What is the best course of action for a patient with a head injury presenting with persistent hematemesis (vomiting of blood) and headache?

Management of Head Injury with Hematemesis and Headache

This patient requires immediate stabilization with hemorrhage control as the first priority, followed by urgent neuroimaging to identify both the source of gastrointestinal bleeding and any intracranial pathology—do not transfer an actively bleeding, hypotensive patient. 1

Immediate Stabilization and Assessment

Hemorrhage Control Takes Precedence

• Assume hypotension is due to hemorrhage until proven otherwise and control bleeding before any transfer or advanced imaging 1
• Establish large-bore IV access immediately and apply direct pressure to any external bleeding sites 2
• Activate major hemorrhage protocol if the patient shows signs of shock (hypotension, tachycardia, altered mental status) 2
• Do not transfer a hypotensive, actively bleeding patient—correction of major hemorrhage takes precedence over transfer 1

Fluid Resuscitation Strategy

• Use 0.9% normal saline exclusively for initial crystalloid resuscitation in head-injured patients 1
• Avoid Ringer's lactate and Ringer's acetate—these are hypotonic when real osmolality is measured and will worsen cerebral edema 1
• Target systolic blood pressure of 80-100 mmHg in patients without brain injury, but avoid hypotension (systolic <110 mmHg) in patients with head injury 1
• If the patient has severe head trauma, hypotonic solutions must be avoided entirely 1

Assess Bleeding Severity

• Obtain serum lactate and base deficit immediately—these are superior to single hematocrit measurements for estimating bleeding severity 2
• Administer high-flow oxygen and begin resuscitation with warmed blood products (not crystalloids alone) if hemodynamically unstable 2

Diagnostic Approach

Urgent Imaging

• Perform CT angiography (CTA) immediately in hemodynamically stable patients to identify both intracranial pathology and the source of gastrointestinal bleeding 1, 2
• Non-contrast head CT should be obtained first if intracranial hemorrhage is suspected, followed by CT angiography 1
• The administration set should include a filter when infusing contrast 3

Determine Source of Hematemesis

The combination of head injury and hematemesis suggests either:

• Swallowed blood from facial/nasal trauma (most common)
• Stress ulceration from severe trauma
• Esophageal or gastric injury from associated thoracoabdominal trauma

Definitive Management Based on Findings

If Active Arterial Bleeding Identified

• Selective angiographic embolization is the preferred intervention for identified arterial bleeding on CTA 2
• Use microcoils as the primary embolic agent, embolizing in a superselective, distal-to-proximal fashion 2
• Surgical evacuation and packing should be performed if angiographic embolization fails or is unavailable 2

Coagulopathy Management

• Administer tranexamic acid 1 g IV over 10 minutes, then 1 g over 8 hours if given within 3 hours of bleeding onset for mortality benefit 2, 4
• Maintain fibrinogen >1 g/L and platelet count >75 × 10⁹/L 2
• Administer fresh frozen plasma (15 mL/kg) early if PT/aPTT >1.5 times normal 2
• Use prothrombin complex concentrate (not FFP) for rapid reversal of warfarin if the patient is anticoagulated 1

Temperature Management

• Implement early measures to reduce heat loss and actively warm hypothermic patients to achieve normothermia 1, 4
• Remove wet clothing immediately and cover the patient to prevent ongoing heat loss 4
• Hypothermia impairs platelet function and coagulation factor activity by 10% per degree Celsius drop 4

Intracranial Pressure Management (If Indicated)

When to Use Mannitol

• If signs of elevated intracranial pressure develop (deteriorating consciousness, pupillary changes, posturing), administer mannitol 0.25 to 2 g/kg IV as a 15% to 25% solution over 30-60 minutes 3
• Do not administer mannitol if the patient has well-established anuria, severe dehydration, or active intracranial bleeding except during craniotomy 3
• Monitor serum sodium and potassium carefully during mannitol administration 3

Critical Monitoring

• Mannitol may increase cerebral blood flow and worsen intracranial hypertension in the first 24-48 hours post-injury 3
• Discontinue mannitol if renal, cardiac, or pulmonary status worsens 3

Ongoing Management

Hemodynamic Targets

• Maintain systolic blood pressure >110 mmHg in head-injured patients 1
• Use small boluses of α-agonists (metaraminol) or noradrenaline infusion (via central line only) if hypotension persists after correcting hypovolemia 1
• Manage hypertension with increased sedation and small boluses of labetalol 1

Monitoring and Disposition

• Admit to critical care for monitoring of coagulation parameters, hemoglobin, vital signs, and neurological status 2
• Monitor serum sodium closely—cerebral salt-wasting syndrome can develop even after minor head injury 5
• Start venous thromboprophylaxis as soon as hemostasis is secured 2

Critical Pitfalls to Avoid

• Never use hypotonic fluids (Ringer's lactate, Ringer's acetate) in head-injured patients—they worsen cerebral edema 1
• Do not rely on single hematocrit measurements to assess bleeding severity 2
• Do not transfer an unstable, actively bleeding patient—stabilize first 1
• Do not delay tranexamic acid beyond 3 hours from bleeding onset—the mortality benefit is lost 2
• Do not give mannitol to dehydrated patients or those with active intracranial bleeding (except during craniotomy) 3