Gunshot Wound Patients Research Articles

Geo-demographics of gunshot wound injuries in Miami-Dade county, 2002\u20132012

BackgroundWe evaluated correlates of gunshot wound (GSW) injuries in Miami-Dade County, Florida. Firearm-related injury has previously been linked to socio- and geo-demographic indicators such as occupation, income, neighborhood and race in other metropolitan areas, but remains understudied in Miami.MethodsWe reviewed 4,547 cases from a Level I trauma center’s patient registry involving an intentional firearm-related injury occurring from 2002 to 2012. During this eleven-year study period, this trauma center was the only one in Miami-Dade County, and thus representative of countywide injuries.ResultsThe crude morbidity rate of GSW injury over the 11-year period was 15 per 100,000 persons with a crude mortality rate of 0.27 per 100,000 persons. The case fatality rate of injured patients was 15.4%. Both morbidity and mortality increased modestly over the 11-year study period. The total number of GSW patients rose annually during the study period and patients were disproportionately young, black males, though we observed higher severity of injury in white populations. Geo-demographic analysis revealed that both GSW incident locations and patient home addresses are spatially clustered in predominantly poor, black neighborhoods near downtown Miami, and that these patterns persisted throughout the study period. Using spatial regression, we observed that census tract-level GSW incidence rates (coded by home address) were associated with a census tract’s proportion of black residents (P < .001), single-parent households (P < .001), and median age (P < .001) (R2 = .42).ConclusionsThese findings represent the first representative geo-demographic analysis of GSW injuries in Miami-Dade County, and offer evidence to support urgent, targeted community engagement and prevention strategies to reduce local firearm violence.

Selective nonoperative management of abdominal gunshot wounds with isolated solid organ injury

ObjectiveTo review selective nonoperative management (SNOM) of gunshot wound (GSW) patients with isolated abdominal solid organ injury. MethodsPatients who sustained isolated solid organ injury secondary to GSW from 2003 to 2014 were studied. The use of SNOM over time was analyzed, and comparisons of initial SNOM and operative management (OM) groups were performed. ResultsOf 127 patients, 63 (50%) underwent SNOM. There were no significant differences between the early/late or SNOM/OM groups in demographics, physiologic presentation, or Injury Severity Score. SNOM increased from the early to late cohorts (31%–67%, p < 0.001), without any change in outcomes. SNOM patients had shorter hospital stays (5.8 vs. 10.0 days, p < 0.001), received fewer PRBCs (0.8 vs. 4 units, p < 0.001), and suffered fewer complications (13% vs. 28%, p < 0.05) than the OM group. ConclusionAn increase in SNOM vs. OM was associated with equivalent outcomes. Patients undergoing SNOM received fewer PRBCs and had shorter LOS.

Police transport versus ground EMS: A trauma system-level evaluation of prehospital care policies and their effect on clinical outcomes.

Rapid transport to definitive care ("scoop and run") versus field stabilization in trauma remains a topic of debate and has resulted in variability in prehospital policy. We aimed to identify trauma systems frequently using a true "scoop and run" police transport approach and to compare mortality rates between police and ground emergency medical services (EMS) transport. Using the National Trauma Databank (NTDB), we identified adult gunshot and stab wound patients presenting to Level 1 or 2 trauma centers from 2010 to 2012. Hospitals were grouped into their respective cities and regional trauma systems. Patients directly transported by police or ground EMS to trauma centers in the 100 most populous US trauma systems were included. Frequency of police transport was evaluated, identifying trauma systems with high utilization. Mortality rates and risk-adjusted odds ratio for mortality for police versus EMS transport were derived. Of 88,564 total patients, 86,097 (97.2%) were transported by EMS and 2,467 (2.8%) by police. Unadjusted mortality was 17.7% for police transport and 11.6% for ground EMS. After risk adjustment, patients transported by police were no more likely to die than those transported by EMS (OR = 1.00, 95% CI: 0.69-1.45). Among all police transports, 87.8% occurred in three locations (Philadelphia, Sacramento, and Detroit). Within these trauma systems, unadjusted mortality was 19.9% for police transport and 13.5% for ground EMS. Risk-adjusted mortality was no different (OR = 1.01, 95% CI: 0.68-1.50). Using trauma system-level analyses, patients with penetrating injuries in urban trauma systems were found to have similar mortality for police and EMS transport. The majority of prehospital police transport in penetrating trauma occurs in three trauma systems. These cities represent ideal sites for additional system-level evaluation of prehospital transport policies. Prognostic/epidemiologic study, level III.

