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. 2020 May 28;5(1):e000483.
doi: 10.1136/tsaco-2020-000483. eCollection 2020.

Multicenter assessment of the Brain Injury Guidelines and a proposal of guideline modifications

Abid D Khan  1 , Anna J Elseth  1 , Jacqueline A Brosius  2 , Eliza Moskowitz  1 , Sean C Liebscher  2 , Michael J Anstadt  2 , Julie A Dunn  3 , John H McVicker  4 , Thomas Schroeppel  1 , Richard P Gonzalez  2
Affiliations

Multicenter assessment of the Brain Injury Guidelines and a proposal of guideline modifications

Abid D Khan et al. Trauma Surg Acute Care Open. .

Abstract

Background: The Brain Injury Guidelines provide an algorithm fortreating patients with traumatic brain injury (TBI) and intracranial hemorrhage(ICH) that does not mandate hospital admission, repeat head CT, orneurosurgical consult for all patients. The purposes of this study are toreview the guidelines' safety, to assess resource utilization, and to proposeguideline modifications that improve patient safety and widespreadreproducibility.

Methods: A multi-institutional review of TBI patients was conducted. Patients with ICH on CT were classified as BIG 1, 2, or 3 based on the guidelines. BIG 3 patients were excluded. Variables collected included demographics, Injury Severity Score (ISS), hospital length of stay (LOS), intensive care unit LOS, number of head CTs, type of injury, progression of injury, and neurosurgical interventions performed.

Results: 269 patients met inclusion criteria. 98 were classifiedas BIG 1 and 171 as BIG 2. The median length of stay (LOS) was 2 (2,4)days and the ICU LOS was 1 (0,2) days. Most patients had a neurosurgeryconsultation (95.9%) and all patients included had a repeat head CT. 370repeat head CT scans were performed, representing 1.38 repeat scans perpatient. 11.2% of BIG 1 and 11.1% of BIG 2 patients demonstratedworsening on repeat head CT. Patients who progressed exhibited a higherISS (14 vs. 10, p=0.040), and had a longer length of stay (4 vs. 2 days;p=0.015). After adjusting for other variables, the presence of epiduralhematoma (EDH) and intraparenchymal hematoma were independent predictors ofprogression. Two BIG 2 patients with EDH had clinical deteriorationrequiring intervention.

Discussion: The Brain Injury Guidelines may improve resourceallocation if utilized, but alterations are required to ensure patientsafety. The modified Brain Injury Guidelines refine the originalguidelines to enhance reproducibility and patient safety while continuing toprovide improved resource utilization in TBI management.

Keywords: brain injuries, traumatic; head injuries, closed; practice guideline.

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Conflict of interest statement

Competing interests: None declared.

Figures

Figure 1
Figure 1
Study eligibility. BIG, Brain Injury Guidelines; GCS, Glasgow Coma Scale score; ICH, intracranial hemorrhage.
Figure 2
Figure 2
Modified Brain Injury Guidelines. BIG, Brain Injury Guidelines; ED, emergency department; EDH, epidural hematoma; EtOH, blood alcohol level; fx, fracture; GCS, Glasgow Coma Scale score; ICH, intracranial hemorrhage; IPH, intraparenchymal hematoma; IVH, intraventricular hemorrhage; mBIG, modified BIG; SAH, subarachnoid hemorrhage; SDH, subdural hematoma; TBI, traumatic brain injury.
See this image and copyright information in PMC

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