Oct 27, 2025
Contributor: Aaron Lessen, MD
Educational Pearls:
Traumatic Brain Injuries are a frequent complaint in the Emergency Department and have increased in recent years. The American Association for Surgery of Trauma (AAST) has created Brain Injury Guidelines (BIG), in an attempt to categorize brain injuries and the level of treatment they require. They are…
BIG 1
- Normal neuro exam
- Not intoxicated
- Not on anticoagulation or antiplatelet medications
- Minimal findings on head CT
- No fracture
- <4 mm bleed (subdural, epidural, intraparenchymal (max one location))
- Maximum of “trace” subarachnoid hemorrhage
- No intraventricular hemorrhage
- Monitor for 6 hours
- No need to repeat the head CT
- No need to consult neurosurgery
BIG 2
- Normal neuro exam
- Not on anticoagulation or antiplatelet medications
- Any of the following
- Intoxicated
- Slightly more findings on head CT
- Non-displaced skull fracture
- 4-8 mm bleed (subdural, epidural, intraparenchymal (max two locations))
- Maximum of “localized” subarachnoid hemorrhage
- No intraventricular hemorrhage
- Hospitalize
- No need to transfer
- No need to repeat the head CT
- No need to consult neurosurgery
BIG 3
- Abnormal neuro exam
- On anticoagulation or antiplatelet medications
- Intoxicated
- Significant findings on head CT
- Displaced skull fracture
- >8 mm bleed (subdural, epidural, intraparenchymal (or more than 2 locations))
- “Scattered” subarachnoid hemorrhage
- Intraventricular hemorrhage
- Full treatment, admission to trauma center, neurosurgery evaluation
References
- Joseph B, Friese RS, Sadoun M, Aziz H, Kulvatunyou N, Pandit V, Wynne J, Tang A, O'Keeffe T, Rhee P. The BIG (brain injury guidelines) project: defining the management of traumatic brain injury by acute care surgeons. J Trauma Acute Care Surg. 2014 Apr;76(4):965-9. doi: 10.1097/TA.0000000000000161. PMID: 24662858.
- Joseph B, Obaid O, Dultz L, Black G, Campbell M, Berndtson AE, Costantini T, Kerwin A, Skarupa D, Burruss S, Delgado L, Gomez M, Mederos DR, Winfield R, Cullinane D; AAST BIG Multi-institutional Study Group. Validating the Brain Injury Guidelines: Results of an American Association for the Surgery of Trauma prospective multi-institutional trial. J Trauma Acute Care Surg. 2022 Aug 1;93(2):157-165. doi: 10.1097/TA.0000000000003554. Epub 2022 Mar 28. PMID: 35343931.
