Tangential Gun-Shot Wound to the Head: A Serious Injury
ABSTRACT & COMMENTARY
Source: Anglin D, et al. Intracranial hemorrhage associated with tangential gunshot wounds to the head. Acad Emerg Med 1998;5:672-678.
Anglin and associates performed a retrospective study investigating the occurrence of intracranial hemorrhage (ICH) in emergency department (ED) patients with tangential gunshot wounds (GSW) to the head (TGSWH)-defined as a GSW to the head in which the missile does not penetrate the inner table of the skull. The study, performed over 2.7 years in an inner-city, level-one trauma center with an annual ED volume of 171,000, identified all patients with GSWs to the head and neck region using the trauma registry, ED log, and hospital's discharge diagnosis database. Demographic, clinical, and follow-up (return ED visit, telephone inquiry, and coroner's reports) data were compiled. Data analysis was ultimately limited to patients with TGSWH who underwent cranial CT scan.
Four hundred twenty patients with GSW to the head were identified with 174 TGSWH; 20 of these patients did not undergo head CT scan, leaving 154 (37%) cases for data analysis. Considering only TGSWH patients who underwent CT imaging, head CT scan demonstrated 25 (16%) skull fractures and 37 (24%) ICHs. Twenty-three (16%) patients had a history of a loss of consciousness (LOC), 17 (11%) had a Glasgow Coma Scale score (GCS) of less than 15, and 75 (49%) had retained extracranial missile fragments. One hundred-thirteen study patients had both a normal GCS and a normal neurologic examination, as well as an absence of LOC; 17 (15%) of these patients had ICH. Among 37 total CNS bleeds, ICH types included subarachnoid in 21 (57%), contusion in 17 (46%), subdural in 12 (32%), intraparenchymal in six (16%), and epidural in one (3%). Fifty-six (37%) patients were directly released from the ED; one death was reported. No deaths or repeat presentation for missed neurologic injury were noted in the 20 patients who did not undergo head CT scan; 24 patients in the study group were lost to follow-up. No clinical finding-including LOC, abnormal GCS, skull fracture, TGSWH location, or retained extracranial bullet fragment-was predictive of ICH, though each of these demonstrated an increased risk for CNS hemorrhage. Of course, the absence of these clinical findings was not associated with the lack of ICH.
COMMENT BY WILLIAM J. BRADY, MD
Previous work has suggested that TGSWH-related ICH is not rare, and has revealed that many emergency physicians are not aware of such injury potential. Stone and colleagues demonstrated that approximately 50% of ICHs related to TGSWH were not initially diagnosed in the ED and were inadvertently discharged.1 This study supports the work of Stone et al by noting the somewhat frequent occurrence of ICH resulting from TGSWH. Unfortunately, the results do not provide clinical features that strongly suggest the presence of ICH. The study does suggest that LOC, abnormal GCS, and the presence of skull fracture are all associated with an increased risk for ICH. In most instances, any patient with GSW to the head-tangential or not-with any of the three noted risk factors would undergo cranial CT scan. The rate of ICH in patients without major obvious risks (normal GCS, normal neurologic examination, and no LOC) was 15%; these patients had demonstrated skull fracture and/or retained extracranial missile fragment. The major pitfall of this study is the lack of CT scan use in all patients; this failing, however, does not detract from 1) the finding that approximately 25% of patients with TGSWH experience ICH and 2) that a normal neurological examination coupled with an absence of LOC at any time does not rule-out ICH. Emergency physicians should strongly consider the use of head CT in all such cases.
Reference
1. Stone JL, et al. Civilian cases of tangential gunshot wounds to the head. J Trauma Inj Infect Crit Care 1996;40:57-60.
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