Therapeutic Interventions and Outcomes in Civilian and Military Isolated Gunshot Wounds to the Head

Abstract

Objective: The purpose of this study was to compare therapeutic strategies and outcomes, following isolated gunshot wounds of the head, between military and civilian populations. Background: Recent military conflicts introduced new concepts in trauma care, including aggressive surgical intervention in severe head trauma. Methods: This was a cohort-matched study, using the civilian Trauma Quality Improvement Program (TQIP) database of the American College of Surgeons (ACS) and the Department of Defense Trauma Registry (DoDTR), during the period 2013 to 2016. Included in the study were patients with isolated gunshots to the head. Exclusion criteria were dead on arrival, civilians transferred from other hospitals, and patients with major extracranial associated injuries (body area Abbreviated Injury Scale >3). Patients in the military database were propensity score–matched 1:3 with patients in the civilian database. Results: A total of 136 patients in the DoDTR database were matched for age, sex, year of injury, and head Abbreviated Injury Scale with 408 patients from TQIP. Utilization of blood products was significantly higher in the military population (P<0.001). In the military group, patients were significantly more likely to have intracranial pressure monitoring (17% vs 6%, P<0.001) and more likely to undergo craniotomy or craniectomy (34% vs 13%, P<0.001) than in the civilian group. Mortality in the military population was significantly lower (27% vs 38%, P=0.013). Conclusions: Military patients are more likely to receive blood products, have intracranial pressure monitoring and undergo craniectomy or craniotomy than their civilian counterparts after isolated head gunshot wounds. Mortality is significantly lower in the military population. Level of Evidence: Level III—therapeutic.

Committee on Surgical Combat Casualty Care position statement: Neurosurgical capability for the optimal management of traumatic brain injury during deployed operations

“…Additional studies have shown the time-critical nature of these injuries and need for expert neurosurgical intervention; these are not cases that can be safely “stabilized and evacuated” to Role 4 or 5 (Fig. 1) facilities with neurosurgical capabilities 7,8 . A commonly proffered solution or stopgap measure has been to have general or trauma surgeons perform emergent decompressive cranial surgery.…”

“…1) facilities with neurosurgical capabilities. 7,8 A commonly proffered solution or stopgap measure has been to have general or trauma surgeons perform emergent decompressive cranial surgery. This approach ignores the available literature and experience and represents a form of magical thinking that must be removed from modern military medical planning.…”