The Effect of Combined Out-of-Hospital Hypotension and Hypoxia on Mortality in Major Traumatic Brain Injury - 19/04/17
, Chengcheng Hu, PhD a, d, Bentley J. Bobrow, MD a, c, e, Vatsal Chikani, MPH a, e, Bruce Barnhart, RN, CEP a, Joshua B. Gaither, MD a, c, Kurt R. Denninghoff, MD a, c, P. David Adelson, MD b, Samuel M. Keim, MD, MS a, c, Chad Viscusi, MD a, c, Terry Mullins, MBA e, Duane Sherrill, PhD dAbstract |
Study objective |
Survival is significantly reduced by either hypotension or hypoxia during the out-of-hospital management of major traumatic brain injury. However, only a handful of small studies have investigated the influence of the combination of both hypotension and hypoxia occurring together. In patients with major traumatic brain injury, we evaluate the associations between mortality and out-of-hospital hypotension and hypoxia separately and in combination.
Methods |
All moderate or severe traumatic brain injury cases in the preimplementation cohort of the Excellence in Prehospital Injury Care study (a statewide, before/after, controlled study of the effect of implementing the out-of-hospital traumatic brain injury treatment guidelines) from January 1, 2007, to March 31, 2014, were evaluated (exclusions: <10 years, out-of-hospital oxygen saturation ≤10%, and out-of-hospital systolic blood pressure <40 or >200 mm Hg). The relationship between mortality and hypotension (systolic blood pressure <90 mm Hg) or hypoxia (saturation <90%) was assessed with multivariable logistic regression, controlling for Injury Severity Score, head region severity, injury type (blunt versus penetrating), age, sex, race, ethnicity, payer, interhospital transfer, and trauma center.
Results |
Among the 13,151 patients who met inclusion criteria (median age 45 years; 68.6% men), 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 4 study cohorts was 5.6%, 20.7%, 28.1%, and 43.9%, respectively. The crude and adjusted odds ratios for death within the cohorts, using the patients with neither hypotension nor hypoxia as the reference, were 4.4 and 2.5, 6.6 and 3.0, and 13.2 and 6.1, respectively. Evaluation for an interaction between hypotension and hypoxia revealed that the effects were additive on the log odds of death.
Conclusion |
In this statewide analysis of major traumatic brain injury, combined out-of-hospital hypotension and hypoxia were associated with significantly increased mortality. This effect on survival persisted even after controlling for multiple potential confounders. In fact, the adjusted odds of death for patients with both hypotension and hypoxia were more than 2 times greater than for 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 emergency medical services traumatic brain injury treatment guidelines but clearly reveal the need for further study to determine their influence on outcome.
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| Please see page 63 for the Editor’s Capsule Summary of this article. |
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| Supervising editor: Theodore R. Delbridge, MD, MPH |
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| Author contributions: DWS, BJB, JBG, KRD, PDA, CV, and DS were responsible for study concept and design. DWS, CH, BJB, VC, and BB were responsible for acquisition of the data. DWS, CH, BJB, VC, and DS were responsible for analysis and interpretation of the data. DWS, CH, and BJB were responsible for drafting the article. All authors were responsible for critical revision of the article for important intellectual content. CH and DS were responsible for statistical expertise. DWS, BJB, JBG, KRD, CV, and DS were responsible for obtaining funding. VC, BB, and TM were responsible for administrative, technical, and material support. DWS takes responsibility for the paper as a whole. |
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| Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org/). The authors have stated that no such relationships exist. This research was supported by the National Institute of Neurological Disorders and Stroke of the National Institutes of Health (NIH) under award R01NS071049. The University of Arizona receives funding from the NIH supporting the EPIC study. This includes support for Drs. Spaite, Bobrow, Gaither, Denninghoff, Adelson, Viscusi, and Sherrill, and Mssrs. Chikani and Barnhart. |
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| Trial registration number: NCT01339702 |
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| The content of this article is solely the responsibility of the authors and does not necessarily represent the official views of the NIH. |
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Vol 69 - N° 1
P. 62-72 - janvier 2017 Retour au numéro
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