In the United States, gunshot wounds (GSW) are now the leading cause of death from TBI; GSW result in more than 33,000 deaths annually. Of these, slightly more than half are from homicide, with most of the remaining suicides. As a bullet passes through the brain, it creates a cavity 3 to 4 times greater than its diameter. The damage, however, is due to more than just the penetration of the bullet. Also involved in a major transfer of kinetic energy of the bullet to the brain matter. The amount
of transferred kinetic energy is dependent on the mass of the missile and the velocity squared (E = 2 mr). The result is that a small increase in bullet velocity results in large increases in energy delivered and resultant damage. The resulting concussive force can damage tissue outside of the bullet's path. (Wound ballistics is discussed in detail in Chap.,.256.)
The prognosis of a patient with a GSW to the brain can be predicted by the GCS if they are not intoxicated. Patients with a GCS of greater than 8, and reactive pupils have a 25 percent mortality risk. Those with a GCS of less than 5 approach 100 percent mortality. All patients with a penetrating GSW to the brain should be intubated and treated with prophylactic antibiotics and anticonvulsants.
Stab wounds have very low energy and impart only direct damage to the area contacted by the penetrating object. Therefore, the morbidity and mortality from these injuries is much less than from those with GSWs. Essentially all patients sustain penetrating injury require operative intervention. Impaled objects should be left in place until surgical removal. Patients should receive broad-spectrum antibiotics and be admitted.
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