Guidelines for the

Management of Acute Blunt

Head Trauma in Alaska 2017

F R A N K S A C C O M D FA C S

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Isolated Blunt Head Injury in Alaska
2011-2015
1873 Isolated blunt head injuries.
About half (966) taken care in Anchorage/Seattle , Half (907) at hospital without neurosurgical
capability
74.5% (1397) GCS of 14,15
10.2% (191) GCS 9-13
15.2% (285) GCS 3-8
About one patient /day admitted with isolated blunt head trauma. Many more patients when
you consider patients seen and discharged from EDs and patients with TBI and multisystem
trauma are not included in these numbers
Transferred Patients from Non-neurosurgical Facilities
Sample 600pts with CT report and entered in state trauma registry

Mild 44% transfer rate

Transferred patients CT scans 82% abnormal 18%
normal

Moderate 66% transfer rate

Severe 70% transfer rate
Patients kept in Non-neurosurgical
facilities with GCS 14-15 (sample 260)
260 patients with GCS 14 or 15 initially admitted non-neurosurgical
facilities.
6.5% Secondary transfer rate (Transfer to another facility after initial
admission at another hospital)
There were no deaths in this group of 260 patients initially admitted
to non-neurosurgical facilities.
Natural History of Minor and Moderate
Head Injury
Teleradiology and Neurosurgical
consults
Head injured patients can be managed using teleradiology with
neurosurgeon review.
Telehealth consultations reduce patient transfers with subsequent low
rates of late transfer due to either clinical or radiological deterioration.

Ashkenazi I, Zeina AR, Kessel B, Peleg K, Givon A, Khashan T, Dudkiewicz M, Oren M, Alfici R, Olsha O. Effect of
teleradiology upon pattern of transfer of head injured patients from a rural general hospital to a neurosurgical
referral centre: follow-up study. Journal of Emergency Medicine. 2015;32(12):946-50.
Moya M, Valdez J, Yonas H, Alverson D. The impact of a telehealth web-based solution on neurosurgery triage
and consultation. Telemedicine Journal and E-Health. 2010;16:945-949.
Teleradiology for Head Injury
Italy
Germany
Israel

All with extensive use and experience with Teleradiology for TBI.
All showed 60-70% reduction in need for transfer
Results of UNM Gallup Teleradiology Pilot
42% (11) patients were treated locally

58% (15) patients were transferred to UNMH or elsewhere

Treatment Location

Local
Level I
Trauma
Center
2003 Alaska Head Injury Guidelines
Guidelines developed when many rural facilities did not have CT scan on site.
Question in 2003 “Which patients with blunt head trauma need to be
transferred for Neurosurgical care or CT imaging?”
Since then many rural facilities have acquired CT scan availability
Neurosurgery still only consistently available in Anchorage or Seattle.
The additional Question today 2017 is “Which patients with blunt head trauma
and abnormal head CT scans need to be transferred to a facility with
neurosurgical capabilities ?”
Medevac Safety and Availability
(NIOSH) reported that commercial pilots flying on commuter airlines or
charters in Alaska have a mortality rate five times that of pilots in the rest of the
United States.2

Although the safety of aeromedical evacuation services has improved over

time, the risk to patients and flight crews remains an important factor in
deciding to transfer patients.

Despite increased availability of medevacs it is still a limited resource and if it is

activated the region may be uncovered for time critical emergencies .
Medevac Costs
The cost of aeromedical transportation varies greatly across the state.
Fixed wing transportation costs to Anchorage ranges from $19,000 from the
Mat-Su Valley to $82,000 from Barrow.
Transport costs to Seattle, average approximately $160,000 per transport.
Aeromedical evacuation costs in the Southeast region are similar to Anchorage
or Seattle .
These risks and costs must be weighed when considering patient transport.
Medivac Cost by City
Transfer to Anchorage vs Seattle

$250,000.00

$200,000.00

$150,000.00

Cost to Anchorage_x000d_FIXED WING

Axis Title $100,000.00 Cost to Seattle_x000d_FIXED WING

$50,000.00

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2017 Management of Head Injured
Patients
Since 2003 many rural facilities have acquired CT scan availability.
Neurosurgery still only consistently available in Anchorage or Seattle.

