Medical emergencies – ClinCaseQuest

Focused Assessment with Sonography for Trauma (FAST): Online Calculator

Nataliia Lopina — Sat, 21 May 2022 16:28:07 +0000

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.

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 fluid	Absent
	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.
Suprapubic	place 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 fluid	Absent	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

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)
Positive	in the unstable patient, emergent exploratory laparotomy is recommended. In a stable patient, cross-sectional imaging (CT scan) is recommended.
Equivocal	in the unstable patient, diagnostic peritoneal aspiration (DPA) is recommended. In a stable patient, cross-sectional imaging (CT scan) is recommended.
Negative	in 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

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Multiple Myeloma Diagnostic Criteria – Online Calculator

Email (indicate if you want the results to be sent to your email)

Date of assessment

≥1 of the following (A or B)

A. Clonal bone marrow plasma cells ≥10%

B. Biopsy-proven bony or extramedullary plasmacytoma

≥1 myeloma defining event (C1 or C2)

• C1. End organ damage attributable to underlying plasma cell disorder (≥1 of the following): *

o Hypercalcemia (Serum calcium >1 mg/dL (>0.25 mmol/L) higher than upper limit of normal or >11 mg/dL (>2.75 mmol/L))

o Renal insufficiency (Creatinine clearance<40 mL per min or serum creatinine >2 mg/dL (177 μmol/L))

o Anemia (Hemoglobin >2 g/dL (20 g/L) below lower limit of normal

o Bone lesions (≥1 osteolytic lesion on skeletal x-ray

• C2. ≥1 of the following biomarkers of malignancy: *

o Clonal bone marrow plasma cells ≥60%

o Involved:uninvolved sFLC ratio ≥100

o >1 focal lesion on MRI

Result

Diagnostic result

Negative. Not positive for multiple myeloma by IMWG criteria

Diagnostic result

Positive for multiple myeloma by IMWG criteria

Details:

* Required

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Revised Multiple Myeloma International Staging System (R-ISS) Online Calculator

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Shock Index, Pediatric Age-Adjusted (SIPA) online calculator

Nataliia Lopina — Mon, 24 Jan 2022 02:06:00 +0000

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.

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 SIPA	Risk of blunt injury if SIPA is elevated
4–6 years	65–110	90–110	1.22	22.0%
7–12 years	60–100	100–120	1.00	25.1%
13-16 years	55–90	100–135	0.90	32.0%

NB!

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.
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.
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/

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

King’s College Criteria for Non- Acetaminophen Toxicity acute hepatic failure

Nataliia Lopina — Tue, 04 Jan 2022 10:07:00 +0000

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

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.

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References

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/
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/
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/
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
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/

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Charlson Comorbidity Index (CCI) Online Calculator

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Email (indicate if you want the results to be sent to your email)

Date of assessment

Myocardial infarction *

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

Yes

Congestive heart failure *

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

Yes

Peripheral vascular disease *

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

Yes

Cerebrovascular accident or Transient ischemic attack *

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

Yes

Dementia *

Chronic cognitive deficit

Yes

Chronic obstructive pulmonary disease *

Yes

Connective tissue disease *

Yes

Peptic ulcer disease *

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

Yes

Liver disease *

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)

None

Mild

Moderate to severe

Diabetes mellitus *

None or diet-controlled

Uncomplicated

End-organ damage

Hemiplegia *

Yes

Moderate to severe chronic kidney disease *

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

Yes

Solid tumor *

None

Localized

Metastatic

Leukemia *

Yes

Lymphoma *

Yes

AIDS *

Yes

Charlson Comorbidity Index

10-year survival

VariablePointsAge <50…

Multiple Myeloma Diagnostic Criteria – Online Calculator

February 5, 2023

Email (indicate if you want the results to be sent to your email)

Date of assessment

≥1 of the following (A or B)

A. Clonal bone marrow plasma cells ≥10%

B. Biopsy-proven bony or extramedullary plasmacytoma

≥1 myeloma defining event (C1 or C2)

