Gunshot Wounds and Nonmissile Penetrating Brain Injuries Flashcards
Primary injury from gunshot wound of head results from which factor?
● A. Injury to the soft tissue (direct scalp or facial injury, soft tissue and bacteria dragged intracranially, and pressure waves of gas combustion)
● B. Comminuted fracture of bone (may injure subjacent vascular or cortical tissue)
● C. Cerebral injuries from missile (from fragmentation of bullet, ricochet off the bone)
● D. Coup + contrecoup injury from missile impact on head
● E. All of the above
E. All of the above
Secondary injury from gunshot wound of head (GSWH) includes cerebral edema which may cause rapid rise in ICP within minutes. Cardiac output also falls initially which together with high ICP adversely affects cerebral perfusion pressure. Other complicating factors may include DIC and intracranial hemorrhage from lacerated blood and vessels. Which of the following statements is incorrect regarding late complications of this injury?
● A. Cerebral abscess
● B. Typically aneurysm which is rare in distal ACA
● C. Seizures
● D. Fragment migration (migration into the ventricles may cause hydrocephalus)
● E. Lead toxicity
B. Typically aneurysm which is rare in distal ACA
Entry gunshot wound is typically smaller than the exit wound due to bullet mushrooming. Also, at the surgery or autopsy, entry wound would typically show beveling of the inner table while exit wound has a beveled outer table. A salvageable patient after some time of gunshot wound of head
(GSWH) developed delayed hemorrhage and the trajectory of the bullet on investigations is found to be through the named vessels. What investigation does this patient need to determine vascular status?
● A. Doppler ultrasound
● B. CT of brain with bone window
● C. CT angiography
● D. Bone scan
● E. Dexa scan
C. CT angiography
A patient with gunshot wound injury of head needs initial control of bleeding, measures to lower ICP including head of bed (HOB) elevation, steroids, hyperventilation, and mannitol. What is the goal of surgery in these patients?
● A. Debridement of devitalized tissue and evacuation of hematoma
● B. Removal of accessible bone fragments and retrieval of bullet fragment
● C. Obtaining hemostasis and watertight dural closure
● D. Separation of intracranial compartment from air sinuses traversed by the bullet and identification of entry and exit wound for forensic purpose
● E. All of the above
E. All of the above
The level of consciousness is the most important prognosticator after gunshot wound of head (GSWH). Especially poor prognosis is associated with which of the following?
● A. Bullet that crosses the midline
● B. Bullet that passes through the geographic center of the brain
● C. Bullet that enters and traverses the ventricles
● D. More lobes traversed by the bullet
● E. All of the above
E. All of the above
What are the indications of preoperative angiography in a patient with gunshot wound of head (GSWH)?
● A. Object passes in the region of large named artery
● B. Object passes near dural sinus
● C. Visible evidence of arterial bleeding
● D. Unexpected delayed hemorrhage
● E. All of the above
E. All of the above
What is the surgical technique for removal of foreign body in a patient with nonmissile penetrating injury (injury from knives, arrows, and lawn darts)?
● A. Empiric antibiotic coverage before surgery
● B. Optimal control by performing craniotomy
● C. Dura is opened before removing the object
● D. Removal of the object ideally should follow the entry trajectory
● E. Debridement of any easily accessible impacted bone and other extracranial tissue and material along the track
● F. All of the above
F. All of the above
AP and lateral skull X-rays provide useful information in case of gunshot injury to head as they are less susceptible to artifact from the bullet than the CT scan. It also helps to localize metal and bone fragments and entrance and exit wounds. What information can we get with brain CT of the patient?
● A. It demonstrates location of bone and metal
● B. It delineates the bullet trajectory
● C. It assess the passage of the bullet through ventricles and how many quadrants of the hemisphere have been traversed by the bullet
● D. It shows amount of blood within the brain and assesses intracranial hematomas
● E. All of the above
E. All of the above
Bullet injury can cause explosive intracranial injury that is uniformly fatal. It can also cause laceration and maceration along the path of the trajectory. Shock waves and temporary cavitation are produced by the bullet at what velocity?
● A. More than 100 m/s
● B. More than 250 m/s
● C. More than 1000 m/s
● D. At 600 to 750 m/s
● E. None of the above
D. At 600 to 750 m/s
Which one of the following is incorrect regarding initial management of a patient with gunshot wound injury of head?
● A. Controlling of bleeding and shaving of skull to see entry and exit wounds
● B. Initiating the medical therapy including HOB elevation, mannitol, hyperventilation, and steroids
● C. Prophylaxis against GI ulcers and antiseizure medication
● D. There is no need of tetanus toxoid administration in this patient
● E. Administration of antibiotics
D. There is no need of tetanus toxoid administration in this patient
What is the most lethal type of head injury?
● A. Motor vehicle accident
● B. Gunshot wounds to head
● C. Acute subdural hematoma
● D. Extradural hematoma
● E. Posterior fossa hemorrhagic contusions
B. Gunshot wounds to head
A postoperative CSF fistula after surgery for gunshot
wound to head should be repaired if it persists more than how long?
● A. Always repair immediately
● B. 1 day
● C. 3 days
● D. 1 week
● E. 14 days
E. 14 days
Most organisms are sensitive to penicillinase resistant agents, for example, nafcillin, and it is recommended for how long to prevent meningitis and abscess formation?
● A. Single shot
● B. 24 hours
● C. 3 days
● D. 5 days
● E. 2 weeks
D. 5 days
What is the usual location for traumatic aneurysm?
● A. Distal ACA
● B. Proximal MCA
● C. Middle MCA
● D. Vertebral artery
● E. Basilar apex
A. Distal ACA
What is the most important prognostic factor in the outcome for gunshot wound of head (GSWH)?
● A. Level of consciousness
● B. Path of bullet
● C. Hematoma seen on CT
● D. Suicide attempt
● E. CSF leak
A. Level of consciousness
