Management of Patients Transferred to Level II Trauma Center for Low-Risk Traumatic Brain Injury

The modified Brain Injury Guidelines (mBIG) classify traumatic brain injury (TBI) based on intracranial hemorrhage (ICH) size, type, and patient risk factors. Studies suggest that mBIG1 patients do not require neurosurgical evaluation, repeat imaging, or observation beyond six hours. Most studies on the use of mBIG have been performed at large academic centers, with little published on their application in community settings. Our goal was to assess the safety and effectiveness of applying mBIG for mild TBI management in a regional trauma catchment area.

This was a retrospective observational analysis of all isolated TBI patients transferred to a Level II trauma center from 14 community sites from 11/2021 – 12/2024. Patient presentation, management, and outcomes were gathered from the EMR at both the referring and receiving hospitals. Those with a Glasgow Coma Scale (GCS) of 12 or less or focal neurologic deficit were excluded. The mBIG score was determined by a trauma surgeon at the receiving level II trauma center utilizing clinical data provided by the referring facility. Upon presentation, patients were re-evaluated and had the mBIG scores confirmed.

Over 3 years, 1178 patients were transferred to a level II trauma center for management of traumatic ICH. 44 patients were deemed to be mBIG1 by the receiving physician. 42 of these 44 had no worsening of ICH on repeat head CT and did not require neurosurgical intervention. Two patients that were classified as a mBIG1 suffered worsening of intracranial hemorrhage on repeat head CT. Both were admitted for observation, but did not require neurosurgical intervention. 21 patients were transferred to the level II trauma center with a reported mBIG1 but were deemed to have a higher score upon arrival. Nine of these were due to anticoagulant use initially missed by the referring facility, 7 were found to have larger bleeds when the original head CT was seen by the trauma center radiologist, and 4 were found to have an elevated blood alcohol level that was not measured prior to transfer.

Incomplete or incorrect clinical information when employing the mBIG criteria in transfer can lead to poor clinical outcomes. Trauma receiving systems utilizing this tool should place close attention to alcohol intoxication, use of anticoagulants, and radiographic sizing. Under sizing these intracranial bleeds may lead to delayed neurosurgical intervention.