Initial serum electrolyte imbalances and mortality in patients with traumatic brain injury: a retrospective study

doi:10.5847/wjem.j.1920-8642.2025.064

Abstract

Abstract:

BACKGROUND: Electrolyte imbalance is common following traumatic brain injury (TBI) and can significantly impact patient outcomes. We aimed to explore the occurrence, patterns, and consequences of electrolyte imbalance in adult patients with TBI.

METHODS: A retrospective study was conducted from 2016 to 2021 at a level 1 trauma center among hospitalized TBI patients. On admission, the levels of serum electrolytes, including sodium, potassium, calcium, magnesium, and phosphate, were analyzed. Demographics, injury characteristics, and interventions were assessed. The primary outcome was the in-hospital mortality. Multivariate logistic regression analysis was performed to identify independent predictors of mortality in TBI patients.

RESULTS: A total of 922 TBI patients were included in the analysis, of whom 902 (98%) had electrolyte imbalance. The mean age of patients with electrolyte imbalance was 32.0±15.0 years. Most patients were males (94%). The most common electrolyte abnormalities were hypocalcemia, hypophosphatemia, and hypokalemia. The overall in-hospital mortality rate was 22% in the entire cohort. In multivariate logistic analysis, the predictors of mortality included age (odds ratio [OR]=1.029, 95% confidence intervals [CI]: 1.013-1.046, P<0.001), low GCS (OR=0.883, 95%CI: 0.816-0.956, P=0.002), high Injury Severity Score (ISS) scale (OR=1.051, 95%CI: 1.026-1.078, P<0.001), hypernatremia (OR=2.175, 95%CI: 1.196-3.955, P=0.011), hyperkalemia (OR=4.862, 95%CI: 1.222-19.347; P=0.025), low serum bicarbonate levels (OR=0.926, 95%CI: 0.868-0.988, P=0.020), high serum lactate levels (OR=1.128, 95%CI: 1.022-1.244, P=0.017), high glucose levels (OR=1.072, 95%CI: 1.014-1.133, P=0.015), a longer activated partial thromboplastin time (OR=1.054, 95%CI: 1.024-1.084, P<0.001) and higer international normalized ratio (INR) (OR=3.825, 95%CI: 1.592-9.188, P=0.003).

CONCLUSION: Electrolyte imbalance is common in TBI patients, with the significant prevalence of hypocalcemia, hypophosphatemia, and hypokalemia. However, hypernatremia and hyperkalemia were associated with the risk of mortality, emphasizing the need for further research to comprehend electrolyte dynamics in TBI patients.

Key words: Electrolyte imbalance, Traumatic brain injury, Mortality

Ahammed Mekkodathil, Ayman El-Menyar, Talat Chughtai, Ahmed Abdel-Aziz Bahey, Ahmed Labib Shehatta, Ali Ayyad, Abdulnasser Alyafai, Hassan Al-Thani. Initial serum electrolyte imbalances and mortality in patients with traumatic brain injury: a retrospective study[J]. World Journal of Emergency Medicine, 2025, 16(4): 331-339.

Figures/Tables 6

Figure 1.

Figure 2.

Table 1.

Table 2.

Severity of electrolyte imbalances and outcomes in traumatic brain injury (TBI) patients (n=902)

