Penetrating head injury

Abstract

Managing the patient with a penetrating injury to the brain requires an understanding of the pathophysiologic mechanisms involved in creating these lesions that cause such extensive tissue destruction and continue to have such a poor outcome. This paper summarizes the differences between civilian and military gunshot wounds, the initial management of these patients in the emergency room setting, the indications for surgery, the goals of surgery and postoperative problems such as epilepsy, hydrocephalus, or brain abscesses one might encounter in treating these patients. The goals of surgery in these patients are to control bleeding, evacuate any large hematomas causing mass effect, debride devitalized tissues, and accomplish a meticulous closure of the dura and galea. Removal of every single bullet or indriven bone fragment, on the other hand, is not necessary nor is it often safe. The indications for monitoring intracranial pressure (ICP), how that can be done, and how to treat elevations of ICP, including barbiturate coma, are carefully and clearly reviewed. Special situations like orbitofacial penetrating injuries will require extremely meticulous attention to surgical detail to prevent late complications such as CSF leaks.