Improving Survival Rates after Civilian Gunshot

Wounds to the Brain

Bellal Joseph, MD, FACS, Hassan Aziz, MD, Viraj Pandit, MD, Narong Kulvatunyou,
Terence OKeeffe, MB, ChB, FACS, Julie Wynne, MD, FACS, Andrew Tang, MD, FACS,
Randall S Friese, MD, FACS, Peter Rhee, MD, FACS

MD, FACS,

Gunshot wounds to the brain are the most lethal of all firearm injuries, with reported survival
rates of 10% to 15%. The aim of this study was to determine outcomes in patients with
gunshot wounds to the brain, presenting to our institution over time. We hypothesized
that aggressive management can increase survival and the rate of organ donation in patients
with gunshot wounds to the brain.
STUDY DESIGN: We analyzed all patients with gunshot wounds to the brain presenting to our level 1 trauma
center over a 5-year period. Aggressive management was defined as resuscitation with blood
products, hyperosmolar therapy, and/or prothrombin complex concentrate (PCC). The
primary outcome was survival and the secondary outcome was organ donation.
RESULTS:
There were 132 patients with gunshot wounds to the brain, and the survival rates increased
incrementally every year, from 10% in 2008 to 46% in 2011, with the adoption of aggressive
management. Among survivors, 40% (16 of 40) of the patients had bi-hemispheric injuries.
Aggressive management with blood products (p 0.02) and hyperosmolar therapy (p 0.01)
was independently associated with survival. Of the survivors, 20% had a Glasgow Coma Scale
score  13 at hospital discharge. In patients who died (n 92), 56% patients were eligible for
organ donation, and they donated 60 organs.
CONCLUSIONS: Aggressive management is associated with significant improvement in survival and organ
procurement in patients with gunshot wounds to the brain. The bias of resource use can
no longer be used to preclude trauma surgeons from abandoning aggressive attempts to
save patients with gunshot wound to the brain. (J Am Coll Surg 2014;218:58e65.

2014 by the American College of Surgeons)

BACKGROUND:

Because of the high mortality rate in this group, aggressive

management is often withheld in patients who arrive at the
trauma center with a low Glasgow Coma Scale (GCS) score
(3 to 5) or with bi-hemispheric head injuries in order to
preserve precious resources.5,6 However, over the last 30 years,
advances in surgical techniques, resuscitation patterns, and
critical care inpatient management have resulted in marked
reduction in mortality and morbidity in patients admitted
to hospitals with traumatic brain injury.7,8 Recent reports
comparing survival in military vs civilian patients with
gunshot wound to the brain, have shown higher survival rates
with aggressive operative management and intracranial
monitoring.9 Recently, gunshot wounds to the brain came
to national and international attention on January 8, 2011,
when US Congresswoman Gabrielle Gifford was shot in
the brain. Her successful recovery highlights the need for
evidence-based treatment algorithms for management of
patients with gunshot wound to the brain.7
At our institution, starting in 2008, we implemented
the policy of aggressively resuscitating all patients with

Gunshot wounds to the brain are the most lethal of

all firearm injuries, with reported survival rates of only
7% to15%.1 According to the literature, about 90% of
the time, the victims die before arriving at the hospital.2,3
For victims who survive and make it to the hospital,
about 50% die in the emergency room.2,3 Each year in
the United States, there are an estimated 70,000 victims
of gunshot wound, resulting in 30,000 deaths.4 The
high morbidity and mortality of gunshot injuries to the
brain, impose a staggering burden on hospitals, families,
court systems, and society.
Disclosure Information: Nothing to disclose.
Received July 26, 2013; Revised August 20, 2013; Accepted August 27,
2013.
From the Division of Trauma, Critical Care, Emergency Surgery, and
Burns, Department of Surgery, University of Arizona, Tucson, AZ.
Correspondence address: Bellal Joseph, MD, FACS, University of Arizona,
Department of Surgery, Division of Trauma, Critical Care, Emergency
Surgery, and Burns, 1501 N Campbell Ave, Room No. 5411, PO Box
245063, Tucson, AZ 85724. email: bjoseph@surgery.arizona.edu

2014 by the American College of Surgeons

Published by Elsevier Inc.

