Mortality From Rural Traumatic Brain Injury Are Underestimated Without Inclusion of Prehospital Deaths

Rural residents are more likely to suffer moderate and severe traumatic brain injury (TBI) and experience delay to definitive care than urban patients. Prior studies comparing these populations were based on hospitalised patients only. We examined TBI outcomes incorporating pre-hospital mortality to determine the association between location of injury and mortality risk.

Twelve-month (2019) retrospective cohort study was performed on all adult patients with TBI within one Trauma System. Demographics, geographical location of injury, mechanism, scene vital parameters and interventions, injury severity, polytrauma status, TBI morphology and outcomes were collected for all hospital and prehospital deaths. Uni- and multivariate analysis was conducted including binary logistic regression to examine associations between mortality and potential confounders of mortality.

266 patients (145 hospitalised and 121 prehospital deaths) with median age 53.6 years (18-98), 72.6% males, scene Glasgow Coma Scale (GCS) < 14 (48.3%), were included. Ninety-four (36%) patients were urban and, 167 (64%) were regional, rural or remote. Rural compared to urban patients had higher risk of death (adjusted OR 1.934, 95% CI 1.07-3.49) without differences in GCS, pupillary status, injury pattern, radiological TBI severity or initial management. The strongest risk factor for mortality was polytrauma (adjusted OR 7.804, 95% CI 4.155-14.62, p < 0.01).

Comprehensive assessment of TBI mortality indicates that rurality is associated with mortality and polytrauma status is a profound risk factor. These findings highlight that prehospital mortality is essential to monitor and optimisation of polytrauma care is a potential modifiable factor in TBI outcomes.