Evaluation of gunshot wounds in the emergency department

BACKGROUND: 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.
METHODS: 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 theTrauma and Injury Severity Score (TRISS) probability of survival for penetrating trauma were calculated for all patients.
RESULTS: 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.
CONCLUSION: 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%.

Acil serviste ateþli silah yaralanmalarýnýn analizi

AMAÇ: Bu çalýþmada, acil servise ateþli silah yaralanmasý nedeniyle baþvuran hastalarýn yaralanma özellikleri, görüntüleme yöntemlerinin sonuçlarý, tedavi türleri, sonlaným, ölüm ve komplikasyon oranlarý araþtýrýldý.
GEREÇ VE YÖNTEM: Bu geriye dönük tanýmlayýcý çalýþmaya 1 Ocak 1999 ile 31 Aralýk 2013 tarihleri arasýnda Hacettepe Üniversitesi Eriþkin Acil Servisi’ne ateþli silah yaranmasý nedeniyle getirilen 142 hasta alýndý. Tüm hastalar için Glaskow Koma Skalasý (GKS), Revize Travma Skoru (RTS), Yaralanma Ciddiyet Skoru (ISS) ve penetran yaralanmalarda Travma ve Yaralanma Ciddiyet Skoru ve Saðkalým Olasýlýðý (TRISS) oranlarý hesaplandý.
BULGULAR: Çalýþmaya alýnan 142 hastanýn 128’i (%90.1) erkekti. Ortalama yaþ 36 olarak hesaplandý. Baþvuru anýnda ortalama GKS skoru 13, ortalama RTS 6.64, ortanca ISS 5 ve ortanca TRISS penetran travma için sað kalým olasýlýðý %99.4 hesaplandý. FAST ile hastalarýn üçünde (%13) karýn içi serbest sývý saptanýrken abdomen bilgisayarlý tomografi (BT) ile hastalarýn 11’inde (%58) solid organ ve baðýrsak yaralanmasý saptandý. Direkt akciðer grafisi ile bir hastada hemotoraks saptanýrken, toraks BT ile 10 (%40) hastada pnömotoraks, hemotoraks ve akciðer yaralanmasý tespit edildi. Çalýþmada 24 hasta hayatýný kaybetti; 18 (%75) hastada izole intrakraniyal yaralanma, iki (%8.3) hastada baþ boyun yaralanmanýn eþlik ettiði toraks yaralanmasý, dört (%16.7) hastada karýn içi organ yaralanmasý (bir hastada kraniyal yaralanma eþlik ediyordu) bulunuyordu. Acil servise 10 hasta kardiyopulmoner arrest olarak getirildi. Hayatýný kaybeden hastalarda GKS, RTS ve TRISS yaþayan hastalara göre anlamlý derecede düþük, ISS ise anlamlý derecede yüksek saptandý. Hayatýný kaybeden hastalarýn 23’ü (%95.8) ISS’ye göre kritik yaralanma düzeyine (ISS 25–75, aralýðýnda ve ISS >50) sahipti.
TARTIÞMA: Ateþli silahlara baðlý kraniyal yaralanmalarda mortalite düzeyleri çok yüksektir. Acil servise arrest olarak getirilen hastalarda spontan geri dönüþ görülmemektedir. Kurþuna baðlý iç organ hasarý tahmin edilenden daha fazla olmaktadýr. Toraks ve abdomendeki ateþli silah yaralanmalarýnda direkt grafiler ve FAST tanýda yetersiz olabilmektedir. Bu nedenle bu hastalarda ölümcül olan yaralanmalarýn erken dönemde tespit edilmesi için toraks ve abdomen BT istemi erken dönemde planlanmalýdýr. Yaralanma Ciddiyet Skoru, RTS ve GKS prognoz ve mortaliteyi öngörmede yaralýdýr. Özellikle ISS >50 olgularda mortalite oraný %96’ya kadar yükselmektedir.