Validating the Brain Injury Guidelines: Results of an American Association for the Surgery of Trauma prospective multi-institutional trial

Prolonged hourly neurological examinations are associated with increased delirium and no discernible benefit in mild/moderate geriatric traumatic brain injury

BACKGROUND

Serial neurological examinations (NEs) are routinely recommended in the intensive care unit (ICU) within the first 24 hours following a traumatic brain injury (TBI). There are currently no widely accepted guidelines for the frequency of NEs. Disruptions to the sleep-wake cycles increase the delirium rate. We aimed to evaluate whether there is a correlation between prolonged hourly (Q1)-NE and development of delirium and to determine if this practice reduces the likelihood of missing the detection of a process requiring emergent intervention.

METHODS

A retrospective analysis of patients with mild/moderate TBI, admitted to the ICU with serial NEs, was performed. Cohorts were stratified by the duration of exposure to Q1-NE, into prolonged (≥24 hours) and nonprolonged (<24 hours). Our primary outcomes of interest were delirium, evaluated using the Confusion Assessment Method; radiological progression from baseline images; neurological deterioration (focal neurological deficit, abnormal pupillary examination, or Glasgow Coma Scale score decrease >2); and neurosurgical procedures.

RESULTS

A total of 522 patients were included. No significant differences were found in demographics. Patients in the prolonged Q1-NE group (26.1%) had higher Injury Severity Score with similar head Abbreviated Injury Score, significantly higher delirium rate (59% vs. 35%, p < 0.001), and a longer hospital/ICU length of stay when compared with the nonprolonged Q1-NE group. No neurosurgical interventions were found to be performed emergently as a result of findings on NEs. Multivariate analysis demonstrated that prolonged Q1-NE was the only independent risk factor associated with a 2.5-fold increase in delirium rate. The number needed to harm for prolonged Q1-NE was 4.

CONCLUSION

Geriatric patients with mild/moderate TBI exposed to Q1-NE for periods longer than 24 hours had nearly a threefold increase in ICU delirium rate. One of five patients exposed to prolonged Q1-NE is harmed by the development of delirium. No patients were found to directly benefit as a result of more frequent NEs.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level IV.

Implementation of the Modified Brain Injury Guidelines Might Be Feasible and Cost-Effective Even in a Nontrauma Hospital

INTRODUCTION

The modified Brain Injury Guidelines (mBIG) provide a framework to stratify traumatic brain injury (TBI) patients based on clinical and radiographic factors in level 1 and 2 trauma centers. Approximately 75% of all U.S. hospitals do not carry any trauma designation yet could also benefit from these guidelines. To the best of our knowledge, this is the first report of applying the mBIG protocol in a community hospital without any trauma designation.

METHODS

All adult patients with a TBI in a single center from 2020 to 2022 were retrospectively classified into mBIG categories. The primary outcomes included neurological deterioration, progression on computed tomography of the head, and surgical intervention. Additional outcomes included the hospital costs incurred by the mBIG 1 and mBIG 2 groups.

RESULTS

Of the 116 included patients, 35 (30%) would have stratified into mBIG 1, 23 (20%) into mBIG 2, and 58 (50%) into mBIG 3. No patient in mBIG 1 had a decline in neurological examination findings or progression on computed tomography of the head or required neurosurgical intervention. Three patients in mBIG 2 had radiographic progression and one required surgical decompression. Two patients in mBIG 3 demonstrated a neurological decline and six had radiographic progression. Of the 21 patients who received surgical intervention, 20 were stratified into mBIG 3. Implementation of the mBIG protocol could have reduced costs by >$250,000 during the 2-year period.

CONCLUSIONS

The mBIG protocol can safely stratify patients in a nontrauma hospital. Because nontrauma centers tend to see more patients with minor TBIs, implementation could result in significant cost savings, reduce unnecessary hospital and intensive care unit resources, and reduce transfers to a tertiary institution.

Application of Brain Injury Guidelines at a Pediatric Level 1 Trauma Center predicts reliability, safety, and improved resource utilization

PURPOSE

Brain Injury Guidelines (BIG) have been established to guide management related to TBI in adults. Here, BIG criteria were applied to pediatric TBI patients to evaluate reliability, safety, and resource utilization.

METHODS

A retrospective study was performed on all pediatric TBI patients aged 18 years or younger from January 2012 to July 2023 at a Level 1 Pediatric Trauma Center. The severity of TBI (BIG 1/2/3) was rated by review of initial cranial imaging by two independent observers. Inter-observer reliability was assessed. Predictions based on BIG criteria regarding repeat cranial imaging, ICU admission, and neurosurgical consultation were compared with observations from the cohort. Outcome data was collected, including neurosurgical intervention and mortality rate.

