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.