Cervical spine immobilization may be of value following firearm injury to the head and neck

BackgroundPenetrating injuries to the head and neck may not be able to cause unstable fractures without concomitant spinal cord injury, rendering prehospital spinal immobilization (PHSI) ineffectual, and possibly harmful. However, this premise is based on reports including predominantly chest and abdominal injuries, which are unlikely to cause cervical spine (CS) injuries. MethodsWe performed a retrospective review of all patients presenting with a penetrating wound to the head or neck over a 4-year period at an urban, level 1 trauma center to determine if there was a benefit of PHSI. ResultsOne hundred seventy-two patients were identified, of which 16 (9.3%) died prior to CS evaluation. Of 156 surviving patients, mechanism was gunshot wound (GSW) in 36 (28%) and stab wound (SW) in 120 (72%). Fifty-eight patients had PHSI placed (37%), and GSW patients' odds of having PHSI were greater than SW patients (OR 2.3; CI 1.08-4.9). Eight of 156 surviving patients eventually died (5.1%), and the odds of mortality were greater among those that had PHSI than those without (OR 5.54; CI 1.08–28.4). Six (3.8%; 5 GSW, 1 SW) patients had a CS fracture. Two GSW patients (5.6%) had unstable CS fractures with a normal neurological exam at initial evaluation. ConclusionsOf patients with a GSW to the head or neck that survived to be evaluated, 5.6% had unstable fractures without an initial neurologic deficit. PHSI may be appropriate in this population. Further studies are warranted prior to a determination that PHSI is unnecessary in penetrating head and neck injuries.

Factors affecting survival following self-inflicted head and neck gunshot wounds: a single-centre retrospective review

Self-inflicted head and neck gunshot wounds are a common modality of suicide in the USA. This study reviewed all self-inflicted head and neck gunshot wound patients with complete records (n=157) treated at a tertiary centre between 2002 and 2012 inclusive. The associations between mortality and patient/clinical variables were evaluated with the χ2 test or Fisher's exact test for statistical difference testing. Outcomes recorded were death (n=92, 59%), discharge to long-term care/rehabilitation (n=58, 37%), and discharge home (n=7, 4%). The majority of patients were male (86.6%) and single/separated/divorced (55.5%). The mortality rate by site, in descending order, was temporal 82%, frontal scalp 69%, submental/intraoral 30%, and neck 25%. Involvement of the central nervous system (n=127) resulted in a 70% mortality, but a lower mortality was observed among patients with an avulsion injury (P=0.025). A tracheostomy within 24h of admission was statistically associated with improved survival (P<0.001), but confounding factors were found. Multivariate analysis revealed increasing age, temporal entry site, and the severity of central nervous system involvement to be positively associated with an increased mortality.

Long-term mortality of patients surviving firearm violence

ObjectiveWe aim to calculate the 5-year mortality after surviving to hospital discharge after a firearm injury and estimate the association of firearm injury with later mortality.MethodsWe performed a retrospective cohort...

Evaluation of gunshot wounds in the emergency department.

