Abstract 362: Differential Effect of the Prehospital Traumatic Brain Injury Guidelines on Survival in Isolated and Multisystem Traumatic Brain Injury

Introduction: The Prehospital TBI Guidelines (PTGs) are intended for both isolated and multisystem TBI (ITBI/MTBI). However, uncontrolled hemorrhage and potential detrimental effects of fluid resuscitation in MTBI may lead to differential effectiveness compared to ITBI. Methods: Preplanned subgroup analysis of PTG effectiveness in ITBI and MTBI from EPIC (before/after system study; 133 agencies, >11,000 trained; NIH R01NS071049). Interventions: Prevention/treatment of hypoxia, hypotension, hyperventilation. Inclusion: Barell Matrix 1; 1/07-6/15. Severity subgroups [Head Region Severity Score (HRSS; AIS equivalent)]: Moderate = 1-2; Severe = 3-4; Critical = 5-6. Definitions: ITBI: TBI with no other RSS ≥3 injury. MTBI: TBI plus non-head region RSS ≥3 injuries. Pre (P1) and post-implementation (P3) cohorts were compared using logistic regression. Results: Cases: 21,852; median age 45 (IQR 24, 66); 67% male. ITBI: 16,663 (76.3%); P1 = 11,602, P3 = 5061. MTBI: 5189 (23.7%); P1 = 3626, P3 = 1563]. Hypotension occurred much more frequently in MTBI (15.8%) than ITBI (4.5%; OR = 3.9 (3.5, 4.4); p<0.0001) and, after PTG implementation, MTBI patients were much more likely to receive a fluid bolus (10.7%; 167/1563) than ITBI (5.3%; 267/5061; p<0.0001). There was highly significant improvement in aOR for survival in severe (HRSS 3-4) ITBI and MTBI (Fig 1). Furthermore, the severe ITBI and MTBI patients who were intubated or who received any positive pressure ventilation (PPV; basic or advanced) also improved dramatically (Fig 2). Conclusions: PTG implementation was independently associated with improved odds of survival in severe ITBI and MTBI. Despite a rate of hypotension 4 times higher in MTBI, survival improvement was at least as strong as for ITBI. Since the MTBI cohort was much more likely to receive fluid resuscitation, these findings support the PTG recommendation for aggressive treatment of hypotension in TBI even in patients with potential ongoing hemorrhage.

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Faculty Opinions recommendation of Saline or albumin for fluid resuscitation in patients with traumatic brain injury.

Faculty Opinions – Post-Publication Peer Review of the Biomedical Literature ◽

10.3410/f.1097043.553013 ◽

2007 ◽

Author(s):

Samuel Stratton

Keyword(s):

Traumatic Brain Injury ◽

Brain Injury ◽

Fluid Resuscitation

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Abstract 230: Differential Effects of Prehospital Hypotension and Injury Severity in Isolated vs. Multisystem Major Traumatic Brain Injury

Circulation ◽

10.1161/circ.138.suppl_2.230 ◽

2018 ◽

Vol 138 (Suppl_2) ◽

Author(s):

Daniel W Spaite ◽

Chengcheng Hu ◽

Bentley J Bobrow ◽

Bruce J Barnhart ◽

Vatsal Chikani ◽

...

Keyword(s):

Traumatic Brain Injury ◽

Brain Injury ◽

Injury Severity ◽

Treatment Effectiveness ◽

Guideline Implementation ◽

Body Region ◽

Head Region ◽

Differential Effects ◽

Severe Tbi

Background: In hospital-based studies, hypotension (HT, SBP <90) is more likely to occur in multisystem traumatic brain injury (MTBI) than isolated (ITBI). However, there are few EMS studies on this issue. Hypothesis: Prehospital HT is associated with differential effects in MTBI and ITBI and these effects are influenced by the severity of primary brain injury. Methods: Inclusion: TBI cases in the EPIC Study (NIH 1R01NS071049) before TBI guideline implementation (1/07-3/14). ITBI: Major TBI cases (CDC Barell Matrix Type 1) that had no injury with ICD9-based Regional Severity Score [RSS (AIS equivalent)] ≥3 in any other body region. MTBI: Type 1 TBI plus at least one non-head region injury with RSS ≥3. Results: Included were 13,435 cases [Excl: age <10 (5.9%), missing data (6.2%)]. 10,374 (77.2%) were ITBI, 3061 (22.8%) MTBI. Mortality: ITBI: 7.7% (797/10,374), MTBI: 19.2% (587/3061, p<0.0001). Prehospital HT occurred 3.5 times more often in MTBI (14.8%, 453/3061 vs 4.2%, 437/10,374; p<0.0001). Among HT cases, 40.8% (185/453) with MTBI died vs 30.9% with ITBI (135/437; p<0.0001). In the hypotensive moderate/severe TBI cohort (RSS-Head 3/4), MTBI mortality was 2.4 times higher (17.2%, 40/232) than ITBI (7.1%, 17/240, p = 0.001). However, in the hypotensive very/extremely severe TBI group (RSS-Head 5/6), mortality was almost identical in MTBI (73.4%, 141/192) and ITBI (72.1%, 116/161, p = 0.864). Conclusion: Among major TBI patients with prehospital HT, those with MTBI were much more likely to die than those with ITBI. However, this association varied dramatically with TBI severity. In mod/severe TBI cases with HT, MTBI mortality was 2.4 times higher than in ITBI. In contrast, in very/extremely severe TBI with HT, there was no identifiable mortality difference. Thus, in cases with substantial potential to survive the primary brain injury (mod/severe), outcome is markedly worse in patients with multisystem injuries. However, in very/extremely severe TBI, non-head region injuries have no apparent association with mortality. This may be because the TBI is the primary factor leading to death in these cases. The main EPIC study is evaluating whether this severity-based difference in “effect” has implications for TBI guideline treatment effectiveness.

