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Published on: August 16, 2019
Application of Brain Injury Guidelines at a Pediatric Level 1 Trauma Center predicts reliability, safety, and
Sabrina L Zeller1, Aleena Khan2, Joon Yong Chung2
1Department of Neurosurgery, Westchester Medical Center, 100 Woods Road, Valhalla, NY, 10595, USA. Sabrina.Zeller@wmchealth.org.
Insights
The Brain Injury Guidelines (BIG) can reliably assess pediatric traumatic brain injury (TBI). Applying BIG criteria to children reduced unnecessary imaging and ICU admissions without missing critical neurosurgical cases.
Area of Science:
- Pediatric Traumatology
- Neurosurgery
- Emergency Medicine
Background:
- Established Brain Injury Guidelines (BIG) aid adult Traumatic Brain Injury (TBI) management.
- Pediatric TBI management requires specific considerations distinct from adults.
Purpose of the Study:
- Evaluate the reliability and safety of applying adult Brain Injury Guidelines (BIG) to pediatric TBI patients.
- Assess the impact of BIG criteria on resource utilization, including imaging and ICU admissions.
Main Methods:
- Retrospective analysis of pediatric TBI patients (≤18 years) at a Level 1 Pediatric Trauma Center (Jan 2012-July 2023).
- Two independent observers rated TBI severity (BIG 1/2/3) using initial cranial imaging.
- Compared BIG predictions for repeat imaging, ICU admission, and neurosurgical consultation with actual patient management.
Main Results:
- High inter-observer reliability (96.4%) in applying BIG criteria to 359 pediatric TBI patients.
- BIG criteria predicted fewer repeat CT/MRI scans and ICU admissions compared to actual utilization.
- No neurosurgical interventions were needed for BIG 1/2 injuries; all 37 interventions were in BIG 3 patients.
Conclusions:
- BIG criteria are reliably applicable to pediatric TBI by non-neurosurgical specialists.
- Retrospective application of BIG criteria suggests potential for reduced imaging and ICU resource utilization in pediatric TBI.
- BIG criteria effectively identified pediatric TBI patients requiring neurosurgical intervention, demonstrating safety.
Purpose:
Brain Injury Guidelines (BIG) have been established to guide management related to TBI in adults. Here, BIG criteria were applied to pediatric TBI patients to evaluate reliability, safety, and resource utilization.
Methods:
A retrospective study was performed on all pediatric TBI patients aged 18 years or younger from January 2012 to July 2023 at a Level 1 Pediatric Trauma Center. The severity of TBI (BIG 1/2/3) was rated by review of initial cranial imaging by two independent observers. Inter-observer reliability was assessed. Predictions based on BIG criteria regarding repeat cranial imaging, ICU admission, and neurosurgical consultation were compared with observations from the cohort. Outcome data was collected, including neurosurgical intervention and mortality rate.
Results:
Three hundred fifty-nine patients were included with mean age of 5.3 years. Injury severity included 44 BIG 1 (12.2%), 170 BIG 2 (47.4%), and 145 BIG 3 injuries (40.4%). Inter-rater reliability was 96.4%. Neurosurgical consultation was obtained in all patients, though only predicted by guidelines in 40.4%. Repeat imaging was obtained in 166 BIG 1/2 patients, with an average of 1.3 CT scans and 0.8 MRIs/rapid MRIs per patient. ICU was utilized in 104 (77.6%) patients not recommended per BIG criteria. Ultimately, 37 patients, all BIG 3, required neurosurgical intervention; no neurosurgical interventions were required in those classified as BIG 1/2.
Conclusions:
BIG criteria can be applied to pediatric TBI with high inter-observer reliability and without formal neurosurgical training. Retrospective application of BIG predicted fewer imaging studies, ICU admissions, and neurosurgical consults without overlooking patients requiring neurosurgical intervention.
