End-tidal and arterial carbon dioxide gradient in serious traumatic brain injury after prehospital emergency anaesthesia: a retrospective observational study

Price, James; Sandbach, Daniel D; Ercole, Ari; Wilson, A.; Barnard, Ed

doi:10.1136/emermed-2019-209077

Cited by 19 publications

(36 citation statements)

References 31 publications

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“…Two recent publications investigated the CO 2 gap in critically ill patients after prehospital emergency anesthesia [25,26]. Their ndings are in line with our results and showed only moderate correlation between EtCO 2 and PaCO 2 , con rming that EtCO 2 alone should be used with caution to guide ventilation in the critically ill.…”

Section: The Co 2 Gapsupporting

confidence: 90%

End-tidal to arterial carbon dioxide gradient in traumatic brain injury after prehospital emergency anesthesia is associated with in-hospital mortality: a retrospective observational study

Doppmann

Meuli

Sollid

et al. 2021

Preprint

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Background Early definitive airway protection and normoventilation are key principles in the treatment of severe traumatic brain injury. These are currently guided by end tidal CO2 as a proxy for PaCO2. We assessed whether the difference between end tidal CO2 and PaCO2 at hospital admission is associated with in-hospital mortality.Method We conducted a retrospective observational cohort study of consecutive patients with traumatic brain injury who were intubated and transported by Helicopter Emergency Medical Services to a Level 1 trauma center between January 2014 and December 2019. We assessed the association between the CO2 gap—defined as the difference between end tidal CO2 and PaCO2—and in-hospital mortality using multivariate logistic regression models.Results 105 patients were included in this study. The mean ±SD CO2 gap at admission was 1.64 (± 1.09) kPa and significantly greater in non-survivors than survivors (2.26 ±1.30 kPa vs. 1.42 ±0.92 kPa, p<.001). The correlation between EtCO2 and PaCO2 at admission was low (Pearson's r=.287). The mean CO2 gap after 24 hours was only 0.64 ±0.82 kPa, and no longer significantly different between non-survivors and survivors. The multivariate logistic regression model showed that the CO2 gap was independently associated with increased mortality in this cohort and associated with a 2.7-fold increased mortality for every 1 kPa increase in the CO2 gap (OR 2.692, 95% CI 1.293 to 5.646, p=.009).Conclusions This study demonstrates that the difference between EtCO2 and PaCO2 is significantly associated with in-hospital mortality in patients with traumatic brain injury. EtCO2 was significantly lower than PaCO2, making it an unreliable proxy for PaCO2 when aiming for normocapnic ventilation. The higher-than-expected CO2 gap will lead to iatrogenic hypoventilation when normocapnic ventilation is aimed at, and might thereby increase in-hospital mortality.

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Section: The Co 2 Gapsupporting

confidence: 90%

End-tidal to arterial carbon dioxide gradient in traumatic brain injury after prehospital emergency anesthesia is associated with in-hospital mortality: a retrospective observational study

Doppmann

Meuli

Sollid

et al. 2021

Preprint

View full text Add to dashboard Cite

show abstract

“…Two recent publications investigated the CO 2 gap in critically ill patients after prehospital emergency anesthesia 25 , 26 . Their findings are in line with our results and showed only moderate correlation between EtCO 2 and PaCO 2 , confirming that EtCO 2 alone should be used with caution to guide ventilation in the critically ill.…”

Section: Discussionmentioning

confidence: 99%

End-tidal to arterial carbon dioxide gradient is associated with increased mortality in patients with traumatic brain injury: a retrospective observational study

