The BIG (brain injury guidelines) project: Defining the management of traumatic brain injury by acute care surgeons

BACKGROUND: It is becoming a standard practice that any ''positive'' identification of a radiographic intracranial injury requires transfer of the patient to a trauma center for observation and repeat head computed tomography (RHCT). The purpose of this study was to define guidelinesVbased on each patient's history, physical examination, and initial head CT findingsVregarding which patients require a period of observation, RHCT, or neurosurgical consultation. METHODS: In our retrospective cohort analysis, we reviewed the records of 3,803 blunt traumatic brain injury patients during a 4-year period. We classified patients according to neurologic examination results, use of intoxicants, anticoagulation status, and initial head CT findings. We then developed brain injury guidelines (BIG) based on the individual patient's need for observation or hospitalization, RHCT, or neurosurgical consultation. RESULTS: A total of 1,232 patients had an abnormal head CT finding. In the BIG 1 category, no patients worsened clinically or radiographically or required any intervention. BIG 2 category had radiographic worsening in 2.6% of the patients. All patients who required neurosurgical intervention (13%) were in BIG 3. There was excellent agreement between assigned BIG and verified BIG. J statistic is equal to 0.98. CONCLUSION: We have proposed BIG based on patient's history, neurologic examination, and findings of initial head CT scan. These guidelines must be used as supplement to good clinical examination while managing patients with traumatic brain injury. Prospective validation of the BIG is warranted before its widespread implementation. (J Trauma Acute Care Surg. 2014;76: 965Y969

Methamphetamine spasm in the large caliber arteries—the severity is likely underestimated

This report describes two cases of rarely reported, severe large arterial vascular spasms seen on computed tomography images after methamphetamine abuse. Although the effects of methamphetamine on the central nervous system and smaller arteries are relatively well known, its effects on large caliber arteries are rarely discussed. We present two cases of severe large arterial multisegmented vasospasm, captured on contrast-enhanced computed tomography, several hours after methamphetamine abuse. One of the patients was discharged without apparent tissue loss or organ failure. The other developed severe heart failure, liver failure, and toe gangrene. The publication of the de-identified images has been approved by the VA Central California Health Care System's Research and Development Committee and Privacy Officer. Vascular surgeons and, perhaps, acute care physicians, who are usually aware of small arterial vasospastic conditions, should also be aware of this methamphetamine-induced large arterial finding, which can be quite dramatic in appearance on imaging