Prehospital hypertension is predictive of traumatic brain injury and is associated with higher mortality

Barmparas, Galinos; Liou, Douglas Z.; Lamb, Alexander W.; Gangi, Afshin; Chin, M.; Ley, Eric J.; Salim, Ali; Bukur, Marko

doi:10.1097/ta.0000000000000382

Cited by 30 publications

(15 citation statements)

References 28 publications

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“…However, there have been no major investigations of Cushing’s sign predicting immediate neurosurgical intervention in TBI patients. Previously, many investigators reported the prognostic factors or models in TBI patients at an early stage after injury using vital signs, including GCS or pupillary reaction [4, 5, 12, 14, 15]. Among them, either prehospital hypertension or prehospital hypotension were revealed to be associated with higher mortality due to possible intracranial hypertension or paroxysmal sympathetic hyperactivity and impaired cerebral blood flow [3–5, 12].…”

Section: Discussionmentioning

confidence: 99%

“…Multiple logistic regression analysis was performed employing the forced entry method. Odds ratio and 95% confidence interval (CI) for LT-BI in each category based on the pSBP and pHR were described after adjusting for potential confounders including age, gender, chest AIS score (≥4 vs. <4), abdomen AIS score (≥4 vs. <4), and extremity AIS score (≥4 vs. <4), considering patients with pSBP of 100 to 139 mmHg and pHR of 60 to 99 bpm as the reference group [4]. P values of <0.05 were considered statistically significant.…”

Section: Methodsmentioning

confidence: 99%

“…Systemic hypertension may also be associated with paroxysmal sympathetic hyperactivity [3]. Hypertension in the prehospital setting is predictive of TBI and is associated with higher mortality [4]. Paradoxically, hypotension, which can lead to impaired cerebral perfusion, is also associated with increased mortality in patients with severe TBI [5].…”

Section: Introductionmentioning

confidence: 99%

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Impact of Cushing’s sign in the prehospital setting on predicting the need for immediate neurosurgical intervention in trauma patients: a nationwide retrospective observational study

Yumoto

Mitsuhashi

Yamakawa

et al. 2016

Scand J Trauma Resusc Emerg Med

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BackgroundCushing’s reflex usually results from intracranial hypertension. Although Cushing’s sign can implicate severe traumatic brain injury (TBI) in injured patients, no major investigations have been made. The purpose of this study was to assess the predictability of life-threatening brain injury requiring immediate neurosurgical intervention (LT-BI) among trauma patients with Cushing’s sign in the prehospital setting.MethodsThis was a retrospective study using data from the Japan Trauma Data Bank from the period of 2010 to 2014. Patients 16 years old or older with blunt mechanisms of injury who were transported directly from the scene and Glasgow Coma Scale for eye opening of one in the prehospital setting were included. LT-BI was defined as patients requiring burr hole evacuation or craniotomy within 24 h of hospital arrival and patients who were non-survivors due to isolated severe TBI. Prehospital systolic blood pressure (pSBP) and heart rate (pHR) were assessed using area under the receiver operating characteristic curve (AUROC) and multiple logistic regression analysis to predict LT-BI.ResultsOf 6332 eligible patients, 1859 (29%) exhibited LT-BI. AUROC of LT-BI using pSBP and pHR was 0.666 (95% confidence interval (CI); 0.652–0.681, P < 0.001), and 0.578 (95% CI; 0.563–0.594, P < 0.001), respectively. AUROC of pSBP was the highest among the 60 ≤ pHR ≤ 99 subgroup, of which AUROC was 0.680 (95% CI; 0.662–0.699, P < 0.001).Multiple logistic regression analysis showed that the higher the pSBP and the lower the pHR, the more likely that the patients had LT-BI. In a group with pSBP ≥ 180 mmHg and pHR ≤ 59 beats/min, the odds ratio and 95% CI of LT-BI after adjusting for age, sex, and severity of injuries to other body regions was 4.77 (2.85–7.97), P < 0.001 was compared with the reference group, which was defined as patients with normal vital signs.DiscussionOur study has found that the combination of hypertension and bradycardia, which are the components of Cushing's sign without eye opening in the prehospital setting was a weak but a significant predictor of LT-BI, or death due to possible isolated severe TBI.ConclusionsPrehospital Cushing’s sign with disturbed level of consciousness in trauma patients was a weak but significant predictor of the need for immediate neurosurgical intervention.

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Section: Discussionmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Impact of Cushing’s sign in the prehospital setting on predicting the need for immediate neurosurgical intervention in trauma patients: a nationwide retrospective observational study

Yumoto

Mitsuhashi

Yamakawa

et al. 2016

Scand J Trauma Resusc Emerg Med

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“…[17] Few other studies found a correlation between prehospital hypertension and higher mortality in TBI patients. [18] In our study, mean MAP at admission was 97.23 (±13.97) mm Hg, indicating that many of the patients with isolated TBI patients presented with admission hypertension. Although there are guidelines regarding early management of hypotension, there are no fixed recommendation for identification and treatment of admission hypertension in TBI.…”

