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Moderate traumatic brain injury — MRCEM SBA MCQ

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HardTraumaModerate traumatic brain injuryMRCEM SBA

A 29-year-old man arrives at a trauma unit 85 minutes after falling 2 m and striking his head. His Glasgow Coma Scale components are E3, V3 and M5. He is maintaining his airway, oxygenating normally and haemodynamically stable. Primary and secondary surveys find no suspected active extracranial bleeding. Cervical spine precautions remain in place. He has received no tranexamic acid, and CT is available immediately. Which management plan is most appropriate?

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Correct answer: C — Give 2 g intravenous tranexamic acid before imaging; arrange urgent CT head and cervical spine.

His GCS is 11: E3 + V3 + M5. He therefore meets NICE’s threshold of 12 or less for considering tranexamic acid after head injury when active extracranial bleeding is not suspected. At 85 minutes after injury, he remains within the 2-hour treatment window. The recommended adult regimen in this setting is a 2 g intravenous bolus as soon as possible and before imaging. Giving it must not delay urgent CT. His initial GCS also independently indicates both CT head and CT cervical spine within 1 hour of identifying the risk factor. ([nice.org.uk](https://www.nice.org.uk/guidance/NG232/chapter/recommendations)) A wrongly makes CT confirmation a prerequisite for tranexamic acid. B resembles a regimen studied in hospital patients but is not the regimen specified by this NICE recommendation for an adult with suspected isolated traumatic brain injury. D correctly prioritises early tranexamic acid but misses the cervical spine CT indication, despite the absence of reported neck symptoms. E reverses the significance of the bleeding assessment: *absence* of suspected active extracranial bleeding is part of the head-injury recommendation, not a reason to withhold treatment. If extracranial bleeding were suspected, the major-trauma haemostatic guidance would instead apply. ([nice.org.uk](https://www.nice.org.uk/guidance/NG232/chapter/recommendations))

Reference: NICE NG232: Head injury—recommendations (2023) — https://www.nice.org.uk/guidance/NG232/chapter/recommendations NICE NG39: Major trauma—assessment and initial management (2016) — https://www.nice.org.uk/guidance/ng39/chapter/Recommendations