Independent risk of death from hemorrhage and traumatic brain injury in polytrauma: findings from a prospective, multi-center study in the Western Cape of South Africa

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BACKGROUND: Injury is one of the leading causes of death globally, with the largest burden in low- and middle-income countries. Injuries resulting in both hemorrhage and traumatic brain injury (TBI) are associated with high mortality. We seek to quantify the contribution of each injury process, hemorrhage and TBI, and their severity on mortality among patients with concurrent hemorrhage + TBI. METHODS: This is a secondary analysis from the Epidemiology and Outcomes of Prolonged Trauma Care (EpiC) study conducted in the Western Cape, South Africa. Adult patients experiencing both hemorrhage + TBI were included. Hemorrhage and TBI severity (mild, moderate, or severe) were assigned according to physiology, injury severity, laboratory and imaging data, and clinical interventions. The independent association of hemorrhage and TBI severity on 7-day mortality was assessed by an adjusted Cox proportional hazards model. Adjustment covariates included age, sex, primary EMS transport, TEWS, and NISS. Secondary endpoints included 48-h and 30-day mortality. RESULTS: A total of 877 patients were included in the final analysis. Patients were 86% (n = 758) male with a median age of 32 years. 66% (n = 581) of patients were injured by a non-penetrating force. The adjusted rate of death was significantly higher with increasing severity of both hemorrhage and TBI. For the primary outcome of 7-day mortality, severe TBI compared to mild had a 5.11 times higher rate of mortality (aHR 5.11, 95% CI 3.29-7.93) and severe versus moderate TBI had a 5.02 times higher rate (aHR 5.02, 95% CI 4.22-5.96). When assessing across hemorrhage severity, the rate of 7-day mortality was 4.5 times higher (aHR 4.5, 95% CI 3.70-5.47) comparing severe to mild and 3.2 times higher (aHR 3.2, 95% CI 2.53-4.12) comparing severe to moderate. The largest increased rate of death was found in the 48-h mortality analysis comparing severe to mild hemorrhage, with an 18.4 times higher mortality rate (aHR 18.4, 95% CI 12.02-28.21). CONCLUSIONS: Increasing severity of hemorrhage and TBI are both independently associated with a three to five times higher rate of 7-day mortality. These findings highlight the importance of timely hemorrhage control and resuscitation to reduce mortality and the risk of progression to severe disease.

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