Not All Prehospital Events Are Equivalent in Pediatric Severe TBI: Insights From the ADAPT Trial

Introduction: Resuscitation in the pre-hospital setting is critical in preventing secondary brain injury and improving outcomes after severe TBI (sTBI). Although individual pre-hospital adverse events have been linked to outcomes, their relative and cumulative effects are not well defined. This study describes specific pre-hospital events’ associations with mortality and their additive effect on outcomes in children with sTBI.


Methods: This is a non-prespecified secondary analysis of the Approaches and Decisions for Acute Pediatric TBI (ADAPT) database, which included patients < 18y, Glasgow Coma Scale (GCS) ≤ 8 with intracranial pressure monitoring (2014-2018). Admission-level characteristics, pre-hospital events (apnea, aspiration, cardiac arrest, hyperthermia, hyperventilation, hypothermia, hypotension, hypoxia, and seizure) and mortality were retrospectively examined. We evaluated the association of each pre-hospital event on mortality using both univariable and multivariable logistic regression (MLR) models. Additionally, we developed an UpSet plot, a method for visualizing overlapping sets, to assess combinations of pre-hospital events and their association with mortality.


Results: Among 967 patients (median age 6y [IQR 2-12y], admission GCS 6 [3-7], mortality 18%), 254 (26%) experienced at least one pre-hospital event, and 163 (17%) experienced > 1 pre-hospital event. The most common events were hypotension (14%), seizures (13%), and apnea (12%). With univariable analysis, the only events that did not show association with mortality were seizures and hyperthermia. In MLR, accounting for possible confounders, only cardiac arrest (OR 4.67, p < 0.001) and aspiration (OR 1.77, p =0.03) had significant associations with mortality. Overall, mortality increased with the cumulative number of pre-hospital events, with combinations involving pre-hospital cardiac arrest associated with the highest mortality rates.


Conclusions: In children with sTBI, the burden, type (specifically cardiac arrest and aspiration), and combination of pre-hospital events were associated with mortality. Though less common, specific pre-hospital event clusters were consistently associated with poor outcomes, highlighting the additive effect of pre-hospital insults.