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Multicenter assessment of the Brain Injury Guidelines and a proposal of guideline modifications
  1. Abid D Khan1,
  2. Anna J Elseth1,
  3. Jacqueline A Brosius2,
  4. Eliza Moskowitz1,
  5. Sean C Liebscher2,
  6. Michael J Anstadt2,
  7. Julie A Dunn3,
  8. John H McVicker4,
  9. Thomas Schroeppel1,
  10. Richard P Gonzalez2
  1. 1Department of Trauma and Acute Care Surgery, UCHealth Memorial Hospital Central, Colorado Springs, Colorado, USA
  2. 2Department of Surgery, Loyola University Chicago Stritch School of Medicine, Maywood, Illinois, USA
  3. 3Department of Trauma and Acute Care Surgery, Medical Center of the Rockies, Loveland, Colorado, USA
  4. 4Department of Neurosurgery, UCHealth Memorial Hospital Central, Colorado Springs, Colorado, USA
  1. Correspondence to Dr Abid D Khan; adkhan{at}


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.

  • brain injuries, traumatic
  • head injuries, closed
  • practice guideline

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  • Contributors All authors have made substantial contributions to study design, drafting, critical revision, and approval of the final article.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval This project was approved by the Institutional Review Boards at UCHealth (#17-6101) and at Loyola University Medical Center (#209254) prior to beginning data collection.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement No data are available. This is not a clinical trial and data are not available.

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