RESULTS

Three hundred fifty-nine patients were included with mean age of 5.3 years. Injury severity included 44 BIG 1 (12.2%), 170 BIG 2 (47.4%), and 145 BIG 3 injuries (40.4%). Inter-rater reliability was 96.4%. Neurosurgical consultation was obtained in all patients, though only predicted by guidelines in 40.4%. Repeat imaging was obtained in 166 BIG 1/2 patients, with an average of 1.3 CT scans and 0.8 MRIs/rapid MRIs per patient. ICU was utilized in 104 (77.6%) patients not recommended per BIG criteria. Ultimately, 37 patients, all BIG 3, required neurosurgical intervention; no neurosurgical interventions were required in those classified as BIG 1/2.

CONCLUSIONS

BIG criteria can be applied to pediatric TBI with high inter-observer reliability and without formal neurosurgical training. Retrospective application of BIG predicted fewer imaging studies, ICU admissions, and neurosurgical consults without overlooking patients requiring neurosurgical intervention.

The Brain Injury Guidelines (BIG) and emergency department observation and admission rates: A retrospective cohort study

BACKGROUND

Emergency Department (ED) Observation Units (OU) can provide safe, effective care for low risk patients with intracranial hemorrhages. We compared current ED OU use for patients with subdural hematomas (SDH) to the validated Brain Injury Guidelines (BIG) to evaluate the potential impact of implementing this risk stratification tool.

METHODS

Retrospective cohort of patients ≥18 years old with SDH of any cause from 2014 to 2020 to evaluate for potential missed OU cases. Missed OU cases were defined as patients with an initial Glasgow Coma Score (GCS) of 15 with hospital length of stays (LOS) <2 days, who did not meet the composite outcome and were not cared for in the OU or discharged from the ED. Composite outcome included in-hospital death or transition to hospice care, neurosurgical intervention, GCS decline, and worsening SDH size. Secondary outcomes were whether application of BIG would increase ED OU use or reduce CT use.

RESULTS

264 patients met inclusion criteria over 5.3 year study timeframe. Mean age was 61 years (range 19-93) and 61.4% were male. SDH were traumatic in 76.9% and 60.2% of the cohort had additional injuries. The admission rate was 81.4% (n = 215). Fourteen (6.5%) missed OU cases were identified (2.6/year). Retrospective application of BIG resulted in 82.6% (n = 217) at BIG 3, 10.2% (n = 27) at BIG 2 and 7.6% (n = 20) at BIG 1. Application of BIG would not have decreased admission rates (82.6% BIG 3) and BIG 1 and 2 admissions were often for medical co-morbidities. The composite outcome was met in 50% of BIG 3, 22% of BIG 2, and no BIG 1 patients.

CONCLUSION

In a level 1 trauma center with an established observation unit, current clinical care processes missed very few patients who could be discharged or placed in ED OU for SDH. Hospital admissions in BIG 1/2 were driven by co-morbidities and/or injuries, limiting applicability of BIG to this population.

Identification and management of low-risk isolated traumatic brain injury patients initially treated at a rural level IV trauma center

STUDY OBJECTIVE

Our goal was to determine if low-risk, isolated mild traumatic brain injury (TBI) patients who were initially treated at a rural emergency department may have been safely managed without transfer to the tertiary referral trauma center.

METHODS

This was a retrospective observational analysis of isolated mild TBI patients who were transferred from a rural Level IV Trauma Center to a regional Level I Trauma Center between 2018 and 2022. Patients were risk-stratified according to the modified Brain Injury Guidelines (mBIG). Data abstracted from the electronic medical record included patient presentation, management, and outcomes.

RESULTS

250 patients with isolated mild TBI were transferred out to the Level I Trauma Center. Fall was the most common mechanism of injury (69.2%). 28 patients (11.2%) were categorized as low-risk (mBIG1). No mBIG1 patients suffered a progression of neurological injury, had worsening of intracranial hemorrhage on repeat head CT, or required neurosurgical intervention. 12/28 (42.9%) of mBIG1 patients had a hospital length of stay of 2 days or less, typically for observation. Those with longer lengths of stay were due to medical complications, such as sepsis, or difficulty in arranging disposition.

CONCLUSION

We propose that patients who meet mBIG1 criteria may be safely observed without transfer to a referral Level I Trauma Center. This would be of considerable benefit to patients, who would not need to leave their community, and would improve resource utilization in the region.

Key Findings on Computed Tomography of the Head that Predict Death or the Need for Neurosurgical Intervention From Traumatic Brain Injury

BACKGROUND

Traumatic brain injury (TBI) requires rapid management to avoid secondary injury or death. This study evaluated if a simple schema for quickly interpreting CT head (CTH) imaging by trauma surgeons and trainees could be validated to predict need for neurosurgical intervention (NSI) or death from TBI within 24 hours.

METHODS

We retrospectively reviewed TBI patients presenting to our trauma center in 2020 with blunt mechanism and GCS ≤ 12. Primary independent variables were presence of 7 normal findings on CTH (CSF at foramen magnum, open fourth ventricle, CSF around quadrigeminal plate, CSF around cerebral peduncles, absence of midline shift, visible sulci/gyri, and gray-white differentiation). Trauma surgeons and trainees separately evaluated each patient's CTH, scoring findings as normal or abnormal. Primary outcome was NSI/death in 24 hours.

