It’s near the end of a 24-hour shift when the call comes. EMS is dispatched to a residence for a 20-something-year-old male who’s reportedly fallen at home while intoxicated and has facial trauma. His family was unable to get him into their private vehicle, so 9-1-1 is called for ambulance transport to the ED of the local rural hospital.
At the scene, the patient is found lying supine on the floor, attended by family members. Upon entering the residence, blood is noted on the floor. The patient tracks the responders’ movement with his eyes as he’s approached.
Figure 1: Location of patient’s injuries
He’s responsive to verbal stimuli, answering questions appropriately, and is alert and oriented to person, place and time. When asked what happened, the patient states that he remembers coming home intoxicated from the bar the night before, then waking up in his home coughing and spitting blood out of his mouth. He has no recollection of what happened after he arrived at home until awakening in the morning.
The patient complains of head and neck pain, which he rates as 9 out of 10 in intensity, so he’s placed in manual spinal precautions. On exam, vitals include a blood pressure of 142/86, pulse of 88, respirations at 20.
There’s a large hematoma to the right side of the face, extending from the right maxilla to slightly above the hairline. The right eye is completely swollen shut with a small trickle of serosanguinous fluid leaking from the medial edge of the eye. The left pupil is round and reactive to light; the right pupil isn’t observable due to the severe swelling. (See Figure 1.)
No bleeding or drainage is noted from the ears. The mouth is normal: All teeth are present and intact, and there are no lacerations, cuts, or other oral trauma noted. A small abrasion running from his lip into his right nostril is noted. There’s also bruising on the right side of the neck.
The patient reports pain to palpation of the cervical spine. There’s dried blood on both hands and covering the patient’s right shoulder. No other trauma is noted on physical inspection. He’s vascularly and neurologically intact and symmetrical in both upper and lower extremities. There’s equal and symmetrical chest rise with clear breath sounds bilaterally. His abdomen is soft and normal upon inspection. The initial impression is of an individual who had fallen while intoxicated, striking his head on the way down, suffering facial trauma and possibly a cervical spinal injury.
The patient is placed in full spinal precautions and moved to the ambulance. A large bore IV is established with a saline lock and 2 mg of morphine is administered for pain en route. He remains alert and oriented throughout transport; vitals are monitored with no significant changes noted.
While completing paperwork in the ED, the medics are interrupted by an excited radiology technician. “Did he say anything about getting shot?!”
While awaiting the formal teleradiology report, the ED physician arranges for transfer to the nearest appropriate referral hospital and the medics repackage the patient for transportation due to craniocerebral trauma from a gunshot wound. (See Figure 2, top.)
The patient spends time in the ICU at the referral hospital, receiving neurosurgical care. His injuries are limited to the facial and frontal lobe trauma; no significant cervical spinal injury is suffered. His subsequent recovery is complicated only by significant depression, for which he receives ongoing care, but he remains neurologically intact following the injury.
The abrasion above the lip was likely the result of the recoiling barrel of the firearm discharging the bullet into the right nare, which was of similar caliber to the bullet. Passage through the medial wall of the orbit and impact with the frontal bone was the cause of the facial trauma observed. The globe of the eye itself was spared. The right-sided neck ecchymosis was due to the dependent movement of the extravasated blood.
Gunshot wounds to the head (GSWH) are among the most lethal firearm injuries. Among civilian GSWH, the vast majority are self-inflicted suicidal actions. Such was the case with this patient, though at the time of the EMS call he didn’t recall the action nor the motivation.
Historically, GSWH survival rates have been approximately 10%; with aggressive management these rates are improving. A recent report shows survival increasing to nearly 50% between 2008 and 2011 in one institution.1 Among factors associated with survival and good functional recovery are younger age, Glasgow coma scale ≥ 5, the presence of pupil reactivity, and a bullet trajectory involving the front of the brain.2–4 Each of these factors was in our patient’s favor. A predictive algorithm for survival and function has been proposed for these injuries.2 (See Table 1.)
Despite the lethality of GSWH, such injuries in the absence of immediate incapacitation—as was the case in this patient—do occur. Most cases have been reported in the context of multiple-shot suicides5,6 or other forensic cases where the distance of the weapon from the body raised questions of possible foul play.7 One case identified on autopsy likely occurred years prior to the individual’s ultimate death from other, unrelated causes.8
The role of routine spinal immobilization in the context of gunshot wounds is controversial. Although spine injuries are common among asymptomatic patients after GSWH,9 studies suggest that routine immobilization isn’t warranted following GSWH in examinable patients without symptoms consistent with spinal injury.10–13
In this case, the patient had symptoms suggestive of cervical spine trauma, so immobilization was clearly indicated.
This case is a reminder that serious traumatic brain injury and open head wounds may not be apparent on initial—or even subsequent—examination. The mechanism of injury, and the energies involved, may be quite different than the patient and witness histories and even initial scene evaluation would indicate. The entry wound may be masked.
In this case, the bullet entered via the nares, which are uncommon orifices into which to insert the gun muzzle in suicide attempts.14 The patient’s mental and neurological exam may underestimate the extent of the intracranial damage, especially in cases of frontal lobe damage such as the present one.
Strict adherence to protocols in managing all cases of head trauma can ensure appropriate patient care even when the severity of the injury turns out to be far more significant than was initially apparent.
It’s also a reminder that survivability in GSWH cases is possible—with increasingly aggressive care, even probable. Diligent and efficient prehospital care is a critical component of the management of these wounds.
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13. DuBose J, Teixeira PG, Hadjizacharia P, et al. The role of routine spinal imaging and immobilisation in asymptomatic patients after gunshot wounds. Injury. 2009;40(8):860–863.
14. Lee KA, Opeskin K. Gunshot suicide with nasal entry. Forensic Sci Int. 1995;71(1):25–31.