Head

The BIG Brain Injury Guidelines

June 6, 2025 The Trauma Pro Leave a comment

Until five years ago, there was tremendous variability in the way brain injuries were managed at trauma centers. There were no clear guidelines describing what should be done during the initial evaluation, and no consensus as to when to involve neurosurgery. This resulted in a lot of flailing about and unnecessary calls to our neurosurgical colleagues.

Then the Brain Injury Guidelines (BIG) came along 15 years ago. They were developed to allow trauma programs to stratify head injuries in such a way as to better utilize resources such as hospital beds, CT scanning, and neurosurgical consultation.

Injuries are stratified into three BIG categories, and management is based on them. Here is the stratification algorithm:

And here is the management algorithm based on the stratification above:

(RHCT = repeat head CT)

The original study was published ten years ago and was a retrospective review of 4,000 patient records. It found that a significant number of these patients could be managed exclusively by the trauma surgeons.

The AAST BIG Multi-Institutional Group set about prospectively validating this system to ensure that it was accurate and safe. They identified adult patients from ten high level trauma centers that had a positive initial head CT scan. They looked at the the need for neurosurgical intervention, change in neuro exam, progression on repeat head CT, any visits to the ED after discharge, and readmission for the injury within 30 days.

Here are the factoids:

About 2,000 patients were included in the study, with BIG1 = 15%, BIG2 = 15%, and BIG3 = 70% of patients
BIG1: no patients worsened, 1% had progression on CT, none required neurosurgical intervention, no readmits or ED visits
BIG2: 1% worsened clinically, 7% had progression on CT, none required neurosurgical intervention, no readmits or ED visits
All patients who required neurosurgical intervention were BIG3 (20% of patients)

The authors concluded that using the BIG criteria, CT scan use and neurosurgical consultation would have been decreased by 29%.

Bottom line: This is an exciting paper! BIG has been around for awhile, and some centers have already started using it for planning the management of their TBI patients. This study provides some validation that the system works and keeps patients safe while being respectful of resource utilization.

My only criticism is that the number of patients in the BIG1 and BIG2 categories is low (about 600 combined). Thus, our experience in these groups remains somewhat limited. However, the study is very promising, and more centers should consider adopting BIG to help them refine their management of TBI patients.

This was the first prospective study of the BIG criteria. A great deal of additional work has been done. And now, an attempt has been made to simplify this algorithm even further.

In my next post, I’ll review the modified BIG (mBIG) criteria and describe them in detail.

References:

The BIG (brain injury guidelines) project: defining the management of traumatic brain injury by acute care surgeons. Journal of Trauma and Acute Care Surgery, 76(4), 965-969.
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.

Equipment

So You Want Your Own Hybrid Room?!

June 3, 2025 The Trauma Pro Leave a comment

You’re hooked! You are thinking back to a number of cases that you think might have done better with a hybrid room. And now let’s assume you already have one in your OR suite. Now what do you do? Here’s my final post in this series to give you some things to think about.

The key is to avoid jumping right in and sending your next eligible patient straight to that room. You absolutely must take some time to develop policies and guidelines to make sure things go smoothly.

Here are some important things to think about:

Identify which specific patients are eligible so you don’t squander this resource
Who calls the OR to secure the room (surgeon, resident, other)?
Who calls the interventional radiologist?
What if another case (TEVAR, etc) is already on the table?
What if another case is getting ready to use the OR? How are conflicts resolved?
Develop an initial in-room report process so all the teams know the game plan
Assign an extra circulator to the room. You’ll need them!
Make sure all retractor and positioning systems (abdomen, crani) fit the table! Remember that little asterisk in the previous section? Some retraction systems may need adaptors to work with your table. Don’t find this out at the last minute!
What about lithotomy position? How will this work with your hybrid table? Most don’t have sections that break away, so this will not be available to you.
Ensure radiation protection for all, including thyroid shields.
Bag the bottom x-ray detector, otherwise it will get very, very gross!
Create an external fixator equipment cart that can be moved into the hybrid room. This will save time over having someone go pick individual items from the central core.
Create an embolization cart with appropriate wires, catheters, coils, etc. This stuff may not be stocked normally in the hybrid room.
If embolization is needed, be sure to have a “gopher” to fetch any equipment that’s not already on the cart or in the room.

