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. 2025 Jan 2;8(1):e2457506.
doi: 10.1001/jamanetworkopen.2024.57506.

Adverse Prehospital Events and Outcomes After Traumatic Brain Injury

Amelia W Maiga  1   2 , Hsing-Hua Sylvia Lin  3   4 , Stephen R Wisniewski  4 , Joshua B Brown  5 , Ernest E Moore  6 , Martin A Schreiber  7 , Bellal Joseph  8 , Chad T Wilson  9 , Bryan A Cotton  10 , Daniel G Ostermayer  11 , Brian G Harbrecht  12 , Mayur B Patel  1   2 , Jason L Sperry  5 , Francis X Guyette  13 , Henry E Wang  14
Affiliations

Adverse Prehospital Events and Outcomes After Traumatic Brain Injury

Amelia W Maiga et al. JAMA Netw Open. .

Abstract

Importance: While national guidelines recommend avoidance of hypoxia, hypotension, and hypocarbia in the prehospital care of traumatic brain injury (TBI), limited data validate the association of these adverse physiologic events with TBI outcomes.

Objective: To validate the associations of prehospital hypoxia, hypotension, and hypocarbia with TBI outcomes in a US national trauma network.

Design, setting, and participants: This cohort study examined data from 8 level I trauma centers and their affiliated ground and air emergency medical services (EMS) agencies in the Linking Investigations in Trauma and Emergency Services (LITES) Network from January 1, 2017, to June 30, 2021. Adult patients (aged ≥18 years) with confirmed TBI (head Abbreviated Injury Score [AIS] of 1-6) and Injury Severity Score (ISS) of at least 9 were included. Interfacility transfers and patients who underwent prehospital cardiopulmonary resuscitation were excluded. Data were analyzed between April 20, 2022, and November 27, 2023.

Exposures: Adverse prehospital TBI events, including hypoxia, hypotension, or hypocarbia.

Main outcomes and measures: The primary outcomes were death in the emergency department (ED), hospital death, and unfavorable discharge disposition. Log-binomial regression models were used to estimate the association between adverse TBI events and outcomes, adjusting for sex, race and ethnicity, age, study site, transport mode, initial Glasgow Coma Scale, ISS, head AIS score, injury mechanism, and multiple trauma.

Results: The analytic cohort included 14 994 patients (median [IQR] age, 47 [31-64] years; 71% male; median [IQR] head AIS, 3 [2-4]). Patients with adverse TBI events included 12% (1577 of 13 604) with hypoxia, 10% (1426 of 14 842) with hypotension, and 61% (650 of 1068) with hypocarbia among those with advanced airway management. Patient outcomes included 2% (259 of 14 939) who died in the ED, 12% (1764 of 14 623) who died in the hospital, and 25% (3705 of 14 623) with an unfavorable discharge disposition. Hypoxia (adjusted relative risk [ARR], 2.24; 95% CI, 1.69-2.97), hypotension (ARR, 2.05; 95% CI, 1.54-2.72), and hypocarbia (ARR, 7.99; 95% CI, 2.47-25.85) were associated with increased risks of ED death. Each adverse TBI event exposure was also associated with higher risks of hospital death and unfavorable discharge disposition.

Conclusions and relevance: In this multicenter cohort study, prehospital hypoxia, hypotension, and hypocarbia were associated with poorer TBI outcomes. These results underscore the importance of optimal oxygenation, ventilation, and perfusion in prehospital TBI care.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Moore reported receiving grants from the Ernest E. Moore Shock Trauma Center at Denver Health during the conduct of the study. Dr Schreiber reported receiving grants from the US Department of Defense (DOD) during the conduct of the study. Dr Cotton reported receiving grants from the Linking Investigations in Trauma and Emergency Services (LITES) Network during the conduct of the study. Dr Harbrecht reported receiving grants from the DOD during the conduct of the study. Dr Patel reported receiving grants from the DOD and National Institutes of Health, and honoraria from Elsevier outside the submitted work and a patent issued for latent image-derived features for prognostic modeling. Dr Sperry reported receiving grants from the DOD during the conduct of the study. Dr Guyette reported receiving contractor fees for work on the LITES Network from the DOD during the conduct of the study. No other disclosures were reported.

Figures

Figure.
Figure.. Study Flowchart for the Analytic Cohort
AIS indicates Abbreviated Injury Score; CPR, cardiopulmonary resuscitation; EMS, emergency medical services; LITES TO1, Linking Investigations in Trauma and Emergency Services Task Order One; TBI, traumatic brain injury.
See this image and copyright information in PMC

Comment in

  • doi: 10.1001/jamanetworkopen.2024.57512

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