• C1. End organ damage attributable to underlying plasma cell disorder (≥1 of the following): *

o Hypercalcemia (Serum calcium >1 mg/dL (>0.25 mmol/L) higher than upper limit of normal or >11 mg/dL (>2.75 mmol/L))

o Renal insufficiency (Creatinine clearance<40 mL per min or serum creatinine >2 mg/dL (177 μmol/L))

o Anemia (Hemoglobin >2 g/dL (20 g/L) below lower limit of normal

o Bone lesions (≥1 osteolytic lesion on skeletal x-ray

• C2. ≥1 of the following biomarkers of malignancy: *

o Clonal bone marrow plasma cells ≥60%

o Involved:uninvolved sFLC ratio ≥100

o >1 focal lesion on MRI

Result

Diagnostic result

Negative. Not positive for multiple myeloma by IMWG criteria

Diagnostic result

Positive for multiple myeloma by IMWG criteria

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

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

King’s College Criteria for Acetaminophen Toxicity

Nataliia Lopina — Sun, 19 Dec 2021 07:42:00 +0000

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

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.

Criteria	PPV	Sensitivity	Specificity	Predictive Accuracy
Arterial pH < 7.30	0.95	0.49	0.99	0.81
HE + PT + Cr	0.67	0.45	0.94	0.83
Lactate*		0.81	0.95	0.92
Phosphate**	1	0.89	1	0.98

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

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/
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/
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/
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
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/

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Charlson Comorbidity Index (CCI) Online Calculator

May 10, 2023

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

Email (indicate if you want the results to be sent to your email)

Date of assessment

Myocardial infarction *

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

Yes

Congestive heart failure *

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

Yes

Peripheral vascular disease *

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

Yes

Cerebrovascular accident or Transient ischemic attack *

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

Yes

Dementia *

Chronic cognitive deficit

Yes

Chronic obstructive pulmonary disease *

Yes

Connective tissue disease *

Yes

Peptic ulcer disease *

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

Yes

Liver disease *

None

Mild

Moderate to severe

Diabetes mellitus *

None or diet-controlled

Uncomplicated

End-organ damage

Hemiplegia *

Yes

Moderate to severe chronic kidney disease *

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

Yes

Solid tumor *

None

Localized

Metastatic

Leukemia *

Yes

Lymphoma *

Yes

AIDS *

Yes

Charlson Comorbidity Index

10-year survival

VariablePointsAge <50…

Multiple Myeloma Diagnostic Criteria – Online Calculator

February 5, 2023

Email (indicate if you want the results to be sent to your email)

Date of assessment

≥1 of the following (A or B)

A. Clonal bone marrow plasma cells ≥10%

B. Biopsy-proven bony or extramedullary plasmacytoma

≥1 myeloma defining event (C1 or C2)

• C1. End organ damage attributable to underlying plasma cell disorder (≥1 of the following): *

o Hypercalcemia (Serum calcium >1 mg/dL (>0.25 mmol/L) higher than upper limit of normal or >11 mg/dL (>2.75 mmol/L))

o Renal insufficiency (Creatinine clearance<40 mL per min or serum creatinine >2 mg/dL (177 μmol/L))

o Anemia (Hemoglobin >2 g/dL (20 g/L) below lower limit of normal

o Bone lesions (≥1 osteolytic lesion on skeletal x-ray

• C2. ≥1 of the following biomarkers of malignancy: *

o Clonal bone marrow plasma cells ≥60%

o Involved:uninvolved sFLC ratio ≥100

o >1 focal lesion on MRI

Result

Diagnostic result

Negative. Not positive for multiple myeloma by IMWG criteria

Diagnostic result

Positive for multiple myeloma by IMWG criteria

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

Revised Multiple Myeloma International Staging System (R-ISS) Online Calculator

January 17, 2023

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

CURB-65 Score for Pneumonia Severity

Nataliia Lopina — Wed, 15 Dec 2021 02:51:00 +0000

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.

