Emergency – ClinCaseQuest https://clincasequest.hospital Medical education in clinical cases Sun, 22 Sep 2024 11:54:02 +0000 en-US hourly 1 https://wordpress.org/?v=6.2.13 https://clincasequest.hospital/wp-content/uploads/sites/7/2020/02/logo-ru-project-90x90.png Emergency – ClinCaseQuest https://clincasequest.hospital 32 32 Focused Assessment with Sonography for Trauma (FAST): Online Calculator https://clincasequest.hospital/fast/ Sat, 21 May 2022 16:28:07 +0000 https://clincasequest.hospital/?p=34015 Focused Assessment with Sonography for Trauma (FAST) predicts the presence of pericardial or intra-abdominal injury after penetrating or blunt trauma. FAST should be used liberally…

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]]> Focused Assessment with Sonography for Trauma (FAST) predicts the presence of pericardial or intra-abdominal injury after penetrating or blunt trauma.

  • FAST should be used liberally in the evaluation of trauma patients.
  • Especially useful in patients with penetrating thoracic trauma and in unstable patients after blunt abdominal trauma.

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FAST is a rapid, non-invasive, and repeatable imaging modality that can guide the surgeon in the decision to operate.

Performed in trauma bay (does not require patient transport out of the emergency department, which is risky in unstable patients).

FAST results alone should not determine the decision to operate. However, FAST can be a helpful adjunct in clinical decision making, particularly in an unstable blunt trauma patient in order to rapidly assess the chest and abdomen for potential causes of hypotension.

Most clinicians use the low-frequency phased array ultrasound probe (a.k.a. cardiac probe), to obtain all windows in FAST.

  
Pericardial fluidAbsent
 Present
 Equivocal
Right upper quadrant (Morison’s pouch) fluid  Absent
 Present
 Equivocal
Left upper quadrant (splenorenal recess) fluid  Absent
 Present
 Equivocal
Suprapubic fluid  Absent
 Present
 Equivocal

Most clinicians use the low-frequency phased array ultrasound probe (a.k.a. cardiac probe), to obtain all windows in FAST.

Pericardial  place the probe in the subxiphoid area and orient it towards the patient’s left shoulder. Apply downward pressure to look under the costal margin and towards the heart. The heart and pericardium will come into view, allowing inspection for hemopericardium and ultrasound findings of cardiac tamponade.
Right upper quadrant  place probe in right anterior to the midaxillary line (between 11th–12th ribs). Visualization of the hepatorenal recess (Morison’s pouch) allows the assessment of hemoperitoneum in the right upper quadrant. Blood most likely accumulates here if hemoperitoneum is present.
Left upper quadrant  apply transducer firmly onto the skin in the left posterior axillary line (between the 9th–10th ribs) to visualize splenorenal and subphrenic spaces. In practice, it is important to remember that the right and left upper quadrant views are often more posterior than anticipated. It can be helpful to bring the probe all the way down to the stretcher in order to best visualize these windows.
Suprapubicplace transducer superior to pubic symphysis and fan probe inferiorly to visualize the bladder.

Using bedside ultrasound, assess for fluid in each of the following areas:

 Fluid present?
Pericardial fluidAbsentPresentEquivocal
Right upper quadrant (Morison’s pouch) fluidAbsentPresentEquivocal
Left upper quadrant (splenorenal recess) fluidAbsentPresentEquivocal
Suprapubic fluidAbsentPresentEquivocal

Management

Suggested management (clinician must consider additional clinical information including hemodynamic stability and clinical suspicion for injury):

Pericardial FAST (penetrating thoracic trauma)   
Positive   emergent surgical intervention recommended. Median sternotomy preferred if the patient is stable; otherwise, use left anterolateral thoracotomy.
Equivocal  pericardial window or formal transthoracic echocardiography (TTE) is recommended.
Negative  close clinical monitoring or discharge is recommended, according to clinical suspicion for injury.
Abdominal FAST (blunt abdominal trauma) 
Positivein the unstable patient, emergent exploratory laparotomy is recommended. In a stable patient, cross-sectional imaging (CT scan) is recommended.
Equivocalin the unstable patient, diagnostic peritoneal aspiration (DPA) is recommended. In a stable patient, cross-sectional imaging (CT scan) is recommended.
Negativein the unstable patient, diagnostic peritoneal aspiration (DPA) is recommended if clinical suspicion for intra-abdominal bleeding exists. In a stable patient, a CT scan, close clinical monitoring, or discharge is recommended, according to clinical suspicion for injury.

NB!

  • Repeating FAST while preparing to perform diagnostic peritoneal aspiration is useful to quickly reassess unstable patients with blunt abdominal trauma with initially negative FAST. Intra-abdominal hemorrhage may not be significant enough on presentation to be FAST-positive initially.
  • Be cautious if pericardial FAST is negative in patients with penetrating thoracic trauma, especially if unstable. Cardiac injuries can decompress through the injured pericardium, most commonly into the left hemithorax, resulting in negative pericardial FAST. Therefore, unstable patients with this mechanism of injury and FAST finding should undergo a chest x-ray. If it reveals a hemothorax, a chest tube must be placed. Ongoing or high-volume chest tube output in this clinical context may be from a cardiac injury.
  • If the pericardial fluid is seen in the subxiphoid view, surgical intervention is warranted.
  • If intra-abdominal fluid is seen in any of the three abdominal views, emergent laparotomy is indicated in unstable patients.
  • Stable patients with intra-abdominal fluid should proceed to cross-sectional imaging. 

More recently, thoracic views have been added to the FAST exam and termed eFAST. These windows assess the chest bilaterally for pneumo- and hemothorax. In some series, the reported sensitivities of eFAST (86–100%) are superior to that of chest x-ray (27–83%) in the detection of pneumothoraces (Governatori 2015, Nandipati 2011, Wilkerson 2010).

The extended FAST (eFAST) has entered into clinical practice with the addition of bilateral thoracic views to assess for pneumo- and hemothorax.

Negative FAST does not exclude injury. Ultrasound is user-dependent; therefore, clinicians should be cautious in interpreting negative FAST. Sensitivities of abdominal and suprapubic views in FAST vary widely, with ranges of 22–98% reported in recent literature

If clinical suspicion for injury persists despite negative FAST, FAST should be repeated, additional investigations should be performed, or intervention should be pursued, depending on patient’s clinical condition.

.

Literature

  1. Rozycki GS, Ochsner MG, Jaffin JH, Champion HR. Prospective evaluation of surgeons’ use of ultrasound in the evaluation of trauma patients. J Trauma. 1993 Apr;34(4):516-26.
  2. Rozycki GS, Ballard RB, Feliciano DV, Schmidt JA, Pennington SD. Surgeon-performed ultrasound for the assessment of truncal injuries: lessons learned from 1540 patients. Ann Surg. 1998 Oct;228(4):557-567.
  3. Rozycki GS, Ochsner MG, Schmidt JA, et al. A prospective study of surgeon-performed ultrasound as the primary adjuvant modality for injured patient assessment. J Trauma. 1995 Sep;39(3):492-8.
  4. Rozycki GS, Feliciano DV, Ochsner MG, et al. The Role of Ultrasound in Patients with Possible Penetrating Cardiac Wounds: A Prospective Multicenter Study. J Trauma. 1999 Apr;46(4):543-51.
  5. Richards JR, McGahan JP. Focused Assessment with Sonography in Trauma (FAST) in 2017: What Radiologist Can Learn. Radiology. 2017 Apr;283(1):30-48.
  6. Ball CG, Williams BH, Wyrzykowski AD, et al. A Caveat to the Performance of Pericardial Ultrasound in Patients with Penetrating Cardiac Wounds. J Trauma. 2009 Nov;67(5):1123-4.
  7. Nandipati KC, Allamaneni S, Kakarla R, et al. Extended Focused Assessment with Sonography for Trauma (EFAST) in the Diagnosis of Pneumothorax: Experience at a Community Based Level I Trauma Center. Injury. 2011 May;42(5):511-4.
  8. Governatori NJ, Saul T, Siadecki SD, et al. Ultrasound in the Evaluation of Penetrating Thoraco-Abdominal Trauma: A Review of the Literature. Med Ultrason. 2015 Dec;17(4):528-34.
  9. Wilkerson RG, Stone MB. Sensitivity of Bedside Ultrasound and Supine Anteroposterior Chest Radiographs for the Identification of Pneumothorax After Blunt Trauma. Acad Emerg Med. 2010 Jan;17(1):11-7.
  10. Matsushima K, Khor D, Berona K, Antoku D, Dollbaum R, Khan M, Demetriades D. Double Jeopardy in Penetrating Trauma: Get FAST, Get It Right. World J Surg. 2017 Aug 4. [Epub ahead of print]
  11. Carter JW, Falco MH, Chopko MS, Flyn WJ Jr, Wiles Iii CE, Guo WA. Do we really rely on fast for decision-making in the management of blunt abdominal trauma?. Injury. 2015 May;26(5):817-21.

Charlson Comorbidity Index (CCI) Online Calculator

Charlson Comorbidity Index predicts 10-year survival in patients with multiple comorbidities.

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History of definite or probable MI (EKG changes and/or enzyme changes)

Exertional or paroxysmal nocturnal dyspnea and has responded to digitalis, diuretics, or afterload reducing agents

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]]> Interactive OSCE Checklist – Emergency care of a patient with chest pain – Acute Coronary Syndrome with ST-segment elevation and equivalents https://clincasequest.hospital/osce-checklist-chest-pain-emergency/ Sat, 14 May 2022 12:10:00 +0000 https://clincasequest.hospital/?p=33535 Additional materials: Register on our website right now to have access to more learning materials! Register Subscribe to our pages:

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• Opening the consultation

• Availability of a defibrillator

• Presenting complaint

• History of presenting complaint

• Past medical history

• Drug history

• Physical examination

• Intravenous access

• Registration of a 12-channel ECG

• Express test for the determination of cardiac troponin, myoglobin, creatine phosphokinase-MB, if possible

• Making preliminary diagnosis

• Drug therapy (basic)

• Evaluation of the door-balloon time (the choice of further reperfusion strategy aimed as soon as possible to restore the coronary blood flow in the infarct-dependent artery)

• Call the nearest reperfusion center

• P2Y12 receptor inhibitor prescription depending on the chosen strategy of reperfusion therapy

• Carrying out thrombolytic therapy as needed

• Transportation to the nearest reperfusion center

Total: 0 / 62



Additional materials:

Chest Pain History Taking / OSCE guide
Pericarditis: symptoms, diagnosis, treatment
Stephen Smith’s formula for Subtle Anterior STEMI online Calculator
Two masks of the same syndrome: Wellens syndrome
Aslanger’s Pattern

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]]> Interactive OSCE Checklist – Counseling a Patient with an increased INR level https://clincasequest.hospital/osce-checklist-patients-counseling-with-increased-inr/ Sat, 12 Feb 2022 03:52:00 +0000 https://clincasequest.hospital/?p=33243 Register on our website right now to have access to more learning materials! Register Subscribe to our pages:

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• Opening the consultation

• Ideas, concerns, complications and expectations

• Analysis of earlier, current INR results, apropriate INR target range and current warfarin dosing

• Analysis of the factors that may affect the increased INR level

• Providing medical care to the patient if necessary

• Bleeding whilst taking warfarin

• How to take warfarin

• Tips for further warfarin dosing according to the analysis of the reasons that led to the INR levels increase

• Lifestyle advice

• Yellow booklets and alert card

• Closing the consultation

• Key communication skills

• Key clinical skills

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]]> Patient’s counseling with an increased INR level / OSCE guide https://clincasequest.hospital/counseling-a-patient-with-inr-increase-osce-guide/ Mon, 07 Feb 2022 08:12:00 +0000 https://clincasequest.hospital/?p=33067 Join our Simulation Training to gain clinical experience Opening the consultation Ideas, concerns, complications and expectations Ideas Explore what the patient currently understands about increased INR…

