Study objective: We evaluate the effect of implementing the out-of-hospital pediatric traumatic brain injury guidelines on outcomes in children with major traumatic brain injury. Methods: The Excellence in Prehospital Injury Care for Children study is the preplanned secondary analysis of the Excellence in Prehospital Injury Care study, a multisystem, intention-to-treat study using a before-after controlled design. This subanalysis included children younger than 18 years who were transported to Level I trauma centers by participating out-of-hospital agencies between January 1, 2007, and June 30, 2015, throughout Arizona. The primary and secondary outcomes were survival to hospital discharge or admission for children with major traumatic brain injury and in 3 subgroups, defined a priori as those with moderate, severe, and critical traumatic brain injury. Outcomes in the preimplementation and postimplementation cohorts were compared with logistic regression, adjusting for risk factors and confounders. Results: There were 2,801 subjects, 2,041 in preimplementation and 760 in postimplementation. The primary analysis (postimplementation versus preimplementation) yielded an adjusted odds ratio of 1.16 (95% confidence interval 0.70 to 1.92) for survival to hospital discharge and 2.41 (95% confidence interval 1.17 to 5.21) for survival to hospital admission. In the severe traumatic brain injury cohort (Regional Severity Score-Head 3 or 4), but not the moderate or critical subgroups, survival to discharge significantly improved after guideline implementation (adjusted odds ratio = 8.42; 95% confidence interval 1.01 to 100thorn). The improvement in survival to discharge among patients with severe traumatic brain injury who received positivepressure ventilation did not reach significance (adjusted odds ratio = 9.13; 95% confidence interval 0.79 to 100thorn). Conclusion: Implementation of the pediatric out-of-hospital traumatic brain injury guidelines was not associated with improved survival when the entire spectrum of severity was analyzed as a whole (moderate, severe, and critical). However, both adjusted survival to hospital admission and discharge improved in children with severe traumatic brain injury, indicating a potential severity-based interventional opportunity for guideline effectiveness. These findings support the widespread implementation of the out-of-hospital pediatric traumatic brain injury guidelines.

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.

Background: Little is known about the ventilatory aspects of overdose-related OHCA (OD-OHCA). We compared maximum ETCO2 (mETCO2; each patient’s highest CO2 level) and mean for each recorded minute of CPR in OD-OHCA to that of respiratory (R-OHCA) and cardiac (C-OHCA) arrests. Methods: Continuous CO2 data (Zoll E/X series monitors) were obtained from 3 Arizona EMS agencies. Cases had at least 3 min of recorded CO2 during CPR. Arrests were classified as OD-OHCA by EMS and/or hospital documentation. Any drug OD was included (e.g., opioids, mixed). C-OHCA and R-OHCA cases were randomly chosen for comparison. The groups were compared using Fisher’s exact test or Chi-squared for categorical and Kruskal-Wallis for continuous variables. Results: Included were 263 subjects (37 OD-OHCA, 157 C-OHCA and 69 R-OHCA; median age 61, 64% male, 1/10-12/18) with 10,271 min of data [median resuscitation interval 37 min (IQR 29, 47)]. Mean ETCO2 (SD): OD-OHCA [41 mmHg (24)]; R-OHCA [40 (23)], C-OHCA [30 (13); p<0.01]. Median mETCO2: OD-OHCA [57 mmHg (95CI: 50, 77)]; R-OHCA [61 (50, 73)], C-OHCA [48 (44, 50); p<0.001; Fig 1]. While mean ETCO2 and mETCO2 were similar for OD-OHCA and R-OHCA, they were both significantly higher than C-OHCA (p<0.01 for all comparisons). ETCO2 waveforms in OD-OHCA resembled the very high, full waveforms typical of R-OHCA while those in C-OHCA tended to be low and blunted. Conclusions: We believe this is the first report of continuous capnography during resuscitation of OD-OHCA. The mean ETCO2 and median of mETCO2 of OD-OHCA and R-OHCA imply similar physiology (hypoventilation and hypercapnia leading to arrest). Both etiologies had much higher ETCO2 values compared to C-OHCA, where low blood flow delivers minimal CO2 to the lungs and yields low, and morphologically different, waveforms. Future studies assessing OD arrest physiology and various approaches to resuscitation and pharmacological reversal are needed.