58

ISSN 1072-7515/13/$36.00
http://dx.doi.org/10.1016/j.jamcollsurg.2013.08.018

Vol. 218, No. 1, January 2014

Joseph et al

Abbreviations and Acronyms

AIS
GCS
INR
PCC
SBP

Abbreviated Injury Scale

Glasgow Coma Scale
international normalized ratio
prothrombin complex concentrate
systolic blood pressure

gunshot wound to the brain, irrespective of their admission

GCS score, because outcomes in these patients are often
not predictable, especially in the early stages of care. The
aim of this study was to determine outcomes in patients
with gunshot wound to the brain presenting to our institution over time. We hypothesized that aggressive management can increase survival and the rate of organ donation
in patients with gunshot wound to the brain.

METHODS
After the approval from the Institutional Review Board
(IRB) at the University of Arizona, we performed a 5-year
(January 2007 through December 2011) retrospective
analysis of all the patients with gunshot wound to the head
presenting to our level 1 trauma center. Patients with only
gunshot wound to the brain were included. We defined
gunshot wound to the brain as projectile penetrating the
dura with injury to the brain tissue. Patients with gunshot
wound to the face and head without brain penetration
were excluded from this study.
We reviewed the patients electronic medical records
and collected the following data points: age, sex, mode
of injury (suicide, homicide, or accident), pattern of brain
injury (uni-hemispheric or bi-hemispheric), time in the
emergency department, and vital signs on presentation:
systolic blood pressure (SBP); heart rate; temperature;
Glasgow Coma Scale (GCS) score; laboratory parameters
on presentation, which included international normalized
ratio (INR) and platelet count; volume of crystalloid and
blood products (packed red blood cells, platelets, fresh
frozen plasma, and cryoprecipitate) received in the during
the first 24 hours of admission; use, duration, and type of
vasopressors; neurosurgical intervention details (craniotomy, craniectomy, intracranial pressure monitor); time
to neurosurgical intervention; hospital and ICU length
of stay; discharge disposition; GCS on discharge; organ
donation details; and in-hospital mortality. The Injury
Severity Score (ISS) and the abdominal Abbreviated Injury
Scale (AIS) score were obtained from the trauma registry.
At our institution, a change in clinical practice was
established in 2008. Although there was no strict protocol
for management of patients with gunshot wound to the
brain, the trauma surgeons practiced aggressive resuscitation for all patients with gunshot wound to the brain,

Survival after Gunshot Wounds to the Brain

59

irrespective of the pattern of head injury and the GCS on

presentation. This change was implemented and has
become a standard of practice at our institution. Aggressive
management was defined as resuscitation with 1 or more of
the following: blood products, hyperosmolar therapy, vasopressors, and/ or prothrombin complex concentrate (PCC).
Blood product resuscitation was defined as the units of
packed red blood cells, of fresh frozen plasma, and of
platelets administered. Hyperosmolar therapy was defined
as resuscitation with hypertonic saline. For factor replacement, we used 3-factor PCC (Profilnine SD, Grifols Biologicals) at a dosage of 25 units/kg. Vasopressor support
was defined as use of vasopressin, dopamine, epinephrine,
or norepinephrine. Aggressive management was based on
the principles of damage control resuscitation, which was
composed of the following: early use of blood products,
1:1 ratio of pack red blood cells: fresh frozen plasma,
early use of hypertonic saline, and factor replacement
for treatment of coagulopathy.
Coagulopathy was defined by an INR  1.5. Neurosurgical intervention was defined as craniotomy or craniectomy, and time to neurosurgical intervention was
defined as the time from admission to the emergency
department to the start of the skin incision.
The primary outcomes measure of our study was
survival after gunshot wound to the brain over time.
The secondary outcomes measure was organ donation.
We defined organ donation as patients who donated
only solid organs.
Data are reported as mean  standard deviation (SD)
for continuous variables, proportions as nominal variables, and as median (range) for ordinal variables. We
performed the Students t-test to assess differences
between the 2 groups for parametric variables and
Mann Whitney U test for nonparametric variables.
Chi-square test was performed to compare differences
between the 2 groups for ordinal and nominal variables.
To compare change in survival rate and rate of organ
donation over the years, we used the 1-way analysis of
variance (ANOVA) and post hoc analysis. A univariate
analysis was performed to assess factors associated with
survival. Factors with a p value  0.2 were used in
a multivariate logistic regression model to identify independent factors associated with survival after gunshot
wound to the brain. A p value  0.05 was considered
significant. We used the Statistical Package for Social
Sciences (SPSS, version 20; SPSS, Inc) for data analysis.