Doppmann

Meuli

Sollid

et al. 2021

Sci Rep

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Early definitive airway protection and normoventilation are key principles in the treatment of severe traumatic brain injury. These are currently guided by end tidal CO2 as a proxy for PaCO2. We assessed whether the difference between end tidal CO2 and PaCO2 at hospital admission is associated with in-hospital mortality. We conducted a retrospective observational cohort study of consecutive patients with traumatic brain injury who were intubated and transported by Helicopter Emergency Medical Services to a Level 1 trauma center between January 2014 and December 2019. We assessed the association between the CO2 gap—defined as the difference between end tidal CO2 and PaCO2—and in-hospital mortality using multivariate logistic regression models. 105 patients were included in this study. The mean ± SD CO2 gap at admission was 1.64 ± 1.09 kPa and significantly greater in non-survivors than survivors (2.26 ± 1.30 kPa vs. 1.42 ± 0.92 kPa, p < .001). The correlation between EtCO2 and PaCO2 at admission was low (Pearson's r = .287). The mean CO2 gap after 24 h was only 0.64 ± 0.82 kPa, and no longer significantly different between non-survivors and survivors. The multivariate logistic regression model showed that the CO2 gap was independently associated with increased mortality in this cohort and associated with a 2.7-fold increased mortality for every 1 kPa increase in the CO2 gap (OR 2.692, 95% CI 1.293 to 5.646, p = .009). This study demonstrates that the difference between EtCO2 and PaCO2 is significantly associated with in-hospital mortality in patients with traumatic brain injury. EtCO2 was significantly lower than PaCO2, making it an unreliable proxy for PaCO2 when aiming for normocapnic ventilation. The CO2 gap can lead to iatrogenic hypoventilation when normocapnic ventilation is aimed and might thereby increase in-hospital mortality.

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“…These organisations have a total of five bases, from which helicopter or car-based teams are dispatched. 7 There were no changes to tasking criteria during COVID-19.…”

Section: Emergency Medical Servicementioning

confidence: 95%

Comparison of deliberate self-harm incidents attended by Helicopter Emergency Medical Services before and during the first wave of COVID-19 in the East of England

Stevens¹,

Price

Hazlerigg

et al. 2021

Emerg Med J

Self Cite

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IntroductionThere is significant interest in the mental health impact of the COVID-19 pandemic. Helicopter Emergency Medical Services (HEMS) attend the most seriously unwell and injured patients in the community; their data therefore present an early opportunity to examine self-harm trends. The primary aim was to compare the incidence of deliberate self-harm incident (DSH-I) encounters by HEMS before and during the first wave of COVID-19.MethodsData were obtained from all three East of England HEMS: total number of activations and stand-downs, number of DSH-I activations and stand-downs, self-harm mechanism and number of ‘severe’ DSH-I patient encounters, in two 61-day periods: 1 March to 30 April in 2019 (control) and 2020 (COVID-19). Severe DSH-I was defined as cardiac arrest and/or died prehospital. Proportions were compared with a Fisher’s exact test.ResultsThere were a total of 1725 HEMS activations: n=981 (control) and n=744 (COVID-19), a decrease of 24.2% during COVID-19. DSH-I patient encounters increased by 65.4%: n=26 (control) and n=43 (COVID-19). The proportion of encounters that were DSH-I and severe DSH-I both significantly increased during COVID-19: p=0.002 and p=0.001, respectively. The absolute number of hangings and falls from height both approximately tripled during COVID-19, whereas the number of other mechanisms remained almost constant.ConclusionDespite a reduction in overall HEMS patient encounters, there were significant increases in both the proportion of DSH-Is and their severity attended by HEMS during the first wave of the COVID-19 pandemic in the East of England.

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End-tidal and arterial carbon dioxide gradient in serious traumatic brain injury after prehospital emergency anaesthesia: a retrospective observational study

Cited by 19 publications

References 31 publications

End-tidal to arterial carbon dioxide gradient in traumatic brain injury after prehospital emergency anesthesia is associated with in-hospital mortality: a retrospective observational study

End-tidal to arterial carbon dioxide gradient in traumatic brain injury after prehospital emergency anesthesia is associated with in-hospital mortality: a retrospective observational study

End-tidal to arterial carbon dioxide gradient is associated with increased mortality in patients with traumatic brain injury: a retrospective observational study

Comparison of deliberate self-harm incidents attended by Helicopter Emergency Medical Services before and during the first wave of COVID-19 in the East of England

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