Importance Traumatic brain injury (TBI) is a massive public health problem. While evidence-based guidelines directing the prehospital treatment of TBI have been promulgated, to our knowledge, no studies have assessed their association with survival. Objective To evaluate the association of implementing the nationally vetted, evidence-based, prehospital treatment guidelines with outcomes in moderate, severe, and critical TBI. Design, Setting, and Participants The Excellence in Prehospital Injury Care (EPIC) Study included more than 130 emergency medical services systems/agencies throughout Arizona. This was a statewide, multisystem, intention-to-treat study using a before/after controlled design with patients with moderate to critically severe TBI (US Centers for Disease Control and Prevention Barell Matrix-Type 1 and/or Abbreviated Injury Scale Head region severity ≥3) transported to trauma centers between January 1, 2007, and June 30, 2015. Data were analyzed between October 25, 2017, and February 22, 2019. Interventions Implementation of the prehospital TBI guidelines emphasizing avoidance/treatment of hypoxia, prevention/correction of hyperventilation, and avoidance/treatment of hypotension. Main Outcomes and Measures Primary: survival to hospital discharge; secondary: survival to hospital admission. Results Of the included patients, the median age was 45 years, 14 666 (67.1%) were men, 7181 (32.9%) were women; 16 408 (75.1% ) were white, 1400 (6.4%) were Native American, 743 (3.4% ) were Black, 237 (1.1%) were Asian, and 2791 (12.8%) were other race/ethnicity. Of the included patients, 21 852 met inclusion criteria for analysis (preimplementation phase [P1]: 15 228; postimplementation [P3]: 6624). The primary analysis (P3 vs P1) revealed an adjusted odds ratio (aOR) of 1.06 (95% CI, 0.93-1.21; P = .40) for survival to hospital discharge. The aOR was 1.70 (95% CI, 1.38-2.09; P < .001) for survival to hospital admission. Among the severe injury cohorts (but not moderate or critical), guideline implementation was significantly associated with survival to discharge (Regional Severity Score-Head 3-4: aOR, 2.03; 95% CI, 1.52-2.72; P < .001; Injury Severity Score 16-24: aOR, 1.61; 95% CI, 1.07-2.48; P = .02). This was also true for survival to discharge among the severe, intubated subgroups (Regional Severity Score-Head 3-4: aOR, 3.14; 95% CI, 1.65-5.98; P < .001; Injury Severity Score 16-24: aOR, 3.28; 95% CI, 1.19-11.34; P = .02). Conclusions and Relevance Statewide implementation of the prehospital TBI guidelines was not associated with significant improvement in overall survival to hospital discharge (across the entire, combined moderate to critical injury spectrum). However, adjusted survival doubled among patients with severe TBI and tripled in the severe, intubated cohort. Furthermore, guideline implementation was significantly associated with survival to hospital admission. These findings support the widespread implementation of the prehospital TBI treatment guidelines. Trial Registration ClinicalTrials.gov: NCT01339702.

Introduction: The EPIC Study implemented the national EMS TBI Guidelines in a massive, statewide initiative (>11,000 providers trained, 133 agencies). While implementation was not associated with improved survival to discharge in moderate or critically-severe TBI in the primary (all-age) study, the adjusted odds of survival doubled in severe TBI and tripled in severe, intubated TBI. We now report the preplanned pediatric subgroup analysis (“EPIC4Kids”-NIH R01NS071049). Methods: Multisystem, intention-to-treat study using a before/after controlled design in patients with moderate to critically severe TBI. Interventions: Prevention/treatment of hypoxia, hypotension, and hyperventilation by EMS providers. Inclusion: Age<18; CDC Barell Matrix Type 1; 1/07-6/15. Severity subgroups [Head Region Severity Score (IDC-based AIS equivalent)]: Moderate=1-2; Severe=3-4; Critical=5-6. The pre-implementation (P1) and post-implementation (P3) cohorts were compared using logistic regression (Firth’s approach when comparisons had small event numbers), adjusting for risk factors/confounders. Results: Included were 2801 cases [P1=2041 (72.9%), P3=760 (27.1%); median age 11 (IQR 2, 15); 62.9% male]. The all-severity P3 vs P1 cohort analysis yielded adjusted odds (aOR) of 1.16 (95%CI 0.697, 1.92, p=0.57) for survival. In severe TBI (P1=1405, P3=605; 80% of P3 cases), but not moderate or critical TBI, adjusted survival was significantly improved after implementation (Figure; p=0.049). Improvement in survival for those with severe, intubated TBI (P1=174, P3=44) approached significance (Fig; p=0.11). Conclusion: In the first controlled study of its kind, implementation of the EMS TBI guidelines was independently associated with a dramatic increase in adjusted survival among children with severe TBI. The aOR for survival was even larger than that of the overall (all-age) EPIC Study and supports widespread implementation of the guidelines in children.

