Outcomes in patients with gunshot wounds to the brain

Abstract

IntroductionGunshot wounds to the brain (GSWB) confer high lethality and uncertain recovery. It is unclear which patients benefit from aggressive resuscitation, and furthermore whether patients with GSWB undergoing cardiopulmonary resuscitation (CPR) have potential for survival or organ donation. Therefore, we sought to determine the rates of survival and organ donation, as well as identify factors associated with both outcomes in patients with GSWB undergoing CPR.MethodsWe performed a retrospective, multicenter study at 25 US trauma centers including dates between June 1, 2011 and December 31, 2017. Patients were included if they suffered isolated GSWB and required CPR at a referring hospital, in the field, or in the trauma resuscitation room. Patients were excluded for significant torso or extremity injuries, or if pregnant. Binomial regression models were used to determine predictors of survival/organ donation.Results825 patients met study criteria; the majority were male (87.6%) with a mean age of 36.5 years. Most (67%) underwent CPR in the field and 2.1% (n=17) survived to discharge. Of the non-survivors, 17.5% (n=141) were considered eligible donors, with a donation rate of 58.9% (n=83) in this group. Regression models found several predictors of survival. Hormone replacement was predictive of both survival and organ donation.ConclusionWe found that GSWB requiring CPR during trauma resuscitation was associated with a 2.1% survival rate and overall organ donation rate of 10.3%. Several factors appear to be favorably associated with survival, although predictions are uncertain due to the low number of survivors in this patient population. Hormone replacement was predictive of both survival and organ donation. These results are a starting point for determining appropriate treatment algorithms for this devastating clinical condition.Level of evidenceLevel II.

Organ donation in the surgical ICU: an American Association for the Surgery of Trauma Critical Care Committee clinical consensus document

“…Aggressive resuscitation improves patients’ eligibility for organ donation and, in some cases, their chance of survival 32 40 41. A multicenter study demonstrated that even in patients with cranial gunshot wounds undergoing cardiopulmonary resuscitation (CPR), 2.1% survived to discharge, and 17.5% of non-survivors were eligible donors 42…”

“… 32 40 41 A multicenter study demonstrated that even in patients with cranial gunshot wounds undergoing cardiopulmonary resuscitation (CPR), 2.1% survived to discharge, and 17.5% of non-survivors were eligible donors. 42 …”

Review Paper on Penetrating Brain Injury

“…35 Organ donation has been identified as a valid secondary outcome in patients with fatal PBI, with organ donation rates as high as 71% after implementation of aggressive donor care protocols, including hormone replacement therapy. 7,36 Lack of appropriate resuscitative efforts or early termination in patients suffering from PBI may lead to lower organ procurement rates. The presence of a multidisciplinary team and in-house coordinators from OPOs may lead to substantial improvements in donation rates.…”

“…This may be due to confounding factors such as sympathomimetic/parasympatholytic drugs, bullets causing direct oculomotor nerve pressure from a localized hematoma, and optic nerve or direct ocular trauma, which deviates from uncal herniation seen with a space-occupying lesion in blunt traumatic brain injury. [6][7][8] There is also the question of whether patients with either isolated or multicavitary PBI should undergo cardiopulmonary resuscitation or even EDT. A recent multicenter study of patients with PBI receiving cardiopulmonary resuscitation alone demonstrated a dismal 2.1% survival rate (with 74% of these discharged to rehabilitation or home), but a 10.3% organ donation rate.…”

“…The data on pupillary response as predictor of mortality is mixed in PBI. This may be due to confounding factors such as sympathomimetic/parasympatholytic drugs, bullets causing direct oculomotor nerve pressure from a localized hematoma, and optic nerve or direct ocular trauma, which deviates from uncal herniation seen with a space-occupying lesion in blunt traumatic brain injury 6–8…”