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Pediatric intracranial gunshot wounds: the Memphis experience
Michael DeCuypere1, Michael S Muhlbauer1,2,3, Frederick A Boop1,2,3
1Department of Neurosurgery, University of Tennessee Health Science Center;
Insights
This study identified key clinical and radiological factors predicting mortality in pediatric gunshot wounds to the head. The St. Louis Scale shows promise in predicting survival in these critical pediatric brain injury cases.
Area of Science:
- Pediatric Neurosurgery
- Trauma Surgery
- Emergency Medicine
Background:
- Penetrating brain injuries, particularly from gunshot wounds (GSWs), are less common but more severe than blunt head trauma.
- Intracranial GSWs in children have high morbidity and mortality, with limited data on management and outcomes.
- Accurate prognostic tools are crucial for guiding emergency management decisions in pediatric head trauma.
Purpose of the Study:
- To identify clinical and radiological factors predictive of death in pediatric patients with intracranial GSWs.
- To externally validate the St. Louis Scale for Pediatric Gunshot Wounds to the Head for prognostic accuracy.
- To assess the scale's sensitivity, specificity, and predictive values for mortality in this population.
Main Methods:
- Retrospective review of 71 pediatric patients (birth to 18 years) with isolated intracranial GSWs treated at two Level 1 trauma centers (1996-2013).
- Analysis of clinical, laboratory, and radiological factors for prediction of mortality.
- Application and validation of the St. Louis Scale for Pediatric Gunshot Wounds to the Head.
Main Results:
- Overall mortality was 47.9%; 81% of survivors had a favorable outcome (Glasgow Outcome Scale score ≥ 4).
- Significant predictors of mortality included: bilateral fixed pupils, deep nuclear injury, transventricular trajectory, bihemispheric injury, injury to ≥ 3 lobes, low systolic blood pressure, anemia, low Glasgow Coma Scale score, and base deficit.
- The St. Louis Scale demonstrated a positive predictive value of 78% for death (score ≥ 5) in this cohort, appearing more useful for predicting survival.
Conclusions:
- Initial clinical examination, CT imaging, and adequate resuscitation are vital for managing pediatric cranial GSWs.
- The St. Louis Scale shows utility in predicting survival in pediatric patients with intracranial GSWs.
- Further research is needed to refine prognostic tools for severe pediatric brain injuries.
Abstract:
OBJECTIVE Penetrating brain injury in civilians is much less common than blunt brain injury but is more severe overall. Gunshot wounds (GSWs) cause high morbidity and mortality related to penetrating brain injury; however, there are few reports on the management and outcome of intracranial GSWs in children. The goals of this study were to identify clinical and radiological factors predictive for death in children and to externally validate a recently proposed pediatric prognostic scale. METHODS The authors conducted a retrospective review of penetrating, isolated GSWs sustained in children whose ages ranged from birth to 18 years and who were treated at 2 major metropolitan Level 1 trauma centers from 1996 through 2013. Several standard clinical, laboratory, and radiological factors were analyzed for their ability to predict death in these patients. The authors then applied the St. Louis Scale for Pediatric Gunshot Wounds to the Head, a scoring algorithm that was designed to provide rapid prognostic information for emergency management decisions. The scale's sensitivity, specificity, and positive and negative predictability were determined, with death as the primary outcome. RESULTS Seventy-one children (57 male, 14 female) had a mean age of 14 years (range 19 months to 18 years). Overall mortality among these children was 47.9%, with 81% of survivors attaining a favorable clinical outcome (Glasgow Outcome Scale score ≥ 4). A number of predictors of mortality were identified (all p < 0.05): 1) bilateral fixed pupils; 2) deep nuclear injury; 3) transventricular projectile trajectory; 4) bihemispheric injury; 5) injury to ≥ 3 lobes; 6) systolic blood pressure < 100 mm Hg; 7) anemia (hematocrit < 30%); 8) Glasgow Coma Scale score ≤ 5; and 9) a blood base deficit < -5 mEq/L. Patient age, when converted to a categorical variable (0-9 or 10-18 years), was not predictive. Based on data from the 71 patients in this study, the positive predictive value of the St. Louis scale in predicting death (score ≥ 5) was 78%. CONCLUSIONS This series of pediatric cranial GSWs underscores the importance of the initial clinical exam and CT studies along with adequate resuscitation to make the appropriate management decision(s). Based on our population, the St. Louis Scale seems to be more useful as a predictor of who will survive than who will succumb to their injury.