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  • Opening the consultation
    • Wash your hands and don PPE if appropriate
    • Introduce yourself to the patient including your name and role
    • Confirm the patient’s name and date of birth
    • Explain the reason for the consultation
  • Ideas, concerns, complications and expectations
    • Explore what the patient currently understands about increased INR
    • Ask if the patient has any concerns about warfarin
    • Ask if the patient is bleeding now or before counseling
    • Explore what the patient is hoping to get out of the consultation
  • Analysis of earlier, current INR results, apropriate INR target range and current warfarin dosing
    • Evaluate previous warfarin dosages
    • Evaluate the patient’s earlier INR results
    • Assess the patient’s apropriate INR target range
    • Evaluate the results of the current INR
  • Analysis of the factors that may affect the increased INR level
    • Assess the presence of warfarin taking errors, low patient compliance, the complexity of the warfarin regimen for the patient
    • Assess any changes in the patient’s clinical condition
    • Evaluate any changes in medication
    • Evaluate any changes in lifestyle
    • Evaluate changes in alcohol consumption
  • Providing medical care to the patient if necessary
    • Assess the patient’s bleeding and its severity if necessary
      • In case of active bleeding, provide immediate medical care after taking INR results
    • In the absence of bleeding adjust the dosage of warfarin
  • Bleeding whilst taking warfarin
    • Explain that the main side effect of warfarin is bleeding more easily than normal
    • Explain the common types of ‘less serious bleeding’ and what to do if they experience them
    • Explain the rarer types of ‘serious bleeding’ and what to do if they experience them
  • How to take warfarin
    • Explain that warfarin should be taken at the same time each day
    • Explain the different types of warfarin tablets
    • Explain what the patient should do if they forget a dose
    • Advise the patient to let medical professionals know that they take warfarin when they are being prescribed new medications
    • Advise the patient to let the team managing their anticoagulation know when they start taking a new medication
    • Advise the patient about the importance of effective contraception if taking warfarin (if relevant)
  • Tips for further warfarin dosing according to the analysis of the reasons that led to the INR levels increase
    • Estimate the required duration of administration of a concomitant drug that interacts with warfarin (temporary, chronic) as needed
    • Adjust warfarin dosage as needed
    • Withdraw warfarin if necessary
    • Evaluate the rationality and necessity of co-administration of antiplatelet agents and nonsteroidal anti-inflammatory drugs if necessary
  • Lifestyle advice
    • Advise the patient about the impact of diet on the effect of warfarin
    • Advise the patient about the impact of alcohol on the effect of warfarin
    • Advise the patient about brushing teeth, shaving and dental procedures
  • Yellow booklets and alert card
    • Provide the patient with information about the INR monitoring booklet and patient information booklet
    • Explain the importance of carrying the anticoagulant alert card with them at all times
  • Closing the consultation
    • Summarise the key points back to the patient
    • Ask the patient if they have any questions or concerns that have not been addressed
    • Arrange appropriate follow-up
    • Thank the patient for their time
    • Dispose of PPE appropriately and wash your hands
  • Key communication skills
    • Active listening
    • Summarising
    • Signposting
  • Key clinical skills
    • Determining the target INR level depending on the clinical situation
    • Analysis of the factors that may affect the INR increase
    • Providing medical care to the patient with INR increase
    • Advice to the patient and explanations about lifestyle, diet

    • Join our Simulation Training to gain clinical experience

    Opening the consultation

    1. Wash your hands and don PPE if appropriate
    2. Introduce yourself to the patient including your name and role.
    3. Confirm the patient’s name and date of birth
    4. Explain the reason for the consultation

    Ideas, concerns, complications and expectations

    1. Explore what the patient currently understands about increased INR
    2. Ask if the patient has any concerns about warfarin
    3. Ask if the patient is bleeding now or before counseling
    4. Explore what the patient is hoping to get out of the consultation
    IdeasExplore what the patient currently understands about increased INR“Have you heard of increased INR?”
    “Do you understand the reasons that can cause an INR increase?”
    “Have you ever had an INR increase before? What did cause it early?”
    Concerns   Ask if the patient has any concerns about warfarin“Is there anything that worries you about taking warfarin?”
    ComplicationsAsk if the patient is bleeding now or before counseling“Are you bleeding at this moment, or before counseling?”
    “Have you had periods that are more intense and last longer than usual?”
    “Have you had bleeding that stops for a little longer than usual?
    “Have you had a nosebleed (lasting more than 10 minutes)?”
    “Did you have bleeds from your gums while brushing your teeth?”
    “Have you had bruises that appear for no reason?”
    “Did you have red urine or black feces?”
    “Did you have blood in your vomit or a cough with blood?”
    “Have you had severe headaches, convulsions (seizures), changes in vision, numbness or tingling in your arms or legs, or a feeling of extreme tiredness, weakness, or nausea?”
    “Have you had any bleeding from the cut or injury that doesn’t stop or slow down?”
    Expectations  Explore what the patient is hoping to get out of the consultation“What were you hoping we’d discuss today?”

    Analysis of earlier, current INR results, apropriate INR target range and current warfarin dosing

    1. Analysis of earlier, current INR results, apropriate INR target range and current warfarin dosing
    2. Evaluate previous warfarin dosages
    3. Evaluate the patient’s earlier INR results
    4. Assess the patient’s apropriate INR target range
    5. Evaluate the results of the current INR

    Target INR ranges

    The most common target INR is 2.5. Others are:

    Recurrent VTE (DVT or PE) despite adequate anticoagulation3.5
    CardioversionPre – 3.0 Post – 2.5*
    Mechanical Heart ValvesSee below

    *The 2016 European Society of Cardiology (ESC) guidelines on cardioversion state that patients who have been in AF for longer than 48 hours should start OAC therapy at least 3 weeks before cardioversion and continue for 4 weeks afterward (in those without a need for long-term anticoagulation).

    Atrial fibrillation Anticoagulation is normally offered to patients with a CHADSVASc score ≥ 2 and considered in men with a CHADSVASc score of 1.

    Warfarin is not usually indicated for ischaemic stroke without atrial fibrillation (except in antiphospholipid syndrome), retinal vessel occlusion, peripheral artery thrombosis, coronary artery graft or coronary angioplasty, and stents.

    Cardioversion

    Anticoagulation for 4 weeks before and for 3 months afterward. To minimize cardioversion cancellations due to low INRs on the day of the procedure we recommend a target INR of 3.0 prior to the procedure and 2.5 afterward (Oxford guidelines).

    *The 2016 European Society of Cardiology (ESC) guidelines on cardioversion state that patients who have been in AF for longer than 48 hours should start OAC therapy at least 3 weeks before cardioversion and continue for 4 weeks afterward (in those without a need for long-term anticoagulation).

    Mechanical Heart Valves.  Target INR range based on indications

    Target INR in mechanical heart valve replacement Mechanical Prosthesis thrombogenicity*Isolated Aortic Valve ReplacementMitral or Tricuspid Valve Replacement, or
     No risk factors**AVR with Risk factors **
    Low (most current valves)2.53.0
    Medium3.03.5
    High3.53.5***

    *Prosthesis thrombogenicity:

    • Low: Carbomedics (aortic position), Medtronic Hall, St Jude Medical (without silzone)
    • Medium: Bjork-Shiley, other bileaflet valves
    • High: Starr-Edwards, Omniscience, Lillehei-Kaster.

    **Patient-related risk factors for thrombosis:

    • Mitral, tricuspid or pulmonary position
    • Previous arterial thromboembolism
    • Atrial fibrillation
    • Left atrium diameter >50 mm
    • Mitral stenosis of any degree
    • Left ventricular ejection fraction< 35%.

    ***Was 4.0 in ESC guideline

    Analysis of the factors that may affect the increased INR level

    1. Assess the presence of warfarin taking errors, low patient compliance, the complexity of the warfarin regimen for the patient
    2. Assess any changes in the patient’s clinical condition
    3. Evaluate any changes in medication
    4. Evaluate any changes in lifestyle
    5. Evaluate changes in alcohol consumption

    It is necessary to clarify with the patient what doses he/she has taken in the last two weeks and to review the dosing schedule.
    Ask the patient to bring all their drugs and a box of pills to make sure the drug is correct and the dosage regimen is appropriate.

    COMMON CAUSES OF HIGH INRs

    NON‐COMPLIANCE OR
    ERRORS IN DOSING
    (The patient mistakenly took a different dosage regimen than was prescribed)    		– Complex regimen
    – Splitting tablets
    – Dosing error or duplication
    – Multiple tablet strengths
    DRUG THERAPY CHANGES, DRUG INTERACTIONS– Warfarin dose recently altered
    – Recent antibiotic use
    – OTC or herbal product added, deleted, or dose altered
    – Medication added, deleted, or dose altered
    LIFESTYLE CHANGES, MALNUTRITION (vitamin K deficiency)– Increase in alcohol use or binge drinking;
    – Decrease in consumption of Vitamin K containing foods;
    – Chewing tobacco use recently decreased or discontinued;
    ALTERED HEALTH STATES– Fever, acute illness, diarrhea,
    – Reduced food intake
    – Uncontrolled hyperthyroidism
    – CHF exacerbation
    – Liver disease

    The patient should be asked the following questions to assess the factors that may lead to an INR increase

    NON‐COMPLIANCE OR
    ERRORS IN DOSING    		“Do you have difficulties in taking warfarin?”
    “Do you understand the warfarin dosing regimen that was prescribed for you?”
    “Do you understand the warfarin dosing regimen?”
    “Aren’t you confused about taking warfarin?”
    “Is it difficult to take your recommended warfarin dosage regimen?”
    “What dosages of warfarin have you been taking lately?”
    “Is it convenient for you to divide warfarin tablets in half?”
    “Do you remember the mistakes in taking warfarin?”
    “Can you mention the mistakes in warfarin?”
    “Do you remember days when you took a double dose of warfarin?”
    “Do you remember days when you mistakenly took more warfarin than you were prescribed?”
    “Are you experiencing any inconvenience due to the variety of warfarin dosing regimens?”
    “Do you have difficulties with different warfarin regimens on different days?”
    “Are you confusing about the dosing regimens that you assigned on certain days?”
    “Is it convenient for you to divide warfarin tablets in half?”
    “Do you remember the mistakes in taking warfarin?”
    “Can you mention the mistakes in warfarin?”
    “Do you remember days when you took a double dose of warfarin?”
    “Do you remember days when you mistakenly took more warfarin than you were prescribed?”
    “Are you experiencing any inconvenience due to the variety of warfarin dosing regimens?”
    “Do you have difficulties with different warfarin regimens on different days?”
    “Are you confusing about the dosing regimens that you assigned on certain days?”
    DRUG THERAPY CHANGES, DRUG INTERACTIONS“Have you recently had increasing in your warfarin dosage?”
    “Has there been a recent adjustment of warfarin dosage?”
    “Have you had a recent concomitant use of antibiotics and other drugs?”
    “Have you been prescribed antifungals, sulfamethoxazole and trimethoprim, and other drugs?”
    “Have you had a recent concomitant use of amiodarone?”
    “Have you had a recent concomitant use of paracetamol or combination drugs containing paracetamol?”
    “Have you had an acute respiratory illness that required paracetamol or a combination of paracetamol-containing drugs?”
    “Have you taken drugs to reduce the acidity of gastric juice?”
    “Have you taken heartburn remedies?”
    “Have you taken antidepressants?”
    “Did you take statins or fibrates?”
    “Have you confessed to acarbose or lactulose?”
    “Didn’t you use phenytoin?”
    “Did you have any recent additions, withdrawals, or changes in over-the-counter or herbal dosage regimens?”
    “Have you had any recent additions, withdrawals, or changes in the dosage regimen of concomitant therapy?”
    “Didn’t you take thyroid hormones?”
    Have you been prescribed vitamin E? ”
    “Have you been prescribed painkillers?”
    “Have you been prescribed allopurinol?”
    “Have you been vaccinated?”
    “Have you used tramadol, oxandrolone?”
    LIFESTYLE CHANGES, MALNUTRITION (vitamin K deficiency)“Have you had an increase in alcohol or binge drinking lately?”
    “Have you had a reduction in your intake of foods containing vitamin K?”
    “Has there been a decrease in the consumption of products containing vitamin K, such as pickles (fennel), mayonnaise, soybean oil, broccoli, Brussels sprouts, cabbage, leafy greens, kale, lettuce, parsley, spinach, watercress (raw)? »
    “Have you used cranberries (eg juice, supplements)?”
    “Did you drink grapefruit or grapefruit juice?”
    “Has your chewing tobacco consumption decreased or stopped lately?”
    ALTERED HEALTH STATES “Have you had a fever lately?”
    “Have you had an acute illness lately?”
    “Have you had diarrhea recently?”
    “Have you had a reduction in food intake?”
    “Do you suffer from hyperthyroidism? Are you receiving treatment for hyperthyroidism? Do you see an endocrinologist about this? Do you monitor your thyroid function? ”
    “Has your condition been deteriorating lately?”
    “Do you have liver disease?”
    “Has your shortness of breath gotten worse?”
    “Has your exercise tolerance decreased in recent times?”
    “Did your lower extremities swell?”
    “Have you had a feeling of shortness of breath lately?”
    “Do you need to sit down at night due to lack of air?”

    Hyperthyroidism and fever

    Both hyperthyroidism and fever result in a hypermetabolic state, which may accelerate the clearance of vitamin K-dependent clotting factors. Thus the amount of warfarin required to produce an anticoagulant effect would decrease. This means when a patient starts to take carbimazole or propylthiouracil to correct their thyroid function, their warfarin requirement will increase as their thyroid function normalizes.

    Liver disease

    The use of warfarin in patients with severe liver disease is contraindicated due to the unpredictable effects of liver disease on coagulation, such as:

    • vitamin K deficiency due to intra- or extra-hepatic cholestasis
    • reduced synthesis of coagulation factors due to severe hepatocellular damage
    • functional abnormalities of platelets and fibrinogen found in many patients with

    Congestive heart failure

    Heart failure can cause hepatic congestion of blood flow and inhibit the metabolism of warfarin leading to excessive anticoagulation with a risk of bleeding. This can be troublesome in patients with frequent exacerbations of heart failure (ie, worsening of heart failure, usually requiring hospitalization).

