The correct answer is:

The risk of clinically important traumatic brain injury (TBI) is low and the patient can be discharged home.

Key Point:

The 2018 algorithm remains in effect for the initial imaging and admission versus discharge decisions in the management of pediatric head trauma. The guidelines states that patients ≥ 2 years old with normal mental status; no signs of basilar skull fracture; no history of loss of consciousness, vomiting, or headache; and a low-energy mechanism have a low risk of clinically important traumatic brain injury and can be discharged home (in the absence of other concerns).

Explanation:

The 2019 Brain Trauma Foundation guideline addresses the therapeutic management of pediatric patients with severe head trauma and a GCS ≤9. It does not address the initial imaging decisions for pediatric brain trauma in general or admission versus discharge home  decisions, leaving these topics to the 2018 ATLS guideline.

The 2018 ATLS guideline addresses the fact that in pediatric patients, the likelihood of a clinically significant TBI must be weighed against the risk of malignancy from radiation exposure following CT and other radiologic studies. To aid in such decisions, Advanced Trauma Life Support (ATLS) guidelines recommend implementing the Pediatric Emergency Care Applied Research Network (PECARN) algorithm.

According to the PECARN decision tree, children older than 2 years of age who have one or more of the following should undergo CT scan of the head:

• GCS score of 14 or less
• other signs of altered mental status
• signs of a basilar skull fracture

Those who have none of these signs but who have a history of loss of consciousness, vomiting, headache, or a severe mechanism of injury may undergo CT scan of the head or observation, depending on physician and facility experience.

Patients who have none of these signs and symptoms are unlikely to have clinically important TBI and, in such cases, the risk of TBI is lower than the risk of CT-induced malignancies.

References:

American College of Surgeons Committee on Trauma. Advanced Trauma Life Support (ATLS) Student Course Manual. 10th ed., 2018.

Kochanek PM, Tasker RC, Carney N, et al. Guidelines for the management of pediatric severe traumatic brain injury, third edition: Update of the Brain Trauma Foundation guidelines. Pediatr Crit Care Med. 2019; 20 (suppl 1): S1–S82.