Vomiting With Head Trauma and Risk of Traumatic Brain Injury

OBJECTIVES: To determine the prevalence of traumatic brain injuries in children who vomit after head injury and identify variables from published clinical decision rules (CDRs) that predict increased risk. METHODS: Secondary analysis of the Australasian Paediatric Head Injury Rule Study. Vomiting characteristics were assessed and correlated with CDR predictors and the presence of clinically important traumatic brain injury (ciTBI) or traumatic brain injury on computed tomography (TBI-CT). Isolated vomiting was defined as vomiting without other CDR predictors. RESULTS: Of the 19 920 children enrolled, 3389 (17.0%) had any vomiting, with 2446 (72.2%) >2 years of age. In 172 patients with ciTBI, 76 had vomiting (44.2%; 95% confidence interval [CI] 36.9%–51.7%), and in 285 with TBI-CT, 123 had vomiting (43.2%; 95% CI 37.5%–49.0%). With isolated vomiting, only 1 (0.3%; 95% CI 0.0%–0.9%) had ciTBI and 2 (0.6%; 95% CI 0.0%–1.4%) had TBI-CT. Predictors of increased risk of ciTBI with vomiting by using multivariate regression were as follows: signs of skull fracture (odds ratio [OR] 80.1; 95% CI 43.4–148.0), altered mental status (OR 2.4; 95% CI 1.0–5.5), headache (OR 2.3; 95% CI 1.3–4.1), and acting abnormally (OR 1.86; 95% CI 1.0–3.4). Additional features predicting TBI-CT were as follows: skull fracture (OR 112.96; 95% CI 66.76–191.14), nonaccidental injury concern (OR 6.75; 95% CI 1.54–29.69), headache (OR 2.55; 95% CI 1.52–4.27), and acting abnormally (OR 1.83; 95% CI 1.10–3.06). CONCLUSIONS: TBI-CT and ciTBI are uncommon in children presenting with head injury with isolated vomiting, and a management strategy of observation without immediate computed tomography appears appropriate.