Management of Traumatic Brain Injury with Abdominal Pain and Projectile Vomiting

Initial Assessment and Management

The American College of Surgeons recommends maintaining systolic blood pressure >110 mmHg immediately, as hypotension worsens TBI outcomes and cerebral perfusion 2, 3
The American Society of Anesthesiologists suggests securing the airway with tracheal intubation and mechanical ventilation with end-tidal CO2 monitoring, targeting EtCO2 of 30-35 mmHg to prevent both hypercapnia and dangerous hypocapnia-induced cerebral vasoconstriction 1, 2, 3
The Anaesthesia society recommends using vasopressors (phenylephrine or norepinephrine) for rapid blood pressure correction rather than waiting for fluid resuscitation alone 2, 3

The American College of Radiology recommends performing immediate non-contrast head CT AND contrast-enhanced thoraco-abdominal CT to simultaneously evaluate for neurological and abdominal causes 1, 4, 5, 6
The Anaesthesia society suggests evaluating for increased intracranial pressure from mass lesions (subdural/epidural hematoma >5mm thickness with >5mm midline shift) 1
The American Society of Anesthesiologists recommends evaluating for acute hydrocephalus requiring drainage 1
The Praxis Medical Insights society suggests evaluating for diffuse axonal injury patterns on specialized imaging if initial CT is normal but symptoms persist 3

The American College of Surgeons recommends instituting intracranial pressure monitoring for severe TBI 1, 3
The Anaesthesia society suggests performing external ventricular drainage for persistent intracranial hypertension despite sedation 1, 3
The American Society of Anesthesiologists recommends considering decompressive craniectomy (>100 cm² temporal craniectomy with dural plasty) for refractory intracranial hypertension in multidisciplinary discussion 1
The Anaesthesia society recommends pursuing non-operative management (NOM) as first-line for solid organ injuries (liver, spleen, kidney), even high-grade injuries (OIS 4-5), with close clinical and radiological monitoring 4, 5, 6
The American College of Surgeons recommends considering therapeutic angio-embolization for documented active bleeding on CT (contrast extravasation) 4, 6

The World Journal of Emergency Surgery recommends initiating thromboprophylaxis with LMWH within 48-72 hours once bleeding is controlled, as VTE rates increase fourfold when delayed beyond 72 hours 8, 9
The World Journal of Emergency Surgery suggests beginning early enteral feeding within 72 hours unless contraindications exist (uncontrolled shock, vasopressor use, bowel ischemia, obstruction) 8, 9

The American Society of Anesthesiologists recommends not attributing all abdominal symptoms to the head injury - up to 20% of severe trauma patients have significant abdominal injuries that require intervention 5
The Anesthesiology society suggests not delaying imaging - both head and abdominal CT should be performed without delay in this clinical scenario 1, 2, 5
The Anaesthesia society recommends not allowing hypotension to persist - even a single episode of systolic BP <90 mmHg (and particularly <110 mmHg) dramatically worsens TBI outcomes 2, 3