Skip to main content
Key Specialties
Cardiology Diabetology Endocrinology Gastroenterology Geriatrics and Gerontology Gynecology and Obstetrics Hematology Infectious Disease Internal Medicine Nephrology Neurology Oncology Pediatrics Respiratory Medicine Rheumatology Surgery
Congress Coverage
2024 ACC Congress 2023 ESMO Congress 2023 EASD Congress 2023 ERS Congress 2023 ESC Congress 2023 EHA Congress 2023 ASCO Annual Meeting
Clinical Collections
Advances in Alzheimer’s

At a glance: The ONWARDS insulin icodec trials

A round-up of the ONWARDS phase 3 clinical trials evaluating the novel weekly insulin icodec in people with diabetes.
ADVANCED SEARCH
Log in
Top
Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine
Published in: Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 1/2019

Open Access 01-12-2019 | Central Nervous System Trauma | Original research

Prehospital on-scene anaesthetist treating severe traumatic brain injury patients is associated with lower mortality and better neurological outcome

Authors: Toni Pakkanen, Jouni Nurmi, Heini Huhtala, Tom Silfvast

Published in: Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine | Issue 1/2019

Login to get access

Abstract

Background

Patients with isolated traumatic brain injury (TBI) are likely to benefit from effective prehospital care to prevent secondary brain injury. Only a few studies have focused on the impact of advanced interventions in TBI patients by prehospital physicians. The primary end-point of this study was to assess the possible effect of an on-scene anaesthetist on mortality of TBI patients. A secondary end-point was the neurological outcome of these patients.

Methods

Patients with severe TBI (defined as a head injury resulting in a Glasgow Coma Score of ≤8) from 2005 to 2010 and 2012–2015 in two study locations were determined. Isolated TBI patients transported directly from the accident scene to the university hospital were included. A modified six-month Glasgow Outcome Score (GOS) was defined as death, unfavourable outcome (GOS 2–3) and favourable outcome (GOS 4–5) and used to assess the neurological outcomes. Binary logistic regression analysis was used to predict mortality and good neurological outcome. The following prognostic variables for TBI were available in the prehospital setting: age, on-scene GCS, hypoxia and hypotension. As per the hypothesis that treatment provided by an on-scene anaesthetist would be beneficial to TBI outcomes, physician was added as a potential predictive factor with regard to the prognosis.

Results

The mortality data for 651 patients and neurological outcome data for 634 patients were available for primary and secondary analysis. In the primary analysis higher age (OR 1.06 CI 1.05–1.07), lower on-scene GCS (OR 0.85 CI 0.79–0.92) and the unavailability of an on-scene anaesthetist (OR 1.89 CI 1.20–2.94) were associated with higher mortality together with hypotension (OR 3.92 CI 1.08–14.23). In the secondary analysis lower age (OR 0.95 CI 0.94–0.96), a higher on-scene GCS (OR 1.21 CI 1.20–1.30) and the presence of an on-scene anaesthetist (OR 1.75 CI 1.09–2.80) were demonstrated to be associated with good patient outcomes while hypotension (OR 0.19 CI 0.04–0.82) was associated with poor outcome.