RESULTS
A total of 132 patients with gunshot wounds to the brain
were included; 30.3% (n 40) of these patients survived.

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Survival after Gunshot Wounds to the Brain

Mean age was 32.5  17.5 years, 86% were male, 60% had
bi-hemispheric injuries, mean SBP was 94  45 mmHg,
median GCS score was 5 (range 3 to 8), and the median
head AIS was 5 (range 4 to 6). Survivors had a lower
head AIS (p 0.001), higher GCS (p 0.001), higher
SBP on admission (p 0.001), and a lower INR on
presentation (p 0.01) compared with patients who did
not survive. Table 1 demonstrates the demographic differences between survivors and nonsurvivors.
The overall 5-year survival rate was 30.2% (40 of 132).
One hundred seven patients presented with a GCS  8
on presentation; 18% (n 24) patients survived.
Survival rates increased yearly, from 10% in 2008 to
46% in 2011 (p 0.01). Even after excluding patients
with GCS  13 on presentation, survival rates increased
significantly, from 4.7% in 2007 to 41.6% in 2011. On
subanalysis of patients with GCS of 3 to 5 on presentation, survival rates increased from 0% in 2007 to 23%
in 2011 (p 0.01). Figures 1A and 1B highlight the
increase in survival rate in patients with gunshot wound
to the brain.
Use of blood products (p 0.05), hyperosmolar
therapy (p 0.03), and use of PCC (p 0.06) were
higher in the patients who survived. There was no difference in the use of vasopressors between the 2 groups
(p 0.7). Vasopressin was the most common vasopressor
used in both the groups. Table 2 shows the differences in
aggressive management between survivors and nonsurvivors. The use of aggressive management increased from
30% in 2008 to about 70% in 2011. Figure 2 highlights
the increase in aggressive management over the years.
Table 1.

Patient Characteristics

Characteristic

Age, y, mean  SD
Male, n (%)
Gunshot wound, n (%)
Bihemispheric
Unihemispheric
Mode of injury, n (%)
Suicide
Homicide
Craniotomy, n (%)
ISS, median (IQR)
Head AIS score, median (IQR)
GCS, median (IQR)
SBP, mean  SD
Mean INR

Survivors
(n 40)

Nonsurvivors
p
(n 92)
Value*

28  12
32 (80)

37  23
82 (89)

16 (40)
24 (60)

63 (58)
29 (17)

0.1
0.7
0.01

0.02
10 (25)
59 (64)
27 (67)
31 (34)
17 (40)
3 (3)
16 (9e25) 23 (23e25)
4 (3e5)
5 (5e6)
8 (3e11) 3 (3e5)
110  26
79  68
1.4  0.5 1.6  1.1

0.001
0.001
0.001
0.001
0.001
0.01

*p  0.05 significant.
AIS, Abbreviated Injury Scale; GCS, Glasgow Coma Scale; INR, international normalized ratio; IQR, interquartile range; ISS, Injury Severity Score;
SBP, systolic blood pressure.

