Prospective validation of the brain injury guidelines: Managing traumatic brain injury without neurosurgical consultation Bellal Joseph, MD, Hassan Aziz, MD, Viraj Pandit, MD, Narong Kulvatunyou, MD, Moutamn Sadoun, MD, Andrew Tang, MD, Terence O’Keeffe, MB ChB, Lynn Gries, MD, Donald J. Green, MD, Randall S. Friese, MD, Michael G. Lemole, Jr., MD, and Peter Rhee, MD, Tucson, Arizona BACKGROUND: To optimize neurosurgical resources, guidelines were developed at our institution, allowing the acute care surgeons to in- dependently manage traumatic intracranial hemorrhage less than or equal to 4 mm. The aim of our study was to evaluate our established Brain Injury Guidelines (BIG 1 category) for managing patients with traumatic brain injury (TBI) without neurosurgical consultation. METHODS: We formulated the BIG based on a 4-year retrospective chart review of all TBI patients presenting at our Level 1 trauma center. We then prospectively implemented our BIG 1 category to identify TBI patients that were to be managed without neurosurgical consultation (No-NC). Propensity scoring matched patients with No-NC to a similar cohort of patients managed with NC before the implementation of our BIG in a 1:1 ratio for demographics, severity of injury, and type and size of intracranial hemorrhage. Primary outcome measure was need for neurosurgical intervention and 30-day readmission rates. RESULTS: A total of 254 TBI patients (127 of NC and 127 of No-NC patients) were included in the analysis. The mean (SD) age was 40.8 (22.7) years, 63.4% (n = 161) were male, median Glasgow Coma Scale (GCS) score was 15 (range, 13Y15), and median head Abbreviated Injury Scale (AIS) score was 2 (range, 2Y3). There was no neurosurgical intervention or 30-day readmission in both the groups. In the No-NC group, 3.9% of the patients had postdischarge emergency department visits compared with 4.7% of the NC group (p = 0.5). All patients were discharged home from the emergency department. CONCLUSION: We validated our BIG and demonstrated that acute care surgeons can effectively care for minimally injured TBI patients with good outcomes. A national multi-institutional prospective evaluation is warranted. (J Trauma Acute Care Surg. 2014;77: 984Y988. Copyright * 2014 by Lippincott Williams & Wilkins) LEVEL OF EVIDENCE: Therapeutic/care management, level IV. KEY WORDS: Management of traumatic brain injury; neurosurgical consultation; brain injury guidelines; neurosurgical intervention; acute care surgeons. T raumatic brain injury (TBI) continues to burden the health care system of the United States, accounting for more than 1.4 million emergency department (ED) visits each year. 1 Ap- proximately 75% of the patients who are seen in the ED have minor head injury not requiring immediate assessment by neu- rosurgical specialists. 2,3 The current standard of care for patients with traumatic intracranial hemorrhage (ICH) includes neuro- surgical consultation (NC) and/or transfer to a trauma center where neurosurgical services are available. 4,5 However, in recent years, the management of these patients with TBI is evolving. Several studies have emphasized the growing role of acute care surgeons in the care of patients with minor head injury. 4Y10 In a previous study from our institution, we highlighted the management of patients with traumatic ICH without NC. 4 We found that there was no difference in patient outcomes among patients managed by acute care surgeons in comparison with a similar cohort of patients managed by neurosurgeons. However, there are no well-defined guidelines to define the management of these patients. As a result, we developed guidelines termed as Brain Injury Guidelines (BIG) in collaboration with neuro- surgeons at our institution to formulate a therapeutic plan for management of these patients (Fig. 1). 6 Based on these guide- lines, we suggested that mild TBI patients with miniscule findings on the initial computed tomography (CT) scan can be managed safely and effectively by acute care surgeons without NC. 6 However, those guidelines were developed based on a ret- rospective review of patients and require prospective validation before widespread clinical implementation. The aim of our study was to validate our established BIG (BIG 1 category) for managing TBI patients without NC. We hypothesized that trauma surgeons can independently manage TBI patients with- out NC with the implementation of BIG (BIG 1 category). METHODS We performed a prospective cohort analysis of all pa- tients with a TBI seen at our Level 1 trauma center from March 1, 2012, through December 31, 2013. Inclusion and Exclusion Criteria Patients with TBI with an ICH on initial head CT scan meeting BIG 1 criteria were enrolled in this study (Fig. 1). WTA 2014 PLENARY P APER J Trauma Acute Care Surg Volume 77, Number 6 984 Submitted: February 15, 2014, Revised: July 2, 2014, Accepted: July 2, 2014. From the Division of Trauma, Emergency Surgery, Critical Care, and Burns; Department of Surgery, University of Arizona Medical Center, Tucson, Arizona. This study was presented at the 44th Annual Meeting of the Western Trauma As- sociation, March 2Y7, 2014, in Steamboat Springs, Colorado. Address for reprints: Bellal Joseph, MD, Division of Trauma, Critical Care, and Emergency Surgery, Department of Surgery, University of Arizona, 1501 N Campbell Ave, Room.5411, PO Box 245063, Tucson, AZ 85724; email: bjoseph@surgery.arizona.edu. DOI: 10.1097/TA.0000000000000428 Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.