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Minor head injury in a patient taking clopidogrel — MRCEM SBA MCQ

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HardProcedures, imaging and diagnosticsMinor head injury in a patient taking clopidogrelMRCEM SBA

A 59-year-old man attends the emergency department 11 hours after tripping and striking his head on a doorframe. He recalls the entire event and has had no loss of consciousness. He vomited once shortly afterwards but has had no further symptoms. He takes clopidogrel for a previous myocardial infarction and no other antithrombotic medication. His GCS is 15, neurological examination is normal, and there are no signs of skull fracture or other injuries. He is not intoxicated. CT is available immediately, and his partner can supervise him at home. What is the most appropriate imaging and disposition plan?

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

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Correct answer: A — Arrange CT head within 1 hour; if it is normal and he remains well, discharge with head-injury advice.

Clopidogrel is an antiplatelet drug covered by NICE’s recommendation to **consider CT head** after head injury even when no other CT criterion is met; the exception is aspirin *monotherapy*, not clopidogrel. One resolved episode of vomiting does not meet the separate adult criterion of more than one episode, but it adds weight to scanning in this case. Because he presents more than 8 hours after injury, a CT undertaken under the antiplatelet recommendation should be performed within 1 hour. If imaging is normal, he remains at GCS 15 without concerning symptoms, and his partner can supervise him, discharge with verbal and printed advice is appropriate. B applies the wrong clock: the 8-hour interval runs from injury, not arrival, and delayed presentation calls for scanning within 1 hour. C overlooks clopidogrel and the vomiting episode when deciding whether to scan. D treats antiplatelet use alone as a reason for admission despite normal imaging and safe supervision. E similarly imposes a routine repeat scan without clinical deterioration or another reason for continued assessment. NICE says to *consider*, rather than automatically perform, CT in this medication group; the question asks for the best plan given these features.

Reference: NICE NG232: Head injury—assessment and early management, recommendations 1.5.11 and 1.5.13 (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 1.10.2–1.10.9 (18 May 2023) — https://www.nice.org.uk/guidance/NG232/chapter/recommendations NICE NG232: Rationale and impact—anticoagulants and antiplatelets (18 May 2023) — https://www.nice.org.uk/guidance/ng232/chapter/rationale-and-impact