Penetrating Head Injury
Trauma    All Diseases     eMedicine
General Info
 HPI/Physical
Penetrating head trauma:
a wound in which a projectile breaches the cranium but does not exit
Perforating head injury:
a wound in which a projectile passes entirely though the head, leaving both entrance and exit wounds.
Fourth leading cause of death in the US and leading cause of death ages 1-44 .
50% of trauma deaths are due to traumatic brain injury (TBI)
Perforating wounds do worse then penetrating wounds

Siccardi et al (1991)  did a prospective study 314 patients gunshot wounds and found:
73% died at the scene, 12% died within 3 hours, 7% died later =  92% Mortality rate

Stab wounds are worse when:
1. Sustained to the temporal fossa: the bone is thinner and is closer to brainstem.
2. When the object is inserted then removed mortality 1⁄4 compared to 1/10
 History:



Symptoms:



Signs:

Management





Complications/Management:
Initial management:
ATLS resuscitation. C-spine,  IV Access, intubation if indicated

Secondary Management:
Consult: Trauma & Neurosurgery

Avoid NG tubes, OG if necessary
GCS<8:
ICP monitor/Ventriculostomy
Head elevation 30°
Propofol: short 1/2 life for frequent neuro checks

Elevated ICP:
Mannitol
Decompressive craniotomy
Serum osmolality < 320 mOsm/kg:
avoid systemic acidosis and renal failure.
Complications
Epidural hematomas
Intracerebral hematomas
Delayed intracerebral hematomas
Traumatic subarachnoid hemorrhage
Diffuse axonal injury or shearing injury
Work-up:
Labs:
CBC with diff
Comprehensive Metabolic Panel
Coags
Type and cross
Ethanol level
Urine tox

Imaging:
A lateral c-spine and chest x-ray
A CT/CTA head when stable

Alternatives/Additional:
Cerebral angiogram
MRI: If no metal then better for posterior fossa structures and the extent of shearing injuries.

Medications:
Normal Saline/Blood
Tetanus prophylaxis
Seizure Prophylaxis: phenytoin
Broad-spectrum antibiotics
H2 Blocker/PPI: due to propensity for cushing ulcers
Propofol: best agent if intubated
Disposition:

Observation vs. Operating Room

Potrescuscitation GCS is used as a measure
Categorized into 3 levels:
  • Mild injury: 13-15.
  • Moderate injury: 9-12.
  • Severe injury 3-8.
Observation:
No significant lesions on CT scan:
SICU vs. NSICU

Operating Room:
  1. Epidural, subdural, or intracerebral hematoma evacuation;
  2. Remove necrotic brain and prevent further swelling and ischemia;
  3. Control an active hemorrhage