Gunshot Wounds to the Brain

When a bullet travels through a person’s brain, the damage caused can result in a cascade of neurological symptoms and challenges both in the immediate aftermath and over the long term.

“Gunshot wounds are one of the more complicated head traumas we see in this day and age,” said Megan Keiser, MS, RN, APRN-BC, CNRN, a neurosurgery nurse practitioner and secretary/treasurer of the American Association of Neuroscience Nurses (AANN). “There are so many factors that influence patient outcomes, including the ballistics of the bullet, where penetration occurred and what part of the brain is affected.”

Patti Lemke, RN, CNRN, CCRN, a staff nurse in the neuro ICU at Provena Saint Joseph Medical Center, Joliet, IL, shared two scenarios that illustrate the wide variation in clinical presentations following a gunshot wound to the brain.

“I cared for an older lady who had received a gunshot wound to the back of her head, and the thick occipital bone shattered, deflecting the force of the bullet,” she said. “The bone actually protected her brain, so she initially lost vision because of the damage to the occipital lobe, but was regaining vision when she left our unit.”

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A young man who was shot in the left temporal lobe wasn’t as lucky. “The bullet exited the occipital lobe, passing through vital areas of the brain,” Lemke recalled.

“He developed significant swelling in the brain and pseudo-aneurysms because of shearing forces on major blood vessels in his brain. He was responding to commands on one side of his body when he left for imaging, but the swelling abruptly increased and he had a brainstem herniation. After 10 days in the neuro ICU, he succumbed to his injuries.”

Complicating Factors

TBIs in general typically involve one lobe of the brain.

“With that focal component, we can anticipate some deficits based on brain mapping,” explained Tiffany LeCroy, MSN, RN, FNP-C, CRRN, a clinical nurse specialist at Shepherd Center, Atlanta. “If there’s frontal lobe involvement, we can expect changes in mood, personality and problem-solving, for example. If the parietal lobe is injured, patients typically have difficulty with eye/hand coordination and awareness. But gunshot wounds don’t leave that clear-cut picture.”

As the bullet passes through one or more lobes of the brain, it causes direct tissue damage.

“Then there’s the wave effect of the bullet that impacts surrounding tissue, so a lot more of the brain is involved,” LeCroy explained. “On top of that, we need to be concerned about swelling that’s contained in a small skull that doesn’t yield. That swelling increases intracranial pressure and can create more deficits. That type of secondary damage can occur weeks after the injury, so we see it developing in some of our rehab patients.”

When bullets affect critical areas of the brain and/or cross the midline, patients often face significant disabilities from brain damage.

“If the bullet doesn’t damage major blood vessels in the brain and stays away from eloquent areas of the brain, patients can survive with better outcomes,” said Keiser. “Patients with this type of injury have symptoms similar to those of a stroke in the area of the brain affected by the penetrating trauma.”

The least complex gunshot wounds involve small caliber bullets that travel at slower speeds and penetrate minimally into the brain.

“In that situation, we often take the patient to surgery to debride bits of skull, scalp and hair that have been driven into the wound tract,” Keiser explained. “The patient then needs intensive nursing care as outlined in AANN’s Nursing Management of Adults with Severe Traumatic Brain Injury.”

Intensive Nursing Care

There’s no such thing as a simple gunshot wound to the brain, Keiser noted. “Even simple injuries tend to turn more complex within the first 3 days after the injury,” she emphasized. “The initial gunshot wound involves both a wound tract from the projectile and shock waves throughout the brain tissue.

“The patient may look pretty stable for the first couple of days until the effects from the shock wave caused by the bullet begin and the brain tissue starts to swell uncontrollably. Suddenly, the patient won’t look so good.”

According to AANN, nursing care centers on prevention of seizures, glycemic control, adequate nutrition, deep vein thrombosis prevention, maintaining or decreasing intracranial pressure, and maintaining optimal cerebral perfusion.

“In patients with run-of-mill blunt head trauma, the course of brain swelling and increasing intracranial pressure is somewhat more predictable, but that course is not at all predictable with gunshot wounds,” said Keiser. “The ballistics of the bullet and the location and depth of penetration can change the clinical picture.”

Shotgun blasts release multiple pellets that strike different areas of the skull.

“A few will get through and cause skull fractures, but other pellets don’t penetrate,” Keiser said. “In all patients with penetrating head trauma, nurses need to watch carefully for infections – meningitis and cerebritis along the wound tract. These patients need frequent wound assessments, vital signs monitoring and fever management.”

Patients who arrive at Provena Saint Joseph with a gunshot wound to the head are sent for diagnostic imaging, and often go directly to the operating room for a decompressive craniectomy to remove a portion of the skull and allow tissue to swell without damaging the brain.

“It’s an up and down roller coaster ride with any kind of traumatic brain injury,” Lemke noted. “A patient can be out of bed and doing well one day but comatose the next because of swelling or bleeding in the brain.

“Nursing assessment is critical with these patients. We monitor vital signs, intracranial pressure, fluid balance, electrolyte levels, arterial blood gases and coagulation panels to identify DIC [disseminated intravascular coagulation] that’s often seen with TBIs.”

Rehabilitation

Beth Ann Daugherty, MPH, BSN, RN, CRRN, chief nursing officer of Adventist Rehabilitation Hospital of Maryland in Rockville, described the admissions process for patients who have sustained gunshot wounds to the head.

“They arrive in our acute rehabilitation setting once they’ve been stabilized in the acute care hospital,” she said. “Some come directly from ICUs, and there’s a wide range when you’re looking at damage to the brain. If patients show the potential to return to home and community, and can tolerate the 3 hours of daily therapy required in acute rehab, they may come to us.”

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“When we’re caring for patients with brain swelling, monitoring neurological status and providing wound care, we’re delivering medical/surgical care to patients,” Daugherty said. “We’re monitoring all body systems and, on top of that, we’re adding the rehabilitation component to the nursing care of the individual. Our patients aren’t always oriented after brain injuries, but they must be able to follow commands and directions.

“Rehabilitation nurses can supplement understanding of verbal directions with cueing on a regular basis, allowing the patient to participate in the rehab process. We also work with families and with resources in the community where the patient will be discharged. In the 2 years I’ve been here, most of our gunshot wound victims have gone home.”

Daugherty shared a final thought for nurses: “As people with gunshot wounds to the head recover, they start looking normal in appearance, but they still have trauma inside the head,” she explained. “We need to be aware, and teach families to be aware, that they may not act the same even though they look the same.”

Sandy Keefe is a frequent contributor to ADVANCE.

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