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Moderate traumatic brain injury — MRCEM SBA MCQ

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HardResuscitation and critical illnessModerate traumatic brain injuryMRCEM SBA

A 43-year-old man arrives 50 minutes after falling and striking his head on concrete. His GCS is 11/15 (E3 V3 M5), unchanged since the ambulance assessment. He is breathing adequately, protecting his airway and has an SpO₂ of 97% on air, blood pressure of 128/76 mmHg and capillary glucose of 6.2 mmol/L. Examination identifies a scalp haematoma but no suspected active extracranial bleeding. He has received no tranexamic acid. CT is available on site. Which is the most appropriate immediate management plan?

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Correct answer: D — Give 2 g intravenous tranexamic acid now; obtain CT head within 1 hour.

This adult has a moderate head injury, with a GCS of 11/15, and presents within 2 hours of injury without suspected active extracranial bleeding. NICE advises considering a 2 g intravenous bolus of tranexamic acid as soon as possible **before imaging** in this situation. A GCS of 12 or less on initial emergency department assessment also requires CT head within 1 hour of identifying the risk factor. His airway and ventilation are currently adequate, so these steps can proceed without waiting for intubation. Continue close reassessment and use the CT findings and clinical course to guide neurosurgical discussion and disposition. ([nice.org.uk](https://www.nice.org.uk/guidance/NG232/chapter/recommendations)) **A** uses a bolus-plus-infusion regimen rather than the 2 g bolus specified in NICE’s head-injury recommendation. **B** delays tranexamic acid until haemorrhage is demonstrated, losing the recommended pre-imaging opportunity. **C** gives the appropriate bolus but delays CT beyond the 1-hour threshold for his GCS. **E** correctly prioritises tranexamic acid and urgent CT, but makes intubation a prerequisite despite an adequately protected airway and GCS above 8; airway intervention would take priority if his clinical condition deteriorated. ([nice.org.uk](https://www.nice.org.uk/guidance/NG232/chapter/recommendations))

Reference: NICE NG232: Head injury—assessment and early management, recommendations 1.3.17, 1.4.6 and 1.5.8 (18 May 2023) — https://www.nice.org.uk/guidance/NG232/chapter/recommendations NICE NG232: Rationale and impact—tranexamic acid (18 May 2023) — https://www.nice.org.uk/guidance/ng232/chapter/Rationale-and-impact