Medical emergencies – ClinCaseQuest https://clincasequest.hospital Medical education in clinical cases Sat, 12 Feb 2022 22:02:16 +0000 en-US hourly 1 https://wordpress.org/?v=6.2.11 https://clincasequest.hospital/wp-content/uploads/sites/7/2020/02/logo-ru-project-90x90.png Medical emergencies – ClinCaseQuest https://clincasequest.hospital 32 32 Wells’ Deep Vein Thrombosis Criteria – online calculator https://clincasequest.hospital/wells-dvt-criteria/ Sat, 12 Feb 2022 09:34:00 +0000 https://clincasequest.hospital/?p=33466 The Wells’ DVT Criteria can be used in the outpatient and emergency department. By risk stratifying to low risk (Wells’ Score <2) and a negative…

Сообщение Wells’ Deep Vein Thrombosis Criteria – online calculator появились сначала на ClinCaseQuest.

]]> The Wells’ DVT Criteria can be used in the outpatient and emergency department. By risk stratifying to low risk (Wells’ Score <2) and a negative D-dimer the clinician can exclude the further ultrasound (US) diagnostic test to rule out DVT.

The Wells’ Score is less useful in hospitalized patients.

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Treatment or palliation within 6 months

Measured 10 cm below tibial tuberosity

* Required


The physician may not prescribe an ultrasound (ultrasound) to rule out DVT if the patient has low-risk DVT (<2 points) based on risk stratification on Wells` score and negative D-dimer.

The Wells’ scale should only be used after a detailed patient’s history taking and a physical examination in patients who are at risk of DVT.

The Wells’ Deep Vein Thrombosis (DVT) Risk Criteria stratifies patients by risk of DVT. There is a low prevalence of DVT in patients with a low pretest probability of DVT (<25%). Complications of DVT include pulmonary embolism (PE) and pulmonary hypertension, the mortality rate of which is 1-8%, so the timely diagnosis of DVT is the best prevention of PE and pulmonary hypertension.

Traditional diagnosis of DVT involves ultrasonography of the lower extremities, which is associated with time and financial resources. Using Wells` DVT criteria physicians can identify those patients who are generally unlikely have DVT. Further testing of patients for D-dimer can also safely rule out DVT without the necessity for an ultrasound.

The predictive scale includes nine parameters and the clinician’s clinical judgment regarding the likelihood of an alternative diagnosis.Well’s assessment score based on addition of the selected points:

VariablePoints
Active cancer (treatment or palliation within 6 months)1
Bedridden recently >3 days or major surgery within 12 weeks1
Calf swelling >3 cm compared to the other leg (measured 10 cm below tibial tuberosity)1
Collateral (nonvaricose) superficial veins present1
Entire leg swollen1
Localized tenderness along the deep venous system1
Pitting edema, confined to symptomatic leg1
Paralysis, paresis, or recent plaster immobilization of the lower extremity1
Previously documented DVT1
Alternative diagnosis to DVT as likely or more likely-2

There are a few versions of the criteria with minor differences between them. This is the most widely validated scale, based on Wells 2003.

Interpretation:

Шкала Wells’Risk groupPrevalence of DVTRecommendations
≤0Low/unlikely5%These patients should proceed to D-dimer testing:
• A negative high or moderate sensitivity D-dimer results in a probability <1 % and no further imaging is required
• A positive D-dimer should proceed to US testing
• A negative US is sufficient for DVT rule out
• A positive US is concerning for DVT; strongly consider treatment with anticoagulation
1-2Moderate17%These patients should proceed to high-sensitivity D-dimer testing (moderate sensitivity D-dimer is not sufficient)
• A negative high-sensitivity D-dimer is sufficient for rule out of DVT in a moderate risk patient with a probability of <1%
• A positive high sensitivity D-dimer should proceed to US testing
• A negative US is sufficient for ruling out DVT
• A positive US is concerning for DVT, strongly consider treatment with anticoagulation
• Moderate risk group should only undergo D-dimer testing for rule out without ultrasonography if a high-sensitivity D-dimer is being used
≥3High/likely17-53%All DVT likely patients should receive a diagnostic US
• D-dimer testing should be utilized to help risk-stratify these DVT-likely patients
• In DVT likely patients with negative D-dimer: • A negative US is sufficient for ruling out DVT, consider discharge
• A positive US should be concerning for DVT, strongly consider treatment with anticoagulation
•In DVT likely patients with a positive D-dimer:
• A positive US should be concerning for DVT, strongly consider treatment with anticoagulation
• A negative US is still concerning for DVT. A repeat US should be performed within 1 week for re-evaluation

Sometimes patients with DVT and a negative D-dimer are revealed in clinical practice.

  • A negative ultrasound result is sufficient to rule out DVT and consider discharge.
  • A positive ultrasound result indicates the presence of DVT, with the necessity of anticoagulants treatment.

