Prognostic value of secondary insults in traumatic brain injury: results from the IMPACT study.
We determined the relationship between secondary insults (hypoxia, hypotension, and hypothermia) occurring prior to or on admission to hospital and 6-month outcome after traumatic brain injury (TBI). A meta-analysis of individual patient data, from seven Phase III randomized clinical trials (RCT) in moderate or severe TBI and three TBI population-based series, was performed to model outcome as measured by the Glasgow Outcome Scale (GOS). Proportional odds modeling was used to relate the probability of a poor outcome to hypoxia (N = 5661), hypotension ( N = 6629), and hypothermia ( N = 4195) separately. We additionally analyzed the combined effects of hypoxia and hypotension and performed exploratory analysis of associations with computerized tomography (CT) classification and month of injury. Having a pre-enrollment insult of hypoxia, hypotension or hypothermia is strongly associated with a poorer outcome (odds ratios of 2.1 95% CI [1.7-2.6], 2.7 95% CI [2.1-3.4], and 2.2 95% CI [1.6-3.2], respectively). Patients with both hypoxia and hypotension had poorer outcomes than those with either insult alone. Radiological signs of raised intracranial pressure (CT class III or IV) were more frequent in patients who had sustained hypoxia or hypotension. A significant association was observed between month of injury and hypothermia. The occurrence of secondary insults prior to or on admission to hospital in TBI patients is strongly related to poorer outcome and should therefore be a priority for emergency department personnel.
McHugh
Gillian S
GS
Public Health Sciences, University of Edinburgh Medical School, Edinburgh, United Kingdom. Gillian.McHugh@ed.ac.uk
Engel
Doortje C
DC
Butcher
Isabella
I
Steyerberg
Ewout W
EW
Lu
Juan
J
Mushkudiani
Nino
N
Hernández
Adrián V
AV
Marmarou
Anthony
A
Maas
Andrew I R
AI
Murray
Gordon D
GD
D001930:Brain Injuries / Q000150:complications* / Q000175:diagnosis* / Q000503:physiopathology; D016208:Databases, Factual; D023261:Glasgow Outcome Scale; D006801:Humans; D007022:Hypotension / Q000209:etiology*; D007035:Hypothermia / Q000209:etiology*; D000860:Hypoxia / Q000209:etiology*; D011237:Predictive Value of Tests; D011379:Prognosis; D016016:Proportional Hazards Models