    Providing medical care to the patient if necessary

    1. Assess the patient’s bleeding and its severity if necessary
    2. In case of active bleeding, provide immediate medical care after taking INR results
    3. In the absence of bleeding adjust the dosage of warfarin

    Criteria for assessing the severity of bleeding (American College of Cardiology, 2020):

    • destabilization of hemodynamics (SBP <90 mm Hg; decrease in SBP ˃40 mm Hg; drop in SBP ≥20 mm Hg or BP ≥10 mm Hg when moving to vertical position; diuresis <0.5 ml/kg/h);
    • bleeding in the critical area (intracranial hemorrhage – intracerebral, subdural, epidural, subarachnoid; other hemorrhages of the central nervous system – intraocular, interracial and extra-axial spinal hemorrhage; hemo tamponade; hemothorax, intra-abdominal and extra-abdominal hemorrhage; pulmonary hemorrhage, posterior epistaxis; intramuscular and intra-articular bleeding);
    • clinically significant bleeding with a decrease in hemoglobin ≥2 g/dl (20 g/l) or requiring transfusion of ≥2 packets of erythrocyte mass.

    If at least one of the above criteria is present, the bleeding is assessed as severe.

    Algorithm for managing a patient with severe bleeding

    Algorithm for managing a patient with minor bleeding

    According to the recommendations of the European Society of Cardiology (2020), there is mild, moderate, and life-threatening bleeding. Further tactics of the patient depend on the severity of bleeding and the type of oral anticoagulant.

    Algorithm for managing a patient with bleeding with VKA

    Vitamin K is a specific antidote to vitamin K antagonists (warfarin and other coumarins), the drug has a dose-dependent effect, administered orally, intravenously at a dose of 1 to 10 mg. Slow intravenous infusion shows a more controlled and rapid effect (significant reduction in INR occurs within 4-6 hours) compared to other routes of administration.
    In the case of severe bleeding in a patient taking VKA, preference is given to a 4-factor concentrate of prothrombin complex, but not to vitamin K.

    Vitamin K1 is an effective antidote to the anticoagulant effect of warfarin. Despite this, data are lacking to show that its use improves outcomes in life-threatening bleeds. While intravenous or oral routes of administration can be used and are effective in reversing an INR that is raised because of warfarin therapy, the intravenous route achieves a more rapid response compared with oral administration, with an onset of action seen within 6–8 hours. However, both routes achieve a similar correction of INR by 24 hours.

    Vitamin K1 should not be administered by subcutaneous or intramuscular routes.

    Subcutaneous administration is no more effective than placebo, while intramuscular injection in an over-anticoagulated patient may lead to hematoma and bleeding, and its effect on reversal is unpredictable owing to variable absorption – it can be associated with a prolonged increase of vitamin K1 plasma levels, which may hinder re-anticoagulation. The major concern about intravenous vitamin K1 has been anaphylaxis. Although the absolute incidence is unknown, it is most likely rare. There is no convincing association between anaphylaxis and dose, concentration, or rate of administration of vitamin K1 but the literature suggests that current formulations with mixed micelles of lecithin and glycol are safer than the previous preparations containing polyethylene castor oil.

    The 4-factor concentrate of the prothrombin complex contains 4 coagulation factors – II, VII, IX, X, as well as protein C and protein S. The required dose of concentrate depends on the level of INR and bodyweight of the patient: at INR 2-4 – 25 IU/kg is recommended; at INR 4-6 – 35 IU/kg is recommended; at INR> 6 – 50 IU/kg is recommended; the maximum possible dose for administration is 5000 IU.

    Advantages of 4-factor prothrombin complex concentrate over FFP include rapid reconstitution into a small volume for infusion over 20–30 minutes, fast onset of action, no requirement to check a patient’s blood group, minimal risk of viral transmission due to pathogen reduction and inactivation steps during manufacturing, and reduced risk of other clinical adverse reactions such as transfusion-associated circulatory overload or transfusion-associated acute lung injury. The latter is due to circulating antihuman leukocyte antigen or antigranulocyte antibodies in plasma. However, the 4-factor prothrombin complex concentrate does contain small amounts of heparin, and its use to reverse warfarin anticoagulation should be carefully considered in patients with heparin-induced thrombocytopenia.

    FFP contains all coagulation factors present in whole blood but it is not a factor concentrate, and multiple units may be needed if FFP alone is used for warfarin reversal. In addition to the inherent risks of plasma use mentioned already, requirements for its use include the need to determine the patient’s blood group (or to use group AB plasma), appropriate facilities for frozen plasma storage and thawing, and the time taken for infusion. Therefore, FFP should not be used routinely to reverse warfarin anticoagulation; however, where 4-factor prothrombin complex concentrate is unavailable and an emergency reversal is required, FFP should be used, along with vitamin K1 to sustain the reversal effect. Treating a patient with bleeding, regardless of INR For patients on warfarin therapy with bleeding in whom the aim is to normalize the INR, vitamin K1 given intravenously is the preferred treatment because of its faster and predictable onset of action. For this indication, doses 3 mg are ineffective. Consistent with other guidelines, we recommend a dose of 5–10 mg. For life-threatening (critical organ) and clinically significant bleeds, the consensus is to use the maximum dose of 4-factor prothrombin complex concentrate (with vitamin K1 and FFP) and the maximum amount of FFP when 4-factor prothrombin complex concentrate is unavailable.

    Among patients with an elevated INR up to 10.0 who do not have bleeding or risk factors for major bleeding, it has been shown that oral administration of low-dose vitamin K1 does not lower the risk of bleeding compared with placebo and should not be used routinely.36 However, for patients with risk factors for bleeding, vitamin K1 1–2 mg orally or 0.5–1.0 mg intravenously should be considered. Risk factors for major bleeding include a major bleed within the previous 4 weeks, surgery within the previous 2 weeks, a platelet count less than 50×109/L, known liver disease, or concurrent antiplatelet therapy. There are no randomized studies to guide the management of patients whose INR exceeds 10.0 and who are not bleeding. A recent single-arm study involving outpatients with an INR greater than 10.0 reported a low rate of major bleeding when these patients received 2.5 mg of oral vitamin K1. Many patients on warfarin are outpatients and information on individual patient bleeding risk is frequently not available to laboratory staff who are involved in reporting elevated INR results and attempting to communicate results to patients. In these settings, good communication between clinical and laboratory staff is essential.


    The recommended dose of 4-factor prothrombin complex concentrate to reverse the anticoagulant effect of warfarin according to the initial and target international normalized ratio (INR / INR) *

      Initial INR  
    Target INR1.5–2.52.6–3.53.6–10.0> 10.0
    0.9–1.330 IU/kg35 IU/kg50 IU/kg50 IU/kg
    1.4–2.015 IU/k25 IU/kg30 IU/kg40 IU/kg

    *Intern Med J 2011; 41: 337-343

    Fresh-frozen plasma is prescribed in the absence of a 4-factor concentrate of prothrombin complex.

    Fresh frozen plasma contains all the components of the coagulation system and the necessary proteins, but before administration, it is necessary to determine the patient’s blood group according to the ABO system, so the beginning of plasma infusion is often delayed. 10-15 ml/kg of plasma are entered. The following side effects may occur volume overload, allergic reactions, and others.

    Characteristics of 4-factor concentrate of prothrombin complex and fresh-frozen plasma

     Four-Factor Prothrombin Complex Concentrate (4F-PCC)Fresh frozen plasma
    DescriptionPrepared from plasma collected from voluntary donors. Sterile freeze-dried powder containing coagulation factors II, IX, and X and low levels of factor VIISeparated and frozen within 18 hours of collection from volunteer donors. Contains all coagulation factors
    ContraindicationsPatients showing signs of thrombosis or disseminated intravascular coagulationDo not use when coagulopathy can be corrected more effectively with specific therapy, such as vitamin K1, cryoprecipitate or other specific factor concentrates
    SpecificationsAvailable in vials containing 500 IU of factor II, IX, and X to be reconstituted in 20 mL of water for injections. Each vial also contains 25 IU of antithrombin and 192 IU of heparinAvailable in Australia in units of 250–334 mL and in New Zealand as 180–300 mL (typically 240–275 mL). It May be stored in a monitored blood refrigerator at 2–6°C for up to 5 days once thawed, and relabelled “thawed plasma” in accordance with Australian and New Zealand Society of Blood Transfusion Guidelines. Thawed plasma has levels of factors II, VII, IX, and X adequate for warfarin reversal
    AvailabilityFrom relevant blood service or hospital blood bankFrom relevant blood service or hospital blood bank
    Considerations for useNo need to consider the ABO blood groupAvailable in all ABO blood groups and should be ABO-group compatible with patient’s red cells (or use AB plasma)
     Known allergies to prothrombin complex concentrateThe most common adverse events — are allergic reactions and volume overload. Potential for transfusion-related acute lung injury and other transfusion reactions, including the transmission of infections
     Predisposition to venous thrombosis disseminated intravascular coagulation, and myocardial infarction 
     Heparin-induced thrombocytopenia 

    Management of patients on warfarin therapy with bleeding*

    Clinical settingRecommendations and levels of evidence†
    INR ≥1.5 with lifethreatening‡ (critical organ) bleedingCease warfarin therapy and administer:
    • vitamin K1 5.0–10.0 mg IV (2C)
    • and Prothrombinex-VF 50.0 IU/kg§ IV
    • and fresh frozen plasma 150–300 mL
    • If Four-Factor Prothrombin Complex Concentrate (4F-PCC) is unavailable, administer fresh frozen plasma 15 mL/kg
    INR ≥2.0 with clinically significant bleeding (not life-threatening)Cease warfarin therapy and administer:
    • vitamin K1 5.0–10.0 mg IV (2C)
    • and Prothrombinex-VF 35.0–50.0 IU/kg IV according to INR
    • If Four-Factor Prothrombin Complex Concentrate (4F-PCC) is unavailable, administer fresh frozen plasma 15 mL/kg
    Any INR with minor bleedingOmit warfarin, repeat INR the following day and adjust warfarin dose to maintain INR in the target therapeutic range (2C)
    • If the bleeding risk is high** or INR > 4.5, consider vitamin K1, 1.0–2.0 mg orally or 0.5–1.0 mg IV
      

    INR = international normalised ratio. IV = intravenously. * Indication for warfarin therapy should be reviewed; if clinically appropriate, consider permanent cessation. † Level of evidence in parentheses in bold. ‡ Includes intracranial bleeding. § Consider administering a Four-Factor Prothrombin Complex Concentrate (4F-PCC) dose less than 50.0 IU/kg when INR 1.5–1.9. ** Recent major bleed (within previous 4 weeks) or major surgery (within previous 2 weeks), thrombocytopenia (platelet count, < 50×109/L), known liver disease, or concurrent antiplatelet therapy

    Management of patients on warfarin therapy with high INR and no bleeding

    Clinical settingRecommendations and levels of evidence*
    INR<4.5 and no bleedingLower or omit the next dose of warfarin
    Resume therapy at a lower warfarin dose when the INR approaches the therapeutic range
    INR 4.5–10.0 and no bleeding• If the INR is only minimally above therapeutic range (up to 10%) dose reduction is generally not necessary (2C)
    • Cease warfarin therapy; consider reasons for elevated INR and patient-specific factors. Vitamin K1 is usually unnecessary (2C)
    • If the bleeding risk is high:† consider vitamin K1 1.0–2.0 mg orally or 0.5–1.0 mg IV
    • measure INR within 24 h
    • resume warfarin at a reduced dose once INR approaches therapeutic range
    INR > 10.0 and no bleeding• Cease warfarin therapy, administer 3.0–5.0 mg vitamin K1 orally or IV‡ (2C)
    • Measure INR in 12–24 h. Close monitoring of INR daily to second daily over the following week
    • Resume warfarin therapy at a reduced dose once INR approaches therapeutic range
    • If the bleeding risk is high:† consider Four-Factor Prothrombin Complex Concentrate (4F-PCC), 15–30 IU/kg
    • measure INR in 12–24 h. Close monitoring over the following week
    • resume warfarin therapy at a reduced dose once INR approaches the therapeutic range

    INR = international normalised ratio. IV = intravenously. * Level of evidence in parentheses in bold; details. Recommendations with no evidence level are standard practice and not based on gradable evidence. † Recent major bleed (within previous 4 weeks) or major surgery (within previous 2 weeks), thrombocytopenia (platelet count, < 50х109/L), known liver disease, or concurrent antiplatelet therapy. ‡ Extrapolated from oral vitamin K data in absence of IV data.

    Bleeding whilst taking warfarin

    1. Explain that the main side effect of warfarin is bleeding more easily than normal
    2. Explain the common types of ‘less serious bleeding’ and what to do if they experience them
    3. Explain the rarer types of ‘serious bleeding’ and what to do if they experience them

    The main side effect of warfarin involves bleeding more easily than normal (e.g. epistaxis, bleeding gums, heavier periods, bruising). These side effects most commonly occur in the first few weeks of treatment or when the patient is unwell. It is important to discuss the different types of bleeding the patient may experience and inform them what to do in these situations.