Conclusion

Prehospital on-scene anaesthetist treating severe TBI patients is associated with lower mortality and better neurological outcome.
Appendix
Available only for authorised users
Literature
1.
Peeters W, van den Brande R, Polinder S, Brazinova A, Steyerberg EW, Lingsma HF, Maas AI. Epidemiology of traumatic brain injury in Europe. Acta Neurochir. 2015;157:1683–96.CrossRef
2.
Tagliaferri F, Compagnone C, Korsic M, Servadei F, Kraus J. A systematic review of brain injury epidemiology in Europe. Acta Neurochir. 2006;148:255–68 discussion 68.CrossRef
3.
Coronado VG, McGuire LC, Sarmiento K, Bell J, Lionbarger MR, Jones CD, Geller AI, Khoury N, Xu L. Trends in traumatic brain injury in the U.S. and the public health response: 1995-2009. J Saf Res. 2012;43:299–307.CrossRef
4.
Badjatia N, Carney N, Crocco TJ, Fallat ME, Hennes HM, Jagoda AS, Jernigan S, Letarte PB, Lerner EB, Moriarty TM, Pons PT, Sasser S, Scalea T, Schleien CL, Wright DW, Brain Trauma F, Management BTFCfG. Guidelines for prehospital management of traumatic brain injury 2nd edition. Prehosp Emerg Care. 2008;12(Suppl 1):S1–52.CrossRef
5.
Steyerberg EW, Mushkudiani N, Perel P, Butcher I, Lu J, McHugh GS, Murray GD, Marmarou A, Roberts I, Habbema JD, Maas AI. Predicting outcome after traumatic brain injury: development and international validation of prognostic scores based on admission characteristics. PLoS Med. 2008;5:e165 discussion e65.CrossRef
6.
Collaborators MCT, Perel P, Arango M, Clayton T, Edwards P, Komolafe E, Poccock S, Roberts I, Shakur H, Steyerberg E, Yutthakasemsunt S. Predicting outcome after traumatic brain injury: practical prognostic models based on large cohort of international patients. BMJ. 2008;336:425–9.CrossRef
7.
Murray GD, Butcher I, McHugh GS, Lu J, Mushkudiani NA, Maas AI, Marmarou A, Steyerberg EW. Multivariable prognostic analysis in traumatic brain injury: results from the IMPACT study. J Neurotrauma. 2007;24:329–37.CrossRef
8.
Chi JH, Knudson MM, Vassar MJ, McCarthy MC, Shapiro MB, Mallet S, Holcroft JJ, Moncrief H, Noble J, Wisner D, Kaups KL, Bennick LD, Manley GT. Prehospital hypoxia affects outcome in patients with traumatic brain injury: a prospective multicenter study. J Trauma. 2006;61:1134–41.CrossRef
9.
Baxt WG, Moody P. The impact of advanced prehospital emergency care on the mortality of severely brain-injured patients. J Trauma. 1987;27:365–9.CrossRef
10.
Chesnut RM, Marshall LF, Klauber MR, Blunt BA, Baldwin N, Eisenberg HM, Jane JA, Marmarou A, Foulkes MA. The role of secondary brain injury in determining outcome from severe head injury. J Trauma. 1993;34:216–22.CrossRef
11.
Stocchetti N, Furlan A, Volta F. Hypoxemia and arterial hypotension at the accident scene in head injury. J Trauma. 1996;40:764–7.CrossRef
12.
Wang HE, Peitzman AB, Cassidy LD, Adelson PD, Yealy DM. Out-of-hospital endotracheal intubation and outcome after traumatic brain injury. Ann Emerg Med. 2004;44:439–50.CrossRef
13.
Murray JA, Demetriades D, Berne TV, Stratton SJ, Cryer HG, Bongard F, Fleming A, Gaspard D. Prehospital intubation in patients with severe head injury. J Trauma. 2000;49:1065–70.CrossRef
14.
Davis DP. Prehospital intubation of brain-injured patients. Curr Opin Crit Care. 2008;14:142–8.CrossRef
15.
Davis DP. Early ventilation in traumatic brain injury. Resuscitation. 2008;76:333–40.CrossRef
16.
Botker MT, Bakke SA, Christensen EF. A systematic review of controlled studies: do physicians increase survival with prehospital treatment? Scand J Trauma Resusc Emerg Med. 2009;17:12.CrossRef
