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Paediatric head injury with further vomiting during observation — MRCEM SBA MCQ

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HardTraumaPaediatric head injury with further vomiting during observationMRCEM SBA

An 11-year-old is assessed in the emergency department after striking her head in a fall from standing height. Her GCS is 15, neurological examination is normal, and she has had three discrete episodes of vomiting. There was no loss of consciousness, amnesia, seizure or abnormal drowsiness, and there are no signs of skull fracture. She takes no medication and has no bleeding disorder. She is observed in the department. Three hours and 30 minutes after the injury, she vomits again; her GCS remains 15. What is the most appropriate next management step?

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

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Correct answer: E — Arrange a CT head scan within one hour.

Three discrete episodes of vomiting constitute one of the specified risk factors for a child under 16, rather than three separate risk factors. With no other listed risk factor or indication for immediate CT, the initial decision to observe her for at least four hours from the injury was appropriate. The fourth episode occurs during that observation period. NICE specifies **further vomiting during observation** as a trigger for CT head within one hour, even if the GCS remains 15. ([nice.org.uk](https://www.nice.org.uk/guidance/NG232/chapter/recommendations)) A is tempting because the four-hour period is nearly complete, but the new vomiting episode changes the imaging decision. B incorrectly restarts an observation clock: the recommended minimum is measured from the injury, and further vomiting now triggers CT. C delays imaging beyond the one-hour requirement; an eight-hour CT pathway applies to certain other head-injury risk presentations, not this deterioration during paediatric observation. D substitutes admission for the investigation now indicated. Subsequent observation or admission can be decided after imaging and reassessment, but neither replaces prompt CT in this case. ([nice.org.uk](https://www.nice.org.uk/guidance/NG232/chapter/recommendations))

Reference: Head injury: assessment and early management (NG232), recommendations 1.5.10–1.5.12 (18 May 2023) — https://www.nice.org.uk/guidance/NG232/chapter/recommendations Head injury: assessment and early management (NG232), imaging algorithm (18 May 2023) — https://www.nice.org.uk/guidance/ng232/resources/imaging-algorithm-pdf-13061125549