Civilian cerebral gunshot wounds in rural South African patients are associated with significantly higher mortality rates than in urban patients



This study focuses on a specific and often dramatic injury, namely gunshot wounds (GSW) of the head in order to determine whether there is a discrepancy in outcome between patients who sustain their injury in a rural setting and those who sustain it in an urban setting.

Materials and methods

This study involves a retrospective review of our prospectively maintained regional electronic trauma registry. All patients who sustained a cerebral GSW from January 2010 to December 2014 were reviewed.


During the 5-year study period, a total of 102 patients sustained an isolated cerebral GSW. Ninety-two per cent (94/102) were male and the mean age was 29 years. Ninety-four per cent (94/102) of injuries were related to interpersonal violence. Of the 102 patients in the study, 54% (55/102) were urban and were transported directly to our trauma centre. The remaining 46% (47/102) were rural and were transported to a rural district hospital prior to being referred to our trauma centre. The time of injury was available in 60% (61/102) of patients. The mean time from injury to arrival for all patients was 11 h (SD 7). The mean time from injury to arrival was significantly shorter for urban versus rural, 6 h (SD 5) and 15 h (SD 5), respectively (p < 0.001). The median admission GCS score was significantly lower in rural compared to urban patients (p = 0.022). The need for neurosurgery, need for ICU admission or length of hospital stay was not significantly different between rural and urban patients. Rural patients have a fourfold higher mortality compared with urban patients (36 vs 9%, p = 0.001). Amongst survivors, there was no significant difference in median length of hospital stay or mean discharge GCS.


Cerebral GSWs are highly lethal injuries associated with significant mortality. Rural patients have a significantly longer transfer time, lower GCS on arrival and higher mortality than urban patients. Efforts should be directed at improving the pre-hospital EMS system in order to reduce delay to definitive care so that patient outcome can be optimised.

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Corresponding author

Correspondence to D. L. Clarke.

Ethics declarations

Conflict of interest

We received no funding for this research and have no conflicts of interest to declare.

Ethical approval

We have the necessary ethical approval for this study from the Biomedical Research Committee (BREC) of the University of KwaZulu-Natal (BCA221/13). We have ethics approval to keep and use this database (BE 207/09, 221/13).

Author contributions

VYK: analysis and drafting. GLL: design of data capture instrument. JLB, Database maintenance and data retrieval. JO: data cleaning and reference management. BS: statistics. PB: drafting, reference checking. DLC: senior author, general supervision, co-ordination and assistance at all levels.

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Kong, V.Y., Bruce, J.L., Sartorius, B. et al. Civilian cerebral gunshot wounds in rural South African patients are associated with significantly higher mortality rates than in urban patients. Eur J Trauma Emerg Surg 45, 145–150 (2019).

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  • Cerebral gunshot wound
  • Gunshot wound of the head
  • Rural
  • Urban