Bolt gun injury to central forehead, sagittal sinus and frontal lobes: A case report.

INTRODUCTION AND

IMPORTANCE

Bolt gun injuries to the head are rare and are usually in the context of suicide. Bolt guns are used in the meat processing industry to induce unconsciousness prior to slaughter. A bolt penetrates 7-10 cm through the skull into the brain and then is retracted by a spring. Mortality has been reported to be up to 80-90 %, with survivors left with severe neurological and functional deficits.

CASE PRESENTATION: A 24-year-old man presented with a self-inflicted bolt gun injury to the central forehead. He presented confused and agitated to a rural emergency department and was subsequently intubated and transferred to a tertiary trauma centre. CT demonstrated a midline frontal bony defect with an underlying 8.5 cm wound tract into both frontal lobes. There was associated intracranial haemorrhage and impacted skin and bone fragments within the wound tract. CTA/V showed an injury to the superior sagittal sinus but intact arterial vessels. He underwent a bifrontal craniectomy, débridement and evacuation of haematoma with ICP monitor placement. The patient demonstrated a remarkable recovery at 3 months with only mild cognitive impairment.

CLINICAL DISCUSSION: CT imaging including angiography assesses extent of parenchymal and vascular injury. Decompression of the brain and careful debridement off the brain reduced the risk of infection but prevented iatrogenic injury. Prophylactic treatment with broad-spectrum antibiotics prevented intracranial infection.

CONCLUSION

This case report highlights multiple lessons which contributed to successful management of a bolt gun injury to the head: preoperative CT angiography, craniectomy if indicated, cautious debridement and prophylactic antibiotics.