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Comment
. 2024 Apr 1;159(4):363-372.
doi: 10.1001/jamasurg.2023.7155.

EMS Treatment Guidelines in Major Traumatic Brain Injury With Positive Pressure Ventilation

Joshua B Gaither  1   2 , Daniel W Spaite  1   2 , Bentley J Bobrow  3 , Bruce Barnhart  1 , Vatsal Chikani  4 , Kurt R Denninghoff  1   2 , Gail H Bradley  2   5 , Amber D Rice  1   2 , Jeffrey T Howard  4 , Samuel M Keim  1   2 , Chengcheng Hu  1   6
Affiliations
Comment

EMS Treatment Guidelines in Major Traumatic Brain Injury With Positive Pressure Ventilation

Joshua B Gaither et al. JAMA Surg. .

Abstract

Importance: The Excellence in Prehospital Injury Care (EPIC) study demonstrated improved survival in patients with severe traumatic brain injury (TBI) following implementation of the prehospital treatment guidelines. The impact of implementing these guidelines in the subgroup of patients who received positive pressure ventilation (PPV) is unknown.

Objective: To evaluate the association of implementation of prehospital TBI evidence-based guidelines with survival among patients with prehospital PPV.

Design, setting, and participants: The EPIC study was a multisystem, intention-to-treat study using a before/after controlled design. Evidence-based guidelines were implemented by emergency medical service agencies across Arizona. This subanalysis was planned a priori and included participants who received prehospital PPV. Outcomes were compared between the preimplementation and postimplementation cohorts using logistic regression, stratified by predetermined TBI severity categories (moderate, severe, or critical). Data were collected from January 2007 to June 2017, and data were analyzed from January to February 2023.

Exposure: Implementation of the evidence-based guidelines for the prehospital care of patient with TBI.

Main outcomes and measures: The primary outcome was survival to hospital discharge, and the secondary outcome was survival to admission.

Results: Among the 21 852 participants in the main study, 5022 received prehospital PPV (preimplementation, 3531 participants; postimplementation, 1491 participants). Of 5022 included participants, 3720 (74.1%) were male, and the median (IQR) age was 36 (22-54) years. Across all severities combined, survival to admission improved (adjusted odds ratio [aOR], 1.59; 95% CI, 1.28-1.97), while survival to discharge did not (aOR, 0.94; 95% CI, 0.78-1.13). Within the cohort with severe TBI but not in the moderate or critical subgroups, survival to hospital admission increased (aOR, 6.44; 95% CI, 2.39-22.00), as did survival to discharge (aOR, 3.52; 95% CI, 1.96-6.34).

Conclusions and relevance: Among patients with severe TBI who received active airway interventions in the field, guideline implementation was independently associated with improved survival to hospital admission and discharge. This was true whether they received basic airway interventions or advanced airways. These findings support the current guideline recommendations for aggressive prevention/correction of hypoxia and hyperventilation in patients with severe TBI, regardless of which airway type is used.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Gaither reported grants from the US Department of Defense and National Institute of Neurological Disorders and Stroke during the conduct of the study. Dr Spaite reported grants from the National Institute of Neurological Disorders and Stroke during the conduct of the study. Dr Barnhart reported grants and personal fees from Philips Healthcare outside the submitted work. Dr Keim reported grants from the National Institute of Neurological Disorders and Stroke during the conduct of the study. Dr Hu reported grants from the US Department of Defense during the conduct of the study. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Inclusion Tree of Patients in the Preimplementation and Postimplementation Phases
BVM indicates bag-valve-mask ventilation; EPIC, Excellence in Prehospital Injury Care; ETI, endotracheal intubation; PPV, positive pressure ventilation; SGA, supraglottic airway.
Figure 2.
Figure 2.. Adjusted Odds of Survival to Hospital Admission and Discharge Among the Airway Subgroups (All-Severity Analysis)
The values for adjusted odds ratios (aORs) are plotted on a log scale. BVM indicates bag-valve-mask ventilation; ETI, endotracheal intubation; PPV, positive pressure ventilation; SGA, supraglottic airway. aFirth logistic regression was used due to fewer than 200 deaths before discharge.
Figure 3.
Figure 3.. Comparison of Adjusted Odds of Survival During the Postimplementation vs Preimplementation Phases Among the Airway Subgroups
The values for adjusted odds ratios (aORs) are plotted on log scale. BVM indicates bag-valve-mask ventilation; ETI, endotracheal intubation; PPV, positive pressure ventilation; RSS-H, regional severity score–head; SGA, supraglottic airway; TBI, traumatic brain injury. aFirth logistic regression was used due to fewer than 200 deaths before discharge.
See this image and copyright information in PMC

Comment on

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