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

J Trauma Acute Care Surg. 2014 Apr;76(4):965-9. doi: 10.1097/TA.0000000000000161.


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.

Publication types

  • Comparative Study

MeSH terms

  • Adult
  • Brain Injuries / diagnosis*
  • Brain Injuries / surgery
  • Female
  • Follow-Up Studies
  • Glasgow Coma Scale
  • Humans
  • Injury Severity Score
  • Male
  • Middle Aged
  • Neurosurgical Procedures / methods*
  • Neurosurgical Procedures / standards
  • Practice Guidelines as Topic*
  • Reproducibility of Results
  • Retrospective Studies
  • Tomography, X-Ray Computed
  • Trauma Centers*