    Less serious bleeding Minor bleedingSerious bleeding Major bleeding
    “It is normal to bleed more easily when taking warfarin as the medication works by thinning the blood.

    Common types of bleeding include
    – periods that are heavier and last longer than normal
    – bleeding for a little longer than usual if you cut yourself
    – occasional nosebleeds (that last for less than 10 minutes)
    – bleeding from your gums when you brush your teeth
    – bruised that come up more easily and take longer to fade than usual.

    This type of bleeding is not dangerous and should stop by itself. If it happens, keep taking the warfarin, but tell your doctor if the bleeding bothers you or does not stop.”    		“Occasionally, you can have serious bleeding from taking warfarin. This can be dangerous and needs urgent medical attention.”
    “Stop taking warfarin and call your doctor or anticoagulant clinic, or go to A&E if you experience:
    – red pee or black poo,
    – large bruises or bruises that happen for no reason,
    – nosebleeds that last longer than 10 minutes,
    – blood in your vomit or you’re coughing up blood,
    – severe headaches, fits (seizures), changes to your eyesight, numbness or tingling in your arms or legs, or feeling very tired, weak, or sick – these can be signs of bleeding in your brain
    – any bleeding from a cut or injury that will not stop or slow down”

    How to take warfarin

    1. Explain that warfarin should be taken at the same time each day
    2. Explain the different types of warfarin tablets
    3. Explain what the patient should do if they forget a dose
    4. Advise the patient to let medical professionals know that they take warfarin when they are being prescribed new medications
    5. Advise the patient to let the team managing their anticoagulation know when they start taking a new medication
    6. Advise the patient about the importance of effective contraception if taking warfarin (if relevant)

    Key points to communicate when discussing warfarin use:

    • “Warfarin should be taken at the same time each day to keep the levels of warfarin steady.”
    • “Tablets have different colours depending on their strength (e.g. 0.5mg white; 1mg brown; 3mg blue; 5mg pink).”
    • “If you forget to take a dose you should take it as soon as you remember, but if you don’t remember till the following day you should skip the missed dose. You should never take two doses together to make up for a missed dose and you should inform your doctor or warfarin clinic about any missed doses at your next appointment.”
    • “Whenever you are going to purchase or be prescribed a new medication you should let the doctor or pharmacist know that you take warfarin so they can avoid prescribing medications which alter your warfarin level.”
    • “When you start taking a new medication you should let your doctor or anticoagulant clinic know so that they can consider if your warfarin levels need monitoring more frequently.”
    • “You should continue to take your warfarin tablets regularly until you have been told to stop.”
    • “Warfarin is not safe to be used during pregnancy and therefore you should have an effective contraceptive method in place before you start taking warfarin.”
    • “You must inform anticoagulant healthcare staff if you think you have taken too much warfarin or have missed any doses.”
    • “You must inform the relevant healthcare professionals if you start, stop or change the dose of your medicines, or if your diet changes substantially (eg. intake of broccoli, lettuce or spinach /)”Other medicines” include not only prescribed drugs but also products that may be brought without prescription, such as aspirin,  and medicines containing aspirin, vitamins, food supplements and herbal or homoeopathic remedies.”
    • “If you require surgery, dental work, or any other invasive procedure you may need stop taking warfarin temporarily. You should discuss your warfarin management with a healthcare professional prior to the procedure”.

    Tips for further warfarin dosing according to the analysis of the reasons that led to the INR levels increase

    1. Estimate the required duration of administration of a concomitant drug that interacts with warfarin (temporary, chronic) as needed
    2. Adjust warfarin dosage as needed
    3. Withdraw warfarin if necessary
    4. Evaluate the rationality and necessity of co-administration of antiplatelet agents and nonsteroidal anti-inflammatory drugs if necessary
    • Most common drugs that can increase INR:
      • Antibiotics: sulfamethoxazole/trimethoprim, metronidazole, quinolones (ciprofloxacin, levofloxacin), amoxicillin, erythromycin, clarithromycin, azithromycin
      • Azole antifungals: fluconazole, miconazole, voriconazole
      • Cardiac drugs: amiodarone, some statins (fluvastatin), fenofibrate
      • Acetaminophen >1 g/day
      • Levothyroxine dose increases – full effect observed after 4‐6 weeks of dose change
    • Management strategy:
      • If the interacting drug is temporary and significantly increases the INR, may temporarily hold and/or reduce the maintenance dose of warfarin until the interacting effect resolves.
      • If the interacting drug will be used chronically, modify the warfarin dose according to a
      • dosing nomogram.
      • Although warfarin interacts with many drugs, virtually no drug requires complete avoidance in a patient who is also taking warfarin therapy (or vice versa). Increasing the frequency of INR tests, initially, allows for appropriate dosing adjustments, if necessary.
      • There may be some exceptions to this approach. For example, patients receiving chemotherapy with emesis or infection may have INR fluctuation that is difficult to control.
      • In such cases, switching the patient to a low molecular weight heparin (LMWH) until stabilization of the underlying condition is suggested.
      • Note: Antiplatelet agents (acetylsalicylic acid [ASA], clopidogrel, prasugrel, ticagrelor) and Non‐steroidal Anti‐Inflammatory Drugs (NSAIDs) significantly increase the risk of bleeding when combined with warfarin but generally do not change the INR. The indication and clinical necessity of using these agents should be carefully weighed against the increased bleeding risk.

    Strategy approach in a patient with altered health states

    • Transient infectious illness (fever and/or diarrhea):
      • Fever increases the metabolic state which may result in depletion of clotting factors and increased INR.
      • Being ill can also alter diet and may lead to a transient vitamin K deficiency.
    • Uncontrolled hyperthyroidism – leads to increased clearance of clotting factors, resulting in high INR.
    • Congestive heart failure (CHF) exacerbation (perhaps due to liver congestion).
    • Management Strategy:
      • Temporarily reduce the warfarin dose and increase the frequency of INR monitoring until the patient’s health state stabilizes

    Algorithm for warfarin dose adjusting

    It may be necessary to (temporarily) reduce the dose of warfarin and/or skip one or two doses based on the assessment of INR level. The INR should be re-measured to be sure about its decreasing after two or three days.

    INRRecommended dose adjustment of warfarin
    <1.5Increase the weekly dose by 10-20%
    Consider additional doses
    INR control in 4-8 days under the doctor consideration
    1.5 to <2Increase the weekly dose by 10-20%
    INR control in 4-8 days under the doctor consideration
    2.0-3.0Unchanged
    >3.0 to 3.5Decrease the weekly dose by 10-20%
    INR control under the doctor consideration
    4.0 to >5.0Skip 0 to 1 dose
    and/or reduce the weekly dose by 0-20%
    INR control under the doctor consideration
    >4.0 but >5.0Skip 1-2 doses and reduce the weekly dose by 10-20%
    INR control in 3-7 days under the doctor consideration
    5.0 to >9.0
    without significant bleeding    		Skip 1-2 doses
    INR control in 1-2 days under the doctor consideration
    To resume warfarin taking when INR <3.0 with a decrease in a weekly dose by 5-20%
    If urgent surgery is required, the patient should be given fresh-frozen plasma
    ≥9.0
    without significant bleeding    		Do not take warfarin
    Assign vitamin K (2.5-5 mg orally once)
    INR control daily to > 3.0, reducing the weekly dose by 10-20%
    If urgent surgery is required, the patient should be given fresh-frozen plasma

    Altered Nutritional Status

    • Patients who are malnourished are commonly vitamin K deficient.
    • Sudden changes in diet may be due to social circumstances such as a death of a spouse/family member/pet or stressful work or health situations.
    • Management Strategy:
      • Ask the patient to describe their eating pattern and intake.
      • Recommend eating consistent meals or use of a meal replacement beverage (e.g. 4 cans of
      • Ensure contain the required daily amounts of nutrients) or multivitamins containing vitamin K.
      • If this is not successful, consider lowering the maintenance dose and increasing the frequency of monitoring.

    Alcohol consumption

    Even a single moderate consumption or a large amount of alcohol consumed (more than two glasses) can temporarily increase the INR level (for example, alcohol consumption on weekends). In case of cessation of alcohol intake, it is possible to continue the usual maintenance dose.

    It is recommended alcohol abuse prevention.

    Errors in dosing

    The patient may have mistakenly taken a different dosage regimen than what was prescribed.

    Management Strategy:

    • Ask the patient exactly what doses they have taken in the past 2 weeks and review their dosing calendar.
    • Ask the patient to bring in all of their medications and pill box to ensure the correct drugs and doses are being taken. If the patient has a good relationship with their local pharmacy, ask the pharmacist to double check.
    • Use a warfarin dosing calendar. Encourage the patient to use a calendar to record their INRs and warfarin doses taken.
    • Use a warfarin dosette (pill box). The patient or caregiver puts the daily doses in a weekly pill box.
    • Simplify the dosing regimen. Use of a single tablet strength to avoid multiple strength confusion and strategically putting extra/reduced daily doses on days that are easy to remember (e.g. “Take 1 tablet every day except take 2 tables on Sundays.”

    Lifestyle advice

    1. Advise the patient about the impact of diet on the effect of warfarin
    2. Advise the patient about the impact of alcohol on the effect of warfarin
    3. Advise the patient about brushing teeth, shaving and dental procedures
    DietDrastic changes in diet, especially an increase in consumption of foods high in vitamin K (such as broccoli, kale, or spinach) can potentially affect the control of anticoagulation.

    If the patient ever wishes to significantly change their diet, they should inform the anticoagulant clinic so necessary dose adjustments and monitoring requirements can be fulfilled. “Since vitamin K and warfarin work against each other, the amount of vitamin K in your diet can change warfarin’s effects. It is important to keep your dietary intake of vitamin K consistent. Foods such as green leafy vegetables and certain oils have higher contents of vitamin K. (See the table below for a chart of vitamin K content in selected foods).

    If you DECREASE your intake of vitamin K (eat fewer foods containing vitamin K) your dose of warfarin may need to be lowered to prevent bleeding. If you INCREASE your intake of vitamin K, your dose of warfarin may need to be increased to prevent blood clots. A MAJOR change in your vitamin K intake can affect your PT/INR, but normal daily variation in the foods you eat is okay.

    You DON’T have to avoid foods that are high in vitamin K, just keep your diet consistent. You should let your healthcare professional know if there is going to be a major change in your diet, so your PT/INR can be closely monitored”

    Many people are on special diets, such as the Atkin’s or South Beach diets, to lose weight. These diets are high-protein diets and can also affect the way warfarin works in your body. Once you take a dose of warfarin, some of it binds to protein in your bloodstream. While warfarin is attached to this protein, it has no effect on your body. It’s thought that high protein diets can increase the number of proteins in your body and cause more warfarin to be bound to protein.

    This causes a DECREASE in warfarin available to prevent clots, so your warfarin dose may need to be increased. Always check with your healthcare professional before starting any special diets, so your PT/INR can be closely monitored.  

    Certain foods can also affect how your liver clears warfarin from your body, causing warfarin levels to increase or decrease. Examples include alcohol, cranberry products (e.g., juice, supplements), and possibly grapefruit or grapefruit juice. Too much alcohol, cranberry products, or grapefruit products can INCREASE warfarin’s effect and increase your risk of bleeding. Avoid or limit your intake of alcohol, cranberry products, and grapefruit or grapefruit juice.

    Make sure your healthcare professional knows if your diet contains any of these products, so your PT/INR can be closely monitored. Cranberry juice is also known to interact with warfarin and enhance its anticoagulant effect and therefore it should be avoided.    

    “People on vitamin K-rich diets should not change eating habits without at the same time reducing the warfarin dosage, because excessive anticoagulation and bleeding may occur.”  
    Alcohol  Patients should limit their alcohol intake to a maximum of one or two drinks a day and never binge drink.
    If there are major changes in alcohol consumption (e.g. the patient stops drinking, or starts drinking more) the INR can be affected.  
    “People should limit the amount of alcohol to a maximum of one or two drinks a day and never bridge drink.”
    OtherPatients should be advised to take extra care when carrying out routine tasks such as brushing teeth or shaving; a soft toothbrush or an electric razor can help. Patients should also be advised to inform their dentist that they take warfarin when booking an appointment as this may have implications for dental procedures.  

    “Other things to remember when taking warfarin In addition to foods, many prescription and over-the-counter drugs, including vitamins and herbal supplements, can affect your warfarin level. You should not start, stop, or change doses of any drugs or supplements without first talking with your healthcare professional. Try to keep a healthy, well-balanced diet and keep your vitamin K intake consistent. Take your warfarin dose around the same time each day. If you miss a dose, take it as soon as you remember. If it is almost time for the next dose, skip the missed dose and continue your regular dosing schedule. Don’t double up doses without checking with your healthcare professional. Tell your healthcare professional immediately if you have unusual bleeding or bruising, black or bloody stools, blood in the urine, or stomach pain.”

    “People should avoid activities which could cause abrasion, bruising or cuts (eg., contact sports, gardening, sewing), or at least use protection.”