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:

Parameters	Points
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 score	30-day Mortality Risk	Recommendation per Derivation Study
0	0.60%	Low risk; consider home treatment
1	2.70%	Low risk; consider home treatment
2	6.80%	Short inpatient hospitalization or closely supervised outpatient treatment
3	14.00%	Severe pneumonia; hospitalize and consider admitting to intensive care
4 or 5	27.80%	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:

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
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/
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.
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/
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/

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Email (indicate if you want the results to be sent to your email)

Date of assessment

Myocardial infarction *

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

Yes

Congestive heart failure *

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

Yes

Peripheral vascular disease *

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

Yes

Cerebrovascular accident or Transient ischemic attack *

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

Yes

Dementia *

Chronic cognitive deficit

Yes

Chronic obstructive pulmonary disease *

Yes

Connective tissue disease *

Yes

Peptic ulcer disease *

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

Yes

Liver disease *

None

Mild

Moderate to severe

Diabetes mellitus *

None or diet-controlled

Uncomplicated

End-organ damage

Hemiplegia *

Yes

Moderate to severe chronic kidney disease *

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

Yes

Solid tumor *

None

Localized

Metastatic

Leukemia *

Yes

Lymphoma *

Yes

AIDS *

Yes

Charlson Comorbidity Index

10-year survival

VariablePointsAge <50…

Multiple Myeloma Diagnostic Criteria – Online Calculator

February 5, 2023

Email (indicate if you want the results to be sent to your email)

Date of assessment

≥1 of the following (A or B)

A. Clonal bone marrow plasma cells ≥10%

B. Biopsy-proven bony or extramedullary plasmacytoma

≥1 myeloma defining event (C1 or C2)

• C1. End organ damage attributable to underlying plasma cell disorder (≥1 of the following): *

o Hypercalcemia (Serum calcium >1 mg/dL (>0.25 mmol/L) higher than upper limit of normal or >11 mg/dL (>2.75 mmol/L))

o Renal insufficiency (Creatinine clearance<40 mL per min or serum creatinine >2 mg/dL (177 μmol/L))

o Anemia (Hemoglobin >2 g/dL (20 g/L) below lower limit of normal

o Bone lesions (≥1 osteolytic lesion on skeletal x-ray

• C2. ≥1 of the following biomarkers of malignancy: *

o Clonal bone marrow plasma cells ≥60%

o Involved:uninvolved sFLC ratio ≥100

o >1 focal lesion on MRI

Result

Diagnostic result

Negative. Not positive for multiple myeloma by IMWG criteria

Diagnostic result

Positive for multiple myeloma by IMWG criteria

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

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January 17, 2023

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

RESP (Respiratory ECMO Survival Prediction) Score online calculator

Nataliia Lopina — Mon, 29 Nov 2021 06:11:00 +0000

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).

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, years	18-49	0
	50-59	-2
	≥60	-3
Immunocompromised status at time of ECMO Any malignancy, solid organ transplant, HIV, or cirrhosis	No	0
	Yes	-2
Mechanically ventilated before ECMO initiated	>7 days	0
	48 hours to 7 days	+1
	<48 hours	+3
Diagnosis	Viral pneumonia	+3
	Bacterial pneumonia	+3
	Asthma	+11
	Trauma or burn	+3
	Aspiration pneumonitis	+5
	Another acute respiratory diagnosis	+1
	Nonrespiratory or chronic respiratory diagnosis	0
History of central nervous system dysfunction Neurotrauma, stroke, encephalopathy, cerebral embolism, or seizure/epilepsy	No	0
	Yes	-7
Acute associated nonpulmonary infection Any other bacterial, viral, parasitic, or fungal infection not involving the lung	No	0
	Yes	-3
Neuromuscular blockade before ECMO	No	0
	Yes	+1
Nitric oxide before ECMO	No	0
	Yes	-1
Bicarbonate infusion before ECMO	No	0
	Yes	-2
Cardiac arrest before ECMO	No	0
	Yes	-2
PaCO₂ ≥75 mmHg (≥10 kPa)	No	0
	Yes	-1
Peak inspiratory pressure ≥42 cm H₂O (≥4.1 kPa)	No	0
	Yes	-1

Interpretation:

RESP Score	Risk class	In-hospital survival
≥6	I	92%
3-5	II	76%
-1 to 2	III	57%
-5 to -2	IV	33%
≤-6	V	18%

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/

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Email (indicate if you want the results to be sent to your email)