And I’m sure there are more details that I haven’t thought of. If you have some helpful suggestions, policies, or protocols, please share them with me!

Technology

Utility Of The Hybrid OR For Trauma: Recent Literature

May 27, 2025 The Trauma Pro Leave a comment

As I mentioned in the last post, the early literature on the use of the hybrid OR for trauma patients was just so-so. However, additional work has been done, and the real benefits are becoming clearer. Today, I’ll describe a pair of more recent, related papers that examined trauma outcomes in the hybrid OR.

The research was performed at the University of Florida Health, Gainesville. The group published an initial paper analyzing 106 adult trauma patients managed in a regular OR, comparing them with another 186 who were taken to a newly repurposed hybrid OR. This room was a remodeled angiography suite that was located within the OR complex.

Here are the factoids:

Overall demographics of the two groups were similar
Initial hemoglobin in the hybrid group was about 1g/dL lower (10.2 vs 11.1)
Nine times as many hybrid patients had a REBOA balloon placed (9% vs 1%)
The time to hemorrhage control was significantly shorter in the hybrid group
The hybrid OR patients required fewer blood and plasma transfusions between 4 and 24 hours after arrival
Infectious complications and ventilator days were significantly lower in the hybrid OR group
Mortality was similar (13% hybrid vs 10% conventional)

The authors published a follow-up paper three years later in which they analyzed the original data to determine the cost-utility and value. They did this by examining the clinical outcomes relative to the cost of this new resource. They found that the costs across the patient admission were similar in the hybrid and conventional groups ($55K vs $51K). The authors concluded that the better outcomes described in their first paper came with no significant increase in cost.

Bottom line: There is still precious little data on the benefits of the hybrid OR for trauma patients. Even though the total numbers appear to be small, it is difficult to amass the hybrid group sizes described here. It is the best US data we have so far, and shows promising results for minimal extra cost.

In my next post, I’ll conclude with some tips and tricks for setting up your own hybrid room.

References:

Clinical Impact of a Dedicated Trauma Hybrid Operating Room. Journal Am Col Surg 232(4):560-570, 2020.
Retrospective Value Assessment of a Dedicated, Trauma Hybrid Operating Room. J Trauma 94(6):814-822, 2023.

General

Is The Hybrid OR For Trauma Useful?

May 23, 2025 The Trauma Pro Leave a comment

Gee, the hybrid OR sounds like a great idea for specific trauma patients. We’ve seen this before; it’s a great idea but doesn’t always translate into a positive result. Is there any literature?

Unfortunately, very little until a few years ago. A group from the University of Calgary in Alberta published a very detailed paper on the nuts and bolts of how they designed their hybrid room from scratch. This paper is very detailed, and the hospital personnel were thoughtful as they approached the time-consuming and expensive task of designing and building their hybrid room. Of course, they chose a silly acronym as so many do. They called it their RAPTOR room (Resuscitation with Angiography, Percutaneous Treatments, and Operative Resuscitations). Sigh!

Next, they retrospectively analyzed their experience with persistently hypotensive patients arriving at their Level I trauma center over a 17-year period before their hybrid room opened.

Here are the factoids:

Of 911 patients, 510 remained persistently hypotensive (SBP<90 torr)
53% (270 patients) were taken directly to the OR, usually for laparotomy, thoracotomy, or vascular procedure
29% were admitted to an ICU, 13% to a ward bed, and 5% were taken to interventional radiology (IR)
35 patients (7%) required both OR and IR; the majority had pelvic fractures (77%), the rest had liver lacerations
Each case was reviewed, and overall, 6% of patients would have clearly benefited from a hybrid room, and 30% would have potentially benefited

Sounds good so far! But we need some more data. Unfortunately, there’s not a lot of it yet. A Japanese group described their experience treating patients in OR then IR, versus a “hybrid procedure.” This did not involve the use of a true hybrid OR. They moved a C-arm fluoroscopy unit into an OR, and part of the procedure was carried out by an interventional radiologist.