    People should avoid insect bites, especially on their legs, and should use a repellent when exposed to insects.   Patients with deep vein thrombosis should be given the following additional lifestyle advice: regular walking exercise helps to reduce the risk of further deep vein thrombosis and improves circulation in the affected limb the affected leg should be elevated when sitting “If you are traveling for any length of time will need to move your dosing time gradually  – say by an hour a day – to a time that is convenient to the new zone. You may also need to have an INR check while you are away.”

    Yellow booklets and alert card

    1. Remind the patient with information about the INR monitoring booklet and patient information booklet
    2. Remind the patient the importance of carrying the anticoagulant alert card with them at all

    At the start of treatment, all patients should be provided with two yellow anticoagulant booklets, an INR monitoring booklet, and a patient information booklet. Patients should also be provided with an anticoagulant alert card.

    Patients should be advised to always carry the anticoagulant alert card with them in case of an emergency and always take the yellow INR monitoring book with them to each appointment at the anticoagulant clinic and if possible to other appointments (e.g. GP, pharmacy reviews, dental appointments, etc).

    The patient information book is a useful resource since it provides the patient with a point of reference and reinforces what has been covered in this guide.

    Closing the consultation

    1. Summarise the key points back to the patient
    2. Ask the patient if they have any questions or concerns that have not been addressed
    3. Arrange appropriate follow-up
    4. Thank the patient for their time
    5. Dispose of PPE appropriately and wash your hands

    Key communication skills

    Summarise the key points back to the patient.

    Ask the patient if they have any questions or concerns that have not been addressed.

    If you feel that the patient would benefit from a recap session, arrange a follow-up appointment (face-to-face or telephone) and also direct the patient to the yellow anticoagulant information booklet for further reading.

    Thank the patient for their time.

    Dispose of PPE appropriately and wash your hands.

    Key communication skills

    1. Active listening
    2. Summarising
    3. Signposting

    Key clinical skills

    1. Determining the target INR level depending on the clinical situation
    2. Analysis of the factors that may affect the INR increase
    3. Providing medical care to the patient with INR increase
    4. Advice to the patient and explanations about lifestyle, diet

    If necessary, re-detail Counseling a patient who is taking warfarin / OSCE guide

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    Principles for preventing high international normalised ratio (INR)

    • When starting warfarin therapy, avoid high loading doses of warfarin. In general, it is preferable to start treatment using an initial daily dose of 5 mg, or even lower in elderly patients. However, some guidelines have suggested that patients who are considered sufficiently healthy may receive warfarin 10 mg daily for the first 2 days with subsequent doses to be determined by the INR (2C)
    • Consider potential warfarin–drug interactions. Avoid concomitant non-steroidal antiinflammatory drugs and certain antibiotics (2C). Avoid concomitant antiplatelet therapy except where clinical benefit is known, such as mechanical heart valves, acute coronary syndrome, or recent insertion of coronary stents (2C)
    • Test the INR more frequently after starting, stopping or changing the dose of concomitant medication
    • Avoid frequent dose adjustments. A change in warfarin dose will take several days to influence the INR, so testing the INR within 24 or 48 hours of a dose change may not truly reflect the steady-state response to the dose adjustment
    • Avoid excessive increases in dose when the INR drifts below the target INR range
    • Effective patient education can minimise compliance problems
    • Pharmacogenetic testing to guide warfarin dosing is not necessary (1B)

    Vitamin K Content of Selected Foods

    * Note: This is NOT a list of foods to avoid. This list provides information on the vitamin K content of certain foods.

    FoodsLowModerateHigh
    VegetablesGreen beans    AsparagusBroccoli
     CarrotsAvocadoBrussels sprouts
     CauliflowerRed CabbageCabbage
     CeleryGreen peasCollard greens
     Corn Endive (raw)
     Cucumber (peel removed)Pickle (dill)Kale (raw leaf)
     EggplantLettuce (iceberg)Lettuce (bib, red leaf)
     Mushrooms Mustard greens (raw)
     Onions Parsley
     Green pepper Spinach
     Potato Turnip greens (raw)
     Pumpkin Watercress (raw)
     Sauerkraut (canned) Swiss chard
     Tomato  
    FruitsApple  
     Banana  
     Blueberries  
     Grapes  
     Orange  
    MeatsBeef  
     Chicken  
     Pork  
     Tuna  
       Turkey  
    Fats and OilsCorn oilMargarineMayonnaise
     Peanut oilOlive oilCanola oil
     Safflower oil Soybean oil
     Sesame oil  
     Sunflower oil  
    Dairy ProductsButter  
     Cheese (cheddar)  
     Eggs  
     Sour cream  
     Yogurt  
    BeveragesCoffee  
     Cola  
     Fruit juices  
     Milk  
     Tea (black) Tea (green)**
    * Adapted with permission from Clotcare Online Resource at www.clotcare.com. (Accessed April 20, 2005)
    ** There is some controversy as to whether brewing green tea alters the vitamin K content and/or whether green tea may alter the effect of warfarin by some other mechanism

    Potential Interactions of Dietary Supplements with Warfarina

    Potential Increase in Risk of Bleeding  
    Acetyl-L-carnitineFish oilMate
    ArnicaFlaxseed, Flaxseed oilMelatonin
    Alcohol, acute useFo-tiMesoglycan
    Bishop’s weedForskolinMilk thistle
    Black teaForsythiaN-acetyl glucosamine
    BladderwrackGamma-linolenic acidNattokinase
    BoldoGarlicOolong tea
    Borage seed oilGingerPantethine
    BurdockGinkgoPapaya
    CaffeineGinseng, SiberianPeppermint oil
    Chondroitin sulfateGlucosaminePropionyl-L-carnitine
    Cod liver oilGrapefruit, Grapefruit juiceRed clover
    ColtsfootGuaranaReishi mushroom
    Cranberry, cranberry juiceGuggulResveratrol
    DanshenHoly basilSaw palmetto
    Devil’s clawHoneysuckleSea buckthorn
    Dong quaiHorse chestnutTiratricol
    EpimediumIpriflavoneTurmeric
    Eucalyptus oilJiaogulanVinpocetine
    Evening primrose oilKavaVitamin A
    FenugreekL-carnitineVitamin E
    FeverfewLyciumWillow bark
      Wintergreen
    Possible Decrease in Warfarin’s Effects  
    Acerola  
    Alcohol, chronic use  
    Alfalfa  
    Cherokee rosehip  
    Chlorella  
    Coenzyme Q10  
    Corn silk  
    EDTA  
    Ginseng, American  
    Ginseng, Panax  
    Green tea  
    Limonene  
    Rose hip  
    Smartweed  
    Soy  
    Spinach  
    St. John’s wort  
    Stinging nettle  
    Vitamin C  
    Vitamin K  
    Watercress  
    aAdapted from Natural Medicines Comprehensive Database at www.naturaldatabase.com. (Accessed 4/21/05)

    Vitamin K and other Potential Interactions with warfarinDownload

    Loading...

    • Opening the consultation

    • Ideas, concerns, complications and expectations

    • Analysis of earlier, current INR results, apropriate INR target range and current warfarin dosing

    • Analysis of the factors that may affect the increased INR level

    • Providing medical care to the patient if necessary

    • Bleeding whilst taking warfarin

    • How to take warfarin

    • Tips for further warfarin dosing according to the analysis of the reasons that led to the INR levels increase

    • Lifestyle advice

    • Yellow booklets and alert card

    • Closing the consultation

    • Key communication skills

    • Key clinical skills

    Total: 0 / 50

    Clinical case simulator – Sudden INR increase in the women with prosthetic mitral valve taking warfarin
    Counseling a patient who is taking warfarin / OSCE guide

    Literature:

    1. 12020 ACC Expert Consensus Decision Pathway on Management of Bleeding in patients on oral anticoagulants: a report of the American College of cardiology solution set oversight committee. Jam Coll Cardiol. 2020. Aug, Vol.76 (5). 594-622.
    2. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association of Cardio-Thoracic Surgery (EACT). Supplementary data. European Heart Journal (2020), 42, 373-498.
    3. Huyen A Tran et al. Guidelines. An update of consensus guidelines for warfarin reversal. MJA. 2013; Vol.198(4): 7 P. doi: 10.5694/mja12.10614
    4. What You Should Know About Your Diet and Warfarin. PHARMACIST’S LETTER / Prescriber’s Letter to give to their patients. P.O. Box 8190, Stockton, CA 95208. May 2005 ~ Volume 21 ~ Number 210507, 8 p.
    5. Beatty SJ, Mehta BH, Rodis JL. Decreased warfarin effect after initiation of high-protein, lowcarbohydrate diets. Ann Pharmacother 2005;39:744
    6. Committee on Safety of Medicines (CSM). Current Problems in Pharmacovigilance 2003;29:8.
    7. Shields KM. Possible Cranberry and Warfarin Interaction. Pharmacist’s Letter/Prescriber’s Letter 2003;19(11):191103.
    8. Havrda DE, Mai T, Chonlahan J. Enhanced antithrombotic effect of warfarin associated with low-dose alcohol consumption. Pharmacotherapy 2005;25:303-7.
    9. OXFORD HAEMOPHILIA AND THROMBOSIS CENTRE PROTOCOLS FOR OUTPATIENT ORAL ANTICOAGULATION WITH VITAMIN K ANTAGONISTS. Prepared by D. Keeling with input and review from S. Shapiro, N. Curry, V. Price, and L. Mulholland.AC Protocols version 4.1 May 2017
    10. Paulus Kirchhof, Stefano Benussi, Dipak Kotecha, Anders Ahlsson, Dan Atar, Barbara Casadei, Manuel Castella, Hans-Christoph Diener, Hein Heidbuchel, Jeroen Hendriks, Gerhard Hindricks, Antonis S. Manolis, Jonas Oldgren, Bogdan Alexandru Popescu, Ulrich Schotten, Bart Van Putte, Panagiotis Vardas, Stefan Agewall, John Camm, Gonzalo Baron Esquivias, Werner Budts, Scipione Carerj, Filip Casselman, Antonio Coca, Raffaele De Caterina, Spiridon Deftereos, Dobromir Dobrev, José M. Ferro, Gerasimos Filippatos, Donna Fitzsimons, Bulent Gorenek, Maxine Guenoun, Stefan H. Hohnloser, Philippe Kolh, Gregory Y. H. Lip, Athanasios Manolis, John McMurray, Piotr Ponikowski, Raphael Rosenhek, Frank Ruschitzka, Irina Savelieva, Sanjay Sharma, Piotr Suwalski, Juan Luis Tamargo, Clare J. Taylor, Isabelle C. Van Gelder, Adriaan A. Voors, Stephan Windecker, Jose Luis Zamorano, Katja Zeppenfeld, 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS, EP Europace, Volume 18, Issue 11, November 2016, Pages 1609–1678, https://doi.org/10.1093/europace/euw295

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    Lyme disease

    Lyme disease is an infectious disease caused by the spirochete Borrelia burgdorferi, which is transmissible…

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    Сообщение Patient’s counseling with an increased INR level / OSCE guide появились сначала на ClinCaseQuest.

    ]]>         Shock Index, Pediatric Age-Adjusted (SIPA) online calculator https://clincasequest.hospital/sipa/ Mon, 24 Jan 2022 02:06:00 +0000 https://clincasequest.hospital/?p=32927 Shock Index, Pediatric Age-Adjusted (SIPA) predicts mortality in children with blunt trauma SIPA can be used in patients 4-16 years old who have sustained blunt…

    Сообщение Shock Index, Pediatric Age-Adjusted (SIPA) online calculator появились сначала на ClinCaseQuest.

    ]]>     Shock Index, Pediatric Age-Adjusted (SIPA) predicts mortality in children with blunt trauma

    SIPA can be used in patients 4-16 years old who have sustained blunt trauma.

    Loading...

    4-16 years old only

    * Required

    SIPA should be calculated on presentation to the emergency department. Uptrending SIPA between the field and ED may predict poor outcomes but was not examined by the original authors.

    • SIPA can be used in patients 4-16 years old who have sustained blunt trauma
    • Do not use in young infants, toddlers, or patients with penetrating trauma.

    Patients that present with an elevated SIPA are at higher risk of morbidity and mortality following blunt trauma. Early recognition and treatment in these cases, including a possible decision to transfer to a higher level of care, will improve outcomes in these children.

    This predictive scale identifies severely injured children better than mildly injured children than the Shock Index (SI).

    Indicators required for evaluation:

    • Age 4-16 years old only
    • Maximum heart rate Norm: 60-100
    • Minimum systolic blood pressure Norm: 100-120

    Elevated SIPA is associated with the following outcomes (Acker 2015; Nordin 2017):

    • Higher injury severity.
    • Need for blood transfusion in the first 24 hours.
    • Longer ICU and hospital length of stay.
    • Higher number of ventilator days.
    • Discharge to a rehabilitation facility.
    • Increased risk of mortality.

