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• W4386585384 abstract "Figure: head trauma, brain injury, head CT, brain bleedFigureHead bleeds are the leading cause of death in trauma patients. The stakes are even higher when a patient is on antiplatelet or anticoagulant medications, so much so that some have argued that a patient on blood thinners with a head trauma still needs admission for monitoring and repeat imaging even if he has a normal head CT and seems well. (“Minor Head Trauma in the Anticoagulated Patient,” EMN. 2006;28[9]:26; https://bit.ly/3PMO9nF.) But just as there are devastating brain hemorrhages, there are also trivial ones—small bleeds in otherwise well people. These feel almost like incidental CT findings. It can be frustrating to wake up an overtaxed neurosurgeon in the middle of the night just to admit someone we all know is going to be fine in the morning, someone who might in fact recover more quickly if he just went home and slept in his own bed. Enter the brain injury guidelines, or BIG. This decision tool helps identify minor traumatic bleeds we can send home sooner. Bellal Joseph, MD, and colleagues debuted their BIG protocol with a retrospective look at four years of 3800 traumatic brain injury patients at their Arizona trauma center. (J Trauma Acute Care Surg. 2014;76[4]:965.) They classified patients by neurological exam and head CT findings and also by whether they had intoxicants, antiplatelet agents, or anticoagulants on board. (They specifically included aspirin.) Validating BIG 1 The Arizona team found 1232 trauma patients who had an abnormal head CT finding, such as a skull fracture or a brain bleed. But 121 of them—about 10 percent—had only minor bleeds with a normal neurological exam; they were also not drunk and not on aspirin or any other agents that would predispose them to a bleed. Those patients all had a benign course. The authors labeled them BIG 1, and hypothesized that they could have all just been sent home after a period of ED observation. The other 90 percent of patients fell into higher level categories (BIG 2 or BIG 3) and the authors said they indeed needed to be admitted. More could be said about BIG 2 and BIG 3, but basically you had us emergency physicians at “admitted to the hospital.” It's the BIG 1 patient, the head bleed going home after six hours and a sandwich, who interests us. Dr. Joseph and colleagues validated their protocol but only at their own institution. (JAMA Surg. 2015;150[9]:866; https://bit.ly/3HUJ2Q8.) They classified 83 patients as BIG 1 over the next two years and sent them home after six hours of ED observation. No real follow-up was documented, but the authors concluded that their protocol was safe and cost-effective and that it reduced the burden on neurosurgeons. I like the idea of BIG as a HEART score for intracranial hemorrhage, a tool that could help us identify low-risk cases to send home. That said, I'm not sold that the safety of this is established. The studies so far are small, they don't all agree, and they didn't even use the same protocol. ‘Low-Risk’ Epidural Hematoma Colorado trauma researchers tried to validate the Arizona-grown BIG protocols with a retrospective look at two years of their own data. (Trauma Surg Acute Care Open. 2020;5[1]:e000483; https://bit.ly/3hNDz3a.) They identified 98 head traumas as BIG 1, but then saw 11.2 percent of those develop worsening bleeds on repeat head CTs. The authors found this happening with epidural and intraparenchymal hemorrhages, two particularly dangerous intracranial hemorrhages. Trauma teams in Atlanta also reported on their experience managing BIG 1 cases in an emergency department observation unit. (West J Emerg Med. 2021; 22[4]:943; https://bit.ly/3GaMR2h.) But they, too, hedged: Like the Colorado team, they were uncomfortable with the concept of a low-risk epidural hematoma. “We altered the protocol slightly to exclude epidural hematomas,” they said, “based on institutional expert opinion.” I share their alarm about discharging an epidural hematoma after a few hours with no repeat imaging. But this then doesn't validate the safety of BIG 1. It's even worse than that because one of the 169 modified BIG 1 patients they observed in Atlanta died! There's no real information about this provided other than the startling assertion that based “on review of clinical records, this was thought to be due to metabolic encephalopathy and not head injury.” He “encephalopathized to death” in the observation unit, but it was “metabolic,” not related to his skull full of blood. I mean, sure, if you say so; I wasn't there. (As for the other 168 patients, they only followed up with 26 percent of them.) Loosey-Goosey Criteria My read of this literature is we should be more conservative about who we send home. I would admit every patient with epidural and intraparenchymal hemorrhage as well as every patient with a bleeding diathesis. That would include not just patients on apixaban or aspirin, but every dialysis patient and every cirrhotic. Instead, hospitals are so excited about the potential efficiencies—fewer admissions, less hassle for neurosurgeons—that some loosen the already loosey-goosey BIG criteria. At trauma centers where I work, a person can be BIG 1 even when he is on aspirin, never mind that aspirin was excluded in the original BIG protocols. We all want the same thing: We want to be cautious with people at risk of decompensating, and we also don't want to waste time and resources on patients who are fine. The BIG protocol represents an admirable first try at getting us there, but it's definitely a work in progress. Dr. Bivensworks at emergency departments in Massachusetts, including St. Luke's in New Bedford and Beth Israel Deaconess Medical Center in Boston. Follow him on Twitter@matt_bivens." @default.
• W4386585384 created "2023-09-11" @default.
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• W4386585384 date "2023-02-01" @default.
• W4386585384 modified "2023-09-29" @default.
• W4386585384 title "What About This? Brain Bleeds Protocol Is Just Not There Yet" @default.
• W4386585384 doi "https://doi.org/10.1097/01.eem.0000920032.06350.77" @default.
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