Background: Telephone cardiopulmonary resuscitation (TCPR) is associated with improved patient outcomes after out-of-hospital cardiac arrest (OHCA). Compared with TCPR for adults, little is known a...

Aim: Spanish-only speaking residents in the United States face barriers to receiving potentially life-saving 911 interventions such as Telephone-cardiopulmonary resuscitation (TCPR) instructions. Since 2015, 911 dispatchers have placed an increased emphasis on rapid identification of potential cardiac arrest. The purpose of this study was to describe the utilization and timing of the 911 system during suspected out-of-hospital cardiac arrest (OHCA) by Spanish-speaking callers in Metropolitan Phoenix, Arizona.Methods: The dataset consisted of suspected OHCA from 911 centers from October 10, 2010 through December 31, 2013. Review of audio TCPR process data included whether the need for CPR was recognized by telecommunicators, whether CPR instructions were provided, and the time elements from call receipt to initiation of compressions.Results: A total of 3398 calls were made to 911 for suspected OHCA where CPR was indicated. A total of 39 (1.2%) were determined to have a Spanish language barrier. This averages to 18 calls per year with a Spanish language barrier during the study period, compared with 286 OHCAs expected per year among this population. The average time until telecommunicators recognized CPR need was 87.4 s for the no language barrier group compared to 160.6 s for the Spanish-language barrier group (p < 0.001). Time to CPR instructions started was significantly different between these groups (144.4 s vs 231.3 s, respectively) (p < 0.001), as was time to first compression, (174.4 s vs. 290.9 s, respectively) (p < 0.001).Conclusions: Our study suggests that Hispanic callers under-utilize the 911 system, and when they do call 911, there are significant delays in initiating CPR. (C) 2017 Elsevier B.V. All rights reserved.

Background: Telephone cardiopulmonary resuscitation (TCPR) is associated with improved outcomes after out-of-hospital cardiac arrest (OHCA). AHA guidelines recommend that 9-1-1 call takers (CTs) as...

Study objective Out-of-hospital hypotension has been associated with increased mortality in traumatic brain injury. The association of traumatic brain injury mortality with the depth or duration of out-of-hospital hypotension is unknown. We evaluated the relationship between the depth and duration of out-of-hospital hypotension and mortality in major traumatic brain injury. Methods We evaluated adults and older children with moderate or severe traumatic brain injury in the preimplementation cohort of Arizona's statewide Excellence in Prehospital Injury Care study. We used logistic regression to determine the association between the depth-duration dose of hypotension (depth of systolic blood pressure <90 mm Hg integrated over duration [minutes] of hypotension) and odds of inhospital death, controlling for significant confounders. Results There were 7,521 traumatic brain injury cases included (70.6% male patients; median age 40 years [interquartile range 24 to 58]). Mortality was 7.8% (95% confidence interval [CI] 7.2% to 8.5%) among the 6,982 patients without hypotension (systolic blood pressure ≥90 mm Hg) and 33.4% (95% CI 29.4% to 37.6%) among the 539 hypotensive patients (systolic blood pressure <90 mm Hg). Mortality was higher with increased hypotension dose: 0.01 to 14.99 mm Hg-minutes 16.3%; 15 to 49.99 mm Hg-minutes 28.1%; 50 to 141.99 mm Hg-minutes 38.8%; and greater than or equal to 142 mm Hg-minutes 50.4%. Log2 (the logarithm in base 2) of hypotension dose was associated with traumatic brain injury mortality (adjusted odds ratio 1.19 [95% CI 1.14 to 1.25] per 2-fold increase of dose). Conclusion In this study, the depth and duration of out-of-hospital hypotension were associated with increased traumatic brain injury mortality. Assessments linking out-of-hospital blood pressure with traumatic brain injury outcomes should consider both depth and duration of hypotension.

Background: Cardiopulmonary resuscitation (CPR) quality is strongly linked to outcomes following out-of-hospital cardiac arrest (OHCA). However, manual CPR quality varies and has risk to providers....

Introduction: Low body temperatures following prehospital transport are associated with poor outcomes in patients with traumatic brain injury (TBI). However, a minimal amount is known about potential associations across a range of temperatures obtained immediately after prehospital transport. Furthermore, a minimal amount is known about the influence of body temperature on non-mortality outcomes. The purpose of this study was to assess the correlation between temperatures obtained immediately following prehospital transport and TBI outcomes across the entire range of temperatures. Methods: This retrospective observational study included all moderate/severe TBI cases (CDC Barell Matrix Type 1) in the pre-implementation cohort of the Excellence in Prehospital Injury Care (EPIC) TBI Study (NIH/NINDS: 1R01NS071049). Cases were compared across four cohorts of initial trauma center temperature (ITCT): <35.0 degrees C [Very Low Temperature (VLT)]; 35.0-35.9 degrees C [Low Temperature (LT)]; 36.0-37.9 degrees C [Normal Temperature (NT)]; and 38.0 degrees C [Elevated Temperature (ET)]. Multivariable analysis was performed adjusting for injury severity score, age, sex, race, ethnicity, blunt/penetrating trauma, and payment source. Adjusted odds ratios (aORs) with 95% confidence intervals (CI) for mortality were calculated. To evaluate non-mortality outcomes, deaths were excluded and the adjusted median increase in hospital length of stay (LOS), ICU LOS and total hospital charges were calculated for each ITCT group and compared to the NT group. Results: 22,925 cases were identified and cases with interfacility transfer (7361, 32%), no EMS transport (1213, 5%), missing ITCT (2083, 9%), or missing demographic data (391, 2%) were excluded. Within this study cohort the aORs for death (compared to the NT group) were 2.41 (CI: 1.83-3.17) for VLT, 1.62 (CI: 1.37-1.93) for LT, and 1.86 (CI: 1.52-3.00) for ET. Similarly, trauma center (TC) LOS, ICU LOS, and total TC charges increased in all temperature groups when compared to NT. Conclusion: In this large, statewide study of major TBI, both ETs and LTs immediately following prehospital transport were independently associated with higher mortality and with increased TC LOS, ICU LOS, and total TC charges. Further study is needed to identify the causes of abnormal body temperature during the prehospital interval and if in-field measures to prevent temperature variations might improve outcomes.

Objective: Previous work has shown that, separately, the depth-duration doses of prehospital hypoxia (HO) and hypotension (HT) are strongly associated with mortality in Traumatic Brain Injury (TBI). However, because HO and HT are not mutually exclusive, we sought to evaluate the combined-dose effect of these physiological anomalies. Methods: We evaluated major TBI cases (CDC Barell Matrix Type 1) enrolled in the EPIC Study (NIH 1R01NS071049) before TBI guideline implementation (N = 16,711; 1/07-9/14). The HO dose was calculated as SpO2 depth Results: 6682 cases were included [Exclusions: age 200 (2.1%), missing data (12.8%), only 1 recorded SBP or SpO2 (8.3%)]. Mortality rate increased consistently across the quartiles of the unadjusted dose score (Fig A). In the adjusted model, mortality increased monotonically (nearly linearly) with the dose score (B). This is consistent with the monotonically-increasing relationships between the HO and HT doses and their respective adjusted death rates (C, D with 95% bands). Across the entire range of dose, an increase of 1 standard deviation of adjusted dose score is associated with an OR of 1.63 for death among patients with any combination of HO, HT or both. Conclusion: Historically, HO and HT have been assessed dichotomously (present or not) in TBI. These data reveal that the depth-duration dose of combined prehospital HO/HT is strongly associated with increased mortality and that effects of HO and HT are additive . The clinical effects of HO and HT may be significantly more complex than the current literature reflects.

IMPORTANCE Bystander cardiopulmonary resuscitation (CPR) significantly improves survival from out-of-hospital cardiac arrest but is provided in less than half of events on average. Telephone CPR (TCPR) can significantly increase bystander CPR rates and improve clinical outcomes. OBJECTIVE To investigate the effect of a TCPR bundle of care on TCPR process measures and outcomes. DESIGN, SETTING, AND PARTICIPANTS A prospective, before-after, observational study of adult patients with out-of-hospital cardiac arrest not receiving bystander CPR before the 9-1-1 call between October 1, 2010, and September 30, 2013. INTERVENTIONS A TCPR program, including guideline-based protocols, telecommunicator training, data collection, and feedback, in 2 regional dispatch centers servicing metropolitan Phoenix, Arizona. Audio recordings of out-of-hospital cardiac arrest calls were audited and linked with emergency medical services and hospital outcome data. MAIN OUTCOMES AND MEASURES Survival to hospital discharge and functional outcome at hospital discharge. RESULTS There were 2334 out-of-hospital cardiac arrests (798 phase 1 [P1] and 1536 phase 2 [P2]) in the study group; 64% (1499) were male, and the median age was 63 years (age range, 9-101 years; interquartile range, 51-75 years). Provision of TCPR increased from 43.5% in P1 to 52.8% in P2 (P < .001), yielding an increase of 9.3% (95% CI, 4.9%-13.8%). The median time to first chest compression decreased from 256 seconds in P1 to 212 seconds in P2 (P < .001). All rhythm survival was significantly higher in P2 (184 of 1536 [12.0%]) compared with P1 (73 of 798 [9.1%]), with an adjusted odds ratio (aOR) of 1.47 (95% CI, 1.08-2.02; P = .02) in a logistic regression model and an adjusted difference in absolute survival rates (adjusted rate difference) of 3.1% (95% CI, 1.5%-4.9%). Survival for patients with a shockable initial rhythm significantly improved in P2 (107 of 306 [35.0%]) compared with P1 (42 of 170 [24.7%]), with an aOR of 1.70 (95% CI, 1.09-2.65; P = .02) and an adjusted rate difference of 9.6% (95% CI, 4.8%-14.4%). The rate of favorable functional outcome was significantly higher in P2 (127 of 1536 [8.3%]; 95% CI, 6.9%-9.8%) than in P1 (45 of 798 [5.6%]; 95% CI, 4.1%-7.5%), with an aOR of 1.68 (95% CI, 1.13-2.48; P = .01) and an adjusted rate difference of 2.7% (95% CI, 1.3%-4.4%). CONCLUSIONS AND RELEVANCE Implementation of a guideline-based TCPR bundle of care was independently associated with significant improvements in the provision and timeliness of TCPR, survival to hospital discharge, and survival with favorable functional outcome.

Importance Current prehospital traumatic brain injury guidelines use a systolic blood pressure threshold of less than 90 mm Hg for treating hypotension for individuals 10 years and older based on studies showing higher mortality when blood pressure drops below this level. However, the guidelines also acknowledge the weakness of the supporting evidence. Objective To evaluate whether any statistically supportable threshold between systolic pressure and mortality emerges from the data a priori, without assuming that a cut point exists. Design, Setting, and Participants Observational evaluation of a large prehospital database established as a part of the Excellence in Prehospital Injury Care Traumatic Brain Injury Study. Patients from the preimplementation cohort (January 2007 to March 2014) 10 years and older with moderate or severe traumatic brain injury (Barell Matrix Type 1 classification, International Classification of Diseases, Ninth Revision head region severity score of 3 or greater, and/or Abbreviated Injury Scale head-region severity score of 3 or greater) and a prehospital systolic pressure between 40 and 119 mm Hg were included. The generalized additive model and logistic regression were used to determine the association between systolic pressure and probability of death, adjusting for significant/important confounders. Main Outcomes and Measures The main outcome measure was in-hospital mortality. Results Among the 3844 included patients, 2565 (66.7%) were male, and the median (range) age was 35 (10-99) years. The model revealed a monotonically decreasing association between systolic pressure and adjusted probability of death across the entire range (ie, from 40 to 119 mm Hg). Each 10-point increase of systolic pressure was associated with a decrease in the adjusted odds of death of 18.8% (adjusted odds ratio, 0.812; 95% CI, 0.748-0.883). Thus, the adjusted odds of mortality increased as much for a drop from 110 to 100 mm Hg as for a drop from 90 to 80 mm Hg, and so on throughout the range. Conclusions and Relevance We found a linear association between lowest prehospital systolic blood pressure and severity-adjusted probability of mortality across an exceptionally wide range. There is no identifiable threshold or inflection point between 40 and 119 mm Hg. Thus, in patients with traumatic brain injury, the concept that 90 mm Hg represents a unique or important physiological cut point may be wrong. Furthermore, clinically meaningful hypotension may not be as low as current guidelines suggest. Randomized trials evaluating treatment levels significantly above 90 mm Hg are needed.

Background: Bystander CPR (BCPR) and telephone CPR (TCPR) are associated with improved OHCA outcomes. It has been shown that BCPR increases the proportion of patients with an initial shockable cardiac rhythm (VF/VT) when encountered by EMS. It is unknown whether TCPR does the same. Objective: To assess whether TCPR is independently associated with an increase in initial shockable cardiac rhythms during OHCA. Methods: Data from 9-1-1 audio recordings, first care EMS reports and hospital records were linked for OHCAs of presumed cardiac origin (1/2011-12/2014). Three cohorts were analyzed: TCPR, BCPR or no CPR. Using no CPR as the reference group, we assessed whether TCPR and BCPR were independently associated with initial shockable rhythms in a logistic regression model controlling for gender, event location, witness status and EMS response interval. Results: After exclusions, 2715 adult OHCA events with linked outcome data were analyzed (median age: 63; male: 66.8%; 33.3% witnessed arrest). Median response interval was 5 min. The BCPR rate (lay rescuer CPR without telephone instructions) was 24.8% and survival in this group was 15.4%. The TCPR rate (lay rescuer CPR with telephone instructions) was 40.2% and survival in this group was 11.7%. For the no-CPR group, 20.5% had an initial shockable rhythm. For the BCPR group, 34.6 % had an initial shockable rhythm. For the TCPR group, 23.2% had an initial shockable rhythm. Provision of BCPR and of TCPR were each independently associated with shockable rhythms [aOR (BCPR) = 1.7, 95% CI: 1.33-2.17, p=0.0001; aOR (TCPR) = 1.3, 95% CI: 1.04-1.63, p=0.0001]. Conclusion: The provision of both BCPR and TCPR were independently associated with an increased rate of initial shockable cardiac rhythms and an increase in survival to hospital discharge compared to no CPR.

Objective: Prehospital hypotension [systolic BP (SBP) <90 mmHg] dramatically increases mortality in Traumatic Brain Injury (TBI). The literature supporting this concept is based upon a simple dicho...

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.

Introduction: Little is known about prehospital EMS blood pressure patterns in TBI and the effect of serial trends in BP during EMS care remains entirely unclear. Using the comprehensive, linked EMS data in the Excellence in Prehospital Injury Care (EPIC) TBI Study (NIH 1R01NS071049; ClinicalTrials.gov NCT01339702), we evaluated the association between mortality and increases in EMS systolic BP (SBP) after the lowest recorded SBP in major TBI cases. Methods: We used the entire EPIC pre-implementation cohort (before TBI guideline implementation; 1/07-3/14) to assess, in detail, a previous preliminary evaluation. All moderate/severe TBI cases (CDC Barell Matrix Type 1) were evaluated [exclusions: age <10, died before ED arrival, SBP <40 or >300, missing SBP (4%)]. Logistic regression was used to determine associations between increases in EMS SBP after the lowest SBP and the probability of death, adjusted for important confounders. Results: Among 14,567 included cases, 7696 (68% male, median age 45) were in the cohort of interest (had an equal or higher SBP recorded subsequent to the lowest). Figures show the probability of death vs the increase after the nadir (and 95% CIs) in 4 cohorts of lowest SBP (40-89; 90-139; 140-159; 160-300). Conclusion: Increases in EMS SBP after the nadir revealed distinct patterns: Hypotension-Mortality drops significantly if SBP increases after the nadir (dramatic improvement with large increases). Normotension-Mortality is slightly reduced with SBP increases and even large increases were not detrimental. Mild HTN-Mortality decreases with modest SBP increases but large increases (>40mmHg) are associated with higher mortality. Severe HTN-Higher mortality with any subsequent increase. The findings in the hypotensive & normotensive cohorts support the concept of restoring/optimizing cerebral perfusion in TBI. This is further supported by the fact that, even with mild HTN, moderate SBP increases do not appear to be detrimental.