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. Jr. PhD; Fox, Erin E. PhD; Appana, Savitri N.; Baraniuk, Sarah PhD; Bosarge, Patrick L. MD; Bulger, Eileen M. MD; Callcut, Rachel A. MD; Cotton, Bryan A. MD; Goodman, Michael MD; Inaba, Kenji MD; O'Keeffe, Terence; Schreiber, Martin A. MD; Wade, Charles E. PhD; Scalea, Thomas M. MD; Holcomb, John B. MD; Stein, Deborah M. MD; on behalf of the PROPPR Study Group
[Article] Journal of Trauma and Acute Care Surgery. 83(4):668-674, October 2017.

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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.

(C) 2017 Lippincott Williams & Wilkins, Inc.