Gabby Giffords Shooting: Why’d the docs cut out the skull?

By now, you’ve undoubtedly heard about the shooting of U.S. Representative Gabby Giffords in Tucson. She was shot in the head while conducting a public meet and greet outside a supermarket. CNN just published a few articles to promote their special on the medicine behind saving her life to air on Sunday, May 8.

So people wonder what her outlook will be like. She’s deep in therapy now, and I hear she and her astronaut husband are writing a book.

The Big 3

Three things are most important when predicting survival in a patient like Giffords: Blood Pressure, Pupil’s reaction to light, and the Glasgow Coma Scale (GCS).

You want a stable blood pressure. You don’t want it to drop, which can happen if there is significant bleeding.  Paramedics normally place large IV lines with normal saline (NS) to replace lost fluids.  Stable blood pressure means the brain can still get oxygen.

You want normal pupillary reflex.  If a patient has significant brain swelling, one of the early consequences is pressure on the nerve that controls your pupils. In that case, the patient’s pupils will not constrict in response to a bright light. In our special senses lab, you’ll have the chance to flash classmates and yourselves with penlights.

You want a GCS of at least 8 out of 15. This is a quick score paramedics do in the field, and continuously monitor it during the trip to the hospital (and I’m sure they evaluate the score while in the emergency room and trauma center).  It takes into account, motor movements, verbal capabilities and eye opening.  You ask the patient to squeeze your hands, and if they don’t, you do something more painful that the patient SHOULD respond to. You then give a set number of points based on what the patient responds to. If they don’t respond to anything, then that’s bad – a 1 out of a possible 5 points. You grade how the patient responds to your questions and if the eyes open. Gabby scored a 10 total on the GCS. Good sign.

Hopeful

Once shot, the brain goes into shock and shuts down – the patient goes unconscious.  Some believe this is a protective mechanism to prevent more damage to the brain. Imagine if you got something stuck up a machine and you don’t turn it off – you might just shred up the internal parts!

The docs say it was good that the bullet went straight though the skull, instead of being trapped, tumble around, or expand in the brain.  It was a small opening and a slightly larger exit.  They say that luckily the bullet only damaged one side of the brain. A bullet that goes to both sides of the brain will be more difficult to recover from.

Much like an injury elsewhere in the body, the brain will swell when injured. The brain will push down the tentorium cerebelli and foramen magnum – the only sizeable opening in the cranium. This will cause more damage than the initial injury! So the neurosurgeon cut out and remove the left half of Gabby’s skull to allow the brain to swell outwards.

She now has a lot of therapy left to regain lost function. They will focus on the brain’s capacity to rewire to take over the functions controlled by the damaged areas. To do so, they need to work on those lost functions. It’s a slow, cumbersome, long process to learn to speak, form sentences, smile, walk, write again.

Journal of Trauma article:

http://www.ncbi.nlm.nih.gov/pubmed?term=Predictive%20factors%20influencing%20the%20outcome%20after%20gunshot%20injuries%20to%20the%20head-a%20retrospective%20cohort%20study

 

Sources for further reading:

 

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