Penetrating brain injury resulting from nail-gun use is a well-characterized entity, one that is increasing in frequency as nail guns become more powerful and more readily available to the public. We present a case and offer management strategies for a 50-year-old male with two intracranial penetrating nail gun injuries. Nail gun brain injuries are commonly intentionally self-inflicted. Suicide should be considered when straight nails cause wounds to the chest, head, or abdomen. The primary preoperative concern is formation of a traumatic pseudoaneurism, which prompts both preoperative and follow-up cerebral angiography. Surgery for combined intracranial and extracranial injury may require the collaborative expertise of colleagues from the fields of ophthalmology, otolaryngology, and oral maxillofacial surgery. A rational management strategy should permit these patients to be discharged with no additional injury.

OBJECTIVE: Gunshot wounds to the head (GSWH) are devastating injuries with a grim prognosis. Several prognostic scores have been created to estimate mortality and functional outcome, including the so-called Baylor score, an uncomplicated scoring method based on bullet trajectory, patient age, and neurological status on admission. This study aimed to validate the Baylor score within a temporally, institutionally, and geographically distinct patient population. METHODS: Data were obtained from the trauma registry at a level I trauma center in the southeastern US. Patients with a GSWH in which dural penetration occurred were identified from data collected between January 1, 2009, and June 30, 2019. Patient demographics, medical history, bullet trajectory, intent of GSWH (e.g., suicide), admission vital signs, Glasgow Coma Scale score, pupillary response, laboratory studies, and imaging reports were collected. The Baylor score was calculated directly by using its clinical components. The ability of the Baylor score to predict mortality and good functional outcome (Glasgow Outcome Scale score 4 or 5) was assessed using the receiver operating characteristic curve and the area under the curve (AUC) as a measure of performance. RESULTS: A total of 297 patients met inclusion criteria (mean age 38.0 [SD 15.7] years, 73.4% White, 85.2% male). A total of 205 (69.0%) patients died, whereas 69 (23.2%) patients had good functional outcome. Overall, the Baylor score showed excellent discrimination of mortality (AUC = 0.88) and good functional outcome (AUC = 0.90). Baylor scores of 3-5 underestimated mortality. Baylor scores of 0, 1, and 2 underestimated good functional outcome. CONCLUSIONS: The Baylor score is an accurate and easy-to-use prognostic scoring tool that demonstrated relatively stable performance in a distinct cohort between 2009 and 2019. In the current era of trauma management, providers may continue to use the score at the point of admission to guide family counseling and to direct investment of healthcare resources.