Penetrating head injury.

Penetrating head injuries are a significant public health problem in the United States, with an estimated 33,000 gun-related deaths and many more nonfatal shootings per year. Initial treatment for a penetrating head injury is similar to that of a closed head injury. That is, all efforts must be made to prevent any secondary insults, hypoxia, or ischemia. This translates into the standard methodology of care of the trauma patient. The basic neurologic examination consists of using the Glasgow Coma Score and estimation of pupillary function and some estimation of brain stem function and motor power. The radiologic test of choice for a penetrating head injury is the computed tomography scan. There are several indications for surgery: the patient's condition will be improved or significant neurologic sequelae will be averted; the patient is sufficiently stabilized from any other injuries such that he or she can tolerate surgery; the condition of the patient is not so poor that surgery will have no effect; and the area of penetration is reasonably accessible to surgical intervention. Three main goals of medical management of a penetrating head injury include (1) control of hypertension, (2) maintenance of adequate cerebral circulation oxygenation, and (3) prevention of secondary complications. Outcome after a penetrating head injury is related to the extent of brain tissue damage caused either directly or indirectly by the missile as well as any indirect insults. The most significant indicator, particularly in terms of survival versus death, has consistently been the patient's presenting neurologic status. Some investigators have recommended that a patient presenting with a Glasgow Coma Scale Score of > 5 should not be treated. Others have said that patients with a low coma score and transventricular gunshot wounds should not be treated because of the high mortality. If the patient survives a penetrating head injury, he or she generally goes on to experience a relatively good functional outcome. Only if all components of a good treatment regimen are in place will patients and their families obtain the best possible outcome.