Background The Brain Injuries in Greater East Texas (BIGTEX) criteria were developed to identify patients with mild traumatic brain injury (mTBI) who may be managed at Level IV trauma centers (L4TCs). This study compared outcomes of mTBI patients treated at a Level I trauma center (L1TC) vs affiliated L4TCs. Methods A 10-year retrospective review of mTBI admissions was performed. Patients were grouped by location: L1TC or L4TC. Adverse events included neurological deterioration, worsening CT scan, neurosurgical intervention, or death. At L4TCs, patients received routine emergency care with neurological assessments performed by trauma-trained staff. Decisions to transfer were made by the treating emergency physician, independently or in consultation with the affiliated L1TC, using established transfer pathways. Results Seventy-four patients were included: 63 treated at the L1TC and 11 at L4TCs. The L1TC group met BIGTEX criteria; several L4TC patients had minor deviations, including low-dose aspirin (n = 5), intraparenchymal hemorrhage 5-7 mm (n = 1), and subarachnoid hemorrhage (focal n = 1; diffuse n = 2). All presented with GCS 14-15, no intoxication, polytrauma, or skull fractures. All remained neurologically stable, with no neurosurgical interventions or deaths. L4TC patients had more CT scans (median 3 vs 2), slightly longer hospital stays (3 vs 2 days), shorter ICU stays (0 vs 2 days), and lower hospital charges (30, 236 vs 38, 076). Conclusion Selected mTBI patients, including those with minor BIGTEX deviations, were managed at L4TCs without observed adverse outcomes. These findings support the feasibility of local management in carefully selected patients and warrant prospective validation in broader rural trauma populations.
Poudel et al. (2026) studied this question.