Introduction: Gunshot wounds to the head (GSWH) are the most common cause of penetrating brain injury. The literature argues for surgical debridement of the wound with removal of accessible bone fragments. Debridement is thought to lead to decreased risk of infectious complications and some authors believe it may decrease seizure risk. However, with the risks of surgery and the uncertain benefit of this approach in the civilian population we have treated select patients with a more conservative approach including bedside washout of any entry and exit wounds and a course of antibiotics. Here we present our experience with this more conservative approach to GSWH.
Methods: In patients presenting to our level 1 trauma center with GSWH, following physical exam and review of imaging, we treated patients either with surgical debridement or bedside washout, without removing bone fragments, and a short course of CNS-penetrating antibiotics. The conservative approach was favored in patients with initial high GCS, minimal penetration of the cranial vault, absence of a mass-occupying lesion, and particularly in those patients with bone fragments on, or in close proximity, to dural venous sinuses. In these patients, we believed that the risks of surgical debridement outweighed the potential benefits.
Results: In our subset of high GCS patients treated with bedside washout and antibiotics, we had a very low rate of abscess formation and local wound infection. In this same group we did not have any significant problems with post-traumatic seizures.
Conclusions: Although more detailed analysis is required, our experience demonstrates that a more conservative approach to the treatment of civilian GSWH is associated with good outcomes. We are currently performing a retrospective analysis of patients presenting to our trauma center to compare the results of the conservative management approach with traditional surgical debridement.
Patient Care: Treating patients with a bedside procedure instead of surgical debridement eliminates the risks associated with general anesthetic and potential risks associated with the removal of bone fragments. Additionally, this more conservative approach could lead to decreased health care costs and length of stay.
Learning Objectives: By the conclusion of this session, participants should be able to: 1) Identify subset of patients in which bedside washout of GSW to the head could be considered as an alternative to surgical debridement 2) Compare the outcomes in GSW patients following surgical debridement and bedside washout