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Impact of delivered tidal volume on the occurrence of intraventricular haemorrhage in preterm infants during positive pressure ventilation in the delivery room

Archives of Disease in Childhood - Fetal and Neonatal Edition ◽

10.1136/archdischild-2017-313864 ◽

2018 ◽

Vol 104 (1) ◽

pp. F57-F62 ◽

Cited By ~ 19

Author(s):

Qaasim Mian ◽

Po-Yin Cheung ◽

Megan O’Reilly ◽

Samantha K Barton ◽

Graeme R Polglase ◽

...

Keyword(s):

Brain Injury ◽

Tidal Volume ◽

Preterm Infants ◽

Positive Pressure Ventilation ◽

Intraventricular Haemorrhage ◽

Delivery Room ◽

Positive Pressure ◽

Reference Ranges ◽

The Mean ◽

Spontaneously Breathing

Background and objectivesDelivery of inadvertent high tidal volume (VT) during positive pressure ventilation (PPV) in the delivery room is common. High VT delivery during PPV has been associated with haemodynamic brain injury in animal models. We examined if VT delivery during PPV at birth is associated with brain injury in preterm infants <29 weeks’ gestation.MethodsA flow-sensor was placed between the mask and the ventilation device. VT values were compared with recently described reference ranges for VT in spontaneously breathing preterm infants at birth. Infants were divided into two groups: VT<6 mL/kg or VT>6 mL/kg (normal and high VT, respectively). Brain injury (eg, intraventricular haemorrhage (IVH)) was assessed using routine ultrasound imaging within the first days after birth.ResultsA total of 165 preterm infants were included, 124 (75%) had high VT and 41 (25%) normal VT. The mean (SD) gestational age and birth weight in high and normal VT group was similar, 26 (2) and 26 (1) weeks, 858 (251) g and 915 (250) g, respectively. IVH in the high VT group was diagnosed in 63 (51%) infants compared with 5 (13%) infants in the normal VT group (P=0.008).Severe IVH (grade III or IV) developed in 33/124 (27%) infants in the high VT group and 2/41 (6%) in the normal VT group (P=0.01).ConclusionsHigh VT delivery during mask PPV at birth was associated with brain injury. Strategies to limit VT delivery during mask PPV should be used to prevent high VT delivery.

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Racial and ethnic disparities in discharge to rehabilitation following traumatic brain injury

Journal of Neurosurgery ◽

10.3171/2014.10.jns14187 ◽

2015 ◽

Vol 122 (3) ◽

pp. 595-601 ◽

Cited By ~ 39

Author(s):

Ashley D. Meagher ◽

Christopher A. Beadles ◽

Jennifer Doorey ◽

Anthony G. Charles

Keyword(s):

Traumatic Brain Injury ◽

Brain Injury ◽

Racial Disparities ◽

Subgroup Analysis ◽

Insurance Coverage ◽

Inpatient Rehabilitation ◽

Discharge Destination ◽

Black Patients ◽

To Receive ◽

Hispanic White

OBJECT Disparities in access to inpatient rehabilitation services after traumatic brain injury (TBI) have been identified, but less well described is the likelihood of discharge to a higher level of rehabilitation for Hispanic or black patients compared with non-Hispanic white patients. The authors investigate racial disparities in discharge destination (inpatient rehabilitation vs skilled nursing facility vs home health vs home) following TBI by using a nationwide database and methods to address racial differences in prehospital characteristics. METHODS Analysis of discharge destination for adults with moderate to severe TBI was performed using National Trauma Data Bank data for the years 2007–2010. The authors performed propensity score weighting followed by ordered logistic regression in their analytical sample and in a subgroup analysis of older adults with Medicare. Likelihood of discharge to a higher level of rehabilitation based on race/ethnicity accounting for prehospital and in-hospital variables was determined. RESULTS The authors identified 299,205 TBI incidents: 232,392 non-Hispanic white, 29,611 Hispanic, and 37,202 black. Propensity weighting resulted in covariate balance among racial groups. Hispanic (adjusted OR 0.71, 95% CI 0.68–0.75) and black (adjusted OR 0.94, 95% CI 0.91–0.97) populations were less likely to be discharged to a higher level of rehabilitation than were non-Hispanic whites. The subgroup analysis indicated that Hispanic (adjusted OR 0.79, 95% CI 0.71–0.86) and black (OR 0.87, 95% CI 0.81–0.94) populations were still less likely to receive a higher level of rehabilitation, despite uniform insurance coverage (Medicare). CONCLUSIONS Adult Hispanic and black patients with TBI are significantly less likely to receive intensive rehabilitation than their non-Hispanic white counterparts; notably, this difference persists in the Medicare population (age ≥ 65 years), indicating that uniform insurance coverage alone does not account for the disparity. Given that insurance coverage and a wide range of prehospital characteristics do not eliminate racial disparities in discharge destination, it is crucial that additional unmeasured patient, physician, and institutional factors be explored to eliminate them.

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