Management of Traumatic Brain Injury with Vomiting and Altered Consciousness
Intubation is the most appropriate initial management for this patient with severe traumatic brain injury presenting with vomiting, head swelling, and drowsiness following a fall from a tree.
Rationale for Airway Management Priority
The primary concern in this patient is airway protection and prevention of secondary brain injury from hypoxia. The combination of vomiting and altered consciousness (drowsiness) creates immediate risk for aspiration and airway compromise 1. The tongue is the most common cause of upper airway obstruction in comatose patients, and altered consciousness impairs protective airway reflexes 1.
Key Clinical Indicators for Intubation
- Altered level of consciousness (drowsiness) indicates inability to protect the airway, particularly dangerous given active vomiting 1
- Recurrent vomiting (≥4 episodes) significantly increases risk of intracranial injury (OR 2.3) and need for neurosurgical intervention (OR 3.5) 2
- Head swelling suggests significant impact force and potential for evolving intracranial pathology 2
Why Intubation Takes Priority Over Hematoma Evacuation
Securing the airway must precede any surgical intervention. Even if imaging reveals an epidural or subdural hematoma requiring evacuation, the patient cannot safely undergo surgery without a protected airway given the altered consciousness and vomiting 1.
Physiological Imperatives
- Prevention of hypoxia is paramount - hypoxia causes secondary brain injury and dramatically worsens outcomes in traumatic brain injury 3
- Systolic blood pressure must be maintained >110 mmHg to prevent secondary brain injury and increased mortality 4, 5
- Vomiting during altered consciousness poses immediate aspiration risk that can lead to hypoxemia and further neurological deterioration 3
Algorithmic Approach to Management
Immediate Actions (First 5 Minutes)
- Assess airway patency and breathing - if patient cannot maintain airway or has inadequate ventilation, proceed immediately to intubation 1
- Position patient appropriately - elevate head of bed 20-30° if no spinal injury suspected to aid venous drainage 3
- Prepare for rapid sequence intubation given high aspiration risk from vomiting 1
Indications for Immediate Intubation in This Patient
- Glasgow Coma Scale <9 (drowsiness suggests GCS ≤13) 3
- Inability to protect airway (evidenced by vomiting with altered consciousness) 1
- Risk of clinical deterioration from evolving intracranial pathology (head swelling) 3
Post-Intubation Management
- Maintain systolic BP >110 mmHg with vasopressors if needed (phenylephrine or norepinephrine) 4
- Obtain urgent CT head to identify surgical lesions (epidural/subdural hematoma) requiring evacuation 3
- Administer osmotherapy if signs of herniation - mannitol 20% or hypertonic saline at 250 mOsm over 15-20 minutes 3, 6
- Avoid prolonged hypocapnia - target PaCO2 35-40 mmHg as severe hypocapnia worsens outcomes 3
Common Pitfalls to Avoid
Do not delay intubation to obtain imaging. The airway must be secured first, as deterioration can be rapid and catastrophic 1. Attempting CT scan in an unprotected airway with active vomiting risks aspiration and cardiopulmonary arrest.
Do not use metoclopramide for vomiting control in this setting, as it causes drowsiness and anxiety that can obscure neurological assessment 7. If antiemetic needed post-intubation, ondansetron is preferred 7.
Do not assume hematoma evacuation alone will solve the problem. Without airway protection, the patient cannot safely undergo craniotomy, and perioperative aspiration would be catastrophic 1.
Timing Considerations
Intubation should occur within minutes of assessment, not hours. The combination of vomiting and drowsiness represents a neurological emergency where delay increases risk of aspiration, hypoxia, and secondary brain injury 3, 1. Hematoma evacuation, if needed, follows after airway is secured and CT imaging obtained 3.