Maxillofacial Gunshot Injuries at an Urban Level I Trauma Center – 10-year Analysis
Materials: Retrospective analysis of facial gunshot injuries in patients treated at Boston Medical Center, by the Department of Oral and Maxillofacial Surgery, from 2001 to 2011. Data was obtained from the institutional trauma registry and hospital records; and analyzed with respect to length of hospitalization, patient demographics, treatment cost and payments to hospital, using bivariate and multivariate logistic regression, Fisher's exact test, Wilcoxon rank sum test, and Kruskal-Wallis test.
Results:During the study period, there were total of 1,957 patients admitted with gunshot wounds to Boston Medical Center, with 136 (6.9%) involving the facial region. 55 patients met inclusion criteria and were selected for the study. Age ranged from 16 to 61 years, with mean age being 25 years for men and 34 for women. 48/55 (87%) were males and 7/55 (13%) were females. The most common injury was to neck zone III; mandible fractures were encountered in 26 (47%) patients. Fractures were treated within 72 hours from admission for the majority of patients. 12 (22%) patients returned for secondary treatment. 20% patients had associated neurological injuries 9% had cervical spine fractures. Angiography was performed in 33 (60%) patients with 7 (13%) requiring embolization. 38 (70%) patients required airway management. Overall mortality was 9%, and most cases were associated with brain injury or severe bleeding from chest or abdominal injuries; no death occurred from isolated facial gunshot injuries. 18% of patients had private third party medical insurance, 45% had public insurance, and 23% had no insurance. Estimated hospital profit (not including the physician charges) was 11% from treating patients with private insurances. In contrast, there was a loss of 50% while treating patients with public insurance; and a 100% loss when treating uninsured patients.
Conclusions: Airway compromise was the most life-threatening early problems; requiring establishment of definitive airway upon assessment. Brain, vascular and cervical spine injuries were common and warranted further investigation. Patients admitted with higher stages of shock and lower mental status, due to brain, vascular and/or spinal cord injuries: correlated with prolonged hospitalization, increased treatment costs and extended rehabilitation. We advocated early intervention (less than 72 hours), conservative approach, one-stage reconstruction of all involved bony and soft tissue injuries. In our study, African Americans were more frequently injured as compared to other ethnic groups; this was due to the geographic location of our hospital and mission to serve the underprivileged/ low income patients. The majority of the facial gunshot injuries were not presented as life threatening; but typically resulted in significant morbidity. With respect to the cost of healthcare, the vast majority of patients relied on public aid and had no insurance; in all cases the cost of care was more than the reimbursement provided.
References:
McLean B, Tiwana PS, Kushner GM. Gunshot Wounds to the face – acute management. Facial Plastic Surg. 2005,21:191-198.
Peleg M, Sawatari Y. Management of Gunshot Wounds to the Mandible. J of Craniofacial Surg. 2010, 21(4): 1252-1256.