Prehospital Traumatic Brain Injury Treatment Guidelines

What if a single change in field protocols could double a patient's chances of surviving a severe brain injury? In this episode of From Science to the Scene, Research Director Ash Panchal breaks down ground-breaking statistical findings from The Excellence in Prehospital Injury Care (EPIC) Study.

The research analyzed thousands of real-world patient cases to measure the exact impact of standardized care. The data reveals a dramatic outcome. Adhering to clinical guidelines that prevent hypoxia, hypotension, and hyperventilation doubled survival for patients with severe injuries. Even more striking, the findings show a tripling of survival rates among patients who required endotracheal intubation.

This episode transforms complex data into practical knowledge for the entire emergency medical community. Field Clinicians will discover how simple adjustments directly save lives, while EMS leaders will gain the statistical evidence needed to drive system-wide protocol updates.

Listen to the full episode now to see how evidence-based research is actively reshaping emergency care.

Transcript

SPEAKER_00 0:16

Hi, everybody. Thanks for joining. We are looking at a great study that looks at optimizing care for our patients who are suffering traumatic brain injury. I mean, this is unbelievably common, but unfortunately, it can be really associated with significant morbidity and mortality. The study is done by Dan Spate and the EPIC Research Team. That's the excellence in prehospital injury care study team. And they're looking at the association of statewide implementation of a pre-hospital traumatic brain injury treatment guideline with patient survival from traumatic brain injury. Now, this was published in Jamma Surgery. It gives you an idea of the quality of work that was published here. Now, the fundamental question they're asking is as PMS clinicians, we know we can improve outcomes for patients from major traumatic brain injury. And these are the patients that we see all the time, right? These are the MVCs, the falls, any type of trauma. But what we do know is that when we do early treatment of these patients, we can actually help prevent secondary brain injury. And this leads to better outcomes. That's fantastic. Now, the question though, which still is out there, is if we implement these evidence-based guidelines, these treatment recommendations that lead to better TBI, do we actually see this happening in our patients? And that's what this study was looking at. It was conducted in Arizona as part of the Epic trial. Like I said, the excellence and pre-hospital injury care study, which is a controlled before-after, multi-system intention to treat trial. Okay, that's a lot of words, but what it basically means is that this trial is structured before and after with a large system implementation of a protocol to improve outcomes. And the protocol is to improve what we're doing with traumatic brain injury. Now, the way the study is designed, and they show this in the supplement of the study, is it's a three-phase trial, right? In phase one, you have a baseline. This is mostly retrospective, really getting the idea of what risk-adjusted outcomes really look like for the population. At the end of phase one, they begin training. In phase two, they train and run in everyone's experiences so that what the beginning of phase three, training and implementation is complete. And in phase three, this is prospective post-implementation, data collection, and at the end of this whole thing, analysis. So you have three phases. And truthfully, when you think about these, phase one is the baseline, phase three is the uh prospective post-implementation. Those are the groups we'd we'd compare. So, what's the focus of the intervention? So, for you and I on the streets, what are we actually doing to improve outcomes? Well, first, prevention or treatment of hypoxia, and that's through early oxygen administration. Second, airway interventions to optimize oxygenation and ventilation. That could be through positive presser ventilation all the way up to an endotracheal innovation. The third is preventing hyperventilation. I think we've all seen this. And they're using age-appropriate ventilation rates and ventilation adjuncts. That means even lights to remind you when to actually ventilate appropriately. And last but not least, it's avoidance and treatment of hypotension in these patients by infusing isotonic fluids. So, four key concepts, right? Hypoxia, airway interventions to improve oxygenation and ventilation, prevent the hyperventilation, and don't let hypotension occur. Now, when they looked at this particular study, the primary outcome was survival to hospital discharge. That's survival. And the secondary outcome was survival to hospital admission. Now, one of the big things about this concept is what they wanted to really look at in their primary analysis was risk-adjusted associations between survival and the intervention itself. And they did logistic regression and adjusted for important risk factors, which we're going to talk about as we go through the data. One really important thing though, they decided upfront to also look at subgroups. Now, when I say subgroups, I'm talking about people with moderate severity of injury, severe severity injury, and those who got airway interventions like intubation. And this was a this was predefined because of the sole fact that they had recognition that, you know what, some of these moderately injured people may not die because they're not sick enough. So we'll talk a little bit more about that as we go through. So let's work and look a little bit at the results themselves. In the phase one part of this, the baseline measurement part of the trial, it started all the way back in January 2007 with the last agency completing training in June 30th, 2015. So it tells you how much time it took them to not only get baseline data, but get all the training completed so they get to the point that they can do post implementation data collection. So what were the total population enrolled? 