J Am Coll Surg

Neurosurgical intervention was performed in 20

patients; 85% (n 17) of these survived. The mean
time (SD) to emergent neurosurgical intervention was
30  25 minutes. Overall craniotomy rates remained
constant (p 0.1) through the study periods (15%).
Figure 3 shows rate of neurosurgical intervention and
survival over the years.
Table 3 demonstrates the results of univariate and multivariate analyses for factors associated with survival. Aggressive management with blood products (p 0.02),
hyperosmolar therapy (p 0.01), and operative neurosurgical intervention (p 0.04) were independent predictors
for survival. Glasgow Coma Scale score on presentation
(p 0.4) and pattern of head injury (p 0.1) were not associated with survival. The extent of head injury (p 0.01)
was negatively associated with survival in patients with
gunshot wound to the brain.
Table 4 highlights the GCS at discharge in the patients
who survived. Of the survivors who presented with
a GCS of 3 to 5 on presentation (n 12), 18% were discharged from the hospital with a GCS >8. At the time of
hospital discharge, 20% patients had a GCS  13 and
57% had a GCS  9. The mean hospital and ICU
lengths of stay were 21  8 days and 18  4 days,
respectively.
Of the patients who died (n 92), 56% (n 51) were
eligible for organ donation; 24 of these patients donated
a total of 60 solid organs. The conversion rate was 47%
(24 of 51). The overall rate of organs procured per donor
was 2.5. Despite the increase in survival rates, the number
of eligible donors remained the same (p 0.09), but the
number of organs procured increased from 1.3 per donor
in 2008 to 2.8 per donor in 2011 (p 0.02). Figure 4
demonstrates the increase in organs procured per donor
over the years. Table 5 shows the organs procured from
nonsurvivors.

DISCUSSION
Gunshot wounds to the brain can be lethal. In this study,
we showed an increasing survival rate over a 5-year period
in patients with gunshot wound to the brain. This
increase in survival was associated with the adoption of
policy regarding aggressive resuscitation in all patients
presenting with gunshot wound to the brain. Resuscitation with blood products and hyperosmolar therapy
were independently associated with survival. This change
in attitude and policy has resulted in a steady incremental
increase in survival from 10% in the initial year of study
to 46% during the last year of this study. The change
in policy included that a low GCS and presence of
bi-hemispheric injuries should not preclude aggressive

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Survival after Gunshot Wounds to the Brain

61

Figure 1. (A) Survival rates, all patients; (B) Survival rates, Glasgow Coma Scale 3 to 5.

management. The increase in survival rate will surely level

off and we will continue to obtain the data to determine
at what survival rate it will reach a steady state.
Current neurosurgical literature often advocates no
aggressive fluid or surgical management in patients with
low GCS on presentation.10-12 Aldrich and colleagues10
found that the initial GCS is the strongest predictor of
mortality in patients with gunshot wound to the brain.
Clark and associates11 concluded that patients with
a GCS of 3 on presentation invariably die, regardless of
Table 2.

Aggressive Resuscitation

Resuscitation

Blood products
Hyperosmolar therapy
Vasopressor

Survivors
(n 40), n (%)

Nonsurvivors
(n 92), n (%)

p
Value

23 (57)
21 (53)
16 (41)

32 (34)
28 (31)
32 (35)

0.05
0.03
0.6

aggressive fluid or surgical management. Martin and

coworkers12 did not recommend surgical therapy in
patients presenting with a penetrating gunshot wound
to the brain and a low GCS in the absence of hematoma
causing a mass effect. So, in contrast to our policy, the
standard of care in this subset of patients with a low
GCS on presentation was to forgo aggressive fluid and
surgical management.
Rosenfeld13 reported a survival rate of 8% in patients with
gunshot wound to the brain with a presenting GCS of 3 to 5;
Kennedy and coworkers14 reported a survival rate of 9% in
patients with an admission GCS of 3 to 5. In this study,
the survival rate was 28% in patients presenting to our
trauma center with a GCS score of 3 to 5 and 22% in
patients with bi-hemispheric injuries.
Additional changes in policy included the aggressive
use of blood and blood products to resuscitate while

