Prospective validation of the brain injury guidelines: managing traumatic brain injury without neurosurgical consultation.

BACKGROUND: To optimize neurosurgical resources, guidelines were developed at our institution, allowing the acute care surgeons to independently 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, 13-15), and median head Abbreviated Injury Scale (AIS) score was 2 (range, 2-3). 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. LEVEL OF EVIDENCE: Therapeutic/care management, level IV.