What is the management for a patient with traumatic brain injury presenting with abdominal pain and projectile vomiting?

Management of Traumatic Brain Injury with Abdominal Pain and Projectile Vomiting

In a patient with traumatic brain injury presenting with abdominal pain and projectile vomiting, you must immediately rule out both increased intracranial pressure requiring neurosurgical intervention AND concomitant intra-abdominal injury, as these symptoms can represent either neurological deterioration or occult abdominal trauma that demands urgent intervention. 1, 2

Initial Assessment Priority

The critical first step is distinguishing between central neurological causes versus actual abdominal pathology:

• Maintain systolic blood pressure >110 mmHg immediately, as hypotension worsens TBI outcomes and cerebral perfusion 1, 2
• Secure the airway with tracheal intubation and mechanical ventilation with end-tidal CO2 monitoring, targeting EtCO2 of 30-35 mmHg to prevent both hypercapnia and dangerous hypocapnia-induced cerebral vasoconstriction 1, 2
• Use vasopressors (phenylephrine or norepinephrine) for rapid blood pressure correction rather than waiting for fluid resuscitation alone 1, 2

Diagnostic Approach

Perform immediate non-contrast head CT AND contrast-enhanced thoraco-abdominal CT to simultaneously evaluate for:

Neurological Causes:

• Increased intracranial pressure from mass lesions (subdural/epidural hematoma >5mm thickness with >5mm midline shift) 1
• Acute hydrocephalus requiring drainage 1
• Diffuse axonal injury patterns on specialized imaging if initial CT is normal but symptoms persist 2

Abdominal Causes:

• Solid organ injury (liver, spleen, kidney) with active bleeding 1
• Hollow viscus perforation 1
• Diaphragmatic laceration 1

A critical pitfall: Abdominal pain with vomiting in TBI can result from the brain injury itself through spinothalamic tract damage or intestinal barrier dysfunction, NOT just from direct abdominal trauma 3, 4, 5. However, you cannot assume this without imaging to exclude surgical abdominal pathology first 1.

Management Algorithm Based on Findings

If Imaging Shows Increased ICP Without Abdominal Injury:

1. Institute intracranial pressure monitoring for severe TBI 1, 2
2. Perform external ventricular drainage for persistent intracranial hypertension despite sedation 1, 2
3. Consider decompressive craniectomy (>100 cm² temporal craniectomy with dural plasty) for refractory intracranial hypertension in multidisciplinary discussion 1
4. Treat vomiting as a neurological symptom with antiemetics while addressing the underlying ICP elevation 6

If Imaging Shows Abdominal Injury:

For hemodynamically stable patients without peritoneal signs:

• Pursue non-operative management (NOM) as first-line for solid organ injuries (liver, spleen, kidney), even high-grade injuries (OIS 4-5), with close clinical and radiological monitoring 1
• Consider therapeutic angio-embolization for documented active bleeding on CT (contrast extravasation) 1

For hemodynamically unstable patients or those with peritoneal signs:

• Proceed to immediate laparotomy for hemorrhagic shock unresponsive to resuscitation or signs of hollow viscus perforation 1
• Damage control surgery should be employed in severe cases 1

If Both Neurological and Abdominal Injuries Present:

This represents the most challenging scenario with synergistic worsening of prognosis 1:

• Address life-threatening hemorrhage first through angio-embolization or damage control laparotomy while simultaneously managing ICP 1
• Avoid hypotension at all costs as it catastrophically worsens both conditions - use aggressive fluid resuscitation with blood products and vasopressors (dopamine or epinephrine preferred over norepinephrine for their tachycardic effects) 1
• Coordinate neurosurgical and trauma surgery teams for potential simultaneous or staged interventions 1

Ongoing Management Considerations

• Initiate thromboprophylaxis with LMWH within 48-72 hours once bleeding is controlled, as VTE rates increase fourfold when delayed beyond 72 hours 1
• Begin early enteral feeding within 72 hours unless contraindications exist (uncontrolled shock, vasopressor use, bowel ischemia, obstruction) 1
• Monitor for delayed intestinal dysfunction as TBI can cause intestinal barrier breakdown through ischemia-reperfusion injury and inflammatory responses, manifesting days after injury 4, 5
• Consider neuropathic pain medications (pregabalin, gabapentin) if abdominal pain persists despite negative imaging and adequate TBI management, as central pain from spinothalamic tract injury can mimic visceral pain 3

Critical Pitfalls to Avoid

Do not attribute all abdominal symptoms to the head injury - up to 20% of severe trauma patients have significant abdominal injuries that require intervention 1. The presence of vomiting, while a reliable sign of concussion 6, does not exclude concurrent abdominal pathology 1.

Do not delay imaging - both head and abdominal CT should be performed without delay in this clinical scenario 1.

Do not allow hypotension to persist - even a single episode of systolic BP <90 mmHg (and particularly <110 mmHg) dramatically worsens TBI outcomes 1, 2.