With DVT and positive D-dimer:

  • A positive ultrasound result is sufficient to make a diagnosis of DVT necessity of anticoagulants treatment.
  • Negative ultrasound may also occur with DVT. A follow-up ultrasound should be performed within 1 week for re-evaluation.

This predictive score was derived from a series of studies by Wells’ et al. (Wells 1995, Wells 1997, Wells 2003) in an attempt to stratify the risk of DVT in symptomatic outpatients in order to reduce clinical resource burden and avoid overuse of imaging.

This scale has been included in the American College of Pulmonology guidelines for DVT.

NB!

  • The clinician’s clinical assessment should take precedence over the score on this predictive scale. High suspicion for DVT should require imaging regardless of Wells’ score.
  • The presence of DVT is critical in assessing the presence of PE, and if PE is being differentiated, alternative decision-making tools such as the Wells’ PE score or the PERC rule should be used.

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Sources:

  1. Wells PS, Hirsh J, Anderson DR, et al. Accuracy of clinical assessment of deep-vein thrombosis. Lancet. 1995;345(8961):1326-30.https://pubmed.ncbi.nlm.nih.gov/7752753/
  2. Wells PS, Anderson DR, Bormanis J, et al. Value of assessment of pretest probability of deep-vein thrombosis in clinical management. Lancet. 1997;350(9094):1795-8. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(97)08140-3/fulltext
  3. Wells PS, Anderson DR, Rodger M, Forgie M, Kearon C, Dreyer J, Kovacs G, Mitchell M, Lewandowski B, Kovacs MJ. Evaluation of D-dimer in the diagnosis of suspected deep-vein thrombosis. N Engl J Med. 2003 Sep 25;349(13):1227-35. https://pubmed.ncbi.nlm.nih.gov/14507948/
  4. Scarvelis D, Wells PS. Diagnosis and treatment of deep-vein thrombosis. CMAJ. 2006 Oct 24;175(9):1087-92. Review. Erratum in: CMAJ. 2007 Nov 20;177(11):1392. https://pubmed.ncbi.nlm.nih.gov/17060659/
  5. Wells PS, Owen C, Doucette S, Fergusson D, Tran H. Does this patient have deep vein thrombosis? JAMA. 2006 Jan 11;295(2):199-207. Review. https://pubmed.ncbi.nlm.nih.gov/16403932/
  6. Bates SM, Jaeschke R, Stevens SM, Goodacre S, Wells PS, Stevenson M.D., Kearon C, Schunemann HJ, Crowther M, Pauker SG, Makdissi R, Guyatt GH. Diagnosis of DVT: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. https://pubmed.ncbi.nlm.nih.gov/22315267/
  7. Silveira PC, Ip IK, Goldhaber SZ, Piazza G, Benson CB, Khorasani R. Performance of Wells Score for Deep Vein Thrombosis in the Inpatient Setting. JAMA Intern Med. 2015 Jul;175(7):1112-7. doi: 10.1001/jamainternmed.2015.1687. https://pubmed.ncbi.nlm.nih.gov/25985219/

See also:

Well’s criteria for Pulmonary Embolism probability assessment
PERC Rule for Pulmonary Embolism- online calculator

Сообщение Wells’ Deep Vein Thrombosis Criteria – online calculator появились сначала на ClinCaseQuest.

]]> PERC Rule for Pulmonary Embolism- online calculator https://clincasequest.hospital/perc-rule/ Thu, 10 Feb 2022 00:48:00 +0000 https://clincasequest.hospital/?p=33447 Rules out PE if no criteria are present and pre-test probability is ≤15%. The PERC rule can be applied to patients in whom PE is…

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]]> Rules out PE if no criteria are present and pre-test probability is ≤15%.

The PERC rule can be applied to patients in whom PE is suspected, but the patient is considered to be at low risk (clinical pretest probability <15%).

The PERC rule can be applied to patients where the diagnosis of PE is being considered, but the patient is deemed low-risk. A patient deemed low-risk who is also <50 years of age, with a pulse <100 bpm, SaO2 ≥95%, no hemoptysis, no estrogen use, no history of surgery/trauma within 4 weeks, no prior PE/DVT and no present signs of DVT can be safely ruled out and does not require further further diagnostic tests.

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Surgery or trauma ≤4 weeks ago requiring treatment with general anesthesia

Oral contraceptives, hormone replacement or estrogenic hormones use in males or female patients

0
* Required


If any criteria are positive, the PERC rule is not satisfied and cannot be used to rule out PE in this patient.

Pulmonary embolism exclusion criteria can be used by physicians to avoid performing imaging studies in low-risk patients who are not indicated, which will both reduce the iatrogenic impact on the patient and promote the rational use of clinic resources.

