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Original Investigation
December 7, 2016

Mortality and Prehospital Blood Pressure in Patients With Major Traumatic Brain InjuryImplications for the Hypotension Threshold

Author Affiliations
  • 1Arizona Emergency Medicine Research Center, The University of Arizona College of Medicine, Phoenix
  • 2Department of Emergency Medicine, The University of Arizona College of Medicine, Tucson
  • 3The Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson
  • 4Arizona Department of Health Services, Bureau of Emergency Medical Services, Phoenix
  • 5Barrow Neurological Institute, Phoenix Children’s Hospital, Phoenix, Arizona
  • 6Department of Child Health, The University of Arizona College of Medicine, Phoenix
JAMA Surg. Published online December 7, 2016. doi:10.1001/jamasurg.2016.4686
Key Points

Question  Is there a prehospital hypotension threshold for mortality in patients with major traumatic brain injury?

Findings  In this secondary analysis of the Excellence in Prehospital Injury Care Traumatic Brain Injury Study, the association between systolic blood pressure and adjusted probability of death was monotonic across a broad range (40-119 mm Hg), with each 10-point increase in systolic pressure associated with a decrease of 18.8% in the adjusted odds of death.

Meaning  In patients with traumatic brain injury, the concept that 90 mm Hg represents a unique or important physiological cut point may be wrong, and clinically meaningful hypotension may not be as low as current guidelines suggest.

Abstract

Importance  Current prehospital traumatic brain injury guidelines use a systolic blood pressure threshold of less than 90 mm Hg for treating hypotension for individuals 10 years and older based on studies showing higher mortality when blood pressure drops below this level. However, the guidelines also acknowledge the weakness of the supporting evidence.

Objective  To evaluate whether any statistically supportable threshold between systolic pressure and mortality emerges from the data a priori, without assuming that a cut point exists.

Design, Setting, and Participants  Observational evaluation of a large prehospital database established as a part of the Excellence in Prehospital Injury Care Traumatic Brain Injury Study. Patients from the preimplementation cohort (January 2007 to March 2014) 10 years and older with moderate or severe traumatic brain injury (Barell Matrix Type 1 classification, International Classification of Diseases, Ninth Revision head region severity score of 3 or greater, and/or Abbreviated Injury Scale head-region severity score of 3 or greater) and a prehospital systolic pressure between 40 and 119 mm Hg were included. The generalized additive model and logistic regression were used to determine the association between systolic pressure and probability of death, adjusting for significant/important confounders.

Main Outcomes and Measures  The main outcome measure was in-hospital mortality.

Results  Among the 3844 included patients, 2565 (66.7%) were male, and the median (range) age was 35 (10-99) years. The model revealed a monotonically decreasing association between systolic pressure and adjusted probability of death across the entire range (ie, from 40 to 119 mm Hg). Each 10-point increase of systolic pressure was associated with a decrease in the adjusted odds of death of 18.8% (adjusted odds ratio, 0.812; 95% CI, 0.748-0.883). Thus, the adjusted odds of mortality increased as much for a drop from 110 to 100 mm Hg as for a drop from 90 to 80 mm Hg, and so on throughout the range.

Conclusions and Relevance  We found a linear association between lowest prehospital systolic blood pressure and severity-adjusted probability of mortality across an exceptionally wide range. There is no identifiable threshold or inflection point between 40 and 119 mm Hg. Thus, in patients with traumatic brain injury, the concept that 90 mm Hg represents a unique or important physiological cut point may be wrong. Furthermore, clinically meaningful hypotension may not be as low as current guidelines suggest. Randomized trials evaluating treatment levels significantly above 90 mm Hg are needed.

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