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

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EasyTraumaPaediatric blunt head injury with further vomiting during observationMRCEM SBA

A 12-year-old boy attends the emergency department after striking his head during a football match. He has vomited on three separate occasions since the injury. He has a GCS of 15, a normal neurological examination and no other risk factors for intracranial injury. He is kept under observation. Two and a half hours after the injury, he vomits again; his GCS remains 15. CT is available. What is the most appropriate next management plan?

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Correct answer: D — Arrange CT head within 1 hour.

Three discrete episodes of vomiting constitute one of the specified risk factors for a child under 16 with a head injury. With that single risk factor, an initial plan to observe for at least 4 hours from the time of injury is appropriate. The decision changes when he vomits again during observation: NICE NG232 recommends a CT head scan within 1 hour of **further vomiting**, even if the GCS remains 15. The fourth episode is therefore the decisive new finding. ([nice.org.uk](https://www.nice.org.uk/guidance/NG232/chapter/recommendations)) A would provide neurological monitoring but would leave the new indication for timely CT unaddressed. B uses an imaging interval that is not appropriate for this deterioration during paediatric observation. C was a reasonable plan before the further vomiting, but completing the observation period without CT is no longer sufficient. E might be considered after an uncomplicated period of observation and clinical reassessment; it is inappropriate immediately after a new episode of vomiting. The CT result and subsequent clinical course should inform disposition. ([nice.org.uk](https://www.nice.org.uk/guidance/NG232/chapter/recommendations))

Reference: NICE NG232, 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