The dominant Question today 2017 is:

“Which patients with blunt head trauma and abnormal

head CT scans need to be transferred to a facility with
neurosurgical capabilities ?”
Head Trauma Guideline Task Force
Frank Sacco M.D. Chair. General Surgery. Anchorage. Trauma
Director, Alaska Native Medical Center.
Cody Augdahl M.D. Family Medicine. Nome. Norton Sound Health
Corporation.
Elisha Brownson M.D. General Surgery. Anchorage. Alaska Native
Medical Center.
Suzanne Fix M.D. Neurosurgery. Anchorage. Coastal Neurology
and Neurosurgery.
Ellen Hodges M.D. Family Medicine. Bethel. Yukon-Kuskokwim
Health Corporation.
Rick Janik R.N. Juneau. Bartlett Regional Hospital.
Maria Mandich M.D. Emergency Medicine. Fairbanks. Fairbanks
Memorial Hospital.
Darrell Mathieu I.D.M.T. Elmendorf Air Force Base.
Ryan McGhan M.D. Intensive Care. Anchorage. Providence Alaska
Medical Center.
William Montano M.D. General Surgery. Fairbanks.
Patti Paris M.D. Emergency Medicine. Anchorage. Alaska Native
Medical Center.
Julie Rabeau R.N. Anchorage. Department of Health and Social
Services.
Ambrosia Romig M.P.H. Anchorage. Department of Health and
Social Services.
Ben Rosenbaum M.D. Neurosurgery. Anchorage. Anchorage
Neurosurgical Associates.
Ryan Urbonas M.D. Neurosurgery. Anchorage. Alaska Native
Medical Center.
Joel Verbrugge M.D. Radiology. Anchorage. Alaska Native Medical
Center.
Anne Zink M.D. Emergency Medicine. Mat-Su Regional Medical
Center.
Methods
Ad Hoc committee formed comprised of Neurosurgeons, Trauma surgeons, ED
physicians, Hospitalist/Critical Care, Radiology and prehospital representation.
Anchorage
Fairbanks
Nome
Bethel
Juneau
JBER
MatSu
Methods
The literature on evaluating head injured patients was reviewed by a subgroup of providers.
Special attention to guidelines from other organizations and from prospective or high volume
retrospective studies.
Synopsis of pertinent literature and references for these studies sent out to participants prior to
the meeting.
Previous guidelines included for review.
Meeting convened on February 2017
Guidelines approved and disseminated October 1 2017.
Will do interim review Spring 2018.
 Limitations-Small Children and Infants
Evaluation of head trauma in infants and small children presents
challenges. These guidelines apply to clinical practice for children over
the age of five.
Issues include:
Younger children are at higher risk for reactive cerebral edema.
Sedation is required for CT in the very young and carries a small but significant risk.
Lifetime radiation risk from CT is theoretically higher. 1 fatal malignancy /1000-10000 scans.
Availability of skilled medical personnel with training to monitor the very young patient.

(Alaska Guidelines for under 5yo to be developed in 2018)

Limitations –Alcohol and Drug Use.
GCS utility is limited as triage tool however presence of risk factors still suggests
need for CT in severely impaired patients.

If no signs of trauma, but GCS ≤13

Patients should be monitored by a healthcare provider with hourly neurochecks.
If clinical deterioration, head CT scan should be obtained or the patient should be transferred for CT
imaging.
If there no clinical improvement (return to GCS 15) after six hours, a head CT scan should be obtained
or the patient should be transferred for CT imaging.
Limitations- other conditions

These guidelines do not apply to strokes or hemorrhage not

associated with trauma.
- apply for blunt head trauma and are not recommended for
penetrating head trauma.
- apply to isolated head injury and are not recommended for
patients with significant multi-trauma injuries.
Definitions-Acute Blunt Head Trauma
Blunt traumatic brain injury (TBI) is a disruption in the
normal function of the brain that can be caused by a bump,
blow, or jolt to the head.
Includes falls that lead to head strike, including ground
level.
An acute injury is one that is evaluated within 24 hours of
the traumatic event.
 
