2009 Southern Regional Meeting Abstracts

Case Report: There is limited literature on pediatric craniocerebral gunshot wounds. Although rare in children, they are increasing in frequency. The majority of deaths from gunshot wounds occur prior to hospitalization. A series of 30 children with gunshot wounds reported a mortality rate of 20%. While bihemisphetric injuries negatively impact prognosis in children, the outcomes tend to be better than in adults with similar injuries.
KD was a 14 year old female who presented to the emergency room awake, but incoherent, and nonambulatory, complaining of head and neck pain with no recollection of any injury. Her initial Glasgow Coma Scale (GCS) was 12. She was hemi paretic on the right with a right occipital laceration. Cervical spine radiographs, obtained to rule out cervical injury, showed a frontal lobe bullet fragment. She was intubated for airway protection in view of declining mental status. A noncontrasted head CT showed a bullet that trajected from the right occipital region to the left frontal region, diffuse cerebral edema, and intraparenchymal and parafalcine hemorrhage.
Within three hours of admission to the PICU, her GCS decreased to 7T and an external ventricular drain (EVD) was placed. Initial intracranial pressure (ICP) was 25. Medical management consisted of sedation, hypertonic saline, controlled, mild, hyperventilation, and normothermia. Within three days, ICP’s gradually decreased to 10 and the EVD was clamped and then removed on hospital day 6. She was extubated on day 5. Her GCS upon extubation was 15, but with persisting right-sided hemiparesis. She was transferred to the floor on hospital day 7 and discharged on day 25.
With aggressive physical and occupational therapy, KD’s hemiparesis and ability to ambulate improved. At follow-up one month after discharge, KD was ambulating with a walker, with 4/5 strength in the right extremities, normal mental status, and plans to return to school.
The initial, post-resuscitation GCS is one of the most important prognostic indicators in children with craniocerebral gunshot wounds. Transventricular and bihemispheric injuries and occipital entry site are poor prognostic factors. Outcomes in children with penetrating head injuries are better than in adults and these patients should be aggressively resuscitated.