Date of assessment

Myocardial infarction *

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

Yes

Congestive heart failure *

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

Yes

Peripheral vascular disease *

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

Yes

Cerebrovascular accident or Transient ischemic attack *

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

Yes

Dementia *

Chronic cognitive deficit

Yes

Chronic obstructive pulmonary disease *

Yes

Connective tissue disease *

Yes

Peptic ulcer disease *

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

Yes

Liver disease *

None

Mild

Moderate to severe

Diabetes mellitus *

None or diet-controlled

Uncomplicated

End-organ damage

Hemiplegia *

Yes

Moderate to severe chronic kidney disease *

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

Yes

Solid tumor *

None

Localized

Metastatic

Leukemia *

Yes

Lymphoma *

Yes

AIDS *

Yes

Charlson Comorbidity Index

10-year survival

VariablePointsAge <50…

Multiple Myeloma Diagnostic Criteria – Online Calculator

February 5, 2023

Email (indicate if you want the results to be sent to your email)

Date of assessment

≥1 of the following (A or B)

A. Clonal bone marrow plasma cells ≥10%

B. Biopsy-proven bony or extramedullary plasmacytoma

≥1 myeloma defining event (C1 or C2)

• C1. End organ damage attributable to underlying plasma cell disorder (≥1 of the following): *

o Hypercalcemia (Serum calcium >1 mg/dL (>0.25 mmol/L) higher than upper limit of normal or >11 mg/dL (>2.75 mmol/L))

o Renal insufficiency (Creatinine clearance<40 mL per min or serum creatinine >2 mg/dL (177 μmol/L))

o Anemia (Hemoglobin >2 g/dL (20 g/L) below lower limit of normal

o Bone lesions (≥1 osteolytic lesion on skeletal x-ray

• C2. ≥1 of the following biomarkers of malignancy: *

o Clonal bone marrow plasma cells ≥60%

o Involved:uninvolved sFLC ratio ≥100

o >1 focal lesion on MRI

Result

Diagnostic result

Negative. Not positive for multiple myeloma by IMWG criteria

Diagnostic result

Positive for multiple myeloma by IMWG criteria

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

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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

Nataliia Lopina — Sun, 31 Oct 2021 11:00:00 +0000

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

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
Variable	Points
Age > 73 years	1
History of stroke	2
Glucose > 10.6 mmol/l (191 mg/dl)	1
Creatinine > 132.6 mmol/l (1.5 mg/dl)	1
Arterial lactate > 5 mmol/l	2
TIMI flow grade < 3 after PCI	2
Maximum	9

Interpretation

RISK CATEGORIES
Category	Points
Low	0-2
Intermediate	3-4
High	5-9

Cardiogenic Shock Complicating Acute Myocardial Infarction

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

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

Email (indicate if you want the results to be sent to your email)

Date of assessment

Myocardial infarction *

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

Yes

Congestive heart failure *

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

Yes

Peripheral vascular disease *

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

Yes

Cerebrovascular accident or Transient ischemic attack *

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

Yes

Dementia *

Chronic cognitive deficit

Yes

Chronic obstructive pulmonary disease *

Yes

Connective tissue disease *

Yes

Peptic ulcer disease *

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

Yes

Liver disease *

None

Mild

Moderate to severe

Diabetes mellitus *

None or diet-controlled

Uncomplicated

End-organ damage

Hemiplegia *

Yes

Moderate to severe chronic kidney disease *

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

Yes

Solid tumor *

None

Localized

Metastatic

Leukemia *

Yes

Lymphoma *

Yes

AIDS *

Yes

Charlson Comorbidity Index

10-year survival

VariablePointsAge <50…

Multiple Myeloma Diagnostic Criteria – Online Calculator

Email (indicate if you want the results to be sent to your email)

Date of assessment

≥1 of the following (A or B)

A. Clonal bone marrow plasma cells ≥10%

B. Biopsy-proven bony or extramedullary plasmacytoma

≥1 myeloma defining event (C1 or C2)