And the factoids:

A total of 13 “hybrid treatment” patients were compared to 45 who underwent both operation and angiography, but not in the same location
Most of the hybrid patients had a laparotomy, but there was a concomitant thoracotomy in one and a craniotomy in another
The actual survival in the hybrid patients was 85%, while TRISS predicted that only 62% would live
There was no difference in transfusion volumes between the two groups, but total procedure time was significantly shorter in the hybrid group (4 hours vs 6 hours)

Okay, sounds promising. A second Japanese paper was published last year with much larger numbers. Their hybrid OR was actually a hybrid ER! They installed a multi-slice interventional radiology/CT unit in their resuscitation room! Here are the key findings:

A total of 696 patients were reviewed over an 8-year period – 336 hybrid and 360 conventional
Mortality was very significantly decreased in the hybrid group
OR start was significantly shortened from 68 minutes to 47 minutes

Here’s an image of their setup:

Key: A – mobile CT scanner, B – CT / OR table, C – mobile C-arm, D – 56” monitor, E – ultrasound, F- ventilator

Bottom line: This is quite a unique room. Unfortunately, it is not ideal because it is small and cramped. It looks like it would be difficult to fit more than one surgical team in the room. However, the results look good.

We are finally seeing objective data involving a reasonable number of patients. A minority of trauma programs have a hybrid OR available to them, and the number of patients who would benefit from it is low. But if a patient needs it, this setup can be life-saving. So who are those patients, exactly?

In my next post, I will review some of the most recent (and favorable) papers supporting the use of the hybrid OR for trauma.

References:

The evolution of a purpose designed hybrid trauma operating room from the trauma service perspective: The RAPTOR (resuscitation with angiography percutaneous treatments and operative resuscitations). Injury 45:1413-1421, 2014.
The potential benefit of a hybrid operating environment among severely injured patients with persistent hemorrhage: How often could we get it right? J Trauma 80(3):457-460, 2016.
Hybrid treatment combining emergency surgery and intraoperative interventional radiology for severe trauma. Injury 47:59-63, 2016.
The Survival Benefit of a Novel Trauma Workflow that Includes Immediate Whole-body Computed Tomography, Surgery, and Interventional Radiology, All in One Trauma Resuscitation Room. Ann Surg 269(2):370-376, 2019.

Equipment

Why Use A Hybrid OR For Trauma?

May 20, 2025 The Trauma Pro Leave a comment

Trauma is a surgical disease, and specifically, a disease of bleeding. So many of the tools and processes we have developed for its management revolve around the control of hemorrhage.

When a major trauma patient arrives in the resuscitation room, the initial management involves rapid assessment and correction of life-threatening conditions. Recognition of bleeding is paramount. A rapid decision must be made about the source of hemorrhage and the best way to control it.

Traditionally, bleeding control has been relegated to the operating room. Body cavities are opened as appropriate, and exsanguination is controlled by clamping, repairing, and/or suturing.

However, some body regions are much more challenging. The most notable is the pelvis, and specifically, the unstable pelvis. In the old days, after wrapping or applying an external fixator, the best we could do was to ligate the internal iliac arteries bilaterally and hope the bleeding would slow down sufficiently (it never really stopped) so that internal packing might have a chance.

As the use of interventional radiography grew in trauma, it became possible to occlude the internal iliacs noninvasively. Then, the radiologists became skilled enough to selectively identify and embolize more distal bleeding vessels that would dramatically shut down pelvic bleeding.

But this introduced a conundrum. OR vs IR? Where to go after the trauma bay? I’ve long said that the only place an unstable trauma patient can go is to the OR. Not CT, and certainly not the radiology department.

Only the OR, because that’s the only place that something can actually be done about the bleeding. However, that’s not entirely true now.

Here’s the traditional algorithm for a patient with hemorrhage from pelvic fractures:

They go to the operating room or interventional radiology. If they start in the operating room and can be stabilized (think external fixation and/or preperitoneal packing), then they might be able to be packaged and taken to IR for embolization. Likewise, if they were initially stable enough to go to IR but crashed there, then they must immediately be taken to OR.

But what if you could do both in one room with interventional radiology capabilities and a full resuscitation team with surgical instruments?! That’s the beauty of the hybrid room! It is entirely possible to do two, three, and maybe more cases on the same patient in the same room. Hence, the hybrid OR.

Next post: Is the hybrid OR for trauma useful?

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