GCS) score, pupillary abnormalities, patient age, hemodynamic status, and bihemispheric damage. On multinomial regression analysis, the two strongest predictors of death were GCS score and pupillary abnormalities. The GCS score and hemodynamic status were the strongest predictors of disability.</jats:p></jats:sec> <jats:sec> <jats:title>Conclusions</jats:title> <jats:p>There was no difference in the prognostic factors for PMI between developing or more developed countries. Glasgow Coma Scale score, pupillary abnormalities, and hemodynamic status were the strongest predictors of outcome. In conflict zones in developing countries the victims were mostly innocent bystanders, whereas in the more developed countries homicides and suicides were the leading etiological factors.</jats:p></jats:sec>

Pediatric Combat Trauma

“…In a study by Klimo et al, each one-point increase in GCS resulted in a 32 % increased odds of survival [48•]. Other predictors of poor outcome were abnormal or non-reactive pupils and hypotension [47].…”

“…When high intracranial pressure was detected, hypertonic saline and drainage of cerebrospinal fluid were the mainstays of non-operative management [49]. When surgery was required, principals of operative management included aggressive removal of all scalp hair, aggressive subtemporal decompression, minimal surface debridement (no debridement of the tract for penetrating missile injury), duraplasty with onlay dural substitute if needed, and subcutaneous abdominal bone flap preservation for late reconstruction [47]. A high risk for venous thrombosis in postpubescent patients led to aggressive use of fractionated heparin as early as 12 h following surgery [49].…”

“…A high risk for venous thrombosis in postpubescent patients led to aggressive use of fractionated heparin as early as 12 h following surgery [49]. Because there was little local support for the long-term management of severely brain injured children, palliative care was pursued more liberally for those patients with low GCS compared to care delivered in the US civilian population [47].…”

Stray bullet: An accidental killer during riot control

“…[6–1015] Reports cite accidentally sustained injuries as an important cause of mortality and morbidity in firearm injuries. In the last two decades, the increase in domestic and urban violence has led to an increase in the incidence of accidental firearm injuries.…”

Image of the Month—Diagnosis

“…2 In the combat zone, penetrating missile wounds to the head are usually deliberate, not accidental, and can lead to increased mortality and morbidity. 3,4 In this particular case, the event had little to do with war and more to do with competitive sports, civic pride, and subsequent celebration. The local soccer team happened to be the Iraqi national team, playing in Baghdad.…”