This study aimed to evaluate injury patterns of patients admitted to the emergency department with gunshot wounds, results of imaging studies, treatment modalities, outcomes, mortality ratios, and complications. A retrospective descriptive study was carried out including a total number of one hundred and forty-two patients admitted to Hacettepe University Emergency Department with gunshot injuries between January 1, 1999 and December 31, 2013. The Glasgow Coma Scale (GCS), Revised Trauma Score (RTS), Injury Severity Score (ISS), and the Trauma and Injury Severity Score (TRISS) probability of survival for penetrating trauma were calculated for all patients. Among the one hundred and forty-two patients in the study, one hundred and twenty-eight (90.1%) were male. Mean age was 36 years. On admission, the average GCS score was 13, mean RTS was 6.64, median ISS was 5 and median TRISS probability for survival was 99.4% for penetrating trauma. Fluid was detected in three (13%) patients in FAST, whereas intra-abdominal solid organ injury and bowel injury were detected in 11 (58%) patients in abdominal CT. The pneumothorax, hemothorax and lung injuries were detected in 10 (40%) patients, whereas hemothorax was detected only in one patient with thoracic injury by chest X-ray. Twenty four (16.9%) patients died; eighteen patients (75%) had isolated severe intracranial injuries, two (8.3%) had thoracic injuries with head and neck injuries, and four (16.7%) patients had intra-abdominal organ injuries (one with concomitant head injury). Ten patients were brought to the ED in cardiopulmonary arrest. In dead patients, GCS, RTS and TRISS were significantly lower, and ISS were significantly higher than in surviving patients. Twenty three (95.8%) patients were in critical injury level (ISS 25-75, actually ISS >50) in the exitus group. Mortality rates in gunshot wound patients with cranial injuries are very high. Spontaneous return is not seen in patients brought to the ED in arrest state. Bullets can cause internal organ injuries which can be greater than expected. In thoracoabdominal gunshot wound injuries, conventional X-ray and bedside FAST can be ineffective in detecting the whole extent of intrathoracic and intra-abdominal injuries. Thus, thoracic and abdominal CT should be planned early for hemodynamically stable patients in order to eliminate causes of fatality and make a timely and correct diagnosis. ISS, RTS and GCS are useful in predicting prognosis and mortality. Especially in patients with ISS scores >50, the mortality rate can be as high as 96%.

Non-Operative Management of Thoracoabdominal Gunshot Injury: Thirteen Unusual Cases

Background: Recently, the use of a surgical approach in injured patients has begun to be increasingly limited to unstable patients. Advances in imaging techniques and developments in intensive care have increased the applicability of non-operative treatment. Here, we aimed to present our clinical experience with different approaches in some patients. Method: Thirteen inpatients who had thoracoabdominal gunshot injuries but did not undergo emergency surgery between 2009 and 2014 were retrospectively evaluated. Results: Of the patients, nine (69.2%) were male and the mean age was 32.6 ± 9.7 years. The mean trauma-treatment interval was 51.2 ± 15.8 minutes. No surgical procedure was performed in 10 patients, four of whom had tangential injury. Diaphragmatic repair was performed in three patients after stabilization of solid organ injuries. The splenic and liver injuries were allowed to resolve itself through non-operative management, and there was no rush to repair the diaphragm until the splenic and liver recovery occurred. Four patients with tangential injury were shown not to have penetration of the abdominal cavity. Two pregnant patients, one with liver injury and the other with retroperitoneal injury, were successfully treated non-operatively. Conclusions: In centers that provide advanced conditions for emergency surgery, a conservative approach can be performed successfully in selected thoracoabdominal gunshot wound patients, including pregnant patients and those with splenic injuries. Tangential injuries can be managed non-operatively after penetration of cavities is ruled out. When diaphragmatic hernia is accompanied by liver or splenic injury, diaphragmatic repair can be delayed until these injures are restricted themselves. J Curr Surg. 2015;5(4):199-203 doi: http://dx.doi.org/10.14740/jcs281w

Baclofen dosage after traumatic spinal cord injury: A multi-decade retrospective analysis

