Prognostication of civilian gunshot wounds to the head: the Baylor score

OBJECTIVE Gunshot wounds to the head (GSWH) are devastating injuries associated with high rates of morbidity and mortality. Poor outcomes in these patients necessitate identifying which patients may benefit the most from aggressive clinical and surgical management. The Baylor score uses patient age, pupil reactivity, Glasgow Coma Scale (GCS) score, and bullet trajectory at initial presentation to prognosticate mortality and Glasgow Outcome Scale (GOS) score at 6 months. In this cohort of patients with GSWH, the authors aimed to demonstrate internal validation of the Baylor score, which was recently externally validated by a distinct patient cohort at a different level I trauma center. METHODS Data were obtained from the trauma registry at a high-volume level I trauma center. Patients with penetrating cranial gunshot wounds from January 2008 to May 2022 were identified and retrospectively analyzed. Patient demographics, GCS score, pupillary response, and bullet trajectory on CT scan were reviewed, and the Baylor score was calculated for each patient. GOS score was determined for each patient at last follow-up. The validity of the Baylor score to predict mortality and good functional outcomes was assessed using receiver operating characteristic curves and areas under the curve (AUCs) as performance measures. RESULTS Over the 14-year study period, 404 patients met the inclusion criteria (mean age 31.5 [SD 12.9] years, 88.9% male). A total of 227 (56.2%) patients died, while 139 (34.4%) had good functional outcomes defined as GOS score 4 or 5 (moderate disability or good recovery, respectively). The Baylor score demonstrated good prognostication of both mortality (AUC 0.91) and good functional outcomes (AUC 0.93). Baylor scores of 0–2 underestimated good functional outcomes, and scores of 3–5 underestimated mortality. Patients older than 35 years with nonreactive pupils and low GCS score (3 or 4) had 100% mortality. CONCLUSIONS The Baylor score is a useful and accurate tool for clinicians to estimate mortality and functional outcomes in patients with GSWH. The score may be valuable in guiding patient- and family-centered discussions regarding prognosis early in the treatment course.