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Survival after Gunshot Wounds to the Brain

J Am Coll Surg

Figure 2. Aggressive management trends. PCC, prothrombin complex concentrate; PRBC, packed red blood cells.

minimizing crystalloid use. Initial resuscitation followed

the principles of damage control resuscitation except for
permissive hypotension.15 We did, however, use the
concept of early blood products, minimization of crystalloids, and drug therapy to help reverse coagulopathy. This
study also found that use of hyperosmolar therapy was
associated with a survival benefit in patients with gunshot
wound to the brain. In the literature, hypertonic saline
use has shown to be effective in promoting long-term
neuronal survival and behavioral recovery. The use of

hypertonic saline in patients with traumatic brain injury

offers the important benefit of facilitating an increase in
intravascular volume while reducing intracranial pressure,
without potentially causing or exacerbating hypotension.16 DuBose and colleagues16 recently reported a trend
toward improved survival in patients with severe traumatic brain injury who were treated with 5% hypertonic
saline. The advantage of using hypertonic saline is that it
recruits fluid into the intravascular space and resuscitates
as well as decreasing intracranial pressure; this allows for

Figure 3. Craniotomy rates.

Joseph et al

Vol. 218, No. 1, January 2014

Table 3.

Survival after Gunshot Wounds to the Brain

63

Univariate and Multivariate Analyses of Patients Who Survived

Variable

Odds ratio

Age
Male sex
Bi-hemispheric brain injury
Hypotension (SBP <90 mmHg)
Tachycardia (HR >100 beats/min)
Hypothermia (temperature <36.6 C)
GCS  8
Coagulopathy (INR >1.5)
ISS
Head AIS
Hyperosmolar therapy
Blood products
Vasopressors
Neurosurgical intervention

1.3
1.6
0.6
0.7
1.1
1.6
0.7
0.3
0.8
0.5
1.8
1.6
1.6
1.4

Univariate
CI 95%

1.1e1.8
0.9e4.2
0.2e0.9
0.1e0.8
0.9e1.8
1.3e2.5
0.6e0.9
0.1e0.8
0.4e0.9
0.1e0.9
1.4e3.6
1.2e1.8
1.4e3.1
1.1e1.8

p Value

Odds ratio

0.04*
0.2*
0.02*
0.01*
0.4
0.3
0.04*
0.01*
0.01*
0.01*
0.01*
0.02*
0.5
0.01*

1.1
1.6
1.2
1.2
e
e
1.3
1.3
0.4
0.2
1.4
1.2
e
1.2

Multivariate
CI 95%

0.7e1.4
0.4e3.1
0.7e2.4
1.4e2.8
e
e
0.4e1.9
0.7e3.1
0.1e0.5
0.1e0.7
1.2e3.2
1.1e2.1
e
1.1e2.4

p Value

0.2
0.4
0.1
0.09
e
e
0.4
0.6
0.03*
0.01*
0.01*
0.02*
e
0.04*

*p Value is significant.
AIS, Abbreviated Injury Score; GCS, Glasgow Coma Scale; HR, heart rate; INR, international normalized ratio; ISS, Injury Severity Score; SBP, systolic
blood pressure.

minimization of crystalloid fluid, which is consistent with

the popular new method of damage control resuscitation,
in which one of the goals is to minimize crystalloid use.17
In our study, an important component of aggressive
management was correction of coagulopathy. Coagulopathy and traumatic brain injury are a deadly combination,
and rapid correction of coagulopathy in such patients
may provide better outcomes. Early and rapid correction
of traumatic coagulopathy may lead to reduced bleeding,
lower transfusion requirements, and improved survival.18
Dickneite and coauthors19 reported increased survival in
trauma patients after the use of PCC. At our institution,
we routinely use PCC as an adjunct for reversal of coagulopathy during the acute phase of trauma resuscitation.
We believe that PCC can be an effective therapy for
reversal of coagulopathy in patients with fatal gunshot
wound to the brain; however, further research assessing
the utility and cost effectiveness of PCC in trauma
patients is required.
Many authors agree that surgical treatment should not
be offered to patients with a GCS score of 3 and fixed
and dilated pupils with no extra-axial hematomas.11,20
Others believe that patients who suddenly deteriorate or
Table 4.

