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Big Kids: Application Of A Modified Brain Injury Guideline In A Pediatric Trauma Center
Allison G McNickle1, *Stephanie A Jones1, Mais Yacoub2, Stephanie M Streit1, Dina Bailey2, Judith Ben Ari2, Douglas R Fraser1
1Kirk Kerkorian School of Medicine at UNLV, LAS VEGAS, NV;2University Medical Center of Southern Nevada, LAS VEGAS, NV

Background (issue): Brain Injury Guidelines (BIG) stratify the severity of traumatic brain injuries (TBI) to decrease unnecessary CT imaging and neurosurgical consultation. Injuries are classified as mild (BIG-1), moderate (BIG-2) or severe (BIG-3) based on size of bleeds, skull fractures, and neurologic status. We retrospectively reviewed the effect of a modified pediatric BIG algorithm (pBIG, see table). Modifications from the adult pathway include upgrading <4mm epidural hematomas from pBIG-1 to pBIG-2 and elimination of interfacility transfer as a pBIG-2 criteria. The proposed pBIG-1/2 care plans do not recommend repeat CT or neurosurgical consultation.
Methods: Pediatric TBIs were queried from our Level II Pediatric Trauma Registry from 2017-2020. Datasets included age, injury, repeat head CT, neurosurgical consultation and intervention.
Findings: A total of 314 children with a mean age of 4.3 years were included. Skull fractures (213, 68%) and subdural hematomas (161, 51%) were the most common injuries. 89 (28%) children had repeat head CTs (2 (7%) pBIG-1, 26 (25%) pBIG-2, 61 (34%) pBIG-3). Neurosurgical consultation was obtained in 306 (97%), with 50 (16%) requiring intervention (1 (1%) pBIG-2, 49 (27%) pBIG-3). Following the proposed pBIG care plan would decrease neurosurgical consults to 181 (58%) and repeat CTs to 63 (20%).
Conclusions (implications for practice): Implementation of our pBIG algorithm would decrease use of neurosurgery consultation (40% reduction) and repeat CTs (29% reduction) without compromising outcomes.

Pediatric Brain Injury Guidelines
pBIG-1 (n=29)pBIG-2 (n=104)pBIG-3 (n=181)
GCS 15GCS 13-14GCS<=12
SDH/IPH<=4mmAny EDH<8mmEDH/SDH/IPH>=8mm
SAH, traceSDH/IPH 5-7mmSAH, scattered
SAH, localizedDepressed skull fracture


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