USA: Recently reported results from the Excellence in Prehospital Injury Care (EPIC) study revealed that the implementation of the emergency medical service (EMS) guidelines improves survival in patients with severe traumatic brain injury (TBI). The effect of implementing these guidelines in the subgroup of patients who received positive pressure ventilation (PPV) is unknown.
Joshua B. Gaither, College of Medicine—Phoenix, The University of Arizona, Phoenix, and colleagues conducted a subanalysis of the EPIC study to determine if the implementation of the prehospital TBI evidence-based guidelines impacts survival among patients with prehospital PPV. They found that the guideline implementation was associated with improved survival to hospital admission and discharge among patients with severe TBI who received prehospital PPV. The findings were published online in

JAMA Surgery on January 24, 2024.
There is an enormous burden of traumatic brain injury, affecting more than 2.8 million individuals in the US annually. The hope that mitigating secondary brain injury may improve outcomes has led to the promulgation of evidence-based prehospital TBI treatment guidelines. The EPIC study and EPIC4Kids study demonstrated that implementation of the prehospital treatment guidelines was associated with improved survival among patients with severe TBI. This implementation emphasized the prevention and treatment of hypoxia, hyperventilation, and hypotension.
The researchers' group conducted the study to evaluate the association of implementation of prehospital TBI evidence-based guidelines with survival among patients with prehospital PPV.
The EPCI study was an intention-to-treat, multisystem study using a before/after controlled design. Evidence-based guidelines were implemented by EMS agencies across Arizona. The subanalysis was planned a priori and included participants who received prehospital PPV.
Using logistic regression, Outcomes were compared between the preimplementation and postimplementation cohorts, stratified by predetermined TBI severity categories (moderate, severe, or critical).
The study's primary outcome was survival to hospital discharge, and the secondary outcome was survival to admission.
Among the 21 852 participants in the main study, 5022 received prehospital PPV (pre-implementation, 3531 participants; postimplementation, 1491 participants). Of the 5022 included participants, 74.1% were male, and the median age was 36 years.
Key findings:
· Across all severities combined, survival to admission improved (adjusted odds ratio [aOR], 1.59), while survival to discharge did not (aOR, 0.94).
· Within the cohort with severe TBI but not in the moderate or critical subgroups, survival to hospital admission increased (aOR, 6.44), as did survival to discharge (aOR, 3.52).
The study showed that guideline implementation was independently associated with improved survival to hospital admission and discharge in patients with severe TBI who received active airway interventions in the field.
"This holds whether they received basic airway interventions or advanced airways," the researchers wrote.
"These findings support the current guideline recommendations for aggressive correction/prevention of hyperventilation and hypoxia in patients with severe TBI, irrespective of which airway type is used," they concluded.
Reference:
Gaither JB, Spaite DW, Bobrow BJ, et al. EMS Treatment Guidelines in Major Traumatic Brain Injury With Positive Pressure Ventilation. JAMA Surg. Published online January 24, 2024. doi:10.1001/jamasurg.2023.7155