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Cited by 187Traumatic Brain Injury and Neurovascular DisturbancesTrauma and Emergency Care StudiesCardiac Arrest and Resuscitation

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

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Spaite, Daniel W., Hu, Chengcheng, Bobrow, Bentley J., Chikani, Vatsal, Barnhart, Bruce, Gaither, Joshua B., Denninghoff, Kurt R., Adelson, P. David +4 more·2017·Annals of Emergency Medicine
DOI 10.1016/j.annemergmed.2016.08.007PMC PMC5173421
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Abstract

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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Crossref · 10.1016/j.annemergmed.2016.08.007

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  • The incidence of peri-intubation desaturation, hypocapnea, and hypotension in emergency intubations is relatively high.

    “Given the relatively high incidence of peri-intubation desaturation, hypocapnea, and hypotension in emergency intubations”

    From Airway Management in Trauma (2018) · cites this paper as [23]

    The Introduction (Background and Significance; page unavailable) says hypoxia occurs frequently and hypotension is very common during prehospital care of patients with traumatic brain injury. It does not establish their incidence specifically around emergency intubation, and the passages do not address hypocapnea. (LLM, conf=0.86)

    Experimental — accuracy not yet measured

  • Even transient drops in blood pressure are associated with adverse outcomes in trauma patients.

    “even transient drops in blood pressure are associated with adverse outcomes in trauma patients.23,[92][93][94]”

    From Airway Management in Trauma (2018) · cites this paper as [23]

    The Introduction (Background and Significance) says that a single episode of hypotension doubles mortality, supporting the point about transient blood-pressure drops. The paper addresses patients with major traumatic brain injury, however, not trauma patients generally; no page number is provided in our copy. (LLM, conf=0.85)

    Experimental — accuracy not yet measured

  • The combination of hypoxemia and hypotension is additive, with an adjusted odds of death double that of the increased mortality associated with either event alone.

    “The combination of hypoxemia and hypotension is additive, with an adjusted odds of death double that of the increased mortality associated with either event alone.23,97,98”

    From Airway Management in Trauma (2018) · cites this paper as [23]

  • The incidence of post intubation hypotension is high in patients requiring emergency airway management (23%-46%).

    “The incidence of post intubation hypotension is high in patients requiring emergency airway management (23%-46%)”

    From Airway Management in Trauma (2018) · cites this paper as [23]

    The Introduction describes hypotension as common early in the care of traumatic brain injury, but gives no post-intubation incidence. The Limitations section says the study did not analyze the timing of low blood-pressure readings or evaluate interventions. Searches for post-intubation hypotension and emergency airway management found no support for the claimed 23%–46% range. (LLM, conf=0.76)

    Experimental — accuracy not yet measured

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Authors
Spaite, D. W., Hu, C., Bobrow, B. J., Chikani, V., Barnhart, B., Gaither, J. B., Denninghoff, K. R., Adelson, P. D., Keim, S. M., Viscusi, C., Mullins, T., & Sherrill, D.
Affiliations
  • University of Arizona (US)
  • Arizona Department of Health Services (US)
  • Barrow Neurological Institute (US)
Corresponding author
Spaite, Daniel W.
ORCID
Venue
Annals of Emergency Medicine
Publisher
Elsevier BV
Published
2017-01
Volume
69
Issue
1
Pages
62-72
ISSN
0196-0644 (ISSN-L)
DOI
10.1016/j.annemergmed.2016.08.007
PMC
PMC5173421
OpenAlex
W2526007051
Cited by
187
References
1
Citations by year
2026: 28 · 2025: 17 · 2024: 19 · 2023: 18 · 2022: 23 · 2021: 12 · 2020: 24 · 2019: 21 · 2018: 13 · 2017: 12
FWCI
9.91
Type
journal article
Language
en
Open access
Licence
www.elsevier.com/tdm/userlicense/1.0/ (tdm)
Locations
  • Annals of Emergency Medicine (publishedVersion)
  • PubMed (publishedVersion)
  • Europe PMC (PubMed Central) (acceptedVersion)
  • PubMed Central (acceptedVersion)
Funders
National Institute of Neurological Disorders and Stroke (R01NS071049)
Topics
  • Health Sciences › Medicine › Neurology › Traumatic Brain Injury and Neurovascular Disturbances
  • Health Sciences › Medicine › Emergency Medicine › Trauma and Emergency Care Studies
  • Health Sciences › Medicine › Emergency Medicine › Cardiac Arrest and Resuscitation
Keywords
traumatic brain injury, mortality, prehospital care, trauma care guidelines, oxygen saturation, systolic blood pressure, Injury Severity Score, penetrating head injury, blunt head trauma
MeSH terms
Brain Injuries, Traumatic, Adult, Aged, Hypoxia, Female, Humans, Hypotension, Male, Middle Aged

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