The Effect of Combined Out-of-Hospital Hypotension and Hypoxia on Mortality in Major Traumatic Brain Injury

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; Sherrill, Duane L.

doi:10.1016/j.annemergmed.2016.08.007

Cited by 135 publications

(87 citation statements)

References 49 publications

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“…Several factors have been identified as causing secondary brain injury during prehospital care including: hypotension, hypoxia, and hyperventilation. 6–17 Through multiple pathophysiological mechanisms, both elevated body temperature and low body temperature could cause secondary brain injury with resulting increases in morbidity and mortality. 18–23 …”

Section: Introductionmentioning

confidence: 99%

Body Temperature after EMS Transport: Association with Traumatic Brain Injury Outcomes

Gaither¹,

Chikani

Stolz³

et al. 2017

Prehospital Emergency Care

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Introduction Low body temperatures following prehospital transport are associated with poor outcomes in patients with traumatic brain injury (TBI). However, little is known about potential associations across a range of temperatures obtained immediately after prehospital transport. Furthermore, little is known about the influence of body temperature on non-mortality outcomes. The purpose of this study was to assess the correlation between temperatures obtained immediately following prehospital transport and TBI outcomes across the entire range of temperatures. Methods This retrospective observational study included all moderate/severe TBI cases (CDC Barell Matrix Type 1) in the pre-implementation cohort of the Excellence in Prehospital Injury Care (EPIC) TBI Study (NIH/NINDS: 1R01NS071049). Cases were compared across four cohorts of initial trauma center temperature (ITCT): <35.0°C [Very Low Temperature (VLT)]; 35.0–35.9°C [Low Temperature (LT)]; 36.0–37.9°C [Normal Temperature (NT)]; and ≥38.0°C [Elevated Temperature (ET)]. Multivariable analysis was performed adjusting for injury severity score, age, sex, race, ethnicity, blunt/penetrating trauma, and payment source. Adjusted odds ratios (aORs) with 95% confidence intervals (CI) for mortality were calculated. To evaluate non-mortality outcomes, deaths were excluded and the adjusted median increase in hospital length of stay (LOS), ICU LOS and total hospital charges were calculated for each ITCT group and compared to the NT group. Results 22,925 cases were identified and cases with inter-facility transfer (7361, 32%), no EMS transport (1213, 5%), missing ITCT (2083, 9%), or missing demographic data (391, 2%) were excluded. Within this study cohort the aORs for death (compared to the NT group) were 2.41 (CI: 1.83–3.17) for VLT, 1.62 (CI: 1.37–1.93) for LT, and 1.86 (CI: 1.52–3.00) for ET. Similarly, trauma center (TC) LOS, ICU LOS, and total TC charges increased in all temperature groups when compared to NT. Conclusion In this large, statewide study of major TBI, both ETs and LTs immediately following prehospital transport were independently associated with higher mortality and with increased TC LOS, ICU LOS, and total TC charges. Further study is needed to identify the causes of abnormal body temperature during the prehospital interval and if in-field measures to prevent temperature variations might improve outcomes.

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Section: Introductionmentioning

confidence: 99%

Body Temperature after EMS Transport: Association with Traumatic Brain Injury Outcomes

Gaither¹,

Chikani

Stolz³

et al. 2017

Prehospital Emergency Care

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“…3,16,21,28–31,34,38,52 However, the literature that has shaped this understanding has evaluated hypotension as a simple dichotomy (</≥90 mmHg). 3,16,21,28–31,38 Currently there are no published reports with data evaluating the impact of either the depth or the duration of out-of-hospital hypotension.…”

Section: Discussionmentioning

confidence: 99%

“…The data entry system allows an unlimited number of data entries for vital signs. 33,34 In fact, in this sub-study, there are patients with as many as 25 EMS BP measurements recorded in the database and the median number is four per patient. This feature allows the plotting of out-of-hospital blood pressure over time and, hence, an estimation of the depth and duration of hypotensive events (Figures 1, 2).…”

Section: Discussionmentioning

confidence: 99%

“…In this secondary analysis we included patients 10 years of age or older with physical trauma who have trauma center (TC) diagnosis(es) consistent with TBI (isolated or multisystem trauma) and meet at least one of the following definitions for moderate or severe (“major”) TBI: a) Centers for Disease Control (CDC) Barell Matrix-Type 1, b) International Classification of Diseases-Version 9 (ICD-9) head region severity score ≥3, c) Abbreviated Injury Scale (AIS)-head region score ≥3. 33,34 We excluded cases with age <10 years, inter-facility transfer (or unknown), any SBP >200mmHg, SBP of 0 indicating traumatic arrest, missing important confounders/risk-adjusters, and zero or only one recorded out-of-hospital SBP with documented time between six hours before ED arrival to 10 minutes after ED arrival (excludes extreme or obviously-inaccurate time data). The patients with only one timed, recorded SBP measurement were excluded because at least two are needed to establish depth-duration dose.…”