ObjectivesTo perform an analysis of oral baclofen dosage in patients with traumatic spinal cord injuries over time and to ascertain the clinical determinants of long-term baclofen dosage trends. Study designRetrospective cohort study of patient records from the PM&R units at the Johns Hopkins Bayview Medical Center and the Johns Hopkins Hospital. SubjectsA total of 115 PM&R patients suffering spinal cord injury due to trauma leading to either complete or incomplete paralysis. The modes of injury included were motor vehicle accidents (MVA) (n=39), gunshot wounds (GSW) (n=55), falls (n=17), diving (n=2), workplace (n=1) and swimming (n=1) accidents. The location of injury in the spinal cord was categorized into either cervical (n=52), thoracic (n=59), lumbar (n=2), or unspecified (n=2). ResultsFrom time of injury, an aggregate of all dosage assignments for each patient demonstrated a significant yearly increase in baclofen dosage (1.26mg/year, pˆ<0.01). Baclofen dosage for MVA cases were seen to rise at 4.99mg/year (pˆ<0.0001). Kaplan–Meier analysis revealed that GSW patients received their first baclofen dosage earlier than MVA patients (log-rank pˆ<0.05, unadjusted). ConclusionsWe observed a marginal increase in baclofen dosage over nearly 25 years in a single provider's patient database and observed different timings of first dose between two causes of traumatic SCI. These results provide an estimate of baclofen dosage trends over time after spinal cord injury and may be useful for patient counseling or as a method to assess costs of providing SCI patient care.

Pediatric Head and Neck Gunshot Wounds in the United States: A Cohort Study

Objectives: Study head and neck gunshot wounds (GSW) involving pediatric patients in the United States. Methods: Study Design: Retrospective cohort study. Setting: The KIDS Inpatient Database (KID) years 2003, 2006, and 2009. The subpopulation of pediatric patients 21 years and younger admitted with head and neck trauma due to gunshot wounds were compared with all patients admitted with head and neck traumatic injuries. Univariate and multivariate analysis was completed to evaluate demographics, morbidity, and mortality associated with gunshot wounds to the head and neck. Age, sex, and ethnic disparities were also examined. Results: An estimated 1342 (SE, 100.7) pediatric patients suffered gun shot wounds to the head and neck, 3.2% (SE, 0.19) of all head and neck traumatic wounds. The mean age was 17.1 years (SE 0.12). The population was 88.1 % male (SE, 1.1), 48.2% (SE, 2.9) black, and 10.2% (SE, 1.1) died during their hospitalization. Mean total charges were $70,312 (SE, $4216). When compared with the larger population of pediatric head and neck trauma patients, GSW patients were statistically significantly older, male, black, and living in the lowest income quartile (all P &lt; .01). Additionally, GSW patients had longer hospital stays, higher total charges, and higher mortality rates. These findings held constant when controlling for age, sex, and injury severity/mortality risk. Conclusions: Gunshot wounds to the head and neck are an uncommon but serious injury in pediatric patients. Continued research regarding treatment and prevention is warranted.

Increased mortality associated with EMS transport of gunshot wound victims when compared to private vehicle transport

BackgroundRecent studies suggest that mode of transport affects survival in penetrating trauma patients. We hypothesised that there is wide variation in transport mode for patients with gunshot wounds (GSW) and there may be a mortality difference for GSW patients transported by emergency medical services (EMS) vs. private vehicle (PV). Study designWe studied adult (≥16 years) GSW patients in the National Trauma Data Bank (2007–2010). Level 1 and 2 trauma centres (TC) receiving ≥50 GSW patients per year were included. Proportions of patients arriving by each transport mode for each TC were examined. In-hospital mortality was compared between the two groups, PV and EMS, using multivariable regression analyses. Models were adjusted for patient demographics, injury severity, and were adjusted for clustering by facility. Results74,187 GSW patients were treated at 182 TCs. The majority (76%) were transported by EMS while 12.6% were transported by PV. By individual TC, the proportion of patients transported by each category varied widely: EMS (median 78%, interquartile range (IQR) 66–85%), PV (median 11%, IQR 7–17%), or others (median 7%, IQR 2–18%). Unadjusted mortality was significantly different between PV and EMS (2.1% vs. 9.7%, p<0.001). Multivariable analysis demonstrated that EMS transported patients had a greater than twofold odds of dying when compared to PV (OR=2.0, 95% CI 1.73–2.35). ConclusionsWide variation exists in transport mode for GSW patients across the United States. Mortality may be higher for GSW patients transported by EMS when compared to private vehicle transport. Further studies should be performed to examine this question.