• C1. End organ damage attributable to underlying plasma cell disorder (≥1 of the following): *

o Hypercalcemia (Serum calcium >1 mg/dL (>0.25 mmol/L) higher than upper limit of normal or >11 mg/dL (>2.75 mmol/L))

o Renal insufficiency (Creatinine clearance<40 mL per min or serum creatinine >2 mg/dL (177 μmol/L))

o Anemia (Hemoglobin >2 g/dL (20 g/L) below lower limit of normal

o Bone lesions (≥1 osteolytic lesion on skeletal x-ray

• C2. ≥1 of the following biomarkers of malignancy: *

o Clonal bone marrow plasma cells ≥60%

o Involved:uninvolved sFLC ratio ≥100

o >1 focal lesion on MRI

Result

Diagnostic result

Negative. Not positive for multiple myeloma by IMWG criteria

Diagnostic result

Positive for multiple myeloma by IMWG criteria

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

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

4Ts Score System for Heparin-Induced Thrombocytopenia

Elena Shevchenko — Fri, 16 Jul 2021 08:31:00 +0000

4Ts Score System assessment for Heparin-Induced Thrombocytopenia is an alternative evaluation tool prior to time-consuming antibody testing for HIT or empiric substitution of heparin for another anti-coagulant.

Patient’s score	Range	Risk stratification	Probability of HIT	Recommendation
0	0	0	0	0

Consider using the 4Ts scoring system 4Ts Score for Heparin-Induced Thrombocytopenia for:

Differential diagnostic HIT and other causes of thrombocytopenia;
Patients’ risk stratification for HIT in patients with thrombocytopenia who are currently or were recently on heparin derived agents.

Thrombocytopenia	Platelet count fall >50% AND platelet nadir ≥20×10⁹/l	+2
	Platelet count fall 30–50% OR platelet nadir 10–19×10⁹/l	+1
	Platelet count fall <30% OR platelet nadir <10×10⁹/l	0
Timing of platelet count fall	Clear onset between days 5–10 OR platelet fall ≤1 day (prior heparin exposure within 30 days)	+2
	Consistent with days 5–10 fall, but not clear; onset after day 10 OR fall ≤1 day (prior heparin exposure 30–100 days ago)	+1
	Platelet count fall <4 days without recent exposure	0
Thrombosis or other sequelae	New thrombosis OR skin necrosis; acute systemic reaction post-IV heparin bolus	+2
	Progressive OR recurrent thrombosis; non-necrotizing skin lesions; suspected thrombosis (not proven)	+1
	None	0
Other causes for thrombocytopenia	None apparent	+2
	Possible	+1
	Definite	0

Results evaluation:

4Ts Score System for Heparin-Induced Thrombocytopenia consisted of four criteria, each of which was worth 0, 1, or 2 points. To carry out stratification on the scale, it is necessary to summarize the obtained points.

Score	Risk stratification	Probability of HIT
≤3 points	low probability for HIT	≤5% in original study, <1% in meta-analysis
4-5 points	intermediate probability for HIT	~14%
6-8 points	high probability for HIT	~64%

Patients from the low-risk category frequently do not need further testing for HIT based on the assessment with 4Ts Score for Heparin-Induced Thrombocytopenia. Patients from the intermediate or high-risk groups require further laboratory evaluation for HIT or switching to a non-heparin-derived anti-coagulant.

Detailed parameters evaluation:

Category	2 points	1 point	0 points
Thrombocytopenia	Platelet count fall > 50% AND platelet nadir ≥ 20 ×10⁹/l	Platelet count fall 30%–50% OR platelet nadir 10–19 ×10⁹/l	Platelet count fall < 30% OR platelet nadir < 10 ×10⁹/l
Timing of platelet count fall	Clear onset between days 5 and 10 OR platelet fall ≤ 1 day (prior heparin exposure within 30 days)	Consistent with days 5–10 fall, but not clear (e.g. missing platelet counts) OR onset after day 10 OR fall ≤ 1 day (prior heparin exposure 30–100 days ago)	Platelet count fall < 4 days without recent heparin exposure
Thrombosis or other sequelae	New thrombosis (confirmed) OR skin necrosis at heparin injection sites OR acute systemic reaction after intravenous heparin bolus	Progressive or recurrent thrombosis OR nonnecrotizing (erythematous) skin lesions OR suspected thrombosis (not proven)	None
Other causes for thrombocytopenia	None apparent	Possible	Definite

Gold standard for diagnosis of HIT was either:

A platelet serotonin release assay (SRA) and a PF4/polyanion-enzyme immunoassay (EIA) with ≥ 50% serotonin release and positive EIA, OR
A positive heparin-induced platelet activation (HIPA) test in at least three of four donor platelets.

