The Children’s Head injury ALgorithm for prediction of Clinically Important Events (CHALICE) clinical decision rule was developed to predict clinically important brain injuries in children with head trauma. This rule identifies high-risk criteria and divides them into history, examination and mechanism ¹.

Criteria

History

• witnessed loss of consciousness >5 min
• amnesia >5 min (anterograde or retrograde)
• abnormal drowsiness noted by attending doctor
• >2 vomits post injury
• suspicion of non-accidental injury
• seizure after a head injury in a child with no history of epilepsy

Examination

• GCS <14, or <15 if less than 1 year old
• suspicion of penetrating or depressed skull injury or tense fontanelles
• signs of base of skull fracture
  • blood/CSF rhinorrhoea or otorrhoea
  • panda eyes
  • Battle’s sign
  • haemotympanum
• facial crepitus or serious facial injury
• presence of focal neurological signs
• presence of bruise, swelling or laceration >5 cm if <1 year old

Mechanism

• road traffic accident with speed >40 mph in which the patient is an occupant, pedestrian or cyclist
• fall of >3 m in height
• high speed injury from projectile or object

If none of the above criteria are present then the patient is deemed low risk for a clinically significant intracranial finding.

The literature reports an 84-98% sensitivity of the CHALICE clinical decision rule for detecting clinically important intracranial injury in paediatric patients ^1-4.

In studies that have sought to compare clinical decision rules for paediatric head injury assessment - namely the CHALICE, CATCH (Canadian Assessment of Tomography for Childhood Head) and PECARN (Paediatric Emergency Care Applied Research Network) rules - the PECARN rule has been found to have the highest sensitivity (99-100%) in detection of clinically important brain injuries ^2,3. However, the CHALICE rule is applicable in a considerably higher percentage of cases (97-99% all cases vs 75-76% in under 2-year-olds and 74-76% over 2-years-old for PECARN) ^3,4.