Jason Sperry, MD, MPH: GCS in TBI + Shock (10/18/24)

All right, so welcome everybody. It is Friday, October 18th. Welcome to the Florida EMS webinar where we're very fortunate to have incredible folks joining us from across the country and even across the world. I reached out to Dr. Sperry, who you could see is from the Pittsburgh area. Go Pitt. I trained out at UTMC many years ago. He's a professor of surgery and critical care medicine. You probably know his name from many of the big trauma studies such as Pamper and cxa studies, etc. Tara and I reached out to him to talk about his recent publication. So Dr. Sperry, thank you so much for joining us and take it away.

Okay. Appreciate the intro and it's. Anything that's done out of here is with my partner, Dr. Guyette Frank Guyet, who's also emergency medicine physician. And we do a lot of things together and.

Do some cool stuff in the pre hospital early ED phase of care for traumatic injury. So today we're going to talk about a recent paper that we had where we harmonized three different clinical trials and we're going to look at early Glasgow Coma Scale score and the prediction of traumatic brain injury. Okay. I don't have any conflicts. This is polytrauma following injury. This is like the most complex. You know, there's hemorrhage and then the severely injured polytrauma patient, you throw in a little TBI and that even makes them, it makes them sicker. And you don't know whether they have TBI or not, which is, you know the question. You don't know they have TBI until you get the head CT in the ED phase. And does that matter? You know that that's controversial. You may know that they're hemorrhaging, but does it, does it matter whether they have TBI or not? You know, we've changed our resuscitation and how we're in the hospital proper trial one to one to one or early whole blood resuscitation and that's pretty good. But despite our changes, mortality remains high and extremely early. And when you think about if you're going to, this is the mortality rates being really high in the first one or two hours. If you die from hemorrhage in the first one or two hours, that doesn't. That means you don't have a whole lot of, you're not going to be able to intervene in the, in the emergency department. It might be in the pre hospital setting where interventions may have their benefit and it just highlights the pre hospital environment closest to the time of injury in general we're treating strokes as early, close to the time of stroke and myocardial infarctions closest to the time of myocardial infarctions, trauma closest to the time of injury. And then typically.

Trauma doesn't occur in the Level 1 trauma center parking lot, it occurs somewhere else. And so we can intervene now resuscitation, it's undergone significant development whether it's pre hospital plasma, whether it's pre hospital txa, whether it's prehospital whole blood, whether other studies, more recent patch trial again pre hospital txa, ROC txa. So we have evolved for relatively simple interventions that can be done in the pre hospital setting. And what is. So the Pamper cool trial, rather fond of it demonstrated a 10% mortality benefit, but it didn't help everybody, didn't harm anybody, but it didn't help everybody. But who did it help? When we look at the subgroups, what was ultimately found when we looked at it was that plasma benefited those with traumatic brain injury, those poly trauma patients with hemorrhagic shock. That was the inclusion criteria that ultimately were found to have traumatic brain injury. If you didn't have brain injury early, plasma didn't cause any harm, but it didn't benefit. And so that's where the survival benefit was. So it would probably benefit us if we knew if someone had traumatic brain injury. So you could give plasma, you could give whole blood and there's no harm signal. But who might it be benefiting the most to give the personalized pre hospital resuscitation that may be those that you could diagnose or know about traumatic brain injury. So why did we. Well, additional evidence to suggest this. When we looked at lipidomics, metabolomics and proteomics in the Pamper cohort, there's was very, there was something very special in those most severely injured and those with traumatic brain injury. I don't know if you guys can see my arrow. I can never figure that out whether you can see my arrow. But in the right lower quadrant quadrant, this is where the survival was. This is the, it's an, it's called N2 in this paper, endotype 2 severely injured with shock in the TBI cohort. And the other ones, if you didn't have tbi there's no benefit. And if you didn't have TBI with shock, there was no benefit. And there was something special in the multi omic analysis. Something different about this endotype 2 with TBI where plasma either either the patient population was special and plasma benefited them or plasma did some benefit early plasma. So what we want to know is whether someone, or at least we may want to know with personalized pre hospital care, whether you, whether, whether you have TBI or not and whether you can figure that out in the pre hospital setting. So what kind of tools do we have? Well, the topic of this is whether we're whether we can predict traumatic brain injury using pre hospital or gcs. How good is it? And that's what I guess I'm discussing. And you picked up. And what did we do? We harmonized three trials that were run and initiated out of Pittsburgh. The PAMPER trial, 501 patients the STAMP trial, pre hospital TXA, which was 904 or 5 patients and the Power trial, which was a feasibility phase 2 whole blood, pre hospital, whole blood trial that was running.