RESULTS

Our population consisted of 444 patients; 21.4% received NSI or died within 24 hours. By trainees' interpretation, 5.8% of patients without abnormal findings had NSI/death vs 52.0% of patients with ≥1 abnormality; attending interpretation was 8.7% and 54.9%, respectively (P < .001). Sulci/gyri effacement, midline shift, and cerebral peduncle effacement maximized sensitivity and specificity for predicting NSI/death. Considering pooled results, when ≥1 of those 3 findings was abnormal, sensitivity was 77.89%, specificity was 80.80%, positive predictive value was 52.48%, and negative predictive value was 93.07%.

DISCUSSION

Any single abnormality in this schema significantly predicted a large increase in NSI/death in 24 hours in TBI patients, and three particular findings were most predictive. This schema may help predict need for intervention and expedite management of moderate/severe TBI.

Modified Brain Injury Guidelines for preinjury anticoagulation in traumatic brain injury: An opportunity to reduce health care resource utilization

INTRODUCTION

The Brain Injury Guidelines (BIG) stratify patients by traumatic brain injury (TBI) severity to provide management recommendations to reduce health care resource burden but mandates that patients on anticoagulation (AC) are allocated to the most severe tertile (BIG 3). We sought to analyze TBI patients on AC therapy using a modified BIG model to determine if this population can offer further opportunity for safe reductions in health care resource utilization.

METHODS

Patients 55 years or older on AC with traumatic intracranial hemorrhage (ICH) from two centers were retrospectively stratified into BIG 1 to 3 risk groups using modified BIG criteria excluding AC as a criterion. Intracranial hemorrhage progression, neurosurgical intervention (NSI), death, and worsened discharge status were compared.

RESULTS

A total of 221 patients were included, with 23%, 29%, and 48% classified as BIG 1, BIG 2, and BIG 3, respectively. The BIG 3 cohort had a higher rate of AC reversal agents administered (66%) compared with the BIG 1 (40%) and BIG 2 (54%) cohorts ( p < 0.01), as well as ICH progression discovered on repeat head computed tomography (56% vs. 38% vs. 26%, respectively; p < 0.001). No patients in the BIG 1 and 2 cohorts required NSI. No patients in BIG 1 and 3% of patients in BIG 2 died secondary to the ICH. In the BIG 3 cohort, 16% of patients required NSI and 26% died. Brain Injury Guidelines 3 patients had 15 times the odds of mortality compared with BIG 1 patients ( p < 0.01).

CONCLUSION

The AC population had higher rates of ICH progression than the BIG literature, but this did not lead to more NSI or mortality in the lower tertiles of our modified BIG protocol. If the modified BIG used the original tertile management on our population, then NS consultation may have been reduced by up to 52%. These modified criteria may be a safe opportunity for further health care resource and cost savings in the TBI population.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level IV.

First steps toward a BIG change: A pilot study to implement the Brain Injury Guidelines across a 24-hospital system

INTRODUCTION

The modified Brain Injury Guidelines (mBIG) support a subset of low-risk patients to be managed without repeat head computed tomography (RHCT), neurosurgical consult (NSC), or hospital transfer/admission. This pilot aimed to assess mBIG implementation at a single facility to inform future systemwide implementation.

METHODS

Single cohort pilot trial at a level I trauma center, December 2021-August 2022. Adult patients included if tICH meeting BIG 1 or 2 criteria. BIG 3 patients excluded.

RESULTS

No patients required neurosurgical intervention. 72 RHCT and 83 NSC were prevented. 21 isolated BIG 1 were safely discharged home from the ED. No hospital readmissions for tICH. Protocol adherence rate was 92%.

CONCLUSION

Implementation of the mBIG at a single trauma center is feasible and optimizes resource utilization. This pilot study will inform an implementation trial of the mBIG across a 24-hospital integrated health system.

Inpatient management of complicated mTBI with the BIG assessment tool: Review and summary of the evidence

Introduction

The management of mild traumatic brain injury has evolved through the years with an emphasis on the safe discharge of patients given current resources. In this article, we discuss key studies published in the past 12 years that have influenced the direction of complicated mild traumatic brain injury (cmTBI) management. We summarize the evidence on the utilization of the Brain Injury Guideline (BIG) algorithm.

Methods

An independent literature search was conducted on the BIG, updated versions of BIG, and the prognostic studies of adult mild traumatic brain injury admissions cited by the BIG articles. Evidence resources included the search engines of PubMed, Medline, Ovid, Cochrane Library, and Google Scholar bibliographic databases of items published between 1 January 2010 and 30 December 2021. The evidence focused on BIG and its modified versions, as a potential risk assessment tool for discharging mTBI patients early.

Results

Studies supporting the BIG algorithm prior to 2019 presented evidence with serious limitations to their findings. These limitations threaten their veracity and fail to support the efficacy or validation of the BIG algorithm's utilization for mTBI patient management.

Conclusion

The lack of rigor in the BIG algorithm studies suggest the research is currently insufficient to support early discharge and research needs to continue on modified versions of the tool before its widespread use.