Definitions-Medical observation

Neuro checks performed by a health care provider, at least

hourly for a minimum of six hours.
The patient should remain at the facility for a health care
provider to perform these checks.
Medical observation may be liberalized if the patient
returns to GCS 14-15.
Definitions-Glasgow Coma Scale
Eye(s) Opening Best Motor Response
Spontaneous 4
To speech 3 Obeys commands 6
To pain 2 Moves to localized pain 5
No response 1
Verbal Response Flexion withdraws from pain 4
Oriented to time, place, person 5 Abnormal flexion 3
Confused/disoriented 4
Inappropriate words 3 Abnormal extension 2
Incomprehensible sounds 2 No response 1
No response 1
 
Definition-Patients on Anti-coagulant
and anti-platelet therapy
Patients who are on anti-coagulants or anti-platelet therapy pre-
injury have been found to be at increased risk of intracranial
hemorrhage following blunt head trauma.12-15
Anti-coagulants
warfarin
direct oral anticoagulants (DOACs).

Anti-platelet therapy includes clopidogrel and aspirin.

excluding aspirin therapy alone up to 325mg/day.
Risk Factors
*** RISK FACTORS ***RISK FACTORS
Clinical or radiographic signs of skull Age > 65
fracture
Anticoagulation/Coagulopathy
Fracture on skull x-ray
Focal neurologic deficit
Hemotympanum
New onset seizures
Battle’s sign
Vomiting > 2 episodes
Raccoon eyes
Amnesia > 30 minutes
CSF leak
High energy mechanism
Definitions-Abnormal CT findings not requiring neurosurgical
consultation or transfer:

Several imaging abnormalities have been found to have no clinical significance or risk
for deterioration in the setting of isolated blunt head trauma.3,11
Non-depressed skull fracture, open or closed
Isolated pneumocephalus
Solitary cerebral contusion < 10mm
Multiple cerebral contusions < 5mm
Subarachnoid hemorrhage < 5mm
Subdural hemorrhage < 5 mm
These exceptions do not apply to patients who are on anti-coagulant or anti-platelet
therapy.
Guidelines for the Management of Acute Blunt Head Trauma in Alaska

GCS 1 5 No Risk
fa ctors * * * GCS 1 4 GCS 9 -1 3
GCS 8 or le s s
Se e Can adia n without ris k factors * * * GCS 1 4 -1 5 with risk fa ctors * * *
Hea d CT Rule

1 .Pr ote ct a irwa y

2 .Avoid hyp oxia
Me dica l obse rva tion CT Sca n of he a d /
3 .Avoid hyp ot en s ion
for 2 hour s Cs pine
4 .Ele va te HOB if a ble
5 . Cs pine im mobiliza tion

No improvem en t

CT sca n of he a d/ cs p ine if d oe s n’t

NO CT INDICATED de la y tra nsfe r.
Discha rge with S e nd im a ge s for re vie w
he ad injury
pa tient educa tion Ob ta in CT Sc a n he a d / Cs pine
s hee t a nd
com pe tent
obse rve r

Norm a l CT Abn or m a l CT
Norm a l CT Abn or m a l CT Norm a l CT
findings or CT not
findings findings * * findings
obta in ed

NEUROSURGERY 1 .Admit loca lly

1 .Medica l obs e rvat ion
TELERADIOLOGY 2 .Medica l obs e rvat ion TRAUMA Tra ns fe r or
2 .Discha rge with compete nt
CONSULT 3 .Conside r repe a t CT if CONSULT a dmit to
obse rve r whe n GCS 1 5 .
Se nd ima ges for re vie w de teriora tion or no a fte r Tra uma
3 . Cons ide r repe a t CT if
Trans fe r or a dmit clinica l improveme nt in ima ge s Cen te r with
de teriora tion or no clinica l ne uros urgica l
loca lly for obse rva tion 2 3 hrs . s ent for
improve me nt in 2 3 hrs . ca pa bilitie s
a fte r ne uros urgery 4 . GCS drop of 2 is re vie w
4 . GCS drop of 2 is significa nt
consulta tion s ignifica nt