The PERC rule is an “eliminate” tool: all variables must be absent “no” for the result to be negative.

As an exclusion criterion, PERC is not intended for risk stratification.

The rule can be used if the patient has a low risk of PE (<15% pretest probability). For these patients with a low pre-test probability of PE, the risk associated with initiating evaluation and treatment of PE (eg, CT radiation, anaphylaxis from contrast agent administration, bleeding with anticoagulant use) is equivalent to the likelihood of missing a diagnosis.

Age ≥50+1
HR ≥100+1
O₂ sat on room air <95%+1
Unilateral leg swelling+1
Hemoptysis+1
Recent surgery or trauma
Surgery or trauma ≤4 weeks ago requiring treatment with general anesthesia		+1
Prior PE or DVT+1
Hormone use
Oral contraceptives, hormone replacement or estrogenic hormones use in males or female patients		+1

Interpretation

If any of the following is/are present, PE cannot be ruled out:

  • Age ≥50.
  • HR ≥100.
  • O₂ sat on room air <95%.
  • Unilateral leg swelling.
  • Hemoptysis.
  • Recent trauma or surgery.
  • Prior PE or DVT.
  • Hormone use (oral contraceptives, hormone replacement or estrogenic hormones use in males or female patients).
Number of criteriaRecommendation
0 criteria for the PERC rule for pulmonary embolism0 criteria according to the PERC rule for pulmonary embolism.

No need for further workup, as <2% chance of PE.

If no criteria are positive and clinician’s pre-test probability is <15%, PERC Rule criteria are satisfied.
1-8 PERC Criteria for Pulmonary EmbolismIf any criteria are positive, the PERC rule cannot be used to rule out PE in this patient.

The PERC rule for pulmonary embolism was based on the results of a prospective study that included 3148 patients from 10 centers. 21 potential variables were included in the initial analysis, from which eight final variables were selected. For further validation of the data obtained, 1427 low-risk patients and 382 very-low-risk patients from 2 centers were included.

  • In low-risk patients, sensitivity was 96% and specificity 27%.
  • In patients at very low risk, sensitivity was 100% and specificity -15%.
  • The 90-day false-negative rate in low-risk patients was 1.4%, below the testing threshold of 1.8%.

The second stage of validation was carried out in 2008. A threshold of <15% was chosen for the low pretest probability. The study included 8138 patients from 13 centers:

  • 20% of the cohort were at low risk (<15%)
  • For patients with a negative PERC result and a pretest probability <15%, the false-negative rate at 45 days was 1.0% with a sensitivity of 97.4% and a specificity of 21.9%.

Clinical Approach

In a low-risk patient who has one or more PERC criteria, the clinician should consider performing a D-dimer evaluation to further evaluation:

  • If D-dimer is negative and the clinical pretest probability is <15%, such patient does not require further evaluation to rule out PE.
  • This rule helps rule out PE in patients at low risk of PE based on clinical criteria alone.
  • PERC-negative patients do not require D-dimer testing, which has high sensitivity but low specificity.
  • Low-risk PERC-negative patients will not be exposed to the risks associated with unnecessary imaging tests and treatment for PE.
  • If D-dimer is positive, additional investigations such as CT angiography or V/Q scan should be done.

NB!

  • This rule does not apply to patients who are not assessed for PE.
  • If the patient has a moderate or high clinical risk of pre-test probability of PE – the PERC rule cannot be used! Consideration should be given to D-dimer assessment or imaging based on risk.
  • As an exclusion criterion, PERC is not intended for risk stratification.

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Literature

  1. Kline JA, et al. Clinical criteria to prevent unnecessary diagnostic testing in emergency department patients with suspected pulmonary embolism. J Thromb Haemost 2004; 2: 1247–55. https://pubmed.ncbi.nlm.nih.gov/15304025/
  2. Kline JA, et al. Prospective multicenter evaluation of the pulmonary embolism rule-out criteria. J Thromb Haemost 2008; 6: 772–80. (PMID: 18318689). https://pubmed.ncbi.nlm.nih.gov/18318689/
PESI scale (Pulmonary Embolism severity index) online calculator
Simplified version of the PESI scale sPESI (Pulmonary Embolism severity index)
Revised Geneva Score, rGeneva online calculator
Well’s criteria for Pulmonary Embolism probability assessment

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]]> 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.

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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/

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]]> 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%).

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

Subscribe to our pages:

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.