26,873. That's amazing because that tells you that we have a lot of patients that we can look at their outcomes. Now, figure one really gives you the enrollment, but I'm gonna give you a short version of this. You got the 26,873 at the top, but all the way at the bottom, you have 15,000 people who were cared for solely by agencies during the pre-intervention phase. That's the people who had the baseline data. And on the other side, the P3, the phase three people are 6,624 who are cared solely by agencies in the post-intervention phase. So you have very clean populations of before and after that you can compare against. So what did they find? So finding UMA1, when they looked at the statewide implementation of these guidelines, they was not associated with significant improvement in overall survival to hospital discharge. Now, this is across the whole group, and this is a combined combined outcome of moderate all the way to the critical injury spectrum. And you see these results in two different places. And I'm going to take you through them. So in table one of the study, they're looking at patient characteristics and the outcomes. And in here they show you the data about survival to discharge and survival to hospital outcome. And the survival to hospital admission, excuse me, that was the second one. Survival to discharge was statistically different. But if you look at the numbers themselves, it was like 86.6% versus 84.9%. So it's not really all that different. They're very similar numbers. Why are they different? Because statistically, they had so many people in this trial. And of course, this is unadjusted data. This is just the population. When it came to survival hospital admission, there wasn't a different at all. It was like 95% versus 95%. So not different. Now, more importantly, in table two, this is really where you see it. This is their adjusted analysis. And they control for a bunch of factors: age, sex, race, payer mix, trauma type, head injury severity score, injury severity score. Like, is it isolated versus multi-system trauma? Were they transferred to a trauma center? Did they get CPR? That's a lot of things, but they had a lot of people to be able to do that with. And so what did they see in table two? And I'm just going to call your attention to one thing that the intervention itself had an odds ratio of 1.06, which the conference interval crossed across one, which means that there was no difference. No difference at all between the phase one and phase three. Now, most of us would stop for a second and say, hey, wait, okay, that's the trial. We're done. We should stop reading there. But wait, there is indeed more. And that more is actually what's important. So in figure two, they start looking at these subgroups. Remember, I told you this was really important that they looked at these subgroups. Among the severe injury cohort, not the moderate or the critical, just the severe injury, they found that guideline implementation significantly associated with better survival to discharge. And this was true even for people with injury severity scores, which were high, like 16 to 24. Now, in figure two, you see this because you see injury in head injury severity from three to four, they had a doubling of survival. That's 2.03. Huge impact for that population. When your injury severity scores were really high, like 16 to 24, these are people who are really sick. It was 1.6. So getting close to double. So for severe patients, huge benefit. Now, interestingly enough, when you look at that same figure, people who are moderately injured had severity of one to two, or those who are critical, really high numbers, no difference. We'll come back to that. They also saw the same effect in people who were resuscitated and ventilated, um, such that they have better respiratory and ventilatory effort. So this was with positive positive pressure ventilation and endotracheal. Interestingly enough, those who had entertracheal inhibition and were severely injured, that's our severity score of three to four, their outcomes, odds ratio of three, unbelievably a huge benefit for those types of patients. So let's pause for a second. This makes a lot of sense, actually. When we think about it, there the the EMS TBI guidelines give you an emphasis of prevention and treatment for hypoxia, hypotension, and hyperventilation. In the Epic trial, they implemented this across the whole state. So those patients who are severely ill and had bad traumatic brain injury had all those things improved. Of course, those people are going to get better. Now, one of the big things I want to call out though, here, which I think is really important, is though we saw no effect in the overall population, I'm actually not surprised that's true. And why is that? Well, because think about the moderate group. The moderate people with moderate traumatic brain injury, and we see a lot of these. They may have struck their head, they may be concussed, they may have significant findings such that they're altered, but they're unlikely to die, right? So you're not going to see a big effect in that moderate group. On the flip side, let's talk about the truly critically ill people. Now, those people are super sick. They may probably have a bad outcome no matter what you do. No matter if you prevent the hypotension or the hypoxia and all those different things, they may still have a bad outcome. So that kind of gives you an idea of where we are. It's not a perfect trial, right? Nothing ever is. In this case, agencies were in the trial for almost three years, but they could not enforce retraining. So one of the challenges is when they looked at the data more in a more closely manner, they found that they had improvement early on and then they had a fading effect, which really made you focus on the concept of having retraining. Secondly, it was not randomized. But let's be honest, ethically, would any of us want to be in a randomized controlled trial about traumatic brain injury? No, give everyone the best stuff. That's why this has to be pragmatic, real world. And of course, in this situation, this was an outpatient pre-hospital trial, not an inpatient trial. They couldn't control what's inpatient. So, what's our take home? Traumatic brain injury guideline implementation can help the sickest patients we get to get the best possible outcome. So, for us, for you and I today, what can we do to save one more life? Prevent hypoxia, prevent hypotension, uh manage hyperventilation, do those things, and we're gonna be better outcomes for patients just from what we saw in this trial. Thanks for joining, guys. Really cool work. But remember whether you're hitting the books or hitting the streets, stay safe, stay curious, and keep bringing the science to the scene. Thanks.