Section: Discussionmentioning

confidence: 56%

Long term outcome in survivors of decompressive craniectomy following severe traumatic brain injury

et al. 2019

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Background:Decompressive craniectomy (DC) is done for the management of intracranial hypertension due to severe traumatic brain injury (sTBI). Despite DC, a number of patients die and others suffer from severe neurological disability. We conducted this observational study to assess functional outcome as measured by Glasgow outcome scale-extended (GOSE) in survivors of DC. The correlation between various factors at admission and hospital with functional outcome was also obtained.Materials and Methods:Patients (15–65 years) posted for cranioplasty following DC due to sTBI were prospectively enrolled. Demographic profile, clinical data, and GOSE were noted at the time of admission for cranioplasty from the patient or nearest relative or both. Retrospective data noted from hospital records included admission Marshalls grading, Glasgow coma score (GCS), motor response, mean arterial pressure (MAP), and timing of DC at the time of initial admission following sTBI.Results:A total of 85 patients (71 males and 14 females) were enrolled over a period of 2 years. The mean age of the patients was 33.42 ± 12.70 years. The median GCS at the time of admission due to head injury, at the time of discharge, and at the time of cranioplasty was 8 (interquartile range [IQR] 3–15), 10 (IQR 4–15), and 15 (IQR 7–15), respectively. Thirty-one patients (36%) had good functional outcome (GOSE 5–8) and 54 patients (64%) had poor functional outcome (GOSE 1–4). On univariate analysis tracheostomy (P = 0.00), duration of hospital stay (P = 0.002), MAP at admission (P = 0.01), and GCS at discharge (P = 0.01) correlated with outcome [Table 1]. On multivariate analysis MAP at admission (odds ratio [OR] [95% confidence interval {CI}]; 0.07 [0.01–0.40] and tracheostomy (OR [95% CI]; 15 [1.45–162.9]) were found to be the independent predictors of functional outcome.Conclusion:Significant disability is seen among the survivors of DC. Tracheostomy and MAP at admission were found to be independently associated with the patient outcome.

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“…(19–25) Excessive blood pressure and blood flow to the brain may exacerbate a TBI by destabilizing intracerebral clots, promoting hemorrhage, and increasing cerebral edema. (24) In a propensity matched study from Japan, patients with head injury and low GCS were more likely to die if treated with REBOA.…”

Section: Discussionmentioning

confidence: 99%

The effect of resuscitative endovascular balloon occlusion of the aorta, partial aortic occlusion and aggressive blood transfusion on traumatic brain injury in a swine multiple injuries model

Johnson

Williams

Ferencz

et al. 2017

Journal of Trauma and Acute Care Surgery

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Objectives Despite clinical reports of poor outcomes, the degree to which REBOA exacerbates traumatic brain injury (TBI) is not known. We hypothesized that combined effects of increased proximal mean arterial pressure (pMAP), carotid blood flow (Qcarotid), and intracranial pressure (ICP) from REBOA would lead to TBI progression compared to partial aortic occlusion (PAO) or no intervention. Methods 21 swine underwent a standardized TBI via computer Controlled cortical impact followed by 25% total blood volume rapid hemorrhage. After 30 minutes of hypotension, animals were randomized to 60 minutes of continued hypotension (Control), REBOA, or PAO. REBOA and PAO animals were then weaned from occlusion. All animals were resuscitated with shed blood via a rapid blood infuser. Physiologic parameters were recorded continuously and brain computed tomography obtained at specified intervals. Results There were no differences in baseline physiology or during the initial 30 minutes of hypotension. During the 60-minute intervention period, REBOA resulted in higher maximal pMAP (REBOA 105.3±8.8; PAO 92.7±9.2; Control 48.9±7.7, p=0.02) and higher Qcarotid (REBOA 673.1±57.9; PAO 464.2±53.0; Control 170.3±29.4, p<0.01). Increases in ICP were greatest during blood resuscitation, with Control animals demonstrating the largest peak ICP (Control 12.8±1.2; REBOA 5.1±0.6; PAO 9.4±1.1, p<0.01). There were no differences in the percentage of animals with hemorrhage progression on CT (Control 14.3%, 95%CI 3.6–57.9; REBOA 28.6%, 95%CI 3.7–71.0; and PAO 28.6%, 95%CI 3.7–71.0). Conclusions In an animal model of TBI and shock, REBOA increased carotid flow and pMAP, but did not exacerbate TBI progression. PAO resulted in physiology closer to baseline with smaller increases in ICP and pMAP. Rapid blood resuscitation, not REBOA, resulted in the largest increase in ICP after intervention, which occurred in Control animals. Continued studies of the cerebral hemodynamics of aortic occlusion and blood transfusion are required to determine optimal resuscitation strategies for multi-injured patients.

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Prehospital hypertension is predictive of traumatic brain injury and is associated with higher mortality

Cited by 30 publications

References 28 publications

Impact of Cushing’s sign in the prehospital setting on predicting the need for immediate neurosurgical intervention in trauma patients: a nationwide retrospective observational study

Impact of Cushing’s sign in the prehospital setting on predicting the need for immediate neurosurgical intervention in trauma patients: a nationwide retrospective observational study

Long term outcome in survivors of decompressive craniectomy following severe traumatic brain injury

The effect of resuscitative endovascular balloon occlusion of the aorta, partial aortic occlusion and aggressive blood transfusion on traumatic brain injury in a swine multiple injuries model

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