Brain Injury Guidelines
BIG Evaluation and Initial Management of Patients with Traumatic Brain Injury Guideline
Date: 03/2026 | Supersedes: 08/2025 | Location: MH Katy
| Brain Injury Guidelines | |||
|---|---|---|---|
| Variable | BIG 1 | BIG 2 | BIG 3 |
| Loss of consciousness | Yes/No | Yes/No | Yes/No |
| Neurologic examination | Normal (GCS 15) |
Normal (GCS 15) |
Abnormal (GCS <15) |
| Intoxication | No | No/Yes | No/Yes |
| Anticoagulant or antiplatelet medication* | No | No | Yes |
| Skull fracture | No | Non-displaced | Displaced |
| Subdural hematoma | ≤4 mm | 5-7 mm | ≥8 mm |
| Epidural hematoma | ≤4 mm | 5-7 mm | ≥8 mm |
| Intraparenchymal hemorrhage | ≤4 mm and 1 location |
3-7 mm and/or 2 locations |
≥8 mm and/or multiple locations |
| Subarachnoid hemorrhage | Trace (≤3 sulci) | Localized (single hemisphere) |
Scattered (bi-hemispheric) |
| Intraventricular hemorrhage | No | No | Yes |
| *warfarin, aspirin (excluding 81 mg), clopidogrel, DOAC | |||
| Brain Injury Guideline Treatment | |||
|---|---|---|---|
| BIG 1 | BIG 2 | BIG 3 | |
| Hospitalization | No Observation (6 hours) |
Yes Observation (23 hours) |
Yes |
| Repeat CT Head | No | Yes* | Yes |
| Neurosurgery consultation | No | No | Yes |
| Seizure prophylaxis | Yes | Yes | Yes |
| To be categorized as BIG 1, a patient must meet ALL criteria. Any BIG 2 or BIG 3 criterion met places the patient in the GREATER of the two groups. *The original BIG criteria do not require repeat CT Head for BIG 2. As this is a new practice, we plan to obtain repeat CT Head in BIG 2 and track results. |
|||
Follow Up:
- Primary Care Physician – BIG 1 or BIG 2 who are asymptomatic
- MH Katy Trauma Clinic – BIG 1 or BIG 2 who have persistent post concussive symptoms
- Neurosurgery – BIG 3 and any patient seen in consultation by Neurosurgery
Also see:
- Management of Severe Traumatic Brain Injury
- Management of Patients with Traumatic Brain Injury on Anticoagulant or Antiplatelet Therapy
Post traumatic seizure prophylaxis
Levetiracetam (Keppra):
- Loading dose: 1 g IV once
- Maintenance dose: 1 g PO/IV q12 hours for 7 days post-injury
- Pills can be crushed and put down enteral feeding tubes without tube feed disrup-tion
- Note: older patients may become somnolent with the 1g dosing. A lower dose (500mg) may be appropriate but has not been shown to be as effective a 1g in preventing post-traumatic seizures.