Management of Head Injury with Vomiting

Immediate Assessment and Triage

The American Heart Association recommends that a patient with head injury and vomiting requires immediate emergency department evaluation with non-contrast head CT imaging, as vomiting is a validated predictor of clinically important intracranial injury and potential need for neurosurgical intervention 1, 2, 3
Loss of consciousness, worsening headache, repeated vomiting, altered mental status, seizures, visual changes, or scalp swelling/deformities warrant immediate EMS activation, as these signs are associated with life-threatening injuries including epidural hematoma, subdural hematoma, open skull fracture, or brain edema requiring hospital treatment 1

The Canadian CT Head Rule and New Orleans Criteria recommend obtaining head CT if a patient has vomiting, as it is a validated criterion across multiple clinical decision rules for obtaining head CT 2, 3
The American College of Emergency Physicians recommends that any person with signs of head injury must be immediately removed from activity and not allowed to return until evaluated by a healthcare professional 1

The American College of Emergency Physicians recommends obtaining head CT if any of the following are present: vomiting, GCS <15 at 2 hours post-injury, age ≥60-65 years, suspected skull fracture, headache, altered mental status or amnesia, focal neurological deficits, seizure, anticoagulation or coagulopathy, or physical evidence of trauma above clavicles 2, 3, 4
Patients with negative head CT can be safely discharged without admission or prolonged observation, as multiple large prospective studies demonstrate minimal risk for delayed intracranial lesions after negative CT 4

The American Academy of Family Physicians recommends providing instructions to return immediately for memory problems, confusion, abnormal behavior, increased sleepiness, worsening headache, vision problems, or seizures 4
The American Academy of Pediatrics recommends educating patients about expected symptoms, including dizziness, nausea, sensitivity to noise and light, depression, mood swings, anxiety, irritability, and sleep disturbances 1, 4

The American College of Emergency Physicians recommends that higher risk groups, such as patients on anticoagulation therapy, bleeding disorders, or coagulopathy, may require admission despite negative CT 5, 4

The American College of Emergency Physicians recommends not dismissing isolated vomiting as benign, as it is a validated predictor across all major clinical decision rules 2, 3, 5
The American College of Emergency Physicians recommends not relying on skull X-rays alone, as CT is the definitive imaging modality for intracranial injury 2, 3

The American Society of Anesthesiologists recommends 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 6
The American Society of Anesthesiologists guidelines for postanesthetic care emphasize the importance of evaluating vomiting in the context of head trauma, not just as a postoperative complication 7

Research suggests that post-traumatic vomiting should be evaluated as a potential sign of intracranial injury, with a significant increase in odds of requiring neurosurgical intervention (3.5-fold) for recurrent vomiting (≥4 episodes), according to the British Journal of Anaesthesia 8
The Annals of Emergency Medicine recommends that if CT is negative and the patient is stable, discharge instructions should be provided to return immediately for repeated vomiting, worsening symptoms, or altered consciousness 9