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The BIG (brain injury guidelines) project: Defining the management of traumatic brain injury by acute care surgeons

Joseph, Bellal MD; Friese, Randall S. MD; Sadoun, Moutamn MD; Aziz, Hassan MD; Kulvatunyou, Narong MD; Pandit, Viraj MD; Wynne, Julie MD; Tang, Andrew MD; O’Keeffe, Terence MB, ChB; Rhee, Peter MD

Journal of Trauma and Acute Care Surgery: April 2014 - Volume 76 - Issue 4 - p 965–969
doi: 10.1097/TA.0000000000000161
WTA 2013 Plenary Paper

BACKGROUND It is becoming a standard practice that any “positive” identification of a radiographic intracranial injury requires transfer of the patient to a trauma center for observation and repeat head computed tomography (RHCT). The purpose of this study was to define guidelines—based on each patient’s history, physical examination, and initial head CT findings—regarding which patients require a period of observation, RHCT, or neurosurgical consultation.

METHODS In our retrospective cohort analysis, we reviewed the records of 3,803 blunt traumatic brain injury patients during a 4-year period. We classified patients according to neurologic examination results, use of intoxicants, anticoagulation status, and initial head CT findings. We then developed brain injury guidelines (BIG) based on the individual patient’s need for observation or hospitalization, RHCT, or neurosurgical consultation.

RESULTS A total of 1,232 patients had an abnormal head CT finding. In the BIG 1 category, no patients worsened clinically or radiographically or required any intervention. BIG 2 category had radiographic worsening in 2.6% of the patients. All patients who required neurosurgical intervention (13%) were in BIG 3. There was excellent agreement between assigned BIG and verified BIG. κ statistic is equal to 0.98.

CONCLUSION We have proposed BIG based on patient’s history, neurologic examination, and findings of initial head CT scan. These guidelines must be used as supplement to good clinical examination while managing patients with traumatic brain injury. Prospective validation of the BIG is warranted before its widespread implementation.

LEVEL OF EVIDENCE Epidemiologic study, level III.

From the Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, University of Arizona, Tucson, Arizona.

Submitted: January 16, 2013, Revised: November 7, 2011, Accepted: December 2, 2013.

This study was part of the podium presentation for the Earl Young Resident Research Competition at the 43rd Annual Meeting of the Western Trauma Association, March 2013, in Snowmass, Colorado.

Address for reprints: Bellal Joseph, MD, Division of Trauma, Critical Care, and Emergency Surgery, Department of Surgery, University of Arizona, 1501 N Campbell Ave, Room 5411, PO Box 245063, Tucson, AZ 85724; email:

© 2014 Lippincott Williams & Wilkins, Inc.