Outcomes after concomitant traumatic brain injury and hemorrhagic shock: A secondary analysis from the Pragmatic, Randomized Optimal Platelets and Plasma Ratios trial

Samuel M. Galvagno, Erin E. Fox, Savitri N. Appana, Sarah Baraniuk, Patrick L. Bosarge, Eileen M. Bulger, Rachel A. Callcut, Bryan A. Cotton, Michael Goodman, Kenji Inaba, Terence OKeeffe, Martin A. Schreiber, Charles E. Wade, Thomas M. Scalea, John B. Holcomb, Deborah M. Stein

Research output: Contribution to journalArticle

12 Citations (Scopus)

Abstract

BACKGROUND Often the clinician is faced with a diagnostic and therapeutic dilemma in patients with concomitant traumatic brain injury (TBI) and hemorrhagic shock (HS), as rapid deterioration from either can be fatal. Knowledge about outcomes after concomitant TBI and HS may help prioritize the emergent management of these patients. We hypothesized that patients with concomitant TBI and HS (TBI + HS) had worse outcomes and required more intensive care compared with patients with only one of these injuries. METHODS This is a post hoc analysis of the Pragmatic, Randomized Optimal Platelets and Plasma Ratios (PROPPR) trial. TBI was defined by a head Abbreviated Injury Scale score greater than 2. HS was defined as a base excess of -4 or less and/or shock index of 0.9 or greater. The primary outcome for this analysis was mortality at 30 days. Logistic regression, using generalized estimating equations, was used to model categorical outcomes. RESULTS Six hundred seventy patients were included. Patients with TBI + HS had significantly higher lactate (median, 6.3; interquartile range, 4.7-9.2) compared with the TBI group (median, 3.3; interquartile range, 2.3-4). TBI + HS patients had higher activated prothrombin times and lower platelet counts. Unadjusted mortality was higher in the TBI + HS (51.6%) and TBI (50%) groups compared with the HS (17.5%) and neither group (7.7%). Adjusted odds of death in the TBI and TBI + HS groups were 8.2 (95% confidence interval, 3.4-19.5) and 10.6 (95% confidence interval, 4.8-23.2) times higher, respectively. Ventilator, intensive care unit-free and hospital-free days were lower in the TBI and TBI + HS groups compared with the other groups. Patients with TBI + HS or TBI had significantly greater odds of developing a respiratory complication compared with the neither group. CONCLUSION The addition of TBI to HS is associated with worse coagulopathy before resuscitation and increased mortality. When controlling for multiple known confounders, the diagnosis of TBI alone or TBI+HS was associated with significantly greater odds of developing respiratory complications. LEVEL OF EVIDENCE Prognostic study, level II.

Original languageEnglish (US)
Pages (from-to)668-674
Number of pages7
JournalJournal of Trauma and Acute Care Surgery
Volume83
Issue number4
DOIs
StatePublished - Oct 1 2017
Externally publishedYes

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Hemorrhagic Shock
Blood Platelets
Traumatic Brain Injury
Mortality
Abbreviated Injury Scale
Confidence Intervals
Prothrombin Time

Keywords

  • Traumatic brain injury
  • hemorrhagic shock
  • resuscitation
  • trauma

ASJC Scopus subject areas

  • Surgery
  • Critical Care and Intensive Care Medicine

Cite this

Outcomes after concomitant traumatic brain injury and hemorrhagic shock : A secondary analysis from the Pragmatic, Randomized Optimal Platelets and Plasma Ratios trial. / Galvagno, Samuel M.; Fox, Erin E.; Appana, Savitri N.; Baraniuk, Sarah; Bosarge, Patrick L.; Bulger, Eileen M.; Callcut, Rachel A.; Cotton, Bryan A.; Goodman, Michael; Inaba, Kenji; OKeeffe, Terence; Schreiber, Martin A.; Wade, Charles E.; Scalea, Thomas M.; Holcomb, John B.; Stein, Deborah M.

In: Journal of Trauma and Acute Care Surgery, Vol. 83, No. 4, 01.10.2017, p. 668-674.

Research output: Contribution to journalArticle

Galvagno, SM, Fox, EE, Appana, SN, Baraniuk, S, Bosarge, PL, Bulger, EM, Callcut, RA, Cotton, BA, Goodman, M, Inaba, K, OKeeffe, T, Schreiber, MA, Wade, CE, Scalea, TM, Holcomb, JB & Stein, DM 2017, 'Outcomes after concomitant traumatic brain injury and hemorrhagic shock: A secondary analysis from the Pragmatic, Randomized Optimal Platelets and Plasma Ratios trial', Journal of Trauma and Acute Care Surgery, vol. 83, no. 4, pp. 668-674. https://doi.org/10.1097/TA.0000000000001584
Galvagno, Samuel M. ; Fox, Erin E. ; Appana, Savitri N. ; Baraniuk, Sarah ; Bosarge, Patrick L. ; Bulger, Eileen M. ; Callcut, Rachel A. ; Cotton, Bryan A. ; Goodman, Michael ; Inaba, Kenji ; OKeeffe, Terence ; Schreiber, Martin A. ; Wade, Charles E. ; Scalea, Thomas M. ; Holcomb, John B. ; Stein, Deborah M. / Outcomes after concomitant traumatic brain injury and hemorrhagic shock : A secondary analysis from the Pragmatic, Randomized Optimal Platelets and Plasma Ratios trial. In: Journal of Trauma and Acute Care Surgery. 2017 ; Vol. 83, No. 4. pp. 668-674.
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T1 - Outcomes after concomitant traumatic brain injury and hemorrhagic shock

T2 - A secondary analysis from the Pragmatic, Randomized Optimal Platelets and Plasma Ratios trial

AU - Galvagno, Samuel M.

