Penetrating Head Trauma


  1. A wound where projectile enters cranium and does NOT exit
  2. Etiologies
  3. Number has increased greatly in past 25 years


  1. Extent of injury depends on several factors
  2. Primary impact is followed by secondary injuries

Missile Wounds

  1. Majority of penetrating wounds
  2. Damage to brain depends on:
  3. Ballistics
  4. Projectile velocity

Stab Wounds

  1. Minority of penetrating wounds
  2. Usually happen where skull is thinner
  3. No diffuse shearing of neurons as in MVA
  4. No cavitation/ zone of injury as in GSW
  5. Damage mostly confined to tract of wound
  6. May see "slot fracture" in skull
  7. Death usually due to vascular injury/ massive intracerebral hematoma

Skull Damage

  1. Area of skull impacted and angle of projectile determine damage


  1. Lab tests
  2. Imaging
  3. +/- seizures
  4. Monitor for incr ICP


  1. Primary Survey = ABCDE, IV, O2, monitor
  2. Intubation (presume elevated ICP)
  3. ABCs first
  4. C-spine precautions if history indicates MVA or fall
  5. Assess injury carefully
  6. Early neurosurgery involvement
  7. Treat incr ICP: see "Incr ICP Management"
  8. Seizures
  9. Broad spectrum antibiotics


  1. Trauma/ neurosurgical consults
  2. OR for removal of foreign material, debridement and closure


  1. Benzel EC, Day WT, Kesterson L: Civilian craniocerebral gunshot wounds. Neurosurgery 1991 Jul; 29(1): 67-71; discussion 71-2
  2. De Villiers JC: Stab wounds of the brain and skull. In: Vinken PJ, Bruyn GW, eds. Handbook of Clinical Neurology. Vol 23. New York, NY: Elsevier Science Publishing; 1975: 407-503
  3. Rosenberg WS, Harsh GR: Penetraing wounds of the head. In: Wilkins RH, Rengachary SS, eds. Neurosurgery. Vol 2. New York, NY: McGraw Hill; 1996: 2813-2820
  4. Rosenwasser RH, Andrews DW, Jimenez DF: Penetrating craniocerebral trauma. Surg Clin North Am 1991 Apr; 71(2): 305-16
  5. Knightly JJ, Pulliam MW: Military head injuries. In: Narayan R, Wilberger J, Povlishock J, eds. Neurotrauma. New York, NY: McGraw Hill; 1996