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Citation
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Joseph B, Obaid O, Dultz L, Black G, Campbell M, Berndtson AE, Costantini T, Kerwin A, Skarupa D, Burruss S, Delgado L, Gomez M, Mederos DR, Winfield R, Cullinane D. J. Trauma Acute Care Surg. 2022; ePub(ePub): ePub. |
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Abstract
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INTRODUCTION: BIG was developed to effectively utilize healthcare resources including repeat head CT (RHCT) scan and neurosurgical (NSG) consultation in traumatic brain injury (TBI) patients. The aim of this study is to prospectively validate BIG at a multi-institutional level.
METHODS: This is a prospective, observational, multi-institutional trial across 10 Level I and II trauma centers. Adult (age ≥ 16 years) blunt TBI patients with a positive finding on initial head CT-scan were identified. Patients were categorized into BIG 1, BIG 2, and BIG 3 based on their neurologic exam, alcohol intoxication, anti-platelet/anti-coagulant use, and head CT-scan findings. Primary outcome measure was NSG intervention. Secondary outcome measures were neurologic exam worsening, progression on RHCT, post-discharge ED visit, and 30-day readmission.
RESULTS: A total of 2,432 patients met inclusion criteria, of which 2,033 had no missing information and were categorized into BIG 1 (301; 14.8%), BIG 2 (295; 14.5%), and BIG 3 (1437;70.7%). In BIG 1, no patient worsened clinically, 4/301 (1.3%) patients had progression on RHCT with no subsequent change in management, and no patient required NSG intervention. In BIG 2, 2/295 (0.7%) patients worsened clinically, and 21/295 (7.1%) patients had progression on RHCT. Overall, 7/295 (2.4%) patients would have required upgrade from BIG 2 to BIG 3 due to neurologic exam worsening or progression/new bleed on RHCT, but no patient required NSG intervention. There were no TBI-related post-discharge ED visits or 30-day readmissions in BIG 1 and BIG 2 patients. All patients who required NSG intervention were BIG 3 (280/1437; 19.5%). The agreement between the assigned and final BIG categories was excellent (κ = 99%). In this cohort, implementing BIG would have decreased hospitalization, CT-scan utilization, and NSG consultation by 26% overall, with a 100% reduction in BIG 1 patients and a 97% reduction in BIG 2 patients.
CONCLUSION: BIG is safe and defines the management of TBI patients by trauma and acute care surgeons without the routine need for RHCT and NSG consultation. LEVEL OF EVIDENCE: Level III.
Language: en |