4Ts Score for Heparin-Induced Thrombocytopenia was developed based on the prospective studies in patients being evaluated for thrombocytopenia or suspected HIT in two clinical settings: inpatients at Hamilton General Hospital in Canada and various clinicians in a variety of healthcare settings in Germany and Austria. A subsequent review and meta-analysis of the 4Ts scoring system for HIT revealed that patients in the low-risk group had a negative predictive value of 0.998, irrespective of type of clinician, prevalence of HIT, or patient population. However, one of the four components of their scoring system, other causes for thrombocytopenia, is subjective.

Literature:
Lo GK, Juhl D, Warkentin TE, Sigouin CS, Eichler P, Greinacher A. Evaluation of pretest clinical score (4 Ts) for the diagnosis of heparin-induced thrombocytopenia in two clinical settings. J Thromb Haemost 2006; 4: 759–65. https://pubmed.ncbi.nlm.nih.gov/16634744/
Vatanparast R, Lantz S, Ward K, Crilley PA, Styler M. Evaluation of a pretest scoring system (4Ts) for the diagnosis of heparin-induced thrombocytopenia in a university hospital setting. Postgrad Med. 2012 Nov;124(6):36-42. https://pubmed.ncbi.nlm.nih.gov/23322137/

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Mortality SCORE for COVID-19: on-line calculator

Nataliia Lopina — Thu, 20 May 2021 20:25:42 +0000

Mortality risk calculator for hospitalized patients diagnosed with COVID-19. 4C MORTALITY SCORE FOR COVID-19

This scale was developed specifically for hospitalized patients with COVID-19. This may not apply to outpatients. Stratification of the risk of death in hospitalized patients with COVID-19 is important for further decision-making on treatment tactics and predicting the course of the disease.

Mortality Score	Risk group	In-hospital mortality
0	0	0

To assess the risk of mortality in hospitalized patients diagnosed with COVID-19 is required a preliminary assessment of the state of consciousness on the Glasgow scale.

Following the Glasgow scale, the following parameters are assessed to assess the mortality rate from 4C:

	Variable	Points
Age, years	<50	0
	50-59	2
	60-69	4
	70-79	6
	≥80	7
Sex at birth	Female	0
	Male	1
Number of comorbidities*	0	0
	1	1
	≥2	2
Respiratory rate, breaths/min	<20	0
	20-29	1
	≥30	2
Peripheral oxygen saturation on room air	≥92%	0
	<92%	2
Glasgow Coma Scale	15	0
	<15	2
Urea or BUN (use measurement available)	Urea <7 mmol/L (<42 mg/dL) OR BUN <19.6 mg/dL	0
	Urea ≥7 to ≤14 mmol/L (≥42mg/dL to ≤84 mg/dL) OR BUN ≥19.6 to ≤39.2 mg/dL	1
	Urea >14 mmol/L (>84 mg/dL) OR BUN >39.2 mg/dL	3
C-reactive protein, mg/L	<50 mg/L (<5 mg/dL)	0
	50-99 mg/L (5-9.9 mg/dL)	1
	≥100 mg/L (≥10 mg/dL)	2

*Comorbidities include chronic cardiac disease, chronic respiratory disease (excluding asthma), chronic renal disease (estimated glomerular filtration rate ≤30), mild to severe liver disease, dementia, chronic neurological conditions, connective tissue disease, diabetes mellitus (diet, tablet, or insulin controlled), HIV or AIDS, and malignancy.

Interpretation:

4C Mortality Score	Risk group	In-hospital mortality
0-3	Low	1.2-1.7%
4-8	Intermediate	9.1-9.9%
9-14	High	31.4-34.9%
≥15	Very high	61.5-66.2%

Low risk – May be suitable for outpatient management
Intermediate risk – May be suitable for general inpatient treatment
High risk – May require aggressive treatment and higher level of monitoring

Apply to risk stratify patients who are admitted with COVID-19.

Designed specifically for hospitalized COVID-19 patients. This may not apply to patients seen in the outpatient setting.

Requires eight specific predictors of mortality, not all of which may be immediately available in all settings (e.g., CRP).

Patient population in the study had a median age of 73 years old, 82% white, with an overall mortality of 32.2%. All patients were from England, Scotland, and Wales. Consider when applying this to your patient population.

Not externally validated and may lead to unknown applicability and generalizability.

