Joshua B Gaither1, Daniel W Spaite2, Bentley J Bobrow3, Samuel M Keim4, Bruce J Barnhart5, Vatsal Chikani6, Duane Sherrill7, Kurt R Denninghoff2, Terry Mullins6, P David Adelson8, Amber D Rice2, Chad Viscusi2, Chengcheng Hu9. 1. Arizona Emergency Medicine Research Center, College of Medicine-Phoenix, The University of Arizona, Phoenix, AZ; Department of Emergency Medicine, College of Medicine-Tucson, The University of Arizona, Tucson, AZ. Electronic address: jgaither@aemrc.arizona.edu. 2. Arizona Emergency Medicine Research Center, College of Medicine-Phoenix, The University of Arizona, Phoenix, AZ; Department of Emergency Medicine, College of Medicine-Tucson, The University of Arizona, Tucson, AZ. 3. Department of Emergency Medicine, McGovern Medical School at UT Health, Houston, TX. 4. Arizona Emergency Medicine Research Center, College of Medicine-Phoenix, The University of Arizona, Phoenix, AZ; Department of Emergency Medicine, College of Medicine-Tucson, The University of Arizona, Tucson, AZ; Mel and Enid Zuckerman College of Public Health, The University of Arizona, Tucson, AZ. 5. Arizona Emergency Medicine Research Center, College of Medicine-Phoenix, The University of Arizona, Phoenix, AZ. 6. Arizona Department of Health Services, Bureau of EMS, Phoenix, AZ. 7. Mel and Enid Zuckerman College of Public Health, The University of Arizona, Tucson, AZ. 8. Barrow Neurological Institute at Phoenix Children's Hospital and Department of Child Health/Neurosurgery, College of Medicine, The University of Arizona, Phoenix, AZ. 9. Arizona Emergency Medicine Research Center, College of Medicine-Phoenix, The University of Arizona, Phoenix, AZ; Mel and Enid Zuckerman College of Public Health, The University of Arizona, Tucson, AZ.
Abstract
STUDY OBJECTIVE: We evaluate the effect of implementing the out-of-hospital pediatric traumatic brain injury guidelines on outcomes in children with major traumatic brain injury. METHODS: The Excellence in Prehospital Injury Care for Children study is the preplanned secondary analysis of the Excellence in Prehospital Injury Care study, a multisystem, intention-to-treat study using a before-after controlled design. This subanalysis included children younger than 18 years who were transported to Level I trauma centers by participating out-of-hospital agencies between January 1, 2007, and June 30, 2015, throughout Arizona. The primary and secondary outcomes were survival to hospital discharge or admission for children with major traumatic brain injury and in 3 subgroups, defined a priori as those with moderate, severe, and critical traumatic brain injury. Outcomes in the preimplementation and postimplementation cohorts were compared with logistic regression, adjusting for risk factors and confounders. RESULTS: There were 2,801 subjects, 2,041 in preimplementation and 760 in postimplementation. The primary analysis (postimplementation versus preimplementation) yielded an adjusted odds ratio of 1.16 (95% confidence interval 0.70 to 1.92) for survival to hospital discharge and 2.41 (95% confidence interval 1.17 to 5.21) for survival to hospital admission. In the severe traumatic brain injury cohort (Regional Severity Score-Head 3 or 4), but not the moderate or critical subgroups, survival to discharge significantly improved after guideline implementation (adjusted odds ratio = 8.42; 95% confidence interval 1.01 to 100+). The improvement in survival to discharge among patients with severe traumatic brain injury who received positive-pressure ventilation did not reach significance (adjusted odds ratio = 9.13; 95% confidence interval 0.79 to 100+). CONCLUSION: Implementation of the pediatric out-of-hospital traumatic brain injury guidelines was not associated with improved survival when the entire spectrum of severity was analyzed as a whole (moderate, severe, and critical). However, both adjusted survival to hospital admission and discharge improved in children with severe traumatic brain injury, indicating a potential severity-based interventional opportunity for guideline effectiveness. These findings support the widespread implementation of the out-of-hospital pediatric traumatic brain injury guidelines.