Electrolyte imbalances	Severity	Number (%)	Mortality n (%)	Shock Index, Mean ±SD	Glasgow Coma Score, Mean ±SD	Injury Severity Score, Mean ±SD
Hypernatremia (n=118; 13.1%)	Severe	4 (3.4)	3 (75.0)	1.24 ±0.60	3.0±0.0	34.8±13.6
	Moderate	4 (3.4)	3 (75.0)	0.88±0.50	4.0±2.0	35.0±6.0
	Mild	110 (93.2)	53 (48.2)	1.17±0.50	3.9±2.4	31.1±10.3
Hyponatremia (n=38; 4.2%)	Severe	0	0
	Moderate	2 (5.3)	1 (50.0)	0.73±0.20	8.5±4.9	17.5±12.0
	Mild	36 (94.7)	8 (22.2)	0.68±0.20	7.6±4.7	23.7±9.8
Hyperkalemia (n=27; 3.0%)	Severe	3 (11.1)	3 (100)	1.43±0.30	3.3±0.6	36.7±14.0
	Moderate	4 (14.8)	3 (75.0)	1.21±0.69	5.0±4.0	41.8±18.1
	Mild	20 (74.1)	15 (55.6)	1.13±0.67	4.6±3.9	36.3±10.8
Hypokalemia (n=323; 35.8%)	Severe	5 (1.5)	1 (20.0)	0.80±0.43	5.8±4.0	26.2±8.2
	Moderate	44 (13.6)	7 (15.9)	0.78±0.34	6.9±4.6	27.2±10.6
	Mild	274 (84.8)	55 (20.1)	0.88±0.35	5.8±4.1	26.4±9.4
Hypercalcemia (n=7; 0.8%)	Severe	1 (14.3)	1 (100)	1.38	3	34
	Moderate	2 (28.6)	1 (50.0)	1.84±0.32	3.0±0.0	44.0±8.5
	Mild	4 (57.1)	3 (75.0)	1.61±0.70	4.5±3.0	44.0±4.9
Hypocalcemia (n=757; 83.9%)	Severe	310 (41.0)	103 (33.2)	1.10±0.52	4.3±3.2	30.8±10.1
	Moderate	200 (26.4)	42 (21.0)	0.91±0.44	5.1±3.6	26.8±10.1
	Mild	247 (32.6)	35 (14.2)	0.82±0.33	6.3±4.2	25.0±9.5
Hypermagnesemia (n=12; 1.3%)	Severe	0	0
	Moderate	0	0
	Mild	12 (100)	7 (58.3)	0.99±0.49	4.0±2.3	29.3±11.4
Hypomagnesemia (n=283; 31.4%)	Severe	1 (0.4)	0	0.76	3	13
	Moderate	12 (4.2)	5 (41.7)	1.06±0.29	2.9±0.3	27.1±9.2
	Mild	270 (95.4)	39 (14.4)	0.92±0.41	5.5±3.9	28.2±10.5
Hyperphosphatemia (n=118; 13.1%)	Severe	30 (26.5)	26 (86.7)	1.61±1.05	3.9±2.7	38.4±10.6
	Moderate	20 (17.7)	10 (50.0)	1.48±0.46	4.5±2.9	35.2±13.0
	Mild	68 (60.2)	19 (27.9)	1.11±0.53	5.7±4.1	27.3±11.3
Hypophosphatemia (n=607; 67.3%)	Severe	14 (2.3)	4 (28.6)	0.84±0.27	5.1±3.6	21.4±8.2
	Moderate	144 (16.0)	37 (25.7)	0.89±0.36	5.0±3.4	25.9±9.5
	Mild	449 (73.9)	65 (14.5)	0.86±0.47	5.7±4.0	26.3±10.4

Table 2.

Table 3.

Table 4.

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Variables	Mild TBI (GCS 13-15) n=84	Moderate TBI (GCS 9-12) n=134	Severe TBI (GCS 3-8) n=675
Age, years, mean ± SD	37.8 ±17.5	34.0±17.7	31.3±13.7
Males, n (%)	80 (95.2)	123 (91.8)	635 (94.1)
Sodium level, n (%)
Normal	75 (89.3)	116 (86.6)	550 (81.5)
Hyponatremia	6 (7.1)	11 (8.2)	19 (2.8)
Hypernatremia	3 (3.6)	7 (5.2)	106 (15.7)
Potassium level, n (%)
Normal	45 (53.6)	81 (60.4)	421 (62.4)
Hypokalemia	37 (44.0)	51 (38.1)	231 (34.2)
Hyperkalemia	2 (2.4)	2 (1.5)	23 (3.4)
Calcium level, n (%)
Normal	25 (29.8)	39 (29.1)	73 (10.8)
Hypocalcemia	59 (70.2)	94 (70.1)	596 (88.3)
Hypercalcemia	0 (0.0)	1 (0.7)	6 (0.9)
Magnesium level^a, n (%)
Normal	60 (71.4)	88 (65.7)	444 (66.7)
Hypomagnesemia	24 (28.6)	45 (33.6)	211 (31.7)
Hypermagnesemia	0 (0.0)	1 (0.7)	11 (1.7)
Phosphate level^b, n (%)
Normal	24 (28.6)	25 (18.7)	116 (17.4)
Hypophosphatemia	53 (63.1)	92 (68.7)	457 (68.7)
Hyperphosphatemia	7 (8.3)	17 (12.7)	92 (13.8)

