What is the management for a head injury with vomiting?

Management of Head Injury with Vomiting

A patient with head injury and vomiting requires immediate emergency department evaluation with non-contrast head CT imaging, as vomiting is a validated predictor of clinically important intracranial injury and potential need for neurosurgical intervention. 1

Immediate Assessment and Triage

Activate EMS for High-Risk Features

• Loss of consciousness, worsening headache, repeated vomiting, altered mental status, seizures, visual changes, or scalp swelling/deformities warrant immediate EMS activation. 1
• These signs are associated with life-threatening injuries including epidural hematoma, subdural hematoma, open skull fracture, or brain edema requiring hospital treatment. 1

Remove from Activity

• Any person with signs of head injury must be immediately removed from activity (sports/play) and not allowed to return until evaluated by a healthcare professional. 1

Emergency Department Evaluation

CT Imaging Indications

Vomiting after head injury is a validated criterion across multiple clinical decision rules for obtaining head CT:

Canadian CT Head Rule (CCHR) - High-Risk Factors: 1, 2

• Vomiting more than once (≥2 episodes) has 100% sensitivity for predicting need for neurosurgical intervention
• This criterion alone mandates CT imaging regardless of other findings

New Orleans Criteria (NOC): 1, 2

• Any vomiting in patients with GCS 15 and history of loss of consciousness or amnesia has 100% sensitivity (95% CI 95-100%) for intracranial injury
• Additional risk factors include: headache, age >60 years, drug/alcohol intoxication, short-term memory deficits, trauma above clavicles, or seizure

NEXUS Head CT Decision Instrument: 1

• Persistent vomiting is one of eight high-risk criteria requiring CT imaging
• Other criteria include skull fracture evidence, scalp hematoma, neurologic deficit, abnormal alertness, abnormal behavior, coagulopathy, and age ≥65 years

Recurrent Vomiting Carries Higher Risk

• Recurrent vomiting (≥4 episodes) significantly increases risk of intracranial injury (OR 2.3,95% CI 1.7-3.1) and need for neurosurgical intervention (OR 3.5,95% CI 1.5-7.9). 3
• The probability of intracranial injury increases with each additional vomiting episode, especially when accompanied by signs of skull fracture, irritability, or GCS <15 at 2 hours post-injury. 3

Management Algorithm

Step 1: Initial Stabilization

• Assess airway, breathing, circulation with attention to cervical spine protection 4, 5
• Obtain Glasgow Coma Scale score and vital signs 1
• Document all neurological findings including mental status, focal deficits, and pupillary responses 4

Step 2: Risk Stratification

Obtain head CT if ANY of the following present: 1, 2

• Vomiting ≥2 episodes
• GCS <15 at 2 hours post-injury
• Age ≥60-65 years
• Suspected skull fracture (open, depressed, or basilar)
• Headache (especially severe)
• Altered mental status or amnesia >30 minutes
• Focal neurological deficits
• Seizure
• Anticoagulation or coagulopathy
• Physical evidence of trauma above clavicles

Step 3: Post-CT Management

If CT Shows Intracranial Injury: 6

• Neurosurgical consultation for lesions requiring intervention
• Admission for observation with serial neurologic examinations
• Maintain mean arterial pressure ≥80 mmHg and avoid hypoxemia (SaO2 <90%)

If CT is Negative: 6

• Patients with negative head CT can be safely discharged without admission or prolonged observation. 6
• Multiple large prospective studies demonstrate minimal risk for delayed intracranial lesions after negative CT 6
• In one study of 1,170 mild TBI patients with negative CT admitted for 24-hour observation, none experienced neurologic deterioration 6

Discharge Instructions for Negative CT

Return Precautions (Written and Verbal)

Provide instructions to return immediately for: 6

• Memory problems or confusion
• Abnormal behavior
• Increased sleepiness or loss of consciousness
• Worsening headache
• Repeated vomiting
• Vision problems
• Seizures

Postconcussive Symptom Education

Educate about expected symptoms: 6

• Dizziness and balance problems
• Nausea
• Sensitivity to noise and light
• Depression, mood swings, anxiety, irritability
• Sleep disturbances

Important Caveats

• Frequent waking or pupil checks at home are NOT recommended for patients with negative CT scans. 6
• Instructions should be written at 6th-7th grade reading level with font ≥12 points 6

Antiemetic Use

Ondansetron Safety

• Ondansetron can be safely used in children with head injury and vomiting after CT imaging without masking serious conditions. 7
• Use is associated with lower likelihood of return visits within 72 hours (OR 0.49,95% CI 0.26-0.92) 7
• Does not increase risk of missed diagnoses in patients discharged after evaluation 7

Special Populations Requiring Individualized Assessment

Higher Risk Groups (may require admission despite negative CT): 6

• Patients on anticoagulation therapy (warfarin, NOACs) or antiplatelet agents beyond aspirin
• Bleeding disorders or coagulopathy
• Previous neurosurgical procedures
• Inability to follow discharge instructions reliably

Common Pitfalls to Avoid

• Do not dismiss isolated vomiting as benign - it is a validated predictor across all major clinical decision rules 1, 2
• Do not rely on skull X-rays alone - CT is the definitive imaging modality for intracranial injury 4
• Do not assume single episode of vomiting is low-risk - even one episode in context of other risk factors warrants CT 1
• Do not delay imaging in elderly patients (>60-65 years) - age is an independent risk factor for intracranial injury 1, 6