    SIPA = maximum heart rate/minimum systolic blood pressure, where normal values are as follows:

    Interpretation

    Age  Heart rate (normal ranges)Systolic blood pressure (normal values)Maximum normal SIPARisk of blunt injury if SIPA is elevated
    4–6 years65–11090–1101.2222.0%
    7–12 years60–100100–1201.0025.1%
    13-16 years55–90100–1350.9032.0%

    NB!

    1. The use of the SIPA shock index in the prehospital setting was not studied in the original study, so the use of this prognostic system in the prehospital setting is not recommended.  
    2. The use of SIPA to predict morbidity and mortality following admission has not yet been validated. However, a prognostic study in the Journal of Pediatric Surgery (Vandewalle 2018) found that patients who developed an elevated SIPA within the first 24 hours of admission were at increased risk of complications compared to those whose SIPA remained normal throughout the first 48 hours of admission. In addition, time to normalize SIPA directly correlated with length of hospital and ICU stay.
    3. Per the authors, the age-specific cutoffs originally chosen will require further validation.

    The SIPA was originally developed by researchers at the Children’s Hospital of Colorado to help identify severely injured children following blunt trauma. Realizing that pediatric vital signs vary with age and that the standard SI may not be as useful in children, the researchers sought and defined maximum normal heart rate and minimum normal systolic blood pressure using reference ranges. Using these numbers, they determined the maximum normal SI for each age group.  The researchers then retrospectively looked at 543 children who presented to Children’s Hospital Colorado and Denver Health Medical Center between 1/2007 and 6/2013 following blunt trauma with Injury Severity Score >15.

    Elevated SI was present in 49% of children, while elevated SIPA was present in only 27.6% of children (all of whom had the same adverse outcomes identified by using the SI). Hypotension is often a late finding in children with hypovolemic shock.

    SIPA demonstrated improved discrimination of severe injury relative to SI in the following categories:

    • Injury Severity Score >30: 37% vs 26%.
    • Blood transfusion within first 24 hours: 27% vs 20%.
    • Grade III liver/spleen laceration requiring blood transfusion: 41% vs 26%.
    • In-hospital mortality: 11% vs 7%.

    The researchers concluded that SIPA misses fewer children with severe injury while also minimizing over triage.


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    Literature
    1. Acker SN, Ross JT, Partrick DA, Tong S, Bensard DD. Pediatric specific shock index accurately identifies severely injured children. J Pediatr Surg. 2015;50(2):331-4. https://pubmed.ncbi.nlm.nih.gov/25638631/
    2. Linnaus ME, Notrica DM, Langlais CS, et al. Prospective validation of the shock index pediatric-adjusted (SIPA) in blunt liver and spleen trauma: An ATOMAC+ study. J Pediatr Surg. 2017;52(2):340-344. https://pubmed.ncbi.nlm.nih.gov/27717564/
    3. Nordin A, Coleman A, Shi J, et al. Validation of the age-adjusted shock index using pediatric trauma quality improvement program data. J Pediatr Surg. 2017. https://pubmed.ncbi.nlm.nih.gov/29108845/
    4. Acker SN, Bredbeck B, Partrick DA, Kulungowski AM, Barnett CC, Bensard DD. Shock index, pediatric age-adjusted (SIPA) is more accurate than age-adjusted hypotension for trauma team activation. Surgery. 2017;161(3):803-807. https://pubmed.ncbi.nlm.nih.gov/27814956/
    5. Vandewalle RJ, Peceny JK, Dolejs SC, Raymond JL, Rouse TM. Trends in pediatric adjusted shock index predict morbidity and mortality in children with severe blunt injuries. J Pediatr Surg. 2018;53(2):362-366. https://pubmed.ncbi.nlm.nih.gov/29126550/ 
    6. Yasaka Y, Khemani RG, Markovitz BP. Is shock index associated with outcome in children with sepsis/septic shock?*. Pediatr Crit Care Med. 2013;14(8):e372-9. https://pubmed.ncbi.nlm.nih.gov/23962830/
    7. Rousseaux J, Grandbastien B, Dorkenoo A, Lampin ME, Leteurtre S, Leclerc F. Prognostic value of shock index in children with septic shock. Pediatr Emerg Care. 2013;29(10):1055-9. https://pubmed.ncbi.nlm.nih.gov/24076606/
    8. Qazi K, Wright MS, Kippes C. Stable pediatric blunt trauma patients: is trauma team activation always necessary?. J Trauma. 1998;45(3):562-4. https://pubmed.ncbi.nlm.nih.gov/9751551/
    9. Wang MY, Kim KA, Griffith PM, et al. Injuries from falls in the pediatric population: an analysis of 729 cases. J Pediatr Surg. 2001;36(10):1528-34. https://pubmed.ncbi.nlm.nih.gov/11584402/

    Сообщение Shock Index, Pediatric Age-Adjusted (SIPA) online calculator появились сначала на ClinCaseQuest.

    ]]>         King’s College Criteria for Non- Acetaminophen Toxicity acute hepatic failure https://clincasequest.hospital/kings-college-criteria-non-acetaminophen/ Tue, 04 Jan 2022 10:07:00 +0000 https://clincasequest.hospital/?p=31835 Identification of patients who should be immediately referred for liver transplant. INR > 6.5 (Prothrombin time > 100 sec): Yes No Patient age <11 or…

    Сообщение King’s College Criteria for Non- Acetaminophen Toxicity acute hepatic failure появились сначала на ClinCaseQuest.

    ]]>     Identification of patients who should be immediately referred for liver transplant.

    INR > 6.5 (Prothrombin time > 100 sec):
    Yes
    No

    Patient age <11 or > 40 years:
    Yes
    No

    Serum bilirubin level > 300 μmol/l:
    Yes
    No

    More than seven days passed from the onset of jaundice to the development of encelopathy:
    Yes
    No

    INR (international normalized ratio) >3.5 (prothrombin time > 50 seconds):
    Yes
    No

    Etiology – the absence of hepatitis A and B or the presence of an idiosyncratic reaction to a drug:
    Yes
    No

    Lactate >3.5 mmol/L after fluid
    resuscitation (<4 hrs) OR lactate > 3
    mmol/L after full fluid resuscitation (12 hours):
    Yes
    No

    Phosphate > 3.75 mg/dL (1.2 mmol/L) at 48-
    96 hours
    Yes
    No




    Patient’s score Result Comment
    0 0 0

    Patients with acute liver failure should be treated in centers that specialize in the care of such patients. The King’s College criteria can help identify patients who require liver transplantation.

    Criteria for non-acetaminophen-induced acute liver failure include:

    • 1 big criterion – International normalized ratio (INR)> 6.5; and
    • 5 small criteria:
      1. the patient’s age is <11 or> 40 years;
      2. the level of bilirubin in serum is more than 300 μmol per liter;
      3. More than seven days have passed from the onset of jaundice to the development of encelopathy;
      4. INR (international normalized ratio)> 3.5 (prothrombin time> 50 seconds);
      5. etiology – the absence of hepatitis A and B or the presence of an idiosyncratic reaction to a drug.

    Interpretation of results:

    A patient’s survival prognosis is poor if he has at least 1 major criterion or any 3 minor criteria.

    The King’s College criteria are recommended by the American Association for the Study of Liver Diseases (AASLD) for determining the need for liver transplantation in patients with acute liver failure.

    Register on our website right now to have access to more learning materials!

    Subscribe to our pages:

    References

    1. O’Grady JG, Alexander GJ, Hayllar KM, Williams R. Early indicators of prognosis in fulminant hepatic failure. Gastroenterology. 1989 Aug;97(2):439-45. doi: 10.1016/0016-5085(89)90081-4. PMID: 2490426. https://pubmed.ncbi.nlm.nih.gov/2490426/
    2. Bernal W, Donaldson N, Wyncoll D, Wendon J. Blood lactate as an early predictor of outcome in paracetamol-induced acute liver failure: a cohort study. Lancet. 2002 Feb 16;359(9306):558-63. doi: 10.1016/S0140-6736(02)07743-7. PMID: 11867109. https://pubmed.ncbi.nlm.nih.gov/11867109/
    3. Bailey B, Amre DK, Gaudreault P. Fulminant hepatic failure secondary to acetaminophen poisoning: a systematic review and meta-analysis of prognostic criteria determining the need for liver transplantation. Crit Care Med. 2003 Jan;31(1):299-305. doi: 10.1097/00003246-200301000-00048. PMID: 12545033. https://pubmed.ncbi.nlm.nih.gov/12545033/
    4. Schmidt LE, Dalhoff K. Serum phosphate is an early predictor of outcome in severe acetaminophen-induced hepatotoxicity. Hepatology. 2002; 36(3):659–665. doi: 10.1053/jhep.2002.35069. https://aasldpubs.onlinelibrary.wiley.com/doi/epdf/10.1053/jhep.2002.35069
    5. Riordan SM, Williams R. Treatment of hepatic encephalopathy. N Engl J Med. 1997 Aug 14;337(7):473-9. doi: 10.1056/NEJM199708143370707. PMID: 9250851. https://pubmed.ncbi.nlm.nih.gov/9250851/

    Charlson Comorbidity Index (CCI) Online Calculator

    Charlson Comorbidity Index predicts 10-year survival in patients with multiple comorbidities.

    History of definite or probable MI (EKG changes and/or enzyme changes)

    Exertional or paroxysmal nocturnal dyspnea and has responded to digitalis, diuretics, or afterload reducing agents

    Intermittent claudication or past bypass for chronic arterial insufficiency, history of gangrene or acute arterial insufficiency, or untreated thoracic or abdominal aneurysm (≥6 cm)

    History of a cerebrovascular accident with minor or no residua and transient ischemic attacks

    Chronic cognitive deficit

    Any history of treatment for ulcer disease or history of ulcer bleeding

    Severe = cirrhosis and portal hypertension with variceal bleeding history, moderate = cirrhosis and portal hypertension but no variceal bleeding history, mild = chronic hepatitis (or cirrhosis without portal hypertension)

    Severe = on dialysis, status post kidney transplant, uremia, moderate = creatinine >3 mg/dL (0.27 mmol/L)

    VariablePointsAge <50…
    Read More

    Multiple Myeloma Diagnostic Criteria – Online Calculator

    ≥1 of the following (A or B)

    ≥1 myeloma defining event (C1 or C2)

    For Multiple Myeloma Diagnostic Criteria assessment necessary to provide selection of the…
    Read More

    Сообщение King’s College Criteria for Non- Acetaminophen Toxicity acute hepatic failure появились сначала на ClinCaseQuest.

    ]]>         King’s College Criteria for Acetaminophen Toxicity https://clincasequest.hospital/kings-college-criteria-acetaminophen-toxicity/ Sun, 19 Dec 2021 07:42:00 +0000 https://clincasequest.hospital/?p=31821 Identification of patients who should be immediately referred for liver transplant. Arterial pH < 7.30: Yes No INR > 6.5 (PT > 100 sec): Yes…

    Сообщение King’s College Criteria for Acetaminophen Toxicity появились сначала на ClinCaseQuest.

    ]]>     Identification of patients who should be immediately referred for liver transplant.

    Arterial pH < 7.30:
    Yes
    No

    INR > 6.5 (PT > 100 sec):
    Yes
    No

    Creatinine > 3.4 mg/dL (300 µmol/L):
    Yes
    No

    Grade III or IV hepatic encephalopathy (Grade – III hepatic encephalopathy – Marked confusion, incoherent speech, sleeping most of the time but arousable to vocal stimuli Grade – IV hepatic encephalopathy – Comatose, unresponsive to pain; decorticate or decerebrate posturing):
    Yes
    No

    Lactate >3.5 mmol/L after fluid resuscitation (<4 hrs) OR lactate > 3 mmol/L after full fluid resuscitation (12 hours):
    Yes
    No

    Phosphate > 3.75 mg/dL (1.2 mmol/L) at 48-96 hours
    Yes
    No




    Patient’s score Result Comment
    0 0 0

    Patients with acute liver failure should be managed in centers with expertise in caring for these patients. King’s College Criteria for Acetaminophen Toxicity could help identify patients that required liver transplantation. 

    The presence of one of the following should prompt a referral/transfer to a liver transplantation center:

    Arterial pH < 7.30
    INR > 6.5 (PT > 100 sec)
    Creatinine > 3.4 mg/dL (300 µmol/L)
    Grade III or IV hepatic encephalopathy
    • Grade – III hepatic encephalopathy – Marked confusion, incoherent speech, sleeping most of the time but arousable to vocal stimuli
    • Grade –  IV hepatic encephalopathy – Comatose, unresponsive to pain; decorticate or decerebrate posturing
    Lactate > 3.5 mmol/L after fluid resuscitation (<4 hrs) OR lactate > 3 mmol/L after full fluid resuscitation (12 hours)
    Phosphate > 3.75 mg/dL (1.2 mmol/L) at 48-96 hours
    • Acidosis (admission arterial pH < 7.30) OR
    • Hepatic encephalopathy (grade III or IV), AND coagulopathy (PT > 100 s), AND acute kidney injury (creatinine > 3.4 mg/dL), OR
    • Hyperlactatemia (4-hour lactate > 3.5 mmol/L, or 12-hour lactate > 3.0 mmol/L), OR
    • Hyperphosphatemia (48-96 hour phosphate > 3.7 mg/dL) in patients with acetaminophen-induced fulminant hepatic failure.