Variables	Survivors (n=718)	Non-survivors (n=204)	P-value
Age, years, mean ± SD	31.4±14.4	35.8±16.8	0.001
Males, n (%)	671 (93.5)	192 (94.1)	0.730
Injury Severity Score, mean ± SD	25±10	34±9	0.001
Shock index, mean ± SD	0.87±0.35	1.15±0.64	0.001
Glasgow Coma Scale, mean ± SD	6±4	4±2	0.001
Serum sodium, mmol/L, mean ± SD	140.5± 3.9	143.2±6.6	0.001
Serum potassium, mmol/L, mean ± SD	3.8±0.6	4.1±0.9	0.001
Serum calcium, mmol/L, mean ± SD	2.0±0.2	1.9±0.4	0.001
Serum magnesium, mmol/L, mean ± SD	0.6±0.1	0.7±0.1	0.001
Serum phosphate, mmol/L, mean ± SD	0.9±0.4	1.2±0.8	0.001
Serum bicarbonate, mmol/L, mean ± SD	20.1±3.9	17.2±5.2	0.001
Serum lactate, mmol/L, median (IQR)	2.7 (1.9-3.8)	4.6 (2.8-7.4)	0.001
Hemoglobin, g/dL, mean ± SD	12.9±2.3	11.7±2.5	0.001
Serum glucose, mmol/L, mean ± SD	8.5±3.8	11.5±4.9	0.001
Prothrombin time, s, median (IQR)	11.9 (11.0-12.9)	14.7 (12.1-17.3)	0.001
Activated partial thromboplastin time, s, median (IQR)	25.7 (23.7-28.2)	36.9 (28.0-52.3)	0.001
International normalized ratio (INR), median (IQR)	1.1 (1.1-1.2)	1.4 (1.2-1.7)	0.001
Craniectomy/craniotomy, n (%)	163 (22.8)	29 (14.4)	0.010
MTP activation, n (%)	66 (9.2)	66 (32.5)	0.001

Factors	OR	95% CI	P-value
Age	1.029	1.013-1.046	<0.001
ED Glasgow Coma Scale	0.883	0.816-0.956	0.002
Injury Severity Score	1.051	1.026-1.078	<0.001
Serum sodium category
Normal sodium level	Reference
Hypernatremia vs. hyponatremia	2.175	1.196-3.955	0.011
Serum potassium category
Normal potassium level	Reference
Hyperkalemia vs. hypokalemia	4.862	1.222-19.347	0.025
Serum calcium category
Normal calcium level	Reference
Hypercalcemia vs. hypocalcemia	3.471	0.386-31.255	0.267
Serum phosphate category
Normal phosphate level	Reference
Hyperphosphatemia vs. hypophosphatemia	1.672	0.736-3.802	0.220
Serum magnesium category
Normal magnesium level	Reference
Hypermagnesemia vs. hypomagnesemia	0.817	0.102-6.520	0.849
Serum bicarbonate	0.926	0.868-0.988	0.020
Serum lactate	1.128	1.022-1.244	0.017
Serum glucose	1.072	1.014-1.133	0.015
Activated partial thromboplastin time	1.054	1.024-1.084	<0.001
International normalized ratio	3.825	1.592-9.188	0.003
Craniectomy/craniotomy	0.569	0.320-1.010	0.054
MTP activated	0.524	0.265-1.037	0.064

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