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



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.



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.



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.
Arizona Emergency Medicine Research Center, College of Medicine, the University of Arizona, Phoenix, AZ; Department of Emergency Medicine, College of Medicine, the University of Arizona, Tucson, AZ. Electronic address: dan@aemrc.arizona.edu.
Daniel W
DW
Spaite
Arizona Emergency Medicine Research Center, College of Medicine, the University of Arizona, Phoenix, AZ; College of Public Health, the University of Arizona, Tucson, AZ.
Chengcheng
C
Hu
Arizona Emergency Medicine Research Center, College of Medicine, the University of Arizona, Phoenix, AZ; Department of Emergency Medicine, College of Medicine, the University of Arizona, Tucson, AZ; Arizona Department of Health Services, Bureau of EMS and Trauma System, Phoenix, AZ.
Bentley J
BJ
Bobrow
Arizona Emergency Medicine Research Center, College of Medicine, the University of Arizona, Phoenix, AZ; Arizona Department of Health Services, Bureau of EMS and Trauma System, Phoenix, AZ.
Vatsal
V
Chikani
Arizona Emergency Medicine Research Center, College of Medicine, the University of Arizona, Phoenix, AZ.
Bruce
B
Barnhart
Arizona Emergency Medicine Research Center, College of Medicine, the University of Arizona, Phoenix, AZ; Department of Emergency Medicine, College of Medicine, the University of Arizona, Tucson, AZ.
Joshua B
JB
Gaither
Arizona Emergency Medicine Research Center, College of Medicine, the University of Arizona, Phoenix, AZ; Department of Emergency Medicine, College of Medicine, the University of Arizona, Tucson, AZ.
Kurt R
KR
Denninghoff
Barrow Neurological Institute at Phoenix Children's Hospital and Department of Child Health/Neurosurgery, College of Medicine, the University of Arizona, Phoenix, AZ.
P David
PD
Adelson
Arizona Emergency Medicine Research Center, College of Medicine, the University of Arizona, Phoenix, AZ; Department of Emergency Medicine, College of Medicine, the University of Arizona, Tucson, AZ.
Samuel M
SM
Keim
Arizona Emergency Medicine Research Center, College of Medicine, the University of Arizona, Phoenix, AZ; Department of Emergency Medicine, College of Medicine, the University of Arizona, Tucson, AZ.
Chad
C
Viscusi
Arizona Department of Health Services, Bureau of EMS and Trauma System, Phoenix, AZ.
Terry
T
Mullins
College of Public Health, the University of Arizona, Tucson, AZ.
Duane
D
Sherrill
D000328:Adult; D000368:Aged; D000070642:Brain Injuries, Traumatic / Q000150:complications / Q000401:mortality*; D005260:Female; D006801:Humans; D007022:Hypotension / Q000150:complications* / Q000401:mortality; D000860:Hypoxia / Q000150:complications* / Q000401:mortality; D008297:Male; D008875:Middle Aged
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