Gunshot wounds to the brain are the most lethal of firearm injuries, with survival rates of 10 percent to 15 percent. Because of the high mortality rate, aggressive management often is not given to the most severely injured patients with low outcome scores, said BellalJoseph, MD, UA assistant professor of surgery and the study's lead author.
However, military reports on the use of aggressive operative procedures for gunshot wounds to the brain have shown higher survival rates, Dr. Joseph said.Peter M. Rhee, MD, professor and chief of the UA Division of Trauma, Critical Care, Burn and Emergency Surgery, and the study's senior author, used this aggressive management protocol while serving as a military trauma surgeon in Iraq and Afghanistan.Drawing from these reports and Dr. Rhee's experience, UA researchers at The University of Arizona Medical Center Level I Trauma Center began aggressively resuscitating all patients with gunshot wounds to the brain in 2008.
Irrespective of how they scored on the Glasgow Coma Scale (a neurological scale used to measure levels of consciousness in a person following a brain injury), 132 patients with gunshot wounds to the brain received an aggressive management protocol. The protocol included blood products and hyperosmolar therapy to reduce intercranial pressure, thereby promoting long-term survival and recovery.
"After starting the new resuscitation methods, the survival rates started to improve immediately.
There was an increase year after year and during the last year of the study 46 percent of those patients survived," said Dr. Joseph.
Results of the five-year, single-site study also showed the adoption of aggressive management of gunshot wounds to the brain aided in the preservation of organs in non-survivors, increasing the number of organs procured per donor from 1.3 percent to 2.8 percent.
Dr. Rhee said, "Aggressive management is associated with significant improvement in survival and organ procurement in patients with gunshot wounds to the brain. Low outcome scores and the bias of resource use can no longer be used to preclude trauma surgeons from abandoning aggressive attempts to save these patients."
Study authors acknowledged that an increase in survival and organ donation poses some ethical issues. While some patients had good neurologic outcomes, some were discharged in a vegetative state or in comas. Without long-term functional results, it is difficult to know long-term outcomes of survivors.
This study, funded by the UA Department of Surgery, is one of a number of research efforts by trauma surgeons at the UA Department of Surgery Division of Trauma, Critical Care, Burn and Emergency Surgery. Faculty, fellows and residents in the trauma division have published more than 35 peer-reviewed articles and book chapters this year alone, surpassing any previous year at the UA. Most level I trauma institutions have three or four research articles published annually.
Among the UA projects - and currently under review by top medical journals - are research on the epidemiology of trauma and the tracking of gun-related injuries and death trends.
"Trauma research is really important," Dr. Rhee said. "The successful recovery of U.S. Congresswoman Gabrielle Giffords is an example of the benefit of evidence-based treatments for the management of patients with gunshot wounds to the brain.
"We can impact one person at a time in the hospital, but trauma research impacts millions."
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