Risk stratification of admitted COVID-19 patients to aid in determining mortality risk, decision for level of care, and prognostication.

The 4C Mortality Score was derived from a prospective observational cohort study based upon positively tested COVID-19 patients admitted to 260 hospitals in England, Scotland and Wales. The score includes eight variables consisting of age, sex, number of comorbidities, respiratory rate, peripheral oxygen saturation, Glasgow coma scale score, urea level, and C-reactive protein. The score, ranging from 0-21, predicts in-hospital mortality from low risk to very high risk. The score, when compared against existing scores for CAP and COVID-19, performed better in predicting in-hospital mortality in the validation cohort.

Although the score performed well in the internal validation of the study, it requires external validation. The score is limited to determining in-patient hospital mortality and is not designed to be applicable to the outpatient setting. Overall generalizability of the score needs to be further investigated as it was derived and validated in a primarily homogeneous ethnic and age cohort.

Eight specific predictors of mortality are required, not all of which may be available in all settings at once (eg, C-reactive protein).

The median age of patients in the study was 73 years, 82% were Caucasian, with an overall mortality rate of 32.2% in the group. All patients were from England, Scotland and Wales.

Be careful, this scale has not been externally validated at this time. Use with care!

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Сообщение Mortality SCORE for COVID-19: on-line calculator появились сначала на ClinCaseQuest.

DIC scale online calculator

Nataliia Lopina — Fri, 07 May 2021 08:19:09 +0000

Disseminated intravascular coagulation syndrome – is a is a blood clotting disorder due to increased thrombosis.

Online calculator DIC scale:

Score	Diagnosis
0	0

Diagnostic criteria for overt DIC:

Variable	Results	Points
Platelet count, cells x 10⁹/L	≥100	0
	50 to <100	1
	<50	2
Elevated levels of a fibrin-related marker* (e.g. D-dimer, fibrin degradation products)	No increase	0
	Moderate increase	2
	Severe increase	3
Prolonged PT, seconds	<3	0
	3 to <6	1
	≥6	2
Fibrinogen level, g/L	≥1	0
	<1	1

*Use lab-specific cutoff values.

Results:

Score	Diagnosis
<5	Not suggestive of overt DIC, may be non-overt DIC; repeat within next 1-2 days and manage clinically as appropriate
≥5	Compatible with overt DIC; treat for DIC as appropriate and repeat scoring daily

<5 – points: no obvious disseminated intravascular coagulation is expected but does not exclude latent disseminated intravascular coagulation; repeat tests over the next 1-2 days and treat clinically as needed.

> 5 – points: the condition is compatible with overt disseminated intravascular coagulation; treat disseminated intravascular coagulation and repeat scoring daily.

When to apply?

Patients with suspected overt disseminated intravascular coagulopathy (DIC), for example, against the background of malignant neoplasms, severe infection or sepsis, obstetric complications, trauma, prolonged immobilization.

Why uses this scale?

DIC syndrome is a syndrome that complicates number of diseases. It is characterized by systemic activation of pathways leading to the formation of fibrin clots, which can cause multiple organ failure with concomitant decreases in platelets and clotting factors, which can lead to bleeding.
This calculator can help identify possible overt and implicit DIC in patients with underlying medical conditions that increase the risk of coagulopathy.

Benefits / Limitations.

The presence of diseases known to be associated with disseminated intravascular coagulation is a prerequisite for using this scale.
Higher scores are highly correlated with higher mortality rates.
The coagulation profile (platelet level, prothrombin time, D-dimer, fibrinogen) gives us an idea of the dynamic nature of DIC. For monitoring, it is important to conduct a series of tests over time.
This scale is not universal for all categories of patients. For example, if bleeding is suspected due to liver failure and disseminated intravascular coagulation is less likely, liver function tests may be useful, which may be more appropriate to confirm the diagnosis.

The diagnosis of disseminated intravascular coagulation should be made based on appropriate clinical symptoms, confirmed by suitable laboratory tests.

DIC syndrome is a complication of a wide range of pathologies. It is imperative to determine the underlying clinical condition to develop appropriate treatment strategies. The final decision on the tactics of patient management should not be based only on this scale.

References:

Сообщение DIC scale online calculator появились сначала на ClinCaseQuest.