The prevalence of hypotension and hypoxaemia in blunt traumatic brain injury in the prehospital setting of Johannesburg, South Africa: A retrospective chart review

Stassen, Willem; Welzel, Tyson

doi:10.7196/samj.7494

Cited by 12 publications

(10 citation statements)

References 17 publications

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“…6,7,10–40 However, there is almost nothing known about the impact of these factors when they both occur in patients prior to arrival at the hospital. This is because 1) the hypotension/hypoxia combination is an unusual occurrence and 2) studying this question requires the analysis of large numbers of TBI patients with linked prehospital data.…”

Section: Discussionmentioning

confidence: 99%

“…These wide-ranging (and even paradoxical) results were likely due to the very small numbers and, thus, this study could make no conclusions about the impact of the combination of hypotension and hypoxia on outcome. Both Fearnside, et al 11 and Stassen, et al 40 also obtained prehospital clinical data in their evaluations of severe TBI. However, they made no comment at all about the relative impact of the combination of hypotension and hypoxia.…”

Section: Discussionmentioning

confidence: 99%

“…16,22,26 With the exception of a meta-analysis that had major issues with study heterogeneity and missing data, 39 the reports that have looked at the impact of hypotension combined with hypoxia in TBI have had very few cases. 6,16,22,26,28,35,40 Furthermore, even less is known about this issue in the prehospital setting. To our knowledge only two previous studies specifically evaluated the hypotension/hypoxia combination utilizing prehospital data.…”

Section: Introductionmentioning

confidence: 99%

“…It is well established that secondary brain injury is initiated by even brief periods of compromised blood flow or hypoxia. 20,22,23,28,35,40–43 Thus, decreased perfusion and/or hypoxia occurring during the prehospital time interval may have a profound impact on outcome.…”

Section: Introductionmentioning

confidence: 99%

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

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Bobrow

et al. 2017

Annals of Emergency Medicine

135

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BACKGROUND Survival is significantly reduced by either hypotension or hypoxia during the prehospital management of major traumatic brain injury (TBI). However, only a handful of small studies have investigated the influence of the combination of both hypotension and hypoxia occurring together. Objective: In patients with major TBI, we evaluated the associations between mortality and prehospital hypotension and hypoxia, both separately and in combination. METHODS All moderate/severe TBI cases in the pre-implementation cohort of the Excellence in Prehospital Injury Care (EPIC) Study (a statewide, before/after, controlled study of the impact of implementing the prehospital TBI treatment guidelines) from 1/1/07–3/31/14 were evaluated [exclusions: age<10 years; prehospital oxygen saturation ≤10%; prehospital systolic blood pressure (SBP) <40 or >200mmHg]. The relationship between mortality and hypotension (SBP <90mmHg) and/or hypoxia (saturation <90%) was assessed using multivariable logistic regression, controlling for Injury Severity Score, head region severity, injury type (blunt versus penetrating), age, sex, race, ethnicity, payer, inter-hospital transfer, and trauma center. RESULTS Among the 13,151 cases that met inclusion criteria [Median age: 45; Male: 68.6%], 11,545 (87.8%) had neither hypotension nor hypoxia, 604 (4.6%) had hypotension only, 790 (6.0%) had hypoxia only, and 212 (1.6%) had both hypotension and hypoxia. Mortality for the four study cohorts was 5.6%, 20.7%, 28.1%, and 43.9%, respectively. The crude and adjusted odds ratios (cOR/aOR) for death within the cohorts, utilizing the patients with neither hypotension nor hypoxia as the reference, were 4.4/2.5, 6.6/3.0, and 13.2/6.1, respectively. Evaluation for an interaction between hypotension and hypoxia revealed that the effects are additive on the log odds of death. CONCLUSION In this statewide analysis of major TBI, combined prehospital hypotension/hypoxia were associated with dramatically increased mortality. This effect on survival persisted even after controlling for multiple potential confounders. In fact, the adjusted odds of death in patients with both hypotension and hypoxia was more than two times greater than those with either hypotension or hypoxia alone. These findings seem supportive of the emphasis on aggressive prevention and treatment of hypotension and hypoxia reflected in the current EMS TBI treatment guidelines but clearly reveal the need for further study to determine their impact on outcome.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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

Spaite

Bobrow

et al. 2017

Annals of Emergency Medicine

135

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“…These findings add to the growing evidence that close and frequent blood pressure monitoring and management may potentially contribute to improved TBI outcomes. 4,7,8,15,23,30,32,33,36,38 …”

Section: Discussionmentioning

confidence: 99%

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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An online learning programme improves traumatic brain injury guideline adherence in a South African Helicopter Emergency Medical Service

Stassen¹,

Wylie²,

Holgate³

2015

African Journal of Emergency Medicine

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The prevalence of hypotension and hypoxaemia in blunt traumatic brain injury in the prehospital setting of Johannesburg, South Africa: A retrospective chart review

Cited by 12 publications

References 17 publications

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

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

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

An online learning programme improves traumatic brain injury guideline adherence in a South African Helicopter Emergency Medical Service

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