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Paediatric head injury — MRCEM SBA MCQ

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HardPaediatric emergenciesPaediatric head injuryMRCEM SBA

An 8-year-old falls 1.2 m from playground equipment and strikes his head. There is no loss of consciousness. He has three discrete episodes of vomiting before arriving at the emergency department 90 minutes later. His GCS is 15, with no focal neurological deficit or signs of skull fracture. He has no bleeding disorder, and there are no safeguarding concerns. He is kept under observation. At 3 hours after the injury, while remaining alert with a GCS of 15, he vomits again. What is the most appropriate management now?

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Correct answer: A — Arrange a CT head scan within 1 hour.

Three discrete vomiting episodes constitute one of NICE’s specified risk factors for children under 16 with a head injury. In the absence of a second risk factor or an immediate-imaging criterion, the initial decision to observe him for at least 4 hours from the injury was appropriate. The fourth episode occurs during that observation period. NICE specifies that further vomiting during observation triggers a CT head scan within 1 hour, even if the child remains alert with a GCS of 15. ([nice.org.uk](https://www.nice.org.uk/guidance/NG232/chapter/recommendations)) B applies when observation proceeds without further vomiting, reduced GCS or abnormal drowsiness; it is no longer appropriate. C incorrectly restarts an observation clock when further vomiting instead calls for imaging. D delays CT beyond the indicated 1-hour interval. E substitutes admission for the indicated scan; admission and subsequent disposition can be considered after imaging and reassessment. The fall is below NICE’s specified height for a dangerous mechanism in a child, and there are no other features in the stem that independently require immediate CT. ([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 imaging algorithm for people under 16 (18 May 2023) — https://www.nice.org.uk/guidance/ng232/resources/imaging-algorithm-pdf-13061125549