    The King’s College Criteria (KCC) was derived from a retrospective review of 588 patients with fulminant hepatic failure (FHF) over 13 years. The predictors are slightly different based on the etiology of the FHF (acetaminophen versus other causes).

    The arterial pH, hepatic encephalopathy (HE), prothrombin time, and creatinine predictors were derived from 310 acetaminophen-induced FHF patients and retrospectively validated on a separate 121 acetaminophen-induced FHF patients.

    There were establish the next Sensitivity, Specificity, Predictive Accuracy for mention above indicators in predictive the necessity of the liver transplantation.

    CriteriaPPVSensitivitySpecificityPredictive Accuracy
    Arterial pH < 7.300.950.490.990.81
    HE + PT + Cr0.670.450.940.83
    Lactate*0.810.950.92
    Phosphate**10.8910.98

    PPV = Positive predictive value; HE = Hepatic encephalopathy stage III/IV; PT = prothrombin time > 100 s; Cr = creatinine > 3.4 mg/dL
    * Either lactate > 3.5 mmol/L after early resuscitation, or > 3.0 mmol/L after full resuscitation.
    ** Phosphate > 3.7 mg/dL between 48 – 96 hours.

    Patients were transferred to King’s College Hospital at a relatively late stage (median time of 51 hours after acetaminophen ingestion) and were the most severely ill (the majority of patients were admitted with HE stages III or IV). This may have affected the predictive values of the test criteria.

    In a systematic review of 14 eligible studies, the estimated overall sensitivity and specificity of the KCC for predicting mortality were 58% and 95%, respectively.

    The search for earlier prognostic indicators with a higher sensitivity for poor prognosis led to investigations of α-fetoprotein, coagulation factor V, ketone body ratio, lactate and phosphate.

    Lactate and phosphate concentrations were initially found to have improved predictive ability to the KCC. Subsequent studies have shown slightly inferior predictive ability compared to the KCC.

    The addition of lactate or phosphate to the KCC may improve sensitivity and negative predictive value.

    Serum aminotransferases and bilirubin should be monitored daily. Frequent monitoring should be performed for coagulation parameters, complete blood counts, metabolic panels, blood gases, and blood glucose. Patients should be monitored and treated for hypoglycemia, hypokalemia, and hypophosphatemia.

    All patients with acetaminophen-induced hepatotoxicity should be prescibed N-acetylcysteine.

    Fresh frozen plasma (FFP) is indicated only in the setting of active hemorrhage or prior to invasive procedures in coagulopathic patients. Prophylactic administration of FFP is not recommended since it does not improve mortality and can interfere with assessments of liver function.

    Register on our website right now to have access to more learning materials!

    Subscribe to our pages:

    References

    1. O’Grady JG, Alexander GJ, Hayllar KM, Williams R. Early indicators of prognosis in fulminant hepatic failure. Gastroenterology. 1989 Aug;97(2):439-45. doi: 10.1016/0016-5085(89)90081-4. PMID: 2490426. https://pubmed.ncbi.nlm.nih.gov/2490426/
    2. Bernal W, Donaldson N, Wyncoll D, Wendon J. Blood lactate as an early predictor of outcome in paracetamol-induced acute liver failure: a cohort study. Lancet. 2002 Feb 16;359(9306):558-63. doi: 10.1016/S0140-6736(02)07743-7. PMID: 11867109. https://pubmed.ncbi.nlm.nih.gov/11867109/
    3. Bailey B, Amre DK, Gaudreault P. Fulminant hepatic failure secondary to acetaminophen poisoning: a systematic review and meta-analysis of prognostic criteria determining the need for liver transplantation. Crit Care Med. 2003 Jan;31(1):299-305. doi: 10.1097/00003246-200301000-00048. PMID: 12545033. https://pubmed.ncbi.nlm.nih.gov/12545033/
    4. Schmidt LE, Dalhoff K. Serum phosphate is an early predictor of outcome in severe acetaminophen-induced hepatotoxicity. Hepatology. 2002; 36(3):659–665. doi: 10.1053/jhep.2002.35069. https://aasldpubs.onlinelibrary.wiley.com/doi/epdf/10.1053/jhep.2002.35069
    5. Riordan SM, Williams R. Treatment of hepatic encephalopathy. N Engl J Med. 1997 Aug 14;337(7):473-9. doi: 10.1056/NEJM199708143370707. PMID: 9250851. https://pubmed.ncbi.nlm.nih.gov/9250851/

    Charlson Comorbidity Index (CCI) Online Calculator

    Charlson Comorbidity Index predicts 10-year survival in patients with multiple comorbidities.

    History of definite or probable MI (EKG changes and/or enzyme changes)

    Exertional or paroxysmal nocturnal dyspnea and has responded to digitalis, diuretics, or afterload reducing agents

    Intermittent claudication or past bypass for chronic arterial insufficiency, history of gangrene or acute arterial insufficiency, or untreated thoracic or abdominal aneurysm (≥6 cm)

    History of a cerebrovascular accident with minor or no residua and transient ischemic attacks

    Chronic cognitive deficit

    Any history of treatment for ulcer disease or history of ulcer bleeding

    Severe = cirrhosis and portal hypertension with variceal bleeding history, moderate = cirrhosis and portal hypertension but no variceal bleeding history, mild = chronic hepatitis (or cirrhosis without portal hypertension)

    Severe = on dialysis, status post kidney transplant, uremia, moderate = creatinine >3 mg/dL (0.27 mmol/L)

    VariablePointsAge <50…
    Read More

    Multiple Myeloma Diagnostic Criteria – Online Calculator

    ≥1 of the following (A or B)

    ≥1 myeloma defining event (C1 or C2)

    For Multiple Myeloma Diagnostic Criteria assessment necessary to provide selection of the…
    Read More

    Сообщение King’s College Criteria for Acetaminophen Toxicity появились сначала на ClinCaseQuest.

    ]]>         CURB-65 Score for Pneumonia Severity https://clincasequest.hospital/curb65-score-pneumonia-severity/ Wed, 15 Dec 2021 02:51:00 +0000 https://clincasequest.hospital/?p=31908 Estimates mortality of community-acquired pneumonia to help determine inpatient vs. outpatient treatment. The CURB-65 calculator also can be used in the emergency department setting to…

    Сообщение CURB-65 Score for Pneumonia Severity появились сначала на ClinCaseQuest.

    ]]>     Estimates mortality of community-acquired pneumonia to help determine inpatient vs. outpatient treatment. The CURB-65 calculator also can be used in the emergency department setting to risk stratify a patient’s community acquired pneumonia.

    Confusion:
    Yes
    No

    BUN ( blood urea nitrogen) > 19 mg/dl(> 7 mmol/L):
    Yes
    No

    Respiratory Rate ≥30:
    Yes
    No

    Systolic BP < 90 mmHg or Diastolic BP ≤ 60 mmHg:
    Yes
    No

    Age ≥ 65:
    Yes
    No

    Is this a COVID-19 patient?
    Confirmed Positive
    Suspected
    Unlikely
    Confirmed Negative




    CURB-65
    score    		 30-day
    Mortality Risk    		 Recommendation per Derivation Study
    0 0 0

    The CURB-65 scores range from 0 to 5. Assign points as in the table based on confusion status, urea level, respiratory rate, blood pressure, and age. Clinical management decisions can be made based on the score based on the addition of the selected points:

    ParametersPoints
    Confusion+1
    BUN > 19 mg/dl (> 7 mmol/L)+1
    Respiratory Rate ≥ 30+1
    Systolic BP < 90 mmHg or Diastolic BP ≤ 60 mmHg+1
    Age ≥ 65+1

    While many pneumonias are viral in nature, typical practice is to provide a course of antibiotics given the pneumonia may be bacterial.

    Disposition (inpatient vs. outpatient) often dictates further care and management — including lab testing, blood cultures, etc.

    For patients scoring high on CURB-65, it would be prudent to ensure initial triage has not missed the presence of sepsis. Evaluation of SIRS criteria should be considered.

    Score interpretation (as per derivation study):

    CURB-65 score30-day Mortality RiskRecommendation per Derivation Study
    00.60%Low risk; consider home treatment
    12.70%Low risk; consider home treatment
    26.80%Short inpatient hospitalization or closely supervised outpatient treatment
    314.00%Severe pneumonia; hospitalize and consider admitting to intensive care
    4 or 527.80%Severe pneumonia; hospitalize and consider admitting to intensive care

    The original study was a retrospective review of three prospective studies of CAP in the UK, New Zealand, and the Netherlands. It included a total of 1068 patients. A five-point score based on confusion, urea, respiratory rate, blood pressure, and age was developed to stratify patients into different treatment group based on mortality risk. The validation study was done in India and included 150 patients.

    The CURB-65 Score includes points for confusion and blood urea nitrogen, which in the acutely ill elderly patient, could be due to a variety of factors. An alternative scoring system, SOAR, circumvents those two parameters. It uses low systolic BP and poor oxygenation, advancing age, high respiratory rate.

    CURB-65’s original study including co-morbidity variables like chronic lung disease, chronic liver disease, CHF, CVD, and DM, and these were controlled for when developing the relevant criteria for the risk stratification that ultimately led to CURB-65’s risk factors.

    Several other more recent validation studies in several different countries show increasing mortality and even need for intubation with increasing CURB-65 scores, ranging from 0-1.1% (CURB-65 score = 0) to 17-60% (CURB-65 score = 5), with over 3100 patients in these studies when combined.

    Сonclusions

    CURB-65 is fast to compute, requires likely already-available patient information, and provides an excellent risk stratification of community acquired pneumonia. It can facilitate better utilization of resources and treatment initiation.

    In comparison to the pneumonia severity index, CURB-65 offers equal sensitivity of mortality prediction due to community acquired pneumonia. Notably, CURB-65 (74.6%) has a higher specificity than pneumonia severity index (52.2%).

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    References:

    1. Lim WS, van der Eerden MM, Laing R, et al. Defining community acquired pneumonia severity on presentation to hospital: an international derivation and validation study. Thorax. 2003;58(5):377-382. doi:10.1136/thorax.58.5.377 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1746657/?tool=pmcentrez
    2. Aujesky D, Auble TE, Yealy DM, Stone RA, Obrosky DS, Meehan TP, Graff LG, Fine JM, Fine MJ. Prospective comparison of three validated prediction rules for prognosis in community-acquired pneumonia. Am J Med. 2005 Apr;118(4):384-92. doi: 10.1016/j.amjmed.2005.01.006. PMID: 15808136. https://pubmed.ncbi.nlm.nih.gov/15808136/
    3. Shah BA, et. al. Validity of Pneumonia Severity Index and CURB-65 Severity Scoring Systems in Community Acquired Pneumonia in an Indian Setting. The Indian Journal of Chest Diseases & Allied Sciences. 2010;Vol.52.
    4. British Thoracic Society, Myint PK, Kamath AV, Vowler SL, Maisey DN, Harrison BD. Severity assessment criteria recommended by the British Thoracic Society (BTS) for community-acquired pneumonia (CAP) and older patients. Should SOAR (systolic blood pressure, oxygenation, age and respiratory rate) criteria be used in older people? A compilation study of two prospective cohorts. Age Ageing. 2006 May;35(3):286-91. doi: 10.1093/ageing/afj081. PMID: 16638769. https://pubmed.ncbi.nlm.nih.gov/16638769/
    5. Capelastegui A, España PP, Quintana JM, Areitio I, Gorordo I, Egurrola M, Bilbao A. Validation of a predictive rule for the management of community-acquired pneumonia. Eur Respir J. 2006 Jan;27(1):151-7. doi: 10.1183/09031936.06.00062505. PMID: 16387948. https://pubmed.ncbi.nlm.nih.gov/16387948/

    Charlson Comorbidity Index (CCI) Online Calculator

    Charlson Comorbidity Index predicts 10-year survival in patients with multiple comorbidities.

    History of definite or probable MI (EKG changes and/or enzyme changes)

    Exertional or paroxysmal nocturnal dyspnea and has responded to digitalis, diuretics, or afterload reducing agents

    Intermittent claudication or past bypass for chronic arterial insufficiency, history of gangrene or acute arterial insufficiency, or untreated thoracic or abdominal aneurysm (≥6 cm)

    History of a cerebrovascular accident with minor or no residua and transient ischemic attacks

    Chronic cognitive deficit

    Any history of treatment for ulcer disease or history of ulcer bleeding

    Severe = cirrhosis and portal hypertension with variceal bleeding history, moderate = cirrhosis and portal hypertension but no variceal bleeding history, mild = chronic hepatitis (or cirrhosis without portal hypertension)

    Severe = on dialysis, status post kidney transplant, uremia, moderate = creatinine >3 mg/dL (0.27 mmol/L)

    VariablePointsAge <50…
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    Multiple Myeloma Diagnostic Criteria – Online Calculator

    ≥1 of the following (A or B)

    ≥1 myeloma defining event (C1 or C2)

    For Multiple Myeloma Diagnostic Criteria assessment necessary to provide selection of the…
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    Сообщение CURB-65 Score for Pneumonia Severity появились сначала на ClinCaseQuest.

