Discussion

Introduction: Pediatric traumatic brain injury (TBI) is a global public health concern affecting more than 3 million children worldwide. Brain Injury Guidelines (BIG) have been established to stratify severity and guide management related to TBI. This study evaluated the safety and reliability of applying BIG criteria to pediatric TBI patients.

Methods: A retrospective review was performed on all consecutive pediatric TBI patients aged 18 years and younger at a Level 1 Pediatric Trauma Center from January 2018 to July 2023. Severity of TBI was assessed on initial cranial imaging by two independent observers, one with neurosurgical background and one without. Data was collected regarding demographics, outcomes, and resource utilization, which was compared to predicted recommendations from BIG criteria.

Results: A total of 154 patients were included with a mean age of 4.4 years and 63.6% male predominance. Classifications included 19 BIG 1 (12.3%), 74 BIG 2 (48.1%), and 61 BIG 3 injuries (39.6%), with an inter-rater reliability of 95.5%. Neurosurgical consultation was obtained in all patients, though only predicted via criteria in 39.6%. Ninety patients transferred from outside facilities included 57 BIG 1 or 2 patients (63.3%), for whom criteria would recommend observation alone. Repeat imaging was obtained in 68 BIG 1 or 2 patients, with an average of 1.3 head CT scans and 0.7 brain MRIs/rapid MRIs per patient. ICU admission was utilized in 39 patients not recommended per BIG criteria. Ultimately, 18 patients categorized as BIG 3 required neurosurgical intervention; no neurosurgical interventions were required in those classified as BIG 1 or 2.

Conclusion : BIG criteria can be applied to pediatric TBI with high inter-rater reliability without necessitating formal neurosurgical background. Retrospective application of criteria predicts safe application in pediatric patients providing potential reduced ICU admissions, neurosurgical consults, repeat imaging, and hospital transfers without overlooking those who may require neurosurgical intervention.