Discharge Glasgow Coma Scale Score

Discharge Glasgow Coma Scale score

3e5
6e8
9e12
13e15

8
9
15
8

20
23
37
20

who have evidence of mass effect from intracranial collections on CT scans should have immediate surgery.21,22 The
difficulty arises in identifying patients who could be saved,
and those for whom early debridement will reduce the
morbidity associated with the presence of necrotic tissue
and edema along the track of the bullet. Recent military
experience had better outcomes compared with the civilian
experience, and the military also had higher intraoperative
craniotomy rates.9 However, the data from this study show
that although there was a significant increase in survival,
the frequency of operative therapy remained constant.
Valadka and colleagues23 concluded that a selected population of patients with gunshot wound to the brain patients
might enjoy outcomes comparable to those with blunt
severe head injury patients if they are treated with the
same aggressive protocols.
Although aggressive management was associated with
improvement in survival in patients with fatal gunshot
wound to the brain, we believe that this is one of the
many factors associated with better outcomes at our institution. The dedication and commitment of our trauma
surgeons and nursing staff helped us implement and practice aggressive management for all our trauma patients.
Additionally, the practice of not writing off patients because
of their low GCS and mechanism of injury also played an
important part in improving the outcomes. Unfortunately,
none of these factors could be quantified and assessed to
determine their association with improvement in outcomes.
In our study, though the number of potential donors
has declined over the years due to the increased survival
rate, the number of eligible donors did not decrease

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J Am Coll Surg

Figure 4. Organ donation trends.

and the total number of organs procured per donor has

increased every year since adoption of aggressive management. We believe the policy of aggressive management for
all gunshot wounds to the brain has led to an increase in
the number of potential donors and actual donors. The
approach of aggressive management decreases the number
of donors lost from hemodynamic instability and ultimately results in an increase in the number of organs
available for transplantation.24
This increase in survival and in organ donation poses an
ethical issue. At the time of discharge, although some
patients had good neurologic outcomes, there were some
who had poor outcomes. Discharging patients in a vegetative or comatose state is arguably not beneficial to the
patients, their families, or the health care system. Also
aggressive efforts merely to improve organ donation is an
ethical issue without simple answers. However, as medical
care continues to evolve there will be transition points at
which society may be burdened. Of note is that we do
not have long-term functional outcomes, and it is difficult
to know what the ultimate outcome really is. One of the
Table 5.

Organs Procured from Nonsurvivors (n 60)

Organs procured

Lung
Heart
Intestine
Liver
Pancreas
Kidney

86.7
76.7
41.6
63.3
45
80

patients who had a high profile during the last year of

this study survived a through-and-through injury to the
left hemisphere and had improved from a GCS of 9 to
GCS of 15 in 1 year.
Our study does have several limitations. We retrospectively collected and analyzed the data. In addition, our
sample size was small. Because it was a single-center
study, any generalizations between our study population
and those seen at other trauma centers around the United
States may not be valid. Finally, although the standard
practice at our institution is aggressive management, there
is no strict protocol that is followed for aggressive
management including surgical intervention.

CONCLUSIONS
The survival rate increased incrementally over time to
a rate of 46% with early aggressive resuscitation of all
patients with gunshot wounds to the brain regardless of
their presenting clinical picture. Despite the potential
decrease in the number of donors due to the increasing
survival rate, the number of organs donated over time
also increased. The notions of bi-hemispheric injuries as
well as low GCS should not deter the use of resources
to treat and manage these patients.
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