* * ABNORMAL CT FINDINGS NOT REQUIRING

* * *RISK FACTORS * * * RISK FACTORS
CONSULTATION OR TRANSFER
Age > 6 5 Clinica l or radiographic
Non depre ss e d s kull fra cture ope n or clos e d
Anticoa gula tion/ Coa gulopa thy s igns of s kull fra cture
Solita ry ce re bra l contus ion < 1 0mm
Foca l neurologic de ficit Fra cture on s kull xra y
Multiple cerebra l contus ions < 5 mm
Ne w onse t s e izure s Hem otypanum
Su ba ra chnoid he morrha ge < 5 mm
Vomiting > 2 e pis odes Ba ttle ’s sign
Is ola te d pne umocepha lus
Amn es ia > 3 0 minut es Ra coon e ye s
Su bdura l hema toma < 5 mm
High e nergy mecha nism CSF lea k
DOESN’T APPLY TO PATIENTS ON ANTICOAGULATION
GCS 15 without risk factors
GCS 15 No Risk
factors * **
Canadian CT Head Rule:
See Can adian
Head CT Rule A non-contrast head CT should be considered in head trauma patients with
no LOC or post-traumatic amnesia if there is any of the following factors
present:
Suspected open or depressed skull fracture
Signs of basilar skull fracture (hemotympanum, raccoon eyes, Battle’s sign, oto-/rhinorrhea)
2 or more episodes of vomiting
Age ≥ 65

NO CT INDICATED Failure to reach GCS 15 within 2 hours of injury

Discha rge with
head injury Retrograde amnesia to the event ≥30 minutes
patient education
sheet and Dangerous mechanism of injury (pedestrian struck, ejected from MVC, fall from > 3 feet)
competent
obse rver
**These criteria exclude age < 16, use of blood thinners, or patients with seizure after injury
or neurologic deficit.
GCS 14 without risk factors
GCS 14
GCS 14 without risk factors
without risk factors ***

Medical observation for 2 hrs.

If GCS improves to 15 NO CT and discharge home with head injury
Medica l observa tion
for 2 hours
patient education sheet.
If no improvement CT scan head and cspine
NO CT INDICATED
Discharge with
head injury Ob tain CT Scan head / Cspine
Normal CT – observe until GCS 15
patient education
sheet and
competent
observer
Repeat CT if deterioration or no clinical improvement in 23 hrs.
GCS drop 2 is significant
Normal CT Abn ormal CT
findings findings * *
Abnormal CT findings -Neurosurgical Teleradiology
Consult
1.Medical observation
2.Discharge with competent observer when
NEUROSURGERY TELERADIOLOGY Send images for review.
CONSULT
GCS 15 .
Send images for review
3. Consider repeat CT if deterioration or no
clinical improvement in 23 hrs.
Transfer or admit locally for observation
after neurosurgery consultation
Transfer or admit locally for observation after neurosurgery consult
4. GCS drop of 2 is significant
GCS 9-13 and GCS 14 with risk factors
GCS 9 -1 3
GCS 1 4 -1 5 with risk fa ctors * * *
All patients should have a CT scan
If CT scan is normal
CT Sca n of he a d /
Cs pine
Admit locally for medical observation.
Consider repeat CT if deterioration or no clinical improvement
in 23 hrs.
GCS drop of 2 or more is clinically significant.
Abn or ma l CT
findings * *
Norm a l CT
findings If CT is abnormal

NEUROSURGERY 1 .Admit loca lly

TELERADIOLOGY
CONSULT
Se nd ima ges for re vie w
Trans fe r or a dmit
loca lly for obse rva tion
a fte r ne uros urgery
cons ulta tion
Send images for Neurosurgery Teleradiology Consult
2 .Medica l obs e rvat ion
3 .Cons ide r repe a t CT if
de teriora tion or no
clinica l improveme nt in
Transfer to trauma center or admit locally for observation
2 3 hrs .
4 . GCS drop of 2 is
s ignifica nt
based on neurosurgery consultation
GCS 8 or less
GCS 8 or le s s
Protect the airway.
Avoid hypoxia and hypotension
1 .Pr ote ct a irwa y
2 .Avoid hyp oxia
3 .Avoid h yp ot en s ion
4 .Ele va te HOB if a ble
5 . Cs p ine im mob iliza tio n
Elevate head of bed if possible.
Cspine immobilization.
CT s ca n of h e a d / cs p in e if d oe s n’t
d e la y tr a ns fe r.

CT scan of head and Cspine if doesn’t delay transfer.

S e nd im a ge s for re vie w

Send images for review.