17.
Franschman G, Verburg N, Brens-Heldens V, Andriessen TM, Van der Naalt J, Peerdeman SM, Valk JP, Hoogerwerf N, Greuters S, Schober P, Vos PE, Christiaans HM, Boer C. Effects of physician-based emergency medical service dispatch in severe traumatic brain injury on prehospital run time. Injury. 2012;43:1838–42.CrossRef
18.
Pakkanen T, Virkkunen I, Kamarainen A, Huhtala H, Silfvast T, Virta J, Randell T, Yli-Hankala A. Pre-hospital severe traumatic brain injury - comparison of outcome in paramedic versus physician staffed emergency medical services. Scand J Trauma Resusc Emerg Med. 2016;24:62.CrossRef
19.
Pakkanen T, Kamarainen A, Huhtala H, Silfvast T, Nurmi J, Virkkunen I, Yli-Hankala A. Physician-staffed helicopter emergency medical service has a beneficial impact on the incidence of prehospital hypoxia and secured airways on patients with severe traumatic brain injury. Scand J Trauma Resusc Emerg Med. 2017;25:94.CrossRef
20.
21.
Marshall LF, Becker DP, Bowers SA, Cayard C, Eisenberg H, Gross CR, Grossman RG, Jane JA, Kunitz SC, Rimel R, Tabaddor K, Warren J. The National Traumatic Coma Data Bank. Part 1: design, purpose, goals, and results. J Neurosurg. 1983;59:276–84.CrossRef
22.
Teasdale G, Jennett B. Assessment of coma and impaired consciousness. A practical scale. Lancet. 1974;2:81–4.CrossRef
23.
Jennett B, Bond M. Assessment of outcome after severe brain damage. Lancet. 1975;1:480–4.CrossRef
24.
de Jongh MA, van Stel HF, Schrijvers AJ, Leenen LP, Verhofstad MH. The effect of helicopter emergency medical services on trauma patient mortality in the Netherlands. Injury. 2012;43:1362–7.CrossRef
25.
Ringburg AN, Thomas SH, Steyerberg EW, van Lieshout EM, Patka P, Schipper IB. Lives saved by helicopter emergency medical services: an overview of literature. Air Med J. 2009;28:298–302.CrossRef
26.
Frankema SP, Ringburg AN, Steyerberg EW, Edwards MJ, Schipper IB, van Vugt AB. Beneficial effect of helicopter emergency medical services on survival of severely injured patients. Br J Surg. 2004;91:1520–6.CrossRef
27.
Garner AA, Mann KP, Fearnside M, Poynter E, Gebski V. The Head Injury Retrieval Trial (HIRT): a single-centre randomised controlled trial of physician prehospital management of severe blunt head injury compared with management by paramedics only. Emerg Med J. 2015;32:869–75.CrossRef
28.
Carney N, Totten AM, O’Reilly C, Ullman JS, Hawryluk GW, Bell MJ, Bratton SL, Chesnut R, Harris OA, Kissoon N, Rubiano AM, Shutter L, Tasker RC, Vavilala MS, Wilberger J, Wright DW, Ghajar J. Guidelines for the Management of Severe Traumatic Brain Injury, Fourth Edition. Neurosurgery. 2016;80(1):6–15. https://​doi.​org/​10.​1227/​NEU.​0000000000001432​.
29.
Gellerfors M, Fevang E, Backman A, Kruger A, Mikkelsen S, Nurmi J, Rognas L, Sandstrom E, Skallsjo G, Svensen C, Gryth D, Lossius HM. Pre-hospital advanced airway management by anaesthetist and nurse anaesthetist critical care teams: a prospective observational study of 2028 pre-hospital tracheal intubations. Br J Anaesth. 2018;120:1103–9.CrossRef
30.
Ringburg AN, Spanjersberg WR, Frankema SP, Steyerberg EW, Patka P, Schipper IB. Helicopter emergency medical services (HEMS): impact on on-scene times. J Trauma. 2007;63:258–62.CrossRef
31.
Spaite DW, Hu C, Bobrow BJ, Chikani V, Sherrill D, Barnhart B, Gaither JB, Denninghoff KR, Viscusi C, Mullins T, Adelson PD. Mortality and prehospital blood pressure in patients with major traumatic brain injury: implications for the hypotension threshold. JAMA Surg. 2017;152:360–8.CrossRef
