CHALICE (Children's Head injury ALgorithm for the prediction of Important Clinical Events) Rule

CHALICE Rule

History:

Witnessed Loss of Consciousness >5 minutes

Amnesia (antegrade or retrograde) >5 minutes

Abnormal Drowsiness (excess for age)

≥3 Episodes of Vomiting

Suspicion of Non-Accidental Injury

Post-Traumatic Seizure (no epilepsy history)

Examination:

GCS <14 (or <15 if age <1 year)

Suspected Penetrating or Depressed Skull Injury

Tense Fontanelle (infants)

Signs of Basal Skull Fracture

Focal Neurological Signs

Bruise/Swelling/Laceration >5 cm (if age <1 year)

Mechanism:

High-Speed MVC (>40 mph)

Fall >3 Meters in Height

High-Speed Projectile Injury

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Predicts death, need for neurosurgical intervention or CT abnormality in children with head trauma.

Why Use

Aims to balance the risk of missing clinically significant injuries with the risks of over-imaging. Unlike PECARN , which identifies children at very low risk who do not require imaging, this tool uses high-risk criteria for clinically significant intracranial pathology to determine when imaging is indicated (i.e., who to CT versus who not to CT). Recommendations for head imaging in children in the NICE guidelines were largely based on the CHALICE rules.

When to Use

Useful in emergency department settings for determining the need for CT imaging in pediatric patients (<16 years old) with head trauma.

Formula

A CT head is required if any of the following criteria are present: History Witnessed loss of consciousness of >5 min duration. History of amnesia (either antegrade or retrograde) of >5 min duration. Abnormal drowsiness (defined as drowsiness in excess of that expected by the examining doctor). ≥3 vomits after head injury (a vomit is defined as a single discrete episode of vomiting). Suspicion of non‐accidental injury (NAI, defined as any suspicion of NAI by the examining doctor). Seizure after head injury in a patient who has no history of epilepsy. Examination Glasgow Coma Score (GCS) <14, or GCS <15 if <1 year old. Suspicion of penetrating or depressed skull injury, or tense fontanelle. Signs of a basal skull fracture (defined as evidence of blood or cerebrospinal fluid from ear or nose, panda eyes, Battle's sign, hemotympanum, facial crepitus, or serious facial injury). Positive focal neurologic sign (defined as any focal neurologic sign, including motor, sensory, coordination, or reflex abnormality). Presence of bruise, swelling or laceration >5 cm if <1 year old. Mechanism High‐speed road traffic accident either as pedestrian, cyclist or occupant (defined as accident with speed >40 mph). Fall of >3 m in height. High‐speed injury from a projectile or an object. If none of the above variables are present, the patient is at low risk of intracranial pathology.

Pearls / Pitfalls

Derived from a prospective study in the UK of 22,722 children recruited over 2.5 years. The derivation study demonstrated 98% sensitivity and 87% specificity for predicting clinically significant head injuries (e.g., death, need for neurosurgical intervention, abnormality on CT).

Management

If any criteria are met: Proceed with a head CT to evaluate for intracranial injury. If no criteria are met: Monitor and discharge after a period of observation with instructions, if clinically appropriate.

Advice

This tool does not replace clinical judgment; consider the broader clinical context when deciding management.