Gunshot Wound to the Head: Surgical Management and Cases Report in a Tertiary Care Center in Florencia, Colombia

The purpose of this research is to report 10 cases treated in a tertiary care center in the Florencia town in Colombia. The idea was to establish the type, age group, Matson's classification schemes and mortality of the gunshot wound to the head in order to describe the neurological functional prognosis of these patients , made by The Modified Rankin scale (mRS) to 12 months postoperative.


Introduction
The trauma is the first cause of death in Colombia, around 50% of deaths are related to the traumatic brain injury.In Colombia, 76.67% of murders were caused by gunshot [1].In USA, the total cost due to treatment of gunshot wounds to the head is 16 billion dollars per year.In addition, 30% of patients with gunshot wounds to the head arrive alive to the emergency room only [2] [3], its annual incidence is of 2.4/100,000 or 6000 murders per year [4] [5].The deaths related to the gunshot are the second cause of death in the USA because of trauma, 58% of which are murders and 57% suicides [6] [7].

Cases Report
A total of 10 patients were operated.They entered to the emergency room a cause their gunshot wounds of the head, they were 8 men and 2 women, the age range was between 19 and 65 years, the media age was 33.7 years old.At the time of admission, they had less than 8 in the Glasgow Coma Scale, the brain CT Scan (unenhanced) was realized to each one (Figure 1(a)), the Matson's scale was document and I continued with the surgical management.About each case, in general terms, with the bleeding control and the cerebral decompression, it was necessary a contaminated, macerated or ischemic tissue debridement (Figures 1(b)-(c)), the removal of bone and metal fragments, the profuse wash in the surgical bed, hermetically close of the dura matter and finally, the closure of the scalp; it was recommended in these cases [8] [9] (Figures 2(a)-(c)).
In our research 80% were male patients and 20% female patients, the media age was 33.7 years old.All the patients (100%) were registred in the emergency room with less 8 in the Glasgow Coma Scale (Figure 3).
In this way, a patient's survival of 70% was register and 30% of death rate.These deaths were in the first 72 hours at ICU (intensive care unit) a cause the own complications of the gravity of the gunshot wounds of the head.At admission 60% of the patients had III B, 20% IV D, 10% III C and IV B in the Matson's classification schemes respectively (Figure 4).

Discussion
The wound by gunshot are a serious public health problem that affects Colombia, with very high economic costs as well as severe neurological disabilities afflicting predominantly young people.This situation demonstrates the intolerance in our society and insecurity that afflicts us too.

Conclusion
It was confirmed that the Glasgow Coma Scale, at admission, is the most important variable that defines the survival and degree of functional disability of the patient, thus, the lower is the GCS at admission, the highest income will be modified Rankin scale and higher mortality.These results coincide with reports of world literature.The results of this study are synthesized in the Annex 1 (Figure 6).

Figure 1 .Figure 2 .
Figure 1.(a) Brain CT Scan (unenhanced): numerous metal shards from the right frontal region to the right occipital region, subdural hematoma and brain edema; (b) Comminuted fracture of right cranium, dural tear, brain laceration and output mecerated brain; (c) Post surgical subtotal right frontal lobectomy (lobotomy), drainage of intracranial hemorrhage and surgical debridement.