Introduction: Firearm injuries cause an estimated 33,000 deaths annually in the United States. Management algorithms following gunshot wounds to the head (GSWH) have been static for two decades and outcomes remain in need of systematic characterization.
Methods: Adult GSWH patients in the National Sample Program (NSP) of the National Trauma Data Bank (NTDB), years 2003-2012, were extracted. Multivariable regression identified predictors for hospital length of stay (HLOS), ICU LOS, medical complications, mortality, and discharge disposition. Odds ratios (OR) and 95% confidence intervals (95% CI) were reported. Statistical significance was assessed at a < 0.001.
Results: In total, 8,148 patients were included extrapolating to 32,439 national incidents. Age was 36.6 ± 16.4 years. Mean HLOS was 13.9 ± 17.9 days and ICU LOS was 8.6 ± 17.4 days. The mortality was 54.6%. Age, injury intent, Glasgow Coma Scale (GCS) score, Injury Severity Score (ISS), and hypotension were significant predictors as previously reported.
Compared to privately insured patients, Medicare/Medicaid patients had longer HLOS (mean increase 4.4 days, 95% CI [2.6 to 6.3 days], p<0.001). Compared to the Midwest, the South had longer HLOS (mean increase 3.7 days [2.0-5.4 days], p<0.001) and more complications (OR 1.7 [1.4-2.0], p<0.001); the West had less complications (OR 0.6 [0.5-0.7], p<0.001). Compared to handgun, injury from shotgun and hunting rifle had lower odds of death (OR 0.3 [0.2-0.4], p<0.001; OR 0.5 [0.4-0.8], p<0.001). Suicide had lower odds of discharge to home compared to accident (OR 0.5 [0.3-0.7], p<0.001). Relative to level I trauma centers, level II trauma centers had lower odds of discharge to home (OR 0.7 [0.5-0.8], p<0.001).
Conclusions: Firearm type, injury intent, insurance type, and geographic region are important prognosticators in addition to older age, hypotension, and injury severity. Improved understanding of civilian GSWH is critical to increasing awareness and reducing injury burden from firearm injuries.
Patient Care: The impetus to improve national characterization of gunshot wounds to the head (GSWH) is clinically relevant at this time. Civilian GSWH remains critically understudied and carry exceedingly high early mortality. For patients who survive long enough to receive medical management, differences in setting and risk factors need to be identified to account for shifting population demographics and evolving firearm technology. Management recommendations from the 2001 Guidelines for the Management of Penetrating Brain Injury are widely utilized but have not been corroborated by large-scale studies. Given these factors and the increased scrutiny by the media on gun violence, an accurate characterization of GSWH on a national scale is critical.
Learning Objectives: By the conclusion of this session, participants should be able to: 1) Describe the current epidemiology of adult firearm-related traumatic brain injuries, 2) Discuss, in small groups, trends of mortality and injury severity in the civilian population, 3) Identify important prognosticators in injured patients to reduce the burden from firearm-related traumatic brain injuries.