دورية أكاديمية
أعرض في EDS

Optimal Out-of-Hospital Blood Pressure in Major Traumatic Brain Injury: A Challenge to the Current Understanding of Hypotension.

التفاصيل البيبلوغرافية
العنوان: Optimal Out-of-Hospital Blood Pressure in Major Traumatic Brain Injury: A Challenge to the Current Understanding of Hypotension.
المؤلفون: Spaite DW; Arizona Emergency Medicine Research Center, College of Medicine-Phoenix, The University of Arizona, Phoenix, AZ; Department of Emergency Medicine, College of Medicine, The University of Arizona, Tucson, AZ. Electronic address: dan@aemrc.arizona.edu., Hu C; Arizona Emergency Medicine Research Center, College of Medicine-Phoenix, The University of Arizona, Phoenix, AZ; Mel and Enid Zuckerman College of Public Health, The University of Arizona, Tucson, AZ., Bobrow BJ; Department of Emergency Medicine, McGovern Medical School at UT Health, Houston, TX., Barnhart B; Arizona Emergency Medicine Research Center, College of Medicine-Phoenix, The University of Arizona, Phoenix, AZ., Chikani V; Department of Health Services, Bureau of Emergency Medical Services, Phoenix, AZ., Gaither JB; Arizona Emergency Medicine Research Center, College of Medicine-Phoenix, The University of Arizona, Phoenix, AZ; Department of Emergency Medicine, College of Medicine, The University of Arizona, Tucson, AZ., Denninghoff KR; Arizona Emergency Medicine Research Center, College of Medicine-Phoenix, The University of Arizona, Phoenix, AZ; Department of Emergency Medicine, College of Medicine, The University of Arizona, Tucson, AZ., Bradley GH; Department of Emergency Medicine, College of Medicine, The University of Arizona, Tucson, AZ; Department of Health Services, Bureau of Emergency Medical Services, Phoenix, AZ., Rice AD; Arizona Emergency Medicine Research Center, College of Medicine-Phoenix, The University of Arizona, Phoenix, AZ; Department of Emergency Medicine, College of Medicine, The University of Arizona, Tucson, AZ., Howard JT; Department of Public Health, University of Texas at San Antonio, San Antonio, TX., Keim SM; Arizona Emergency Medicine Research Center, College of Medicine-Phoenix, The University of Arizona, Phoenix, AZ; Department of Emergency Medicine, College of Medicine, The University of Arizona, Tucson, AZ.
المصدر: Annals of emergency medicine [Ann Emerg Med] 2022 Jul; Vol. 80 (1), pp. 46-59. Date of Electronic Publication: 2022 Mar 24.
نوع المنشور: Journal Article; Research Support, U.S. Gov't, Non-P.H.S.; Research Support, N.I.H., Extramural
اللغة: English
بيانات الدورية: Publisher: Mosby Country of Publication: United States NLM ID: 8002646 Publication Model: Print-Electronic Cited Medium: Internet ISSN: 1097-6760 (Electronic) Linking ISSN: 01960644 NLM ISO Abbreviation: Ann Emerg Med Subsets: MEDLINE
أسماء مطبوعة: Publication: St. Louis, MO : Mosby
Original Publication: [Lansing, Mich., American College of Emergency Physicians]
مواضيع طبية MeSH: Brain Injuries, Traumatic*/complications , Brain Injuries, Traumatic*/therapy , Hypotension*, Blood Pressure ; Brain ; Child ; Hospitals ; Humans
مستخلص: Study Objective: Little is known about the out-of-hospital blood pressure ranges associated with optimal outcomes in traumatic brain injuries (TBI). Our objective was to evaluate the associations between out-of-hospital systolic blood pressure (SBP) and multiple hospital outcomes without assuming any predefined thresholds for hypotension, normotension, or hypertension.
Methods: This was a preplanned secondary analysis from the Excellence in Prehospital Injury Care (EPIC) TBI study. Among patients (age ≥10 years) with major TBIs (Barell Matrix type 1 and/or Abbreviated Injury Scale-head severity ≥3) and lowest out-of-hospital SBPs of 40 to 299 mmHg, we utilized generalized additive models to summarize the distributions of various outcomes as smoothed functions of SBP, adjusting for important and significant confounders. The subjects who were enrolled in the study phase after the out-of-hospital TBI guideline implementation were used to validate the models developed from the preimplementation cohort.
Results: Among 12,169 included cases, the mortality model revealed 3 distinct ranges: (1) a monotonically decreasing relationship between SBP and the adjusted probability of death from 40 to 130 mmHg, (2) lowest adjusted mortality from 130 to 180 mmHg, and (3) rapidly increasing mortality above 180 mmHg. A subanalysis of the cohorts with isolated TBIs and multisystem injuries with TBIs revealed SBP mortality patterns that were similar to each other and to that of the main analysis. While the specific SBP ranges varied somewhat for the nonmortality outcomes (hospital length of stay, ICU length of stay, discharge to skilled nursing/inpatient rehabilitation, and hospital charges), the patterns were very similar to that of mortality. In each model, validation was confirmed utilizing the postimplementation cohort.
Conclusion: Optimal adjusted mortality was associated with a surprisingly high SBP range (130 to 180 mmHg). Below this level, there was no point or range of inflection that would indicate a physiologically meaningful threshold for defining hypotension. Nonmortality outcomes showed very similar patterns. These findings highlight how sensitive the injured brain is to compromised perfusion at SBP levels that, heretofore, have been considered adequate or even normal. While the study design does did not allow us to conclude that the currently recommended treatment threshold (<90 mmHg) should be increased, the findings imply that the definition of hypotension in the setting of TBI is too low. Randomized trials evaluating treatment levels significantly higher than 90 mmHg are needed.
(Copyright © 2022 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.)
معلومات مُعتمدة: R01 NS071049 United States NS NINDS NIH HHS
سلسلة جزيئية: ClinicalTrials.gov NCT01339702
تواريخ الأحداث: Date Created: 20220327 Date Completed: 20220621 Latest Revision: 20220921
رمز التحديث: 20240628
DOI: 10.1016/j.annemergmed.2022.01.045
PMID: 35339285
قاعدة البيانات: MEDLINE
الوصف
تدمد:1097-6760
DOI:10.1016/j.annemergmed.2022.01.045