Immediate Management of Vomiting After Motorcycle Head Trauma
A patient vomiting after a motorcycle head accident requires immediate emergency department evaluation with neuroimaging (CT scan), as repeated vomiting is a red flag symptom indicating potential intracranial injury requiring urgent intervention. 1
Critical Initial Assessment
Vomiting in the context of head trauma places this patient in the "medium-risk" or "high-risk" mild head injury category, with an intracranial hematoma risk of 1-10%, mandating CT imaging. 2
Immediate Airway Management
Position the patient on their side (lateral decubitus position) to prevent aspiration of vomitus and facilitate drainage of secretions. 1, 3
If lateral positioning is not feasible due to suspected spinal injury, the patient should be logrolled as a unit (head, neck, and torso together) to protect the cervical spine while clearing vomitus. 1
Maintain 20-30° head-up tilt if spinal injury has been ruled out, as this reduces intracranial pressure and aspiration risk. 1, 3
Remove vomitus using finger sweep, cloth, or suction as needed. 1
Indications for Immediate Intubation
Consider emergent intubation if the patient exhibits: 1
- Glasgow Coma Scale (GCS) ≤ 8 1
- Significantly deteriorating conscious level (fall in GCS of 2+ points) 1
- Loss of protective laryngeal reflexes 1
- Copious bleeding into the mouth 1
- Inability to maintain airway patency with massive vomiting 3
Neuroimaging Requirements
CT head scan is mandatory for any head trauma patient with vomiting, as this symptom indicates medium-risk mild traumatic brain injury with 1-3% risk of surgical hematoma. 1, 2
Risk Stratification Based on Vomiting
Medium-risk patients (GCS 15 with vomiting): CT scan should be obtained where one scanner is available per 100,000 population or less. 2
High-risk patients (GCS 14 or vomiting with skull fracture/neurological deficits): CT scan is mandatory with 6-10% risk of surgical hematoma. 2
Blood Pressure Management in Head Trauma
Maintain mean arterial pressure (MAP) ≥ 80 mmHg in patients with suspected traumatic brain injury to prevent secondary brain injury from hypotension. 1
Target systolic blood pressure 80-90 mmHg only applies to trauma patients WITHOUT brain injury. 1
For combined hemorrhagic shock and severe traumatic brain injury, MAP ≥ 80 mmHg takes precedence over permissive hypotension. 1
Use isotonic saline (0.9% NaCl) for fluid resuscitation, as it is the only commonly available isotonic crystalloid that prevents brain water increase. 1
Avoid Ringer's lactate and Ringer's acetate as they are hypotonic and can worsen cerebral edema. 1
Critical Pitfalls to Avoid
Do NOT discharge the patient home with observation instructions. Vomiting after head trauma is specifically listed as a "return to ED" symptom, indicating the patient requires immediate evaluation, not home observation. 1
Do NOT perform abdominal thrusts or Heimlich maneuver to clear vomitus, as these are potentially dangerous and unnecessary. 1
Do NOT use hypotonic fluids (Ringer's lactate, Ringer's acetate) in head-injured patients, as they worsen cerebral edema. 1
Do NOT assume vomiting is benign. Repeated vomiting is one of the key symptoms requiring return to the ED for re-evaluation and indicates potential deterioration. 1
Disposition and Monitoring
All patients with vomiting after head trauma require hospital admission for observation and serial neurological assessments. 1
Monitor for postconcussive symptoms including worsening headache, confusion, focal neurologic deficits, abnormal behavior, increased sleepiness, or seizures. 1
Patients developing repeated vomiting, worsening headache, or decreased level of consciousness require immediate repeat CT imaging. 1