Small Change, BIG Impact: Proposal of the Brain Injury Guidelines for kids (kBIG)

Background: The adult Brain Injury Guidelines (BIG) stratify patients with traumatic intracranial hemorrhage into one of three risk categories and supports management of lower risk traumatic brain injury (TBI) with minimal resources. While the BIG have been widely adopted by adult trauma centers, application to pediatric populations remains unvalidated. The objective of this study was to determine the efficacy of BIG in a pediatric trauma population and develop adapted criteria based on injury patterns that may be unique to children with TBI. Methods: BIG was applied to a retrospective cohort of pediatric TBI patients, defined as <18 years old with skull fracture or intracranial hemorrhage on CT scan, from January 2018 to April 2024. Misclassification of BIG was defined as patients categorized as low- or moderate-risk who required neurosurgical intervention. Based on the performance of BIG, modifications were made to derive a pediatric-specific guideline, BIG for Kids (kBIG). Results: 1894 patients were analyzed. The misclassification rate of BIG 1 and 2 was 0 % and 1.4 %, respectively. We derived kBIG, with modifications to the categorization of minor skull fracture, epidural hematoma, neurologic exam and injury mechanism, which improved the misclassification rate of kBIG 2 to 0.8 % and maintained a rate of 0 % for all low-risk patients. Conclusions: We propose BIG for Kids, a modified version of the adult BIG for the management of TBI in pediatric patients. The kBIG was conservatively designed to ensure safety and to reduce unnecessary radiation exposure and resource utilization. Level of evidence: Cohort study/IV.