Brain and body: Early decision making and outcomes for multiply injured patients with penetrating brain injury.

Abstract

For patients presenting with gunshots to the head and injuries to the neck or torso, head computed tomography (CT) provides essential information for prognosticating and managing brain injury but may delay hemorrhage (HRH) control. We hypothesized that use of preoperative head CT would be common, and clinicians would prioritize neuroimaging over prompt HRH control in patients with multiple penetrating injuries at high risk for HRH. Using a statewide trauma database to identify patients who sustained gunshot wounds (2017-2021) with both penetrating brain injury and penetrating neck or torso injury, patients were characterized as high risk for HRH if they had systolic blood pressure <90 mm Hg, received ≥3 U of packed red blood cell every 4 hours, or required a massive transfusion protocol. Suspected severe traumatic brain injury was defined as Glasgow Coma Scale score of 3, or Glasgow Coma Scale score of ≤8 and abnormal pupils. We compared patient characteristics and outcomes using descriptive statistics. Of 1,094 patients, 428 (39.1%) were HRH. Of these, 287 (67.0%) went to CT from the trauma bay, and 91 (21.2%) went to the operating room (OR). Furthermore, 56.2% of HRH patients who went directly to the OR survived compared with 44.1% who went to CT prior to OR and 16.7% with CT only (p < 0.001). Of the 344 HRH patients (80.4%) who died, having a CT scan and no operation (25.4%) was associated with higher rates of organ donation. For the 84 HRH patients (19.6%) who survived, operative intervention was associated with better motor functional status at discharge. Patients with penetrating injury to the brain and torso often went to CT before the OR, even with high risk of HRH. Having a CT scan without any operation may result in increased organ donation, while forgoing imaging may decrease mortality and improve motor function at discharge. Decision making remains a challenge for these complex patients, but trauma surgeons should prioritize prompt intervention when feasible. Therapeutic/Care Management; Level IV.