Title:  Retrospective Validation of the Brain Injury Guidelines: Management of Traumatic Brain Injury at a Single Community Trauma One Hospital

Author(s): Gianmarino Gianfrate, DO; Stacy Lane, DO; Katherin Ogborn, MD; Micheal Sippel, MD; Gregory Huang, MD, FACS

Email: ggianfrate@mercy.com

Background: Traumatic brain injury (TBI) can lead to widespread devastating effects on the individual and the medical community. The incidence of traumatic brain injury has been on the rise since the early 2000’s, up 20-30% since that time. Although there have been many attempts to create guidelines for non-operative management, currently the evaluation seems to be more extensive than needed. The Brain Injury Guideline (BIG) project in 2013, set forth by the University of Arizona attempted to set specific guidelines for non-operative management and the necessity of neurosurgery evaluation for TBI. Today, during the COVID-19 pandemic and its post-pandemic fallout, the increased incidence of TBI and use of oral anticoagulation has led to a major tax on medical resources.  To curb this burden on the medical field, we will attempt to validate the BIG trial to solidify guidelines for TBI.

Methods:  In our retrospective cohort analysis, we explored all 121 traumatic brain injuries that presented to St. Elizabeth Youngstown Hospital, a level I trauma center, in Youngstown, Ohio from January 1^st, 2018, to April 30th, 2018. Patients were classified according to neurologic examination results, CT imaging (initial and 4-hour repeat), use of intoxicants, tertiary neurological exam, and anticoagulation status. We then verified and cross referenced our cohort with the already developed brain imaging guidelines for individual patient’s need for observation, hospitalization, or neurosurgical consult. Patients discharged had a follow-up neurosurgical evaluation 3-4 weeks after leaving the hospital.

Results:  80 patients had an abnormal head CT finding. All patients in our study group had repeat CT scans of the head at 4 hours and got a neurosurgical evaluation in the hospital and within 5 weeks post-discharge.  In the BIG 1 category, all patients had a stable or improving repeat CT head scan at 4 hours, did not require intervention, had a normal inpatient and outpatient neurosurgical evaluation, and a GCS of 15 on tertiary exam and before discharge. Patients within the BIG 2 category had worsening bleeds 16% of the time, but all were stable on 3^rd CT scan. All BIG 3 patients required prolonged hospital stays with an all-cause mortality of 17%.

Conclusion:  The proposed Brain Imaging Guidelines, originally set forth by the University of Arizona has been validated and further strengthened to be an acceptable guideline for trauma hospitals throughout the United States. We were able to strengthen the original study by adding the finding from our 4-hour repeat imaging, tertiary neurological exam and 3-4 week follow up with a neurosurgical specialist. Without the resources of many larger institutions, regional and community trauma centers can rely on this guideline to help create an algorithm to streamline patient care. This can allow the limited resources to aid in other aspects of patient care. Using the criteria set forth by the BIG project in 2013, along with our own institutional guidelines, we were able to authenticate a non-admission protocol for TBI. We believe this will aid in changing our current practice management guidelines that will support patient care and help distribute the demand for medical resources.