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Paediatric head injury — MRCEM SBA MCQ

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EasyPaediatric emergenciesPaediatric head injuryMRCEM SBA

An 8-year-old boy attends the emergency department after falling 1 metre from playground equipment. He did not lose consciousness and has no amnesia, seizure or abnormal drowsiness. His GCS is 15, neurological examination is normal and there are no signs of skull fracture. He has vomited on three separate occasions since the injury, so neurological observation is started. Two and a half hours after the injury, while still under observation, he vomits again. His GCS remains 15. What is the most appropriate management now?

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Correct answer: D — Arrange a CT head scan within one hour of the further vomiting.

Three discrete episodes of vomiting constitute one of NICE’s specified risk factors for a child under 16 with a head injury. In the absence of another listed risk factor or an immediate indication for CT, the initial decision to observe him for at least four hours from the injury was appropriate. The fourth episode occurs *during that observation*. Further vomiting at this stage changes the decision: NICE recommends a CT head scan within one hour. A GCS that remains 15 does not remove this indication. ([nice.org.uk](https://www.nice.org.uk/guidance/NG232/chapter/recommendations)) A would have been appropriate if no further vomiting, abnormal drowsiness or reduction in GCS occurred during observation. B overlooks the risk factor and his deterioration during observation; discharge advice is relevant after assessment supports discharge. C confuses this urgent imaging indication with circumstances in which an eight-hour CT timeframe may be considered. E may be appropriate when a child needs admission for another reason but does not require CT; observation alone is insufficient once further vomiting triggers the one-hour CT recommendation.

Reference: Head injury: assessment and early management — Recommendations 1.5.11–1.5.12 (18 May 2023) — https://www.nice.org.uk/guidance/NG232/chapter/recommendations