AU - Fox, Erin E.

AU - Appana, Savitri N.

AU - Baraniuk, Sarah

AU - Bosarge, Patrick L.

AU - Bulger, Eileen M.

AU - Callcut, Rachel A.

AU - Cotton, Bryan A.

AU - Goodman, Michael

AU - Inaba, Kenji

AU - OKeeffe, Terence

AU - Schreiber, Martin A.

AU - Wade, Charles E.

AU - Scalea, Thomas M.

AU - Holcomb, John B.

AU - Stein, Deborah M.

PY - 2017/10/1

Y1 - 2017/10/1

N2 - BACKGROUND Often the clinician is faced with a diagnostic and therapeutic dilemma in patients with concomitant traumatic brain injury (TBI) and hemorrhagic shock (HS), as rapid deterioration from either can be fatal. Knowledge about outcomes after concomitant TBI and HS may help prioritize the emergent management of these patients. We hypothesized that patients with concomitant TBI and HS (TBI + HS) had worse outcomes and required more intensive care compared with patients with only one of these injuries. METHODS This is a post hoc analysis of the Pragmatic, Randomized Optimal Platelets and Plasma Ratios (PROPPR) trial. TBI was defined by a head Abbreviated Injury Scale score greater than 2. HS was defined as a base excess of -4 or less and/or shock index of 0.9 or greater. The primary outcome for this analysis was mortality at 30 days. Logistic regression, using generalized estimating equations, was used to model categorical outcomes. RESULTS Six hundred seventy patients were included. Patients with TBI + HS had significantly higher lactate (median, 6.3; interquartile range, 4.7-9.2) compared with the TBI group (median, 3.3; interquartile range, 2.3-4). TBI + HS patients had higher activated prothrombin times and lower platelet counts. Unadjusted mortality was higher in the TBI + HS (51.6%) and TBI (50%) groups compared with the HS (17.5%) and neither group (7.7%). Adjusted odds of death in the TBI and TBI + HS groups were 8.2 (95% confidence interval, 3.4-19.5) and 10.6 (95% confidence interval, 4.8-23.2) times higher, respectively. Ventilator, intensive care unit-free and hospital-free days were lower in the TBI and TBI + HS groups compared with the other groups. Patients with TBI + HS or TBI had significantly greater odds of developing a respiratory complication compared with the neither group. CONCLUSION The addition of TBI to HS is associated with worse coagulopathy before resuscitation and increased mortality. When controlling for multiple known confounders, the diagnosis of TBI alone or TBI+HS was associated with significantly greater odds of developing respiratory complications. LEVEL OF EVIDENCE Prognostic study, level II.

AB - BACKGROUND Often the clinician is faced with a diagnostic and therapeutic dilemma in patients with concomitant traumatic brain injury (TBI) and hemorrhagic shock (HS), as rapid deterioration from either can be fatal. Knowledge about outcomes after concomitant TBI and HS may help prioritize the emergent management of these patients. We hypothesized that patients with concomitant TBI and HS (TBI + HS) had worse outcomes and required more intensive care compared with patients with only one of these injuries. METHODS This is a post hoc analysis of the Pragmatic, Randomized Optimal Platelets and Plasma Ratios (PROPPR) trial. TBI was defined by a head Abbreviated Injury Scale score greater than 2. HS was defined as a base excess of -4 or less and/or shock index of 0.9 or greater. The primary outcome for this analysis was mortality at 30 days. Logistic regression, using generalized estimating equations, was used to model categorical outcomes. RESULTS Six hundred seventy patients were included. Patients with TBI + HS had significantly higher lactate (median, 6.3; interquartile range, 4.7-9.2) compared with the TBI group (median, 3.3; interquartile range, 2.3-4). TBI + HS patients had higher activated prothrombin times and lower platelet counts. Unadjusted mortality was higher in the TBI + HS (51.6%) and TBI (50%) groups compared with the HS (17.5%) and neither group (7.7%). Adjusted odds of death in the TBI and TBI + HS groups were 8.2 (95% confidence interval, 3.4-19.5) and 10.6 (95% confidence interval, 4.8-23.2) times higher, respectively. Ventilator, intensive care unit-free and hospital-free days were lower in the TBI and TBI + HS groups compared with the other groups. Patients with TBI + HS or TBI had significantly greater odds of developing a respiratory complication compared with the neither group. CONCLUSION The addition of TBI to HS is associated with worse coagulopathy before resuscitation and increased mortality. When controlling for multiple known confounders, the diagnosis of TBI alone or TBI+HS was associated with significantly greater odds of developing respiratory complications. LEVEL OF EVIDENCE Prognostic study, level II.

KW - Traumatic brain injury

KW - hemorrhagic shock

KW - resuscitation

KW - trauma

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