Original Investigation
January 24, 2024
EMS Treatment Guidelines in Major Traumatic Brain Injury With Positive Pressure Ventilation
Joshua B. Gaither, Daniel W. Spaite, Bentley J. Bobrow, et al
JAMA Surg. 2024;159(4):363-372. doi:10.1001/jamasurg.2023.7155
Question Did implementation of the prehospital traumatic brain injury (TBI) evidence-based guidelines impact survival among patients with prehospital positive pressure ventilation (PPV)?
Findings In this subanalysis of the EPIC study, guideline implementation was associated with improved survival to hospital admission and discharge among patients with severe TBI who received prehospital PPV.
Meaning Prehospital TBI guideline implementation, focusing on avoiding hypoxia and hyperventilation, was independently associated with improved survival in patients who required PPV prior to arrival to the emergency department.
Abstract
Importance The Excellence in Prehospital Injury Care (EPIC) study demonstrated improved survival in patients with severe traumatic brain injury (TBI) following implementation of the prehospital treatment guidelines. The impact of implementing these guidelines in the subgroup of patients who received positive pressure ventilation (PPV) is unknown.
Objective To evaluate the association of implementation of prehospital TBI evidence-based guidelines with survival among patients with prehospital PPV.
Design, Setting, and Participants The EPIC study was a multisystem, intention-to-treat study using a before/after controlled design. Evidence-based guidelines were implemented by emergency medical service agencies across Arizona. This subanalysis was planned a priori and included participants who received prehospital PPV. Outcomes were compared between the preimplementation and postimplementation cohorts using logistic regression, stratified by predetermined TBI severity categories (moderate, severe, or critical). Data were collected from January 2007 to June 2017, and data were analyzed from January to February 2023.
Exposure Implementation of the evidence-based guidelines for the prehospital care of patient with TBI.
Main Outcomes and Measures The primary outcome was survival to hospital discharge, and the secondary outcome was survival to admission.
Results Among the 21 852 participants in the main study, 5022 received prehospital PPV (preimplementation, 3531 participants; postimplementation, 1491 participants). Of 5022 included participants, 3720 (74.1%) were male, and the median (IQR) age was 36 (22-54) years. Across all severities combined, survival to admission improved (adjusted odds ratio [aOR], 1.59; 95% CI, 1.28-1.97), while survival to discharge did not (aOR, 0.94; 95% CI, 0.78-1.13). Within the cohort with severe TBI but not in the moderate or critical subgroups, survival to hospital admission increased (aOR, 6.44; 95% CI, 2.39-22.00), as did survival to discharge (aOR, 3.52; 95% CI, 1.96-6.34).
Conclusions and Relevance Among patients with severe TBI who received active airway interventions in the field, guideline implementation was independently associated with improved survival to hospital admission and discharge. This was true whether they received basic airway interventions or advanced airways. These findings support the current guideline recommendations for aggressive prevention/correction of hypoxia and hyperventilation in patients with severe TBI, regardless of which airway type is used.