Ab n or m a l CT
Norm a l CT
o r CT no t
fin dings
ob ta in ed

Normal CT –Consult Trauma Service

TRAUMA
Tr a ns fe r or
a dm it to
Abnormal CT - Transfer to Trauma Center with neurosurgical
CONSULT a fte r
im a ges s e nt
for re vie w
Tr a um a Ce nte r
with
ne ur os ur gica l
ca pa b ilitie s
capability
ANTICOAGULATION OR ANTIPLATELET THERAPY
(Including ground level falls, excluding patients on aspirin)
GCS 14 or 15 who are on anti-coagulants or anti-platelet
therapy. a non-contrast CT head should be obtained and
consideration of C-spine CT if clinically indicated.
Warfarin - INR level <3. If
the head CT imaging is normal , medical observation
locally for a minimum of 12 hours.
After medical observation and GCS to 15 discharge with
a competent observer and head injury patient education
sheet.
The patient should be counseled that they are at
increased risk of a delayed bleed and should be given
warning signs requiring repeat medical evaluation.
ANTICOAGULATION OR ANTIPLATELET THERAPY
(Including ground level falls, excluding patients on aspirin)
GCS 14-15
CT imaging normal, INR level is ≥ 3
medical observation locally with a repeat
head CT in 23 hours or if clinical deterioration.
Discontinuation of warfarin therapy and
consideration of reversal as clinically appropriate.
If repeat CT imaging remains normal, patient may
be discharged with a competent observer and
head injury patient education sheet.
The patient should be counseled that they are at
increased risk of a delayed bleed and should be
given warning signs requiring repeat medical
evaluation.
ANTICOAGULATION OR ANTIPLATELET THERAPY
(Including ground level falls, excluding patients on aspirin)

CT imaging is abnormal Images

via teleradiology for review by a
neurosurgeon. Local
admission or transfer based on neurosurgical
recommendations. Consideration of
reversal should be made in consultation with
neurosurgery.
Patients with GCS ≤ 13, the previous
guidelines may be followed.
Check INR levels if the patient is on warfarin
therapy.
Consideration of reversal if the INR is ≥ 3 or if
CT shows intracranial hemorrhage.
REVERSAL ANTICOAGULATION ON ACUTE BLUNT HEAD TRAUMA
PATIENTS
(Including ground level falls, excluding patients on aspirin)
ABNORMAL CT FINDINGS USUALLY NOT
REQUIRING CONSULTATION OR TRANSFER
**ABNORMAL CT FINDINGS NOT REQUIRING CONSULTATION OR TRANSFER
Non depressed skull fracture open or closed
Solitary cerebral contusion < 10mm
Multiple cerebral contusions < 5mm
Subarachnoid hemorrhage < 5mm
Isolated pneumocephalus
Subdural hematoma< 5 mm

DOESN’T APPLY TO PATIENTS ON ANTICOAGULATION

Emergency Craniotomy
Decision should only be made in consultation with a neurosurgeon.
Decompressive craniotomy or burr holes should be a consideration only if:
-There is CT imaging consistent with an epidural or subdural hematoma.
-The patient is rapidly deteriorating.
-A facility with a neurosurgeon is more than two hours away.
Most importantly, there needs to be a surgeon capable of doing the procedure
along with the necessary equipment.
Non Salvageable Head Injuries
Patients should be medically optimized with:

protection of the airway,

avoidance of hypoxia,
avoidance
of hypotension,
elevating the head of bed to greater than thirty
degrees if possible, and cervical spine immobilization.
Non Salvageable Head Injuries

Patients should undergo CT scan imaging and prompt neurosurgical

teleradiology consult.
In some circumstances, it is reasonable not to transport these patients to a
facility with neurosurgical capabilities.
This decision should be made with the input of a neurosurgical consultation.
It is appropriate to transport patients with brain death or impending brain
death that are potential organ donors.
Conclusions

An approach to the evaluation of head injured patients in Alaska,

including facilities that do not have a neurosurgeon or CT imaging
available.
It is an attempt to combine a reading of current literature with the
realities of medical practice and resource availability in our state.
It is not meant to replace clinical judgment.
There are limits to the applicability of these guidelines, including
small children and infants and patients under the influence of drugs
or alcohol.
Conclusions
Our state is unique in the factors that may play into obtaining CT
scans or neurosurgical consults, especially the frequent need for
aeromedical transport and delays in care.

Our hope is that this will offer some guidance to clinicians faced with caring for
the head injured patient in this very challenging environment.
In addition, it will help us utilize our transport and subspecialty resources in a
safe, responsible, and efficient manner.