Contributor: Aaron Lessen, MD

Educational Pearls:

Traumatic Brain Injuries are a frequent complaint in the Emergency Department and have increased in recent years. The American Association for Surgery of Trauma (AAST) has created Brain Injury Guidelines (BIG), in an attempt to categorize brain injuries and the level of treatment they require. They are…

BIG 1

Normal neuro exam
Not intoxicated
Not on anticoagulation or antiplatelet medications
Minimal findings on head CT
- No fracture
- <4 mm bleed (subdural, epidural, intraparenchymal (max one location))
- Maximum of “trace” subarachnoid hemorrhage
- No intraventricular hemorrhage
Monitor for 6 hours
No need to repeat the head CT
No need to consult neurosurgery

BIG 2

Normal neuro exam
Not on anticoagulation or antiplatelet medications
Any of the following
- Intoxicated
- Slightly more findings on head CT
  - Non-displaced skull fracture
  - 4-8 mm bleed (subdural, epidural, intraparenchymal (max two locations))
  - Maximum of “localized” subarachnoid hemorrhage
  - No intraventricular hemorrhage
Hospitalize
No need to transfer
No need to repeat the head CT
No need to consult neurosurgery

BIG 3

Abnormal neuro exam
On anticoagulation or antiplatelet medications
Intoxicated
Significant findings on head CT
- Displaced skull fracture
- >8 mm bleed (subdural, epidural, intraparenchymal (or more than 2 locations))
- “Scattered” subarachnoid hemorrhage
- Intraventricular hemorrhage
Full treatment, admission to trauma center, neurosurgery evaluation

References

Joseph B, Friese RS, Sadoun M, Aziz H, Kulvatunyou N, Pandit V, Wynne J, Tang A, O'Keeffe T, Rhee P. 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. PMID: 24662858.
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; AAST BIG Multi-institutional Study Group. Validating the Brain Injury Guidelines: Results of an American Association for the Surgery of Trauma prospective multi-institutional trial. J Trauma Acute Care Surg. 2022 Aug 1;93(2):157-165. doi: 10.1097/TA.0000000000003554. Epub 2022 Mar 28. PMID: 35343931.

Summarized by Jeffrey Olson, MS4 | Edited by Jeffrey Olson and Jorge Chalit, OMS4

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Episode 980: Brain Injury Guidelines (BIG)

Emergency Medical Minute