Can vomiting in a head trauma patient be attributed to anesthesia-induced vomiting?

Vomiting in Head Trauma: Not Attributable to Anesthesia

No, vomiting in a head trauma patient should NOT be attributed to anesthesia-induced vomiting and must be evaluated as a sign of potential intracranial injury requiring immediate head CT imaging. 1, 2

Critical Clinical Distinction

Vomiting after head trauma is a validated predictor of clinically important intracranial injury across all major clinical decision rules (Canadian CT Head Rule and New Orleans Criteria), regardless of whether the patient received anesthesia. 1, 2 The American Heart Association and American College of Emergency Physicians both mandate immediate emergency department evaluation with non-contrast head CT for any head trauma patient presenting with vomiting. 1, 2

Why This Distinction Matters for Morbidity and Mortality

• Repeated vomiting after head trauma indicates possible epidural hematoma, subdural hematoma, or increased intracranial pressure—all life-threatening conditions requiring urgent neurosurgical intervention. 1, 2
• The probability of intracranial injury increases significantly with the number of vomiting episodes (odds ratio 2.3-2.8), especially when accompanied by other high-risk factors. 3
• Recurrent vomiting (≥4 episodes) increases the odds of requiring neurosurgical intervention by 3.5-fold. 3

Evidence Against Attribution to Anesthesia

While postoperative nausea and vomiting (PONV) is common after general anesthesia (occurring in 30% of surgical patients), the clinical context of head trauma fundamentally changes the diagnostic approach. 4, 5

Key differentiating factors:

• PONV typically occurs 4-5 hours postoperatively in the absence of trauma, whereas post-traumatic vomiting has different clinical significance regardless of timing. 6
• Research specifically examining post-traumatic vomiting demonstrates it should be evaluated as a potential sign of intracranial injury, not dismissed as anesthesia-related. 7
• The ASA guidelines for postanesthetic care recommend routine assessment of nausea and vomiting during recovery, but these guidelines do not apply to patients with concurrent head trauma where vomiting has different clinical implications. 4

Mandatory Clinical Algorithm

For any head trauma patient with vomiting (regardless of anesthesia exposure):

1. Obtain immediate non-contrast head CT scan 1, 2

2. Monitor for additional high-risk features:

   • Loss of consciousness or altered mental status 1, 2
   • Worsening or severe headache 1, 2
   • Focal neurological deficits 1, 2
   • Signs of skull fracture 2, 3
   • Glasgow Coma Scale score <15 at 2 hours post-injury 2, 3
   • Age ≥60-65 years 8, 2
   • Anticoagulation or bleeding disorders 8, 2

3. If CT is negative and patient is stable, provide discharge instructions to return immediately for repeated vomiting, worsening symptoms, or altered consciousness 4, 8, 2

Critical Pitfall to Avoid

The most dangerous error is dismissing vomiting in a head trauma patient as "just anesthesia-related" without obtaining head CT imaging. 2 This assumption can delay diagnosis of life-threatening intracranial hemorrhage. Even if the patient recently underwent anesthesia, the presence of head trauma mandates evaluation of vomiting as a potential sign of intracranial injury. 1, 2

Special Considerations

• Patients on anticoagulation therapy have a 3.9% risk of intracranial hemorrhage versus 1.5% in non-anticoagulated patients, requiring even lower threshold for imaging and possible admission despite negative CT. 8, 2
• In pediatric head trauma, recurrent vomiting (≥4 episodes) is particularly concerning and significantly increases the probability of intracranial injury with each additional episode. 3