STUDY OBJECTIVE: We evaluate the effect of implementing the out-of-hospital pediatric traumatic brain injury guidelines on outcomes in children with major traumatic brain injury. METHODS: The Excellence in Prehospital Injury Care for Children study is the preplanned secondary analysis of the Excellence in Prehospital Injury Care study, a multisystem, intention-to-treat study using a before-after controlled design. This subanalysis included children younger than 18 years who were transported to Level I trauma centers by participating out-of-hospital agencies between January 1, 2007, and June 30, 2015, throughout Arizona. The primary and secondary outcomes were survival to hospital discharge or admission for children with major traumatic brain injury and in 3 subgroups, defined a priori as those with moderate, severe, and critical traumatic brain injury. Outcomes in the preimplementation and postimplementation cohorts were compared with logistic regression, adjusting for risk factors and confounders. RESULTS: There were 2,801 subjects, 2,041 in preimplementation and 760 in postimplementation. The primary analysis (postimplementation versus preimplementation) yielded an adjusted odds ratio of 1.16 (95% confidence interval 0.70 to 1.92) for survival to hospital discharge and 2.41 (95% confidence interval 1.17 to 5.21) for survival to hospital admission. In the severe traumatic brain injury cohort (Regional Severity Score-Head 3 or 4), but not the moderate or critical subgroups, survival to discharge significantly improved after guideline implementation (adjusted odds ratio = 8.42; 95% confidence interval 1.01 to 100+). The improvement in survival to discharge among patients with severe traumatic brain injury who received positive-pressure ventilation did not reach significance (adjusted odds ratio = 9.13; 95% confidence interval 0.79 to 100+). CONCLUSION: Implementation of the pediatric out-of-hospital traumatic brain injury guidelines was not associated with improved survival when the entire spectrum of severity was analyzed as a whole (moderate, severe, and critical). However, both adjusted survival to hospital admission and discharge improved in children with severe traumatic brain injury, indicating a potential severity-based interventional opportunity for guideline effectiveness. These findings support the widespread implementation of the out-of-hospital pediatric traumatic brain injury guidelines.
Authors: Raj K Narayan; Mary Ellen Michel; Beth Ansell; Alex Baethmann; Anat Biegon; Michael B Bracken; M Ross Bullock; Sung C Choi; Guy L Clifton; Charles F Contant; William M Coplin; W Dalton Dietrich; Jamshid Ghajar; Sean M Grady; Robert G Grossman; Edward D Hall; William Heetderks; David A Hovda; Jack Jallo; Russell L Katz; Nachshon Knoller; Patrick M Kochanek; Andrew I Maas; Jeannine Majde; Donald W Marion; Anthony Marmarou; Lawrence F Marshall; Tracy K McIntosh; Emmy Miller; Noel Mohberg; J Paul Muizelaar; Lawrence H Pitts; Peter Quinn; Gad Riesenfeld; Claudia S Robertson; Kenneth I Strauss; Graham Teasdale; Nancy Temkin; Ronald Tuma; Charles Wade; Michael D Walker; Michael Weinrich; John Whyte; Jack Wilberger; A Byron Young; Lorraine Yurkewicz Journal: J Neurotrauma Date: 2002-05 Impact factor: 5.269
Authors: Neeraj Badjatia; Nancy Carney; Todd J Crocco; Mary Elizabeth Fallat; Halim M A Hennes; Andrew S Jagoda; Sarah Jernigan; Peter B Letarte; E Brooke Lerner; Thomas M Moriarty; Peter T Pons; Scott Sasser; Thomas Scalea; Charles L Schleien; David W Wright Journal: Prehosp Emerg Care Date: 2008 Impact factor: 3.077
Authors: P David Adelson; Susan L Bratton; Nancy A Carney; Randall M Chesnut; Hugo E M du Coudray; Brahm Goldstein; Patrick M Kochanek; Helen C Miller; Michael D Partington; Nathan R Selden; Craig R Warden; David W Wright Journal: Pediatr Crit Care Med Date: 2003-07 Impact factor: 3.624
Authors: R M Chesnut; L F Marshall; M R Klauber; B A Blunt; N Baldwin; H M Eisenberg; J A Jane; A Marmarou; M A Foulkes Journal: J Trauma Date: 1993-02
Authors: Craig D Newgard; Peter E Fischer; Mark Gestring; Holly N Michaels; Gregory J Jurkovich; E Brooke Lerner; Mary E Fallat; Theodore R Delbridge; Joshua B Brown; Eileen M Bulger Journal: J Trauma Acute Care Surg Date: 2022-04-27 Impact factor: 3.697