Clinical aspects of ballistic peripheral nerve injury: shrapnel versus gunshot.

Ballistic injuries to peripheral nerves pose special challenges in terms of indications, timing and type of surgical intervention. The aim of the present work was to analyze our experience in the surgical treatment of peripheral nerve ballistic injuries with respect to the mechanism of injury (gunshot versus shrapnel), and identify common and dissimilar prognostic factors in both types of injury. This study was conducted on 42 patients totaling 58 nerves. Twenty-two patients (32 nerves) were injured by gunshot and 20 patients (26 nerves) by shrapnel. Median postoperative follow-up was 33 months (range 12 months to 14 years). Overall postoperative outcome appears to be more favorable for gunshot-wound (GSW) patients than shrapnel-injured patients, especially in terms of neuropathic pain relief (75 % vs. 58 % respectively, p < 0.05). Presence of foreign particles in shrapnel injured patients has a negative impact on the surgical outcome in terms of rate of pain improvement (28 % compared to 67 % in patients with and without foreign particles, respectively). Nerve graft reconstruction, rather than neurolysis, seems to be the more beneficial treatment for shrapnel-induced neuropathic pain (100 % vs. 47 % in improvement rate, respectively). Early surgical intervention (median 2 months after injury) significantly relieved neuropathic pain in 83 % of shrapnel-injured patients compared to 58 % in patients operated later. This study suggests that shrapnel injury is more destructive for nerve tissue than gunshot injury. Our impression is that early surgical intervention in shrapnel injuries and split nerve grafting (especially when small fragments are recognized in the nerve) significantly improve the patient's functional activity and quality of life.

Pre-hospital care of urban gunshot wound patients: a tale of two cities

Pre-hospital care of urban gunshot wound patients: a tale of two cities

Trauma Deserts: Distance From a Trauma Center, Transport Times, and Mortality From Gunshot Wounds in Chicago

We examined whether urban patients who suffered gunshot wounds (GSWs) farther from a trauma center would have longer transport times and higher mortality. We used the Illinois State Trauma Registry (1999-2009). Scene address data for Chicago-area GSWs was geocoded to calculate distance to the nearest trauma center and compare prehospital transport times. We used multivariate regression to calculate the effect on mortality of being shot more than 5 miles from a trauma center. Of 11,744 GSW patients during the study period, 4782 were shot more than 5 miles from a trauma center. Mean transport time and unadjusted mortality were higher for these patients (P < .001 for both). In a multivariate model, suffering a GSW more than 5 miles from a trauma center was associated with an increased risk of death (odds ratio = 1.23; 95% confidence interval = 1.02, 1.47; P = .03). Relative "trauma deserts" with decreased access to immediate care were found in certain areas of Chicago and adversely affected mortality from GSWs. These results may inform decisions about trauma systems planning and funding.

Does payer status matter in predicting penetrating trauma outcomes?

Few data exist regarding payer status as a predictor of outcomes in penetrating trauma. This study determined whether insurance status impacts in-hospital complications and mortality in gunshot and stab wound patients at our inner-city, level I trauma center. Penetrating trauma admissions from 2005 to 2009 were reviewed for patient demographics, insurance, Injury Severity Score, complications, duration of stay, and mortality. A total of 1,347 penetrating trauma patients were admitted with 652 (48.4%) uninsured. Although uninsured patients were more likely to be male (93.3% vs 89.8%, P = .030), there was no difference in age, ISS, or number of radiologic, operative, or interventional procedures. Uninsured patients had lesser intensive care unit (4.4 vs 3.3 days; P = .049) and total hospital length of stay (10.2 vs 8.3; P = .049). No uninsured patients were placed into a rehabilitation facility at the time of discharge (0.0% vs 1.6%, P < .001). There was no difference in frequency of pulmonary complications, thromboembolic complications, sepsis, urinary tract infection, or wound infections. On multivariate analysis, being uninsured was not an independent predictor of in-hospital complications (1.010, 95% confidence interval 0.703-1.450, P = .959) or mortality (odds ratio 0.905, 95% confidence interval 0.523-1.566, P = .722). This is the first study to show that penetrating trauma patients who are uninsured have lesser duration of stay and decreased placement into a rehabilitation facility. Being uninsured added no additional risk of in-hospital complications or mortality.

