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Gunshot wounds and blast injuries to the face are associated with significant morbidity and mortality: Results of an 11-year multi-institutional study of 720 patients

Shackford, Steven R. MD; Kahl, Jessica E. BA; Calvo, Richard Y. PhD(c); Kozar, Rosemary A. MD; Haugen, Christine E. BA; Kaups, Krista L. MD; Willey, Marybeth BA; Tibbs, Brian M. MD; Mutto, Susan M. RN; Rizzo, Anne G. MD; Lormel, Christy S. MPH; Shackford, Meghan C. BA; Burlew, Clay Cothren MD; Moore, Ernest E. MD; Cogbill, Thomas H. MD; Kallies, Kara J. BA; Haan, James M. MD; Ward, Jeanette BA

Journal of Trauma and Acute Care Surgery: February 2014 - Volume 76 - Issue 2 - p 347–352
doi: 10.1097/TA.0b013e3182aaa5b8
WTA 2013 Plenary Paper
Editor's Choice

BACKGROUND Gunshot wounds and blast injuries to the face (GSWBIFs) produce complex wounds requiring management by multiple surgical specialties. Previous work is limited to single institution reports with little information on processes of care or outcome. We sought to determine those factors associated with hospital complications and mortality.

METHODS We performed an 11-year multicenter retrospective cohort analysis of patients sustaining GSWBIF. The face, defined as the area anterior to the external auditory meatuses from the top of the forehead to the chin, was categorized into three zones: I, the chin to the base of the nose; II, the base of the nose to the eyebrows; III, above the brows. We analyzed the effect of multiple factors on outcome.

RESULTS From January 1, 2000, to December 31, 2010, we treated 720 patients with GSWBIF (539 males, 75%), with a median age of 29 years. The wounding agent was handgun in 41%, explosive (shotgun and blast) in 20%, rifle in 6%, and unknown in 33%. Prehospital or resuscitative phase airway was required in 236 patients (33%). Definitive care was rendered by multiple specialties in 271 patients (38%). Overall, 185 patients died (26%), 146 (79%) within 48 hours. Of the 481 patients hospitalized greater than 48 hours, 184 had at least one complication (38%). Factors significantly associated with any of a total of 207 complications were total number of operations (p < 0.001), Revised Trauma Score (RTS, p < 0.001), and head Abbreviated Injury Scale (AIS) score (p < 0.05). Factors significantly associated with mortality were RTS (p < 0.001), head AIS score (p < 0.001), total number of operations (p < 0.001), and age (p < 0.05). An injury located in Zone III was independently associated with mortality (p < 0.001).

CONCLUSION GSWBIFs have high mortality and are associated with significant morbidity. The multispecialty involvement required for definitive care necessitates triage to a trauma center and underscores the need for an organized approach and the development of effective guidelines.

LEVEL OF EVIDENCE Therapeutic/care management, level III.

From the Scripps Mercy Hospital (S.R.S., J.E.K., R.Y.C., M.C.S.), San Diego; and University of California San Francisco/Fresno (K.L.K., M.W.), Fresno, California; University of Texas Houston and Memorial Hermann Hospital (R.A.K., C.E.H.), Houston, Texas; Mercy Hospital (BMT, SMM), Springfield, Missouri; Inova Fairfax Hospital (A.G.R., C.S.L.), Falls Church, Virginia; Denver General Health and University of Colorado (C.C.B., E.E.M.), Denver, Colorado; Gundersen Lutheran Medical Center (T.H.C., K.J.K.), La Crosse, Wisconsin; and Via Christi Hospital (JMH, JW), Wichita, Kansas.

Submitted: February 14, 2013, Revised: August 28, 2013, Accepted: September 15, 2013. Published online: January 6, 2014.

This study was presented at the 43rd Annual Meeting of the Western Trauma Association, March 3–8, 2013, in Snowmass, Colorado.

Address for reprints: Steven R. Shackford, MD, Trauma Service, Scripps Mercy Hospital, 4077 5th Ave, San Diego, CA 92103; email:

© 2014 Lippincott Williams & Wilkins, Inc.