    ]]>         RESP (Respiratory ECMO Survival Prediction) Score online calculator https://clincasequest.hospital/resp-online-calculator/ Mon, 29 Nov 2021 06:11:00 +0000 https://clincasequest.hospital/?p=31641 Predicts in-hospital survival in adult patients after ECMO for acute respiratory failure. RESP Score should be used in patients receiving venovenous (VV) and veno-arterial (VA)…

    Сообщение RESP (Respiratory ECMO Survival Prediction) Score online calculator появились сначала на ClinCaseQuest.

    ]]>     Predicts in-hospital survival in adult patients after ECMO for acute respiratory failure.

    RESP Score should be used in patients receiving venovenous (VV) and veno-arterial (VA) extracorporeal membrane oxygenation (ECMO) for acute respiratory failure. NB! Do not use in patients receiving VA ECMO for cardiogenic shock (see SAVE Score).

    Age, years
    18-49
    50-59
    ≥60

    Immunocompromised status at time of ECMO
    Any malignancy, solid organ transplant, HIV, or cirrhosis:
    Yes
    No

    Mechanically ventilated before ECMO initiated:
    48 hours to 7 days
    <48 hours

    Diagnosis:
    Viral pneumonia
    Bacterial pneumonia
    Asthma
    Trauma or burn
    Aspiration pneumonitis
    Other acute respiratory diagnosis
    Nonrespiratory or chronic respiratory diagnosis

    History of central nervous system dysfunction
    Neurotrauma, stroke, encephalopathy, cerebral embolism, or seizure/epilepsy:
    Yes
    No

    Acute associated nonpulmonary infection
    Any other bacterial, viral, parasitic, or fungal infection not involving the lung:
    Yes
    No

    Neuromuscular blockade before ECMO:
    Yes
    No

    Nitric oxide before ECMO:
    Yes
    No

    Bicarbonate infusion before ECMO:
    Yes
    No

    Cardiac arrest before ECMO:
    Yes
    No

    PaCO₂ ≥75 mmHg (≥10 kPa):
    Yes
    No

    Peak inspiratory pressure ≥42 cm H₂O (≥4.1 kPa):
    Yes
    No




    Patient’s score RESP Score Risk class In-hospital survival
    0 0 0 0

    ECMO is a resource-intensive endeavor with high morbidity, and patients should be selected carefully. Survival estimates may aid the decision process.

    Addition of the selected points:

    Age, years18-490
     50-59-2
     ≥60-3
    Immunocompromised status at time of ECMO
    Any malignancy, solid organ transplant, HIV, or cirrhosis    		No0
     Yes-2
    Mechanically ventilated before ECMO initiated>7 days0
     48 hours to 7 days+1
     <48 hours+3
    DiagnosisViral pneumonia+3
     Bacterial pneumonia+3
     Asthma+11
     Trauma or burn+3
     Aspiration pneumonitis+5
     Another acute respiratory diagnosis+1
     Nonrespiratory or chronic respiratory diagnosis0
    History of central nervous system dysfunction
    Neurotrauma, stroke, encephalopathy, cerebral embolism, or seizure/epilepsy    		No0
     Yes-7
    Acute associated nonpulmonary infection
    Any other bacterial, viral, parasitic, or fungal infection not involving the lung    		No0
     Yes-3
    Neuromuscular blockade before ECMONo0
     Yes+1
    Nitric oxide before ECMONo0
     Yes-1
    Bicarbonate infusion before ECMONo0
     Yes-2
    Cardiac arrest before ECMONo0
     Yes-2
    PaCO₂ ≥75 mmHg (≥10 kPa)No0
     Yes-1
    Peak inspiratory pressure ≥42 cm H₂O (≥4.1 kPa)No0
     Yes-1

    Interpretation:

    RESP ScoreRisk classIn-hospital survival
    ≥6I92%
    3-5II76%
    -1 to 2III57%
    -5 to -2IV33%
    ≤-6V18%

    Other factors may contribute to the decision to initiate ECMO (e.g. life expectancy, quality of life, resource availability).

    The RESP Score only predicts survival before hospital discharge and does not predict neurologic function or functional status, that may be important considerations. The score was derived from a cohort of patients who were placed on ECMO, and likely excluded many patients who may have had different survival rates.

    RESP Score Assessment can be useful in survival prediction and may be incorporated into the decision to initiate VA ECMO.

    Prone positioning was not included in the derivation of the RESP Score, and its effect on the predictive value of the score is unknown.

    The RESP Score was derived in a retrospective cohort study by Schmidt et al (2014), which included 2,355 patients in the Extracorporeal Life Support Organization (ELSO) registry who received ECMO for acute respiratory failure. Patients receiving ECMO for indications other than acute respiratory failure (e.g. cardiogenic shock) were excluded. Predictive variables with p-values ≤0.05 were included to derive the final score.

    The score was prospectively validated in 140 patients (included in initial publication) (c = 0.92, CI 0.89-0.97). In a small retrospective study of 41 patients (Brunet 2017), the score was found to have low predictive value for mortality (c-index 0.60).

    Comprehensive decision-making should not be based solely on one prediction rule, and the threshold to initiate ECMO may vary by institution.

    Predicts chances of mortality after on ECMO in COVID-19 patients, performing better in validations than PRESET Score.

    SAVE (Survival After Veno-Arterial ECMO) Score

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    Literature:
    1. Schmidt M, Bailey M, Sheldrake J, et al. Predicting survival after extracorporeal membrane oxygenation for severe acute respiratory failure. The Respiratory Extracorporeal Membrane Oxygenation Survival Prediction (RESP) score. Am J Respir Crit Care Med. 2014;189(11):1374-82. https://pubmed.ncbi.nlm.nih.gov/24693864/
    2. Brunet J, Valette X, Buklas D, et al. Predicting Survival After Extracorporeal Membrane Oxygenation for ARDS: An External Validation of RESP and PRESERVE Scores. Respir Care. 2017;62(7):912-919. https://pubmed.ncbi.nlm.nih.gov/28536282/

    Charlson Comorbidity Index (CCI) Online Calculator

    Charlson Comorbidity Index predicts 10-year survival in patients with multiple comorbidities.

    History of definite or probable MI (EKG changes and/or enzyme changes)

    Exertional or paroxysmal nocturnal dyspnea and has responded to digitalis, diuretics, or afterload reducing agents

    Intermittent claudication or past bypass for chronic arterial insufficiency, history of gangrene or acute arterial insufficiency, or untreated thoracic or abdominal aneurysm (≥6 cm)

    History of a cerebrovascular accident with minor or no residua and transient ischemic attacks

    Chronic cognitive deficit

    Any history of treatment for ulcer disease or history of ulcer bleeding

    Severe = cirrhosis and portal hypertension with variceal bleeding history, moderate = cirrhosis and portal hypertension but no variceal bleeding history, mild = chronic hepatitis (or cirrhosis without portal hypertension)

    Severe = on dialysis, status post kidney transplant, uremia, moderate = creatinine >3 mg/dL (0.27 mmol/L)

    VariablePointsAge <50…
    Read More

    Multiple Myeloma Diagnostic Criteria – Online Calculator

    ≥1 of the following (A or B)

    ≥1 myeloma defining event (C1 or C2)

    For Multiple Myeloma Diagnostic Criteria assessment necessary to provide selection of the…
    Read More

    Сообщение RESP (Respiratory ECMO Survival Prediction) Score online calculator появились сначала на ClinCaseQuest.

    ]]>         The Intra-Aortic Balloon Counterpulsation in Acute Myocardial Infarction Complicated by Cardiogenic Shock (IABP-SHOCK II) risk score https://clincasequest.hospital/iabp-score/ Sun, 31 Oct 2021 11:00:00 +0000 https://clincasequest.hospital/?p=30949 Cardiogenic shock complicating acute myocardial infarction: IABP-SHOCK II RISK SCORE. Risk assessment of 30-day mortality. Age > 73 years Yes No History of stroke: Yes…

    Сообщение The Intra-Aortic Balloon Counterpulsation in Acute Myocardial Infarction Complicated by Cardiogenic Shock (IABP-SHOCK II) risk score появились сначала на ClinCaseQuest.

    ]]>     Cardiogenic shock complicating acute myocardial infarction: IABP-SHOCK II RISK SCORE. Risk assessment of 30-day mortality.

    Age > 73 years
    Yes
    No

    History of stroke:
    Yes
    No

    Glucose > 10.6 mmol/l (191 mg/dl):
    Yes
    No

    Creatinine > 132.6 mmol/l (1.5 mg/dl):
    Yes
    No

    Arterial lactate > 5 mmol/l*:
    Yes
    No

    TIMI flow grade < 3 after PCI:
    Yes
    No




    Patient’s IABP-SHOCK II score Risk categories Points
    0 0 0

    Mortality from cardiogenic shock remains high and early recognition and risk stratification are mandatory for optimal patient allocation and to guide treatment strategy.

    The Intra-Aortic Balloon Counterpulsation in Acute Myocardial Infarction Complicated by Cardiogenic Shock (IABP-SHOCK II) risk score has shown good results in predicting short-term mortality in cardiogenic shock.

    The IABP-SHOCK II risk score is a simple tool that can be rapidly calculated in the catheterization laboratory setting and applied in clinical routine. It might therefore serve for identifying patients for future clinical trials and, more importantly, it might help stratify patients according to their risk for short-term mortality and thus facilitate clinical decision making. The scoring system attributed one or two points per variable.

    SCORE
    VariablePoints
    Age > 73 years1
    History of stroke2
    Glucose > 10.6 mmol/l (191 mg/dl) 1
    Creatinine > 132.6 mmol/l (1.5 mg/dl)1
    Arterial lactate > 5 mmol/l2
    TIMI flow grade < 3 after PCI2
    Maximum9

    Interpretation

    RISK CATEGORIES
    CategoryPoints
    Low0-2
    Intermediate3-4
    High5-9

    Cardiogenic Shock Complicating Acute Myocardial Infarction

    • acute myocardial infarction risk assessment, MI, AMI, heart attack, acute myocardial infarction, myocardial infarction, mortality risk, myocardial infarction mortality risk, mortality risk assessment, prognosis, calculator, online calculator, medical calculator, online calculators

    The IABP-SHOCK II risk score can be easily calculated in daily clinical practice and strongly correlated with mortality in patients with infarct-related CS. It may help stratify patient risk for short-term mortality and might, thus, facilitate clinical decision making.

    Source:
    1. Pöss J, Köster J, Fuervan G, et al. J Am Coll Cardiol 2017; 69:1913–20
    2. Douglas JS. Primary PCI: Outcomes and Quality Assessment. 2018 Jul 14. In: Watson TJ, Ong PJL, Tcheng JE, editors. Primary Angioplasty: A Practical Guide [Internet]. Singapore: Springer; 2018. Fig. 23.5. Available from: https://www.ncbi.nlm.nih.gov/books/NBK543591/figure/ch23.Fig5/ doi: 10.1007/978-981-13-1114-7_23
    3. Rivas-Lasarte M, Sans-Roselló J, Collado-Lledó E, et al. External validation and comparison of the CardShock and IABP-SHOCK II risk scores in real-world cardiogenic shock patients. European Heart Journal: Acute Cardiovascular Care. January 2020. doi:10.1177/2048872619895230 https://journals.sagepub.com/doi/abs/10.1177/2048872619895230?journalCode=acca

    Register on our website right now to have access to more learning materials!

    Charlson Comorbidity Index (CCI) Online Calculator

    Charlson Comorbidity Index predicts 10-year survival in patients with multiple comorbidities.

    History of definite or probable MI (EKG changes and/or enzyme changes)

    Exertional or paroxysmal nocturnal dyspnea and has responded to digitalis, diuretics, or afterload reducing agents

    Intermittent claudication or past bypass for chronic arterial insufficiency, history of gangrene or acute arterial insufficiency, or untreated thoracic or abdominal aneurysm (≥6 cm)

    History of a cerebrovascular accident with minor or no residua and transient ischemic attacks

    Chronic cognitive deficit

    Any history of treatment for ulcer disease or history of ulcer bleeding

    Severe = cirrhosis and portal hypertension with variceal bleeding history, moderate = cirrhosis and portal hypertension but no variceal bleeding history, mild = chronic hepatitis (or cirrhosis without portal hypertension)

    Severe = on dialysis, status post kidney transplant, uremia, moderate = creatinine >3 mg/dL (0.27 mmol/L)

    VariablePointsAge <50…
    Read More

    Multiple Myeloma Diagnostic Criteria – Online Calculator

    ≥1 of the following (A or B)

    ≥1 myeloma defining event (C1 or C2)

    For Multiple Myeloma Diagnostic Criteria assessment necessary to provide selection of the…
    Read More

    Сообщение The Intra-Aortic Balloon Counterpulsation in Acute Myocardial Infarction Complicated by Cardiogenic Shock (IABP-SHOCK II) risk score появились сначала на ClinCaseQuest.

    ]]>