Mechanisms of injury and treatment principles of gunshot wounds

Gunshot wounds have been an important source of injury for centuries and continue to occur. The military medical communities have developed standard procedural sequences and principles that may assist and serve as references to the care of civilian gunshot wound patients. In addition to the basic understanding of the wounding patterns and potential extent of the damage caused by the ballistic characteristics of the missile, three principles need to be emphasized in the course of the treatment: timely debridement, delivery of antibiotics, and delayed closure of the wound. Despite recent innovations and improvements in medicine, the three principles still stand, and may assist even surgeons with minimal experience in treating gunshot wounds to achieve reliable results. The situation and environment of civilian medical facilities differ from those of the military in war time, and less invasive and more conservative methods may be attempted in accordance with available resources.

Clinical Examination Is Highly Sensitive for Detecting Clinically Significant Spinal Injuries After Gunshot Wounds

The optimal method for spinal evaluation after penetrating trauma is currently unknown. The goal of this study was to determine the sensitivity and specificity of a standardized clinical examination for the detection of spinal injuries after penetrating trauma. After Institutional Review Board approval, all evaluable penetrating trauma patients aged 15 years or more admitted to the Los Angeles County + University of Southern California Medical Center were prospectively evaluated for spinal pain, tenderness to palpation, deformity, and neurologic deficit. During the 6-month study period, 282 patients were admitted after sustaining a penetrating injury; 143 (50.7%) as a result of gunshot wound (GSW) and 139 (49.3%) as a result of stab wound (SW). None of the patients sustaining a SW had a spinal injury. Of the 112 evaluable GSW patients, 9 sustained an injury: 6 with a true-positive and 3 with a false-negative clinical examination. The overall sensitivity, specificity, positive predictive value, and negative predictive value were 66.7%, 89.6%, 46.2% and 95.2%, respectively. For clinically significant injuries requiring surgical intervention, cervical or thoracolumbar spine orthosis, or cord transections, however, the sensitivity of clinical examination was 100.0%, specificity 87.5%, positive predictive value 30.8%, and negative predictive value 87.5%. Clinically significant spinal injury, although rare after SWs, is not uncommon after GSWs. A structured clinical examination of the spine in evaluable patients who have sustained a GSW is highly reliable for identifying those with clinically significant injuries.

Civilian Gunshot Wounds to the Genitourinary Tract: Incidence, Anatomic Distribution, Associated Injuries, and Outcomes

Gunshot wounds (GSW) affecting the genitourinary (GU) system in civilians are uncommon. This study describes the incidence, anatomic distribution, demographics, associated injuries, management, and outcomes after civilian GU GSW. A Level 1 Trauma Center Registry was used to retrospectively identify all patients who sustained GU GSW (January 1997-December 2008). Patient information was abstracted from the Registry, medical, and autopsy records. Multivariate regression detected significant factors associated with mortality. Of 2941 civilian GSW patients, 309 (10.5%) sustained GU injury with/without associated injuries. Mean age was 30.4 ± 11.9 years (range 6.6-80.6 years); 289 patients (93.5%) were male. Mean Injury Severity Score (ISS) 22.2 ± 15.4 (1-75). Incidence of GU GSW increased during the study period. GSW affected the kidneys (55%), scrotum (21%), bladder (19%), testicle (12%), penis (8%), some patients having more than 1 GU organ injured. A total of 284 patients (92%) experienced at least 1 other organ injury. Most GU GSW were managed surgically (mean 2.2 ± 2.0; 0-13 surgeries/patient). There was a 27% (n = 84) overall mortality, with 16% (n = 50) dead on arrival. Mortality and ISS were correlated (P = 0.002; hazard ratio = 3.0; 95% confidence interval 3.0-3.0CI). Large vessel, head/neck, kidney, vascular, heart, lung, spine, and spinal cord injury were statistically significant risk factors for death. GU injury occurred in 10.5% of 2941 civilian GSW patients. Associated injuries were very common, with many cases involving multiple organs. Most injuries (90%) were managed surgically. Mortality is usually the result of associated nongenitourinary injuries. A high index of suspicion for injuries affecting other organs is necessary in managing GU GSW trauma patients.

