# Prehospital Postintubation Hypotension and Survival in Severe Traumatic Brain Injury

## TL;DR

Postintubation hypotension in patients with severe traumatic brain injury is linked to higher 30-day mortality, especially in those with isolated brain injuries.

## Contribution

This study identifies postintubation hypotension as a significant risk factor for mortality in prehospital trauma care for severe TBI.

## Key findings

- Postintubation hypotension was associated with increased 30-day mortality in patients with polytrauma and severe TBI.
- Patients with isolated TBI who experienced hypotension had significantly higher odds of death compared to those without.
- The study highlights the need for interventional strategies to reduce postintubation hypotension in traumatic brain injury cases.

## Abstract

Is postintubation hypotension associated with increased 30-day mortality in patients with severe traumatic brain injury undergoing prehospital rapid sequence induction?

In this cohort study of 555 patients with severe traumatic brain injury, postintubation hypotension was associated with increased mortality for patients with polytrauma and statistically significantly higher for patients with isolated traumatic brain injury.

These findings suggest the need for randomized interventional studies to reduce the incidence of postintubation hypotension in traumatic brain injury.

This cohort study investigates whether postintubation hypotension is associated with 30-day mortality among patients with severe traumatic brain injury undergoing prehospital rapid sequence induction.

Preventing systemic disturbances, such as hypotension and hypoxia, is key to reducing the impact of secondary neuronal injury after traumatic brain injury (TBI). Postintubation hypotension is prevalent and may be associated with worse outcomes in patients with trauma undergoing emergency anesthesia.

To investigate the association between postintubation hypotension and 30-day mortality in patients with severe TBI undergoing prehospital rapid sequence induction.

This multicenter, retrospective, observational cohort study was performed between January 1, 2015, and December 31, 2022, in the East of England Trauma Network, including 3 helicopter emergency medical services (East Anglian Air Ambulance, Essex & Herts Air Ambulance, and Magpas Air Ambulance). A consecutive sample of patients (aged ≥16 years) with trauma and severe TBI who received prehospital rapid sequence induction by helicopter emergency medical services and were transported to a hospital within the East of England Trauma Network were eligible for inclusion. Severe TBI was defined as a Head Abbreviated Injury Scale score of 3 or higher. Data analysis was performed from March to May 2025.

Postintubation hypotension defined as a new systolic blood pressure less than 90 mmHg and induction of anesthesia at 10 minutes or less.

The primary outcome was 30-day mortality.

A total of 555 patients (median [IQR] age, 48 [29-66] years; 408 [73.5%] male) were included in the final analysis; 548 (98.7%) had a blunt mechanism of injury. Within the first 10 minutes of anesthesia, 106 patients (19.1%) had postintubation hypotension, and 169 (30.5%) died within 30 days of injury (46 of 106 [43.4%] in the hypotension group and 123 of 449 [27.4%] in the nonhypotension group). After adjustment for confounders (eg, age and Glasgow Coma Scale score), postintubation hypotension was associated with increased 30-day mortality for patients with polytrauma and severe TBI (adjusted odds ratio [AOR], 1.70; 95% CI, 1.01-2.86; P = .04). For patients with isolated severe TBI who had postintubation hypotension, the odds of death adjusted for confounders (eg, age, Glasgow Coma Scale score, and Injury Severity Score) were significantly higher than for patients without (AOR, 13.55; 95% CI, 3.65-61.66; P < .001).

In this cohort study of patients with severe TBI who received prehospital rapid sequence induction, postintubation hypotension was associated with increased 30-day mortality. This association was strongest for patients with isolated TBI. These findings suggest the need for randomized prehospital interventional studies to reduce the incidence of postintubation hypotension in traumatic brain injury.