Section: Methodsmentioning

confidence: 99%

“…Trauma type (blunt versus penetrating), payment source, and treating TC were included because they have often been confounders in trauma outcome studies 44,45 and were found to be significant covariates in previous EPIC reports. 34,35 …”

Section: Methodsmentioning

confidence: 99%

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

Spaite

Bobrow

et al. 2017

Annals of Emergency Medicine

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Background Out-of-hospital hypotension has been associated with increased mortality in traumatic brain injury (TBI). The association of TBI mortality with the depth or duration of out-of-hospital hypotension is unknown. Methods We evaluated adults and older children with moderate/severe TBI in the pre-implementation cohort of Arizona’s statewide Excellence in Prehospital Injury Care (EPIC) Study. We used logistic regression to determine the association between the depth-duration dose of hypotension [depth of systolic blood pressure <90 mmHg integrated over duration (minutes) of hypotension] and odds of in-hospital death, controlling for significant confounders. Results There were 7,521 TBI cases included [70.6% male, median age 40 (interquartile range 24, 58)]. Mortality was 7.8% (95%CI: 7.2–8.5%) among the 6982 cases without hypotension (SBP≥90 mmHg) and 33.4% (95%CI: 29.4–37.6%) among the 539 hypotensive cases (SBP<90 mmHg). Mortality was higher with increased hypotension dose: 0.01–14.99 mmHg*min, 16.3%; 15–49.99, 28.1%; 50–141.99, 38.8%; ≥142, 50.4%. Log2 (the logarithm in base 2) of hypotension dose was associated with TBI mortality [adjusted odds ratio 1.19 (95% CI: 1.14–1.25) per two-fold increase of dose]. Conclusion In this study, the depth and duration of out-of-hospital hypotension were associated with increased TBI mortality. Assessments linking out-of-hospital blood pressure with TBI outcomes should consider both depth and duration of hypotension.

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Early Oxygen Supplementation After Resuscitation From Cardiac Arrest

Elmer

Guyette

2022

JAMA

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Supplemental oxygen administration was first noted to correct signs and symptoms of hypoxic respiratory failure more than a century ago. 1,2 Since that time, oxygen has become one of the most widely administered therapeutic interventions in medicine. The prevention or reversal of hypoxia can be lifesaving, but excessive oxygen supplementation and resulting hyperoxia promotes resorption atelectasis and free radical formation leading to oxidative damage to tissues, endothelial dysfunction, and other deleterious effects. 3 The optimal dose of supplemental oxygen has been explored in several randomized clinical trials. A single-center trial that included 434 patients in a general intensive care unit (ICU) population and compared oxygen titration to a partial pressure of arterial oxygen (PaO 2 ) of 70 to 100 mm Hg (arterial oxygen saturation [SpO 2 ] of 94%-98%) vs titration to a PaO 2 up to 150 mm Hg (SpO 2 of 97%-100%) found that the lower oxygenation goals reduced mortality. 4 By contrast, subsequent multicenter trials that included general ICU patients (sample sizes of 965, 400, and 2928 patients), [5][6][7] as well as patients with acute respiratory distress syndrome (n = 205) 8 or myocardial infarction (n = 6629) 9 found no benefit from lower oxygen targets.It is uncertain whether data from ICU-based trials in other patient populations generalize to the out-of-hospital and emergency department treatment of patients resuscitated from cardiac arrest. The pathophysiological sequelae of pulselessness and cardiopulmonary resuscitation may increase susceptibility to and potential harm from both hypoxia and hyperoxia in a manner that changes rapidly in the minutes after return of spontaneous circulation (ROSC). Respiratory failure is a common antecedent cause of cardiac arrest, whereas aspiration, pulmonary contusions, atelectasis, and hypotension develop in most patients who are resuscitated and contribute to ventilation-perfusion mismatch and hypoxemia. [10][11][12] Even when SpO 2 and PaO 2 values are within normal range, perivascular edema in the brain can cause tissue hypoxia that may contribute to secondary brain injury after ROSC. 13,14 Conversely, reperfusion injury is a major contributor to organ dysfunction after ROSC that is worsened by hyperoxia. 15 Postarrest hyperoxia may also reduce cerebral blood flow and cardiac output by increasing vascular resistance. 16 In this issue of JAMA, Bernard et al 17 report a multicenter clinical trial that randomized adult patients with ROSC after out-of-hospital cardiac arrest and advanced airway placement to receive rapid reduction in supplemental oxygen delivery targeting an SpO 2 of 90% to 94% or high-flow supplemental oxygen targeting an SpO 2 of 98% to 100%. Paramedics randomized eligible patients and initiated the study interven-

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The Effect of Combined Out-of-Hospital Hypotension and Hypoxia on Mortality in Major Traumatic Brain Injury

Cited by 135 publications

References 49 publications

Body Temperature after EMS Transport: Association with Traumatic Brain Injury Outcomes

Body Temperature after EMS Transport: Association with Traumatic Brain Injury Outcomes

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

Early Oxygen Supplementation After Resuscitation From Cardiac Arrest

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