The Number of Gunshot Wounds Does Not Predict Injury Severity and Mortality

It is presumed that as the number of gunshot wounds (GSWs) increases, so do the Injury Severity Score (ISS) and mortality risk. We hypothesized that the number of bullet wounds relates to ISS and death; however, a single GSW to the head is ominous. We reviewed the charts of all GSW patients admitted to a trauma center from 2004 to 2006 (n = 531). We analyzed patient demographics, ISS, and mortality. There was no correlation with the number of GSWs with either ISS or mortality. There was only a 0.3 per cent increased risk of death for each additional GSW (r2 = 0.12). Patients with a single GSW versus multiple GSWs had no difference in mortality (9.1 vs 8.4%, P = 0.8). A single GSW to the head carried a 50 per cent mortality risk. For those who sustained both head and body GSWs, each additional GSW did not increase mortality (r2 = 0.007). Our study shows that the number of GSWs has no affect on mortality or ISS. Internal triage and management of gunshot victims should not be affected by the categorization of patients as having a single versus multiple GSWs.

Cervical Spine Injury is Highly Dependent on the Mechanism of Injury Following Blunt and Penetrating Assault

The mechanism of injury has not been highly regarded as an important variable when evaluating cervical spine injuries. The aim of this study was to determine the incidence of cervical spine fracture (CSF) and cervical spinal cord injury (CSCI) based on mechanism following blunt and penetrating assault to better aid prioritization of management. Retrospective analysis from two large urban Level I trauma centers over 87 and 144 months caused by gunshot wounds (GSW), stab wounds (SW) or blunt assault (BA). During the study period, there were 57,532 trauma patients evaluated at the two trauma centers, of which 42.3% were following blunt or penetrating assault. The rates of CSF and CSCI for the various mechanisms were similar between the two centers. The rates for having CSF were significantly different (p < 0.05) for the various mechanisms. GSW (1.35%) was the highest followed by BA (0.41%) and then SW (0.12%). The rates of CSCI for GSW (0.94%) were significantly (p < 0.05) higher than BA (0.14%) and SW (0.11%). For GSW patients, all patients with CSF or CSCI had a point of entry between the ears and the nipple. For SW patients, the wound was directly in the neck below the mandible and above the trapezius muscle. Although many of the SW patients also suffered blunt assault, none of the CSF or CSCI injuries were from blunt forces. In addition, all patients, both blunt and penetrating who had CSCI had neurologic deficit at the time of presentation. Surgical stabilization or tongs were applied in 15.5% (26 of 168) of the GSWs, 27.8% (3 of 11) of the SWs and 31.6% (6 of 19) of the BA patients. There was a BA patient (1 of 4,390) patient with CSF that was neurologically intact that required surgical stabilization and this patient had neck pain on admission. No penetrating injury patients with CSCI regained significant neurologic recovery during the hospitalization. The rate of CSF or CSCI is low following assault and dependent on mechanism of injury. Thus the concern and extent of evaluation should also be dependent on the mechanism of injury. Neurologic deficits from penetrating assault were established and final at the time of presentation. Concern for protecting the neck should not hinder the evaluation process or life saving procedures.