Association of Out-of-Hospital Hypotension Depth and Duration With Traumatic Brain Injury Mortality

Spaite, Daniel W; Hu, Chengcheng; Bobrow, Bentley J.; Chikani, Vatsal; Barnhart, Bruce J; Gaither, Joshua B; Denninghoff, Kurt R.; Adelson, P. David; Keim, Samuel M.; Viscusi, Chad; Mullins, Terry; Rice, Amanda D.; Sherrill, Duane L.

doi:10.1016/j.annemergmed.2017.03.027

Cited by 64 publications

(52 citation statements)

References 49 publications

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“…Arterial hypotension, (systolic blood pressure <90 mmHg), was an identified prehospital risk factor for mortality [48]. A study of major traumatic brain injury found that the depth, and duration of out-of-hospital hypotension were strongly associated with increased mortality [49]. Hypothermia (temperature <35 °C) was also identified as a prehospital risk factor for mortality [48,50].…”

Section: Prehospital and Emergency Carementioning

confidence: 99%

Prehospital and Emergency Care in Adult Patients with Acute Traumatic Brain Injury

2019

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Traumatic brain injury (TBI) is a major healthcare problem and a major burden to society. The identification of a TBI can be challenging in the prehospital setting, particularly in elderly patients with unobserved falls. Errors in triage on scene cannot be ruled out based on limited clinical diagnostics. Potential new mobile diagnostics may decrease these errors. Prehospital care includes decision-making in clinical pathways, means of transport, and the degree of prehospital treatment. Emergency care at hospital admission includes the definitive diagnosis of TBI with, or without extracranial lesions, and triage to the appropriate receiving structure for definitive care. Early risk factors for an unfavorable outcome includes the severity of TBI, pupil reaction and age. These three variables are core variables, included in most predictive models for TBI, to predict short-term mortality. Additional early risk factors of mortality after severe TBI are hypotension and hypothermia. The extent and duration of these two risk factors may be decreased with optimal prehospital and emergency care. Potential new avenues of treatment are the early use of drugs with the capacity to decrease bleeding, and brain edema after TBI. There are still many uncertainties in prehospital and emergency care for TBI patients related to the complexity of TBI patterns.

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Section: Prehospital and Emergency Carementioning

confidence: 99%

Prehospital and Emergency Care in Adult Patients with Acute Traumatic Brain Injury

2019

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“…Prehospital interventions that mitigate secondary injury from hypotension, hypoxia, and hypocarbia have also been shown to improve TBI outcomes. 11,[18][19][20] Preliminary, unadjusted subgroup analysis in the PAMPer trial suggested a survival benefit in patients with severe head injury, as defined by Abbreviated Injury Severity (AIS) scores for the head. 8 However, to our knowledge, the association of early plasma administration with survival has not been fully characterized in the subgroup of patients with TBI as confirmed by computed tomography (CT) while adjusting for potential confounding factors.…”

Section: Introductionmentioning

confidence: 99%

Association of Prehospital Plasma With Survival in Patients With Traumatic Brain Injury

et al. 2020

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IMPORTANCE Prehospital plasma administration improves survival in injured patients at risk for hemorrhagic shock and transported by air ambulance. Traumatic brain injury (TBI) is a leading cause of death following trauma, but few early interventions improve outcomes. OBJECTIVE To assess the association between prehospital plasma and survival in patients with TBI. DESIGN, SETTING, AND PARTICIPANTS The Prehospital Air Medical Plasma (PAMPer) trial was a pragmatic, multicenter, phase 3, cluster randomized clinical trial involving injured patients who were at risk for hemorrhagic shock during air medical transport to a trauma center. The trial was conducted at 6 US sites with 9 level-I trauma centers (comprising 27 helicopter emergency services bases). The original trial analyzed 501 patients, including 230 patients who were randomized to receive plasma and 271 randomized to standard care resuscitation. This secondary analysis of a predefined subgroup included patients with TBI. Data analysis was performed from October 2019 to February 2020. INTERVENTIONS Patients were randomized to receive standard care fluid resuscitation or 2 units of thawed plasma. MAIN OUTCOMES AND MEASURES The primary outcome was mortality at 30 days. Patients with TBI were prespecified as a subgroup for secondary analysis and for measurement of markers of brain injury. The 30-day survival benefit of prehospital plasma in subgroups with and without TBI as diagnosed by computed tomography was characterized using Kaplan-Meier survival analysis and Cox proportional hazard regression. RESULTS In total, 166 patients had TBI (median [interquartile range] age, 43.00 [25.00-59.75] years; 125 men [75.3%]). When compared with the 92 patients who received standard care, the 74 patients with TBI who received prehospital plasma had improved 30-day survival even after adjustment for multiple confounders and assessment of the degree of brain injury with clinical variables and biomarkers (hazard ratio [HR], 0.55; 95% CI, 0.33-0.94; P = .03). Receipt of prehospital plasma was associated with improved survival among patients with TBI with a prehospital Glasgow Coma Scale score of less than 8 (HR, 0.56; 95% CI, 0.35-0.91) and those with polytrauma (HR, 0.50; 95% CI, 0.28-0.89). Patients with TBI transported from the scene of injury had improved survival following prehospital plasma administration (HR, 0.45; 95% CI, 0.26-0.80; P = .005), whereas patients who were transferred from an outside hospital showed no difference in survival for the plasma intervention (HR, 1.00; 95% CI, 0.33-3.00; P = .99).