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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

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)

* Required
VariablePointsAge <50…
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Multiple Myeloma Diagnostic Criteria – Online Calculator

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≥1 of the following (A or B)

≥1 myeloma defining event (C1 or C2)

* Required
For Multiple Myeloma Diagnostic Criteria assessment necessary to provide selection of the…
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]]> 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…
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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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]]> 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…

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]]> 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

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

]]> Sgarbossa’s Criteria for MI in Left Bundle Branch Block https://clincasequest.hospital/sgarbossas/ Sat, 04 Sep 2021 07:02:00 +0000 https://clincasequest.hospital/?p=30107 Criteria to diagnose acute MI in patients with prior LBBB. Concordant ST elevation > 1mm in leads with a positive QRS complex: No Yes Concordant…

Сообщение Sgarbossa’s Criteria for MI in Left Bundle Branch Block появились сначала на ClinCaseQuest.

]]> Criteria to diagnose acute MI in patients with prior LBBB.

Concordant ST elevation > 1mm in leads with a positive QRS complex:
No
Yes

Concordant ST depression > 1 mm in V1-V3:
No
Yes

Excessively discordant ST elevation (or depression) in leads with a negative QRS
In proportion to the preceding S-wave (or R-wave) as determined by 1) at least 1 mm of ST elevation (or depression) AND 2) an ST/S ratio ≤-0.25:
No
Yes




Patient’s score Range Clinical advice
0 0 0

Sgarbossa's Criteria, Sgarbossa, mi, myocardial infarction, LBBB, Left Bundle Branch Block, calculator, online calculator, medical calculator

In Normal for LBBB and placed rhythm – ST and T waves in opposite direction to QRS main vector:

In some cases it is often difficult to identify an MI for patients with existing left bundle branch blocks (LBBB). About 1 in 200 patients with MI have LBBB. Sgarbossa’s is a well accepted approach at determining which LBBB are having an MI.

Patient’s scoreRangeClinical advice
 0-2 pointsIn the original Sgarbossa criteria, a score of <3 typically is not considered diagnostic of acute MI, but also does not rule out MI. In concerning patients, repeating ECGs and cardiac enzymes may be helpful, along with cardiology consultation.

NOTE! the Modified Sgarbossa Criteria (which changes the third criteria) does not use the points system, it is positive if any criteria are met.
 ≥3 pointsA score of 3 or more is 90% specific for MI.

NOTE! the Modified Sgarbossa Criteria (which changes the third criteria) does not use the points system, it is positive if any criteria are met.

Addition of the assigned points.

Concordant ST elevation > 1mm in leads with a positive QRS complexYes+5
Concordant ST depression > 1 mm in V1-V3Yes+3
Excessively discordant ST elevation (or depression) in leads with a negative QRS
In proportion to the preceding S-wave (or R-wave) as determined by 1) at least 1 mm of ST elevation (or depression) AND 2) an ST/S ratio ≤-0.25		Yes+2

A score of 3 or more is 90% specific for MI, but not sensitive (36%). Therefore a positive score should be acted upon, but a lower score can not by itself rule out MI – maintain a high index of suspicion if the presentation is consistent with MI.

0-2 points. In the original Sgarbossa criteria, a score of <3 typically is not considered diagnostic of acute MI, but also does not rule out MI. In concerning patients, repeating ECGs and cardiac enzymes may be helpful, along with cardiology consultation.

NOTE: the Modified Sgarbossa Criteria (which changes the third criteria) does not use the points system, it is positive if any criteria are met.

Modified Sgarbossa’s Criteria for MI in Left Bundle Branch Block

As mentioned, Sgarbossa’s criteria does not rule out myocardial infarction in patients with pre-existing Left Bundle Branch Block (it is not sufficiently sensitive), but in patients with ≥ 3 points, it is specific for MI.

Literature:
1. Sgarbossa EB, Pinski SL, Barbagelata A, Underwood DA, Gates KB, Topol EJ, Califf RM, Wagner GS. Electrocardiographic diagnosis of evolving acute myocardial infarction in the presence of left bundle-branch block. GUSTO-1 (Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries) Investigators. N Engl J Med. 1996 Feb 22;334(8):481-7. Erratum in: N Engl J Med 1996 Apr 4;334(14):931. PubMed PMID: 8559200. https://pubmed.ncbi.nlm.nih.gov/8559200/?dopt=Abstract
2. Smith SW, Dodd KW, Henry TD, Dvorak DM, Pearce LA. Diagnosis of ST-elevation myocardial infarction in the presence of left bundle branch block with the ST-elevation to S-wave ratio in a modified Sgarbossa rule. Ann Emerg Med. 2012 Dec;60(6):766-76. doi: 10.1016/j.annemergmed.2012.07.119. Epub 2012 Aug 31. Erratum in: Ann Emerg Med. 2013 Oct;62(4):302. PubMed PMID: 22939607. https://pubmed.ncbi.nlm.nih.gov/22939607/
3. Cai Q, Mehta N, Sgarbossa EB, Pinski SL, Wagner GS, Califf RM, Barbagelata A. The left bundle-branch block puzzle in the 2013 ST-elevation myocardial infarction guