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Published on: November 8, 2024
Outcomes after concomitant traumatic brain injury and hemorrhagic shock: A secondary analysis from the Pragmatic,
Samuel M Galvagno1, Erin E Fox, Savitri N Appana
1From the Division of Critical Care Medicine, Department of Anesthesiology (S.M.G.), University of Maryland Medical Center, Program in Trauma R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland; Division of Acute Care Surgery, Department of Surgery (E.E.F.), Center for Translational Injury Research (CeTIR); Department of Biostatistics (S.N.A.), School of Public Health, School of Public Health (S.B.), University of Texas-Houston Health Sciences Center, Houston, Texas; Division of Acute Care Surgery, Department of Surgery (P.L.B.), University of Alabama School of Medicine, Birmingham, Alabama; Department of Surgery (E.M.B.), University of Washington; Department of Trauma (E.M.B.), Harborview Medical Center, Seattle, Washington; Division of General Surgery (R.A.C.), University of California San Francisco, San Francisco, California; Division of Acute Care Surgery, Department of Surgery (B.A.C.), University of Texas Health Science Center, Houston, Texas; Department of Surgery (M.G.), University of Cincinnati School of Medicine, Cincinnati, Ohio; Department of Surgery (K.I.), University of Southern California Keck School of Medicine, Los Angeles, California; University of Arizona School of Medicine (T.O.), Tucson, Arizona; Division of Trauma, Critical Care, and Acute Care Surgery (M.A.S.), Oregon Health & Science, University School of Medicine Portland, Portland, Oregon; Department of Surgery (C.E.W., J.B.H.), University of Texas Health Science Center, Houston, Texas; Program in Trauma Francis X. Kelly (T.M.S.), and Department of Surgery, Program in Trauma (D.M.S.), R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland.
Background:
Often the clinician is faced with a diagnostic and therapeutic dilemma in patients with concomitant traumatic brain injury (TBI) and hemorrhagic shock (HS), as rapid deterioration from either can be fatal. Knowledge about outcomes after concomitant TBI and HS may help prioritize the emergent management of these patients. We hypothesized that patients with concomitant TBI and HS (TBI + HS) had worse outcomes and required more intensive care compared with patients with only one of these injuries.
Methods:
This is a post hoc analysis of the Pragmatic, Randomized Optimal Platelets and Plasma Ratios (PROPPR) trial. TBI was defined by a head Abbreviated Injury Scale score greater than 2. HS was defined as a base excess of -4 or less and/or shock index of 0.9 or greater. The primary outcome for this analysis was mortality at 30 days. Logistic regression, using generalized estimating equations, was used to model categorical outcomes.
Results:
Six hundred seventy patients were included. Patients with TBI + HS had significantly higher lactate (median, 6.3; interquartile range, 4.7-9.2) compared with the TBI group (median, 3.3; interquartile range, 2.3-4). TBI + HS patients had higher activated prothrombin times and lower platelet counts. Unadjusted mortality was higher in the TBI + HS (51.6%) and TBI (50%) groups compared with the HS (17.5%) and neither group (7.7%). Adjusted odds of death in the TBI and TBI + HS groups were 8.2 (95% confidence interval, 3.4-19.5) and 10.6 (95% confidence interval, 4.8-23.2) times higher, respectively. Ventilator, intensive care unit-free and hospital-free days were lower in the TBI and TBI + HS groups compared with the other groups. Patients with TBI + HS or TBI had significantly greater odds of developing a respiratory complication compared with the neither group.
Conclusion:
The addition of TBI to HS is associated with worse coagulopathy before resuscitation and increased mortality. When controlling for multiple known confounders, the diagnosis of TBI alone or TBI+HS was associated with significantly greater odds of developing respiratory complications.
Level Of Evidence:
Prognostic study, level II.
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