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Head injury with recurrent vomiting during observation — MRCEM SBA MCQ

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HardPaediatric emergenciesHead injury with recurrent vomiting during observationMRCEM SBA

An 11-year-old boy is brought to the emergency department after a witnessed fall of 2 metres onto his head. He has vomited on three separate occasions before arrival. At initial assessment, 80 minutes after the injury, his GCS is 15. He has no amnesia, focal neurological deficit, signs of skull fracture, other injuries or bleeding disorder. There are no safeguarding concerns. He is kept under neurological observation. At 2 hours 20 minutes after the injury, he vomits again; his GCS remains 15. His parent can supervise him at home when discharge is appropriate. What is the most appropriate management plan now?

Educational content. Not a substitute for clinical judgement or local policy.

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Correct answer: A — Arrange CT head within 1 hour, then determine disposition from the scan and clinical course.

Three discrete episodes of vomiting are one of NICE’s specified risk factors for CT assessment in a child with head injury. His 2-metre fall does not meet the separate paediatric CT criterion for a dangerous fall, which requires a height of more than 3 metres; no other listed risk factor is present at initial assessment. Observation for at least 4 hours from injury is therefore appropriate initially. ([nice.org.uk](https://www.nice.org.uk/guidance/NG232/chapter/recommendations)) The additional vomiting episode *during observation* changes the decision: NICE recommends CT head within 1 hour, even though his GCS remains 15. Waiting to complete 4 hours of observation (B), using an 8-hour imaging window (C), or reserving CT for a fall in GCS (D) would miss that escalation criterion. ([nice.org.uk](https://www.nice.org.uk/guidance/NG232/chapter/recommendations)) Option E gets the imaging priority right but makes admission automatic. After normal imaging, discharge can be considered if his GCS remains 15, significant symptoms have resolved, there is no other reason for admission and suitable supervision is available. Persistent concerning symptoms or an important scan abnormality would instead support admission. ([nice.org.uk](https://www.nice.org.uk/guidance/NG232/chapter/recommendations))

Reference: NICE NG232: Head injury: assessment and early management, recommendations 1.5.10–1.5.12 (18 May 2023) — https://www.nice.org.uk/guidance/NG232/chapter/recommendations NICE NG232: Head injury: assessment and early management, recommendations 1.9.1 and 1.10.2 (18 May 2023) — https://www.nice.org.uk/guidance/NG232/chapter/recommendations