Hyperosmolar Therapy for Traumatic Brain Injury Patients in the Pre-Hospital Setting

Document Type

Conference Proceeding - Restricted Access

Publication Date

5-8-2026

Abstract

Traumatic brain injuries (TBIs) continue to present a significant cause of morbidity and mortality across the United States. A central tenant of TBI treatment is gaining control of cerebral perfusion pressure in a timely manner, by ensuring adequate systemic blood pressure and minimizing intracranial pressure (ICP) with hyperosmolar therapy. Two hyperosmolar agents, hypertonic saline (HTS) and mannitol, are the most used for this indication; however, past studies investigating the superiority of either agent or their efficacy in the pre-hospital setting have been inconclusive. Therefore, we performed a retrospective study to analyze outcomes among trauma patients that received hyperosmolar therapy during aeromedical transport. Our hypothesis was that fewer episodes of hypotension would occur in patients who were administered HTS en route to CHW Butterworth hospital.

A retrospective study was performed to evaluate all patients 18 years of age and older who were transported to CHW Butterworth Hospital via AeroMed and received HTS or mannitol for clinical suspicion of increased ICP en route. The primary objective was to compare blood pressure changes associated with the use of either hyperosmolar agent, while the secondary objective was to compare the incidences of subsequent hospital events. Pre-hospital records of qualifying patients were supplied by the AeroMed records and uploaded to a secure REDCap database to ensure confidentiality. The Butterworth trauma registry provided patient data during the patients' hospital course and Epic chart review obtained data points not found in the trauma registry. Descriptive statistics were performed and numeric data was expressed as mean ± standard deviation, and categorical data was expressed as a frequency or percent. Significance was defined as a p value < 0.05.

97 patients were included in this study; 58 (60.0%) received mannitol, while 39 (40.0%) were treated with HTS. Overall, 69.1% were male, 82.5% were white, and 30.5% of injuries came from MVCs. During AeroMed transport, the HTS cohort had significantly lower time-weighted SBPs (119.8 vs. 142.4, p< 0.0001) and minimum SBPs (94.9 vs. 128.2, p< 0.0001), as well as time-weighted Median Arterial Pressures (MAPs) (88.7 vs. 103.0, p< 0.0001) and minimum MAPs (70.1 vs. 93.9, p< 0.0001). Upon arrival to Butterworth Hospital Emergency Department (ED), minimum SBPs (99.4 vs. 115.4, p< 0.0061) and MAPs (70.8 vs. 81.7, p< 0.0106) remained lower in HTS patients. HTS patients were also more likely to have hypotension (SBP < 110) any time during transit (53.8% vs. 5.7%, p< 0.0001), but not after ED admission. There were no significant differences between HTS and mannitol patients during their hospital course with regard to mortality, length of stay, craniotomy/craniectomy, cerebral monitor placement, or adverse hospital events.

In this study, HTS administration during AeroMed transport was associated with lower SBPs, lower MAPs, and increased episodes of hypotension. This was likely influenced by preferential use of HTS in patients with soft blood pressures given the strong diuretic effects of mannitol. While these SBPs and MAPs remained lower upon hospital ED arrival, there was no difference in episodes of hypotension, nor were there differences in in-hospital outcomes. Therefore, we believe that both HTS and mannitol are safe to use for TBI patients in the aeromedical setting.

Comments

2026 Research Day Corewell Health West, Grand Rapids, MI, May 8, 2026. Abstract 2100

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