Optimizing Traumatic Brain Injury Care Without Neurosurgeons: External Validation of the Brain Injury Guidelines in a...

Area of Science:

• Neurosurgery
• Trauma Care
• Public Health

Background:

• Limited neurosurgical care access in low- and middle-income countries (LMICs) poses challenges for traumatic brain injury (TBI) management.
• The Brain Injury Guidelines (BIG) aim to standardize TBI care and resource use, but their effectiveness in neurosurgically underserved areas is unknown.

Purpose of the Study:

• To evaluate the performance and applicability of the Brain Injury Guidelines (BIG) in a trauma center lacking on-site neurosurgical support.
• To assess the BIG's ability to identify patients who do not require neurosurgical intervention in resource-limited settings.

Main Methods:

• Retrospective analysis of 178 adult TBI patients admitted to a Brazilian trauma center (2013-2017) without neurosurgical coverage.
• Patients were classified using BIG criteria (BIG 1-3) based on clinical and radiological data.
• Outcomes included clinical/radiological deterioration, mortality, neurosurgical transfer, repeat CT scans, and length of stay.

Main Results:

• No BIG 1 or BIG 2 patients experienced deterioration, required neurosurgery, or died; all adverse outcomes occurred in the BIG 3 cohort (11.5% mortality).
• The BIG 1-2 group demonstrated 100% sensitivity and NPV for predicting no deterioration or need for neurosurgical intervention.
• Despite low-risk classification, 76.4% of BIG 1-2 patients were transferred for evaluation, and repeat CT scans were common.

Conclusions:

• The BIG effectively discriminates low-risk TBI patients in settings without neurosurgical coverage.
• BIG 1 and BIG 2 classifications reliably indicate that neurosurgical intervention is not needed, supporting selective non-transfer protocols.
• Implementing BIG-guided selective non-transfer can optimize resource utilization in neurosurgically limited trauma systems.