Prehospital Postintubation Hypotension and Survival in Severe Traumatic Brain Injury

Abstract

Importance: Preventing systemic disturbances, such as hypotension and hypoxia, is key to reducing the impact of secondary neuronal injury after traumatic brain injury (TBI). Postintubation hypotension is prevalent and may be associated with worse outcomes in patients with trauma undergoing emergency anesthesia.

Objective: To investigate the association between postintubation hypotension and 30-day mortality in patients with severe TBI undergoing prehospital rapid sequence induction.

Design, setting, and participants: This multicenter, retrospective, observational cohort study was performed between January 1, 2015, and December 31, 2022, in the East of England Trauma Network, including 3 helicopter emergency medical services (East Anglian Air Ambulance, Essex & Herts Air Ambulance, and Magpas Air Ambulance). A consecutive sample of patients (aged ≥16 years) with trauma and severe TBI who received prehospital rapid sequence induction by helicopter emergency medical services and were transported to a hospital within the East of England Trauma Network were eligible for inclusion. Severe TBI was defined as a Head Abbreviated Injury Scale score of 3 or higher. Data analysis was performed from March to May 2025.

Exposure: Postintubation hypotension defined as a new systolic blood pressure less than 90 mmHg and induction of anesthesia at 10 minutes or less.

Main outcomes and measures: The primary outcome was 30-day mortality.

Results: A total of 555 patients (median [IQR] age, 48 [29-66] years; 408 [73.5%] male) were included in the final analysis; 548 (98.7%) had a blunt mechanism of injury. Within the first 10 minutes of anesthesia, 106 patients (19.1%) had postintubation hypotension, and 169 (30.5%) died within 30 days of injury (46 of 106 [43.4%] in the hypotension group and 123 of 449 [27.4%] in the nonhypotension group). After adjustment for confounders (eg, age and Glasgow Coma Scale score), postintubation hypotension was associated with increased 30-day mortality for patients with polytrauma and severe TBI (adjusted odds ratio [AOR], 1.70; 95% CI, 1.01-2.86; P = .04). For patients with isolated severe TBI who had postintubation hypotension, the odds of death adjusted for confounders (eg, age, Glasgow Coma Scale score, and Injury Severity Score) were significantly higher than for patients without (AOR, 13.55; 95% CI, 3.65-61.66; P < .001).

Conclusions and relevance: In this cohort study of patients with severe TBI who received prehospital rapid sequence induction, postintubation hypotension was associated with increased 30-day mortality. This association was strongest for patients with isolated TBI. These findings suggest the need for randomized prehospital interventional studies to reduce the incidence of postintubation hypotension in traumatic brain injury.

Figure 1.. Study Flow of Patients With Trauma Attended by Helicopter Emergency Medical Services Who Received Prehospital Rapid Sequence Induction (RSI) in the East of England Trauma Network (EOETN), 2015-2022

AIS indicates Abbreviated Injury Scale; SBP, systolic blood pressure; TARN, Trauma Audit and Research Network.

Figure 2.. Adjusted Odds Ratios (AORs) of Death for Lowest Postintubation Systolic Blood Pressure (SBP) in Patients With Polytrauma and Severe Traumatic Brain Injury (Group 1) in the East of England Trauma Network, 2015-2022^a

^aSevere traumatic brain injury was defined as Head Abbreviated Injury Scale Score ≥3.

Figure 3.. Adjusted Odds Ratios (AORs) of Death for Lowest Postintubation Systolic Blood Pressure (SBP) in Patients With Trauma and Isolated Severe Traumatic Brain Injury (Head Abbreviated Injury Scale Score ≥3 and All Other Body Region Abbreviated Injury Scale Score <3) in the East of England Trauma Network, 2015-2022

^aIsolated severe traumatic brain injury was defined as head Abbreviated Injury Scale score ≥3 and all other body region Abbreviated Injury Scale score <3.