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 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 Donate : https://emergencymedicalminute.org/donate/
