Head Injury Guideline Updates

Educational Objectives

The goal of this program is to improve assessment and management of traumatic brain injury using standardized guidelines. After hearing and assimilating this program, the clinician will be better able to:

1. Compare outcomes in patients with a Brain Injury Guidelines (BIG) 1 classification vs other classifications.
2. Assess the key modifications to the BIG classification criteria that enhance patient management decisions.

Summary

Traumatic brain injury (TBI): accounts for 2.9 million emergency department visits annually, and its incidence is rapidly increasing, leading to more hospitalizations and deaths; diagnosing and managing TBI remains challenging because of the limitations of current tools; the Glasgow Coma Scale is not always effective during initial assessments, and there is uncertainty about when to repeat noncontrast head computed tomography (CT)

The Brain Injury Guidelines (BIG) project: aimed to identify which elements of the history of presentation, medical history, and initial CT were useful for improving initial assessment and management; the goal was to determine which patients required observation, repeat head CT, or neurosurgical consultations while minimizing unnecessary interventions and health care costs

Classification: Morocho et al (2024) classified patients based on their presentation (eg, loss of consciousness), initial neurologic examination, antiplatelet or anticoagulant use, CT results; BIG 1 included patients with small bleeds and lower mechanism injuries; BIG 2 patients likely needed hospitalization but might not have required a repeat head CT or consultation; none of the 121 BIG 1 patients showed progression on repeat head CT, neurologic deterioration (observation might not have been necessary), or required neurosurgical intervention; in the BIG 2 group (313 patients), 2.6% showed CT progression and 0.63% experienced neurologic deterioration, and no neurosurgical interventions were needed; 19% of BIG 3 patients had immediate surgery after the initial head CT, 21.6% of the remainder showed CT progression, 4.2% had neurologic deterioration, and 3% underwent delayed surgery; the classification system demonstrated high reliability (ie, few reclassifications)

Resource use: the BIG guidelines could have prevented 121 unnecessary hospitalizations, 342 repeat head CTs, and 434 neurosurgical consultations, resulting in a savings of $4772 per patient

Validation: a study of 2400 patients by the American College of Surgeons (ACS; Tsvetkov et al [2024]) confirmed the system’s reliability; there was a 1.3% CT progression rate in BIG 1 (original study, 0%), 7.1% in BIG 2, and significant progression in BIG 3; neurologic deterioration was 0% for BIG 1, 0.7% for BIG 2, and 16% for BIG 3; no neurosurgical interventions were required for BIG 1 or BIG 2, reinforcing the idea that consultation is unnecessary; there was a 100% reduction in repeat head CT for BIG 1 and a 98% for BIG 2; the ACS endorses BIG and states it should be used at all level-1 trauma centers

Modified BIG (mBIG) criteria: concerns have been raised regarding certain elements of the BIG classifications, particularly the dismissal of small epidural hematomas (<4 mm) and intraparenchymal hemorrhage with multiple foci; to address these issues, the mBIG criteria were proposed; a separate retrospective analysis from 2014 to 2016 examined 950 patients (Khan et al [2022]); the changes included establishing a formalized alcohol intoxication cutoff, defining hospitalization criteria more clearly (<24 hr vs >24 hr observation), and adjusting thresholds for epidural hematomas and multifocal intraparenchymal hemorrhage because of concerns about progression rates; all of these are now considered BIG 3; the authors recommended that splitting BIG 2 into 2A and 2B (related to chronic antiplatelet, anticoagulant, or aspirin use); the revised system improved patient safety, as all patients who originally progressed from BIG 2 to BIG 3 had epidural hematomas; mBIG still improved resource allocation and reduced health care costs

Applying mBIG outside of level-1 trauma centers: some validation studies of BIG, with slight modifications, have been conducted in Level-2 and Level-3 trauma centers (the latter had emergency physicians successfully managing cases without acute-care surgeons); pediatric studies, eg, “BIG for small” and “BIG kids,” further support the effectiveness of modified BIG criteria (Azim et al [2017])

Readings

Azim A, Jehan FS, Rhee P, et al. Big for small: validating brain injury guidelines in pediatric traumatic brain injury. J Trauma Acute Care Surg. 2017;83(6):1200-04. doi:10.1097/TA.0000000000001611; Capizzi A, Woo J, Verduzco-Gutierrez M. Traumatic brain injury: an overview of epidemiology, pathophysiology, and medical management. Med Clin North Am. 2020;104(2):213-38. doi:10.1016/j.mcna.2019.11.001; Carney N, Totten AM, O’Reilly C, et al. Guidelines for the management of severe traumatic brain injury, fourth edition. Neurosurgery. 2017;80(1):6-15. doi:10.1227/NEU.0000000000001432; Joseph B, Aziz H, Pandit V, et al. A three-year prospective study of repeat head computed tomography in patients with traumatic brain injury. J Am Coll Surg. 2014;219(1):45-51. doi:10.1016/j.jamcollsurg.2013.12.062; Khan AD, Lee J, Galicia K, et al. A multicenter validation of the modified brain injury guidelines: are they safe and effective?. J Trauma Acute Care Surg. 2022;93(1):106-12. doi:10.1097/TA.0000000000003633; Lee SY, Amatya B, Judson R, et al. Clinical practice guidelines for rehabilitation in traumatic brain injury: a critical appraisal. Brain Inj. 2019;33(10):1263-71. doi:10.1080/02699052.2019.16417474; Morocho B, Meinert J, Stirpe S, et al. Retrospective validation of brain injury guidelines in a rural level II trauma center. J Surg Res. 2024;302:259-62. doi:10.1016/j.jss.2024.07.044; Tsvetkov N, Mallaev M, Gahl B, et al. Validation of the American College of Surgeons surgical risk calculator for thoracic surgery. J Thorac Dis. 2024;16(9):5698-708. doi:10.21037/jtd-24-611; Wasfie T, Ho T, Shapiro B. Acute traumatic epidural hematoma in the elderly: a community hospital experience. Am Surg. 2022;88(6):1328-29. doi:10.1177/0003134820943117.

Disclosures

For this program, members of the faculty and the planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Allen was recorded at the 2024 Rocky Mountain Winter Conference, held February 24-28, 2024, in Steamboat Springs, CO, and presented by EMedHome.com. For information about upcoming CME activities from this presenter, please visit https://Emedhome.com. Audio Digest thanks the speakers and presenters for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0.50 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0.50 CE contact hours.

Lecture ID:

EM420902

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.