32.
Brenner M, Stein DM, Hu PF, Aarabi B, Sheth K, Scalea TM. Traditional systolic blood pressure targets underestimate hypotension-induced secondary brain injury. J Trauma Acute Care Surg. 2012;72:1135–9.CrossRef
33.
Berry C, Ley EJ, Bukur M, Malinoski D, Margulies DR, Mirocha J, Salim A. Redefining hypotension in traumatic brain injury. Injury. 2012;43:1833–7.CrossRef
34.
Fuller G, Hasler RM, Mealing N, Lawrence T, Woodford M, Juni P, Lecky F. The association between admission systolic blood pressure and mortality in significant traumatic brain injury: a multi-centre cohort study. Injury. 2014;45:612–7.CrossRef
35.
Butcher I, Maas AI, Lu J, Marmarou A, Murray GD, Mushkudiani NA, McHugh GS, Steyerberg EW. Prognostic value of admission blood pressure in traumatic brain injury: results from the IMPACT study. J Neurotrauma. 2007;24:294–302.CrossRef
36.
Mosenthal AC, Lavery RF, Addis M, Kaul S, Ross S, Marburger R, Deitch EA, Livingston DH. Isolated traumatic brain injury: age is an independent predictor of mortality and early outcome. J Trauma. 2002;52:907–11.PubMed
37.
Susman M, DiRusso SM, Sullivan T, Risucci D, Nealon P, Cuff S, Haider A, Benzil D. Traumatic brain injury in the elderly: increased mortality and worse functional outcome at discharge despite lower injury severity. J Trauma. 2002;53:219–23 discussion 23-4.CrossRef
38.
Rakier A, Soustiel JF, Gilburd J, Zaaroor M, Alkalai N, Welblum E, Feinsod M. Head injury in the elderly. Harefuah. 1995;128:474–7 528-7.PubMed
39.
Mamelak AN, Pitts LH, Damron S. Predicting survival from head trauma 24 hours after injury: a practical method with therapeutic implications. J Trauma. 1996;41:91–9.CrossRef
40.
41.
Tien HC, Cunha JR, Wu SN, Chughtai T, Tremblay LN, Brenneman FD, Rizoli SB. Do trauma patients with a Glasgow coma scale score of 3 and bilateral fixed and dilated pupils have any chance of survival? J Trauma. 2006;60:274–8.CrossRef
42.
Kotwica Z, Jakubowski JK. Head-injured adult patients with GCS of 3 on admission--who have a chance to survive? Acta Neurochir. 1995;133:56–9.CrossRef
Metadata
Title
Prehospital on-scene anaesthetist treating severe traumatic brain injury patients is associated with lower mortality and better neurological outcome
Authors
Toni Pakkanen
Jouni Nurmi
Heini Huhtala
Tom Silfvast
Publication date
01-12-2019
Publisher
BioMed Central
DOI
https://doi.org/10.1186/s13049-019-0590-x

Other articles of this Issue 1/2019

Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 1/2019 Go to the issue

Original research

Application of prothrombin complex concentrate for reversal of direct oral anticoagulants in clinical practice: indications, patient characteristics and clinical outcomes compared to reversal of vitamin K antagonists

Original research

First-response treatment after out-of-hospital cardiac arrest: a survey of current practices across 29 countries in Europe

Original research

Neurocritical care physicians’ doubt about whether to withdraw life-sustaining treatment the first days after devastating brain injury: an interview study

Original research

Challenges of helicopter mountain rescue missions by human external cargo: need for physicians onsite and comprehensive training

Original research

Impact of a goal-directed factor-based coagulation management on thromboembolic events following major trauma

Case report

Road bike accidents involving cervical fractures presenting as cardiac arrest: a report of two cases