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“…Thus, severely brain-injured patients may benefit from early neurosurgical intervention. Although it has been shown that early physiological stabilization to avoid hypoxia, hypotension, and hypo-and hypercarbia led to improved outcomes from TBI, [34][35][36] the optimum time window for neurosurgical intervention in patients with TBI remains uncertain.…”

mentioning

confidence: 99%

Association of time to craniectomy with survival in patients with severe combat-related brain injury

Shackelford

Junco

Reade³

et al. 2018

Neurosurgical Focus

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OBJECTIVEIn combat and austere environments, evacuation to a location with neurosurgery capability is challenging. A planning target in terms of time to neurosurgery is paramount to inform prepositioning of neurosurgical and transport resources to support a population at risk. This study sought to examine the association of wait time to craniectomy with mortality in patients with severe combat-related brain injury who received decompressive craniectomy.METHODSPatients with combat-related brain injury sustained between 2005 and 2015 who underwent craniectomy at deployed surgical facilities were identified from the Department of Defense Trauma Registry and Joint Trauma System Role 2 Registry. Eligible patients survived transport to a hospital capable of diagnosing the need for craniectomy and performing surgery. Statistical analyses included unadjusted comparisons of postoperative mortality by elapsed time from injury to start of craniectomy, and Cox proportional hazards modeling adjusting for potential confounders. Time from injury to craniectomy was divided into quintiles, and explored in Cox models as a binary variable comparing early versus delayed craniectomy with cutoffs determined by the maximum value of each quintile (quintile 1 vs 2–5, quintiles 1–2 vs 3–5, etc.). Covariates included location of the facility at which the craniectomy was performed (limited-resource role 2 facility vs neurosurgically capable role 3 facility), use of head CT scan, US military status, age, head Abbreviated Injury Scale score, Injury Severity Score, and injury year. To reduce immortal time bias, time from injury to hospital arrival was included as a covariate, entry into the survival analysis cohort was defined as hospital arrival time, and early versus delayed craniectomy was modeled as a time-dependent covariate. Follow-up for survival ended at death, hospital discharge, or hospital day 16, whichever occurred first.RESULTSOf 486 patients identified as having undergone craniectomy, 213 (44%) had complete date/time values. Unadjusted postoperative mortality was 23% for quintile 1 (n = 43, time from injury to start of craniectomy 30–152 minutes); 7% for quintile 2 (n = 42, 154–210 minutes); 7% for quintile 3 (n = 43, 212–320 minutes); 19% for quintile 4 (n = 42, 325–639 minutes); and 14% for quintile 5 (n = 43, 665–3885 minutes). In Cox models adjusted for potential confounders and immortal time bias, postoperative mortality was significantly lower when time to craniectomy was within 5.33 hours of injury (quintiles 1–3) relative to longer delays (quintiles 4–5), with an adjusted hazard ratio of 0.28, 95% CI 0.10–0.76 (p = 0.012).CONCLUSIONSPostoperative mortality was significantly lower when craniectomy was initiated within 5.33 hours of injury. Further research to optimize craniectomy timing and mitigate delays is needed. Functional outcomes should also be evaluated.

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Association of Out-of-Hospital Hypotension Depth and Duration With Traumatic Brain Injury Mortality

Cited by 64 publications

References 49 publications

Prehospital and Emergency Care in Adult Patients with Acute Traumatic Brain Injury

Prehospital and Emergency Care in Adult Patients with Acute Traumatic Brain Injury

Association of Prehospital Plasma With Survival in Patients With Traumatic Brain Injury

Association of time to craniectomy with survival in patients with severe combat-related brain injury

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