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An update on paediatric traumatic brain injury in the emergency department: a narrative review
Sara Alsuwais1,2,3, Charlotte Kennedy4, Silvia Bressan5
1Department of Emergency Medical Services, College of Applied Medical Sciences, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia. Sara.suwais@gmail.com.
Insights
Pediatric traumatic brain injury (TBI) management in the Emergency Department (ED) requires careful assessment. While clinical decision rules aid imaging choices, emerging tools and tailored follow-up are crucial for mild TBI cases.
Area of Science:
- Pediatric Emergency Medicine
- Neurotrauma
- Clinical Decision Making
Background:
- Traumatic brain injury (TBI) in children presents a significant healthcare burden, with presentations varying from mild to severe.
- Most pediatric TBIs are mild, necessitating careful evaluation in the Emergency Department (ED) to guide neuroimaging decisions.
- Persistent symptoms after mild TBI highlight the need for effective discharge advice and follow-up planning.
Purpose of the Study:
- To review current evidence on the assessment, imaging decisions, and early management of pediatric TBI in the ED, focusing on mild cases.
- To identify emerging diagnostic tools and research gaps in pediatric TBI care.
- To emphasize the importance of tailored strategies for diverse patient populations and varying healthcare settings.
Main Methods:
- Review of current evidence on Emergency Department-based assessment and management of pediatric TBI.
- Analysis of clinical decision rules (CDRs) and clinician gestalt in guiding neuroimaging.
- Discussion of emerging diagnostic technologies and future research priorities.
Main Results:
- Clinical decision rules like PECARN are valuable for CT use in mild pediatric TBI, though clinician gestalt may offer better specificity.
- Not all children with mild TBI require neuroimaging, but many experience prolonged symptoms needing specific management.
- Investigational tools like fast MRI and blood biomarkers show potential for improved diagnosis and reduced CT use.
Conclusions:
- Effective management of pediatric TBI in the ED requires balancing diagnostic accuracy with the avoidance of unnecessary imaging.
- Addressing research gaps, including tools for preverbal children and neurodivergent populations, is essential for equitable and effective care.
- Tailored follow-up and counseling are critical for children experiencing prolonged recovery after mild TBI.
Abstract:
Traumatic brain injury (TBI) affects an estimated 330,000 to 500,000 children annually in England and Wales and represents a significant burden on healthcare systems. Presentations range from mild to severe, and each case presents unique challenges to the Emergency Department (ED) clinicians. Most paediatric TBIs are mild, and several validated clinical decision rules (CDRs) such as PECARN help guide CT use. Whilst these rules show good sensitivity, clinician gestalt appears to have better specificity. Not all children with mild TBI require neuroimaging, yet many experience persistent symptoms that require clear discharge advice and follow-up planning. Emerging tools such as fast MRI and blood-based biomarkers may enhance early diagnosis and reduce unnecessary CT use, but these remain investigational. Importantly, mild TBI is increasingly recognised as a condition that may lead to prolonged recovery in a significant proportion of children, highlighting the need for tailored counselling and follow-up. In contrast, the ED approach to moderate and severe TBI prioritises early stabilisation and prevention of secondary injury, though a full review of critical care management is beyond the scope of this paper.This review summarises current evidence relevant to ED-based assessment, imaging decisions, and early management of paediatric TBI, with a focus on mild presentations. We also highlight areas of emerging evidence and identify priority research gaps, including validation of prediction tools in preverbal children, care of neurodivergent populations, and real-world implementation of advanced diagnostics. Finally, we acknowledge the variability in access to imaging and decision-support tools across healthcare settings, and the need for context-specific strategies that support equitable care. What is Known: • Most paediatric TBIs are mild, and clinical decision rules like PECARN support imaging decisions in the ED. • Mild TBI can still result in prolonged symptoms requiring tailored discharge advice and follow-up. What is New: • Emerging tools such as fast MRI and blood-based biomarkers may improve diagnosis but remain investigational. • Priority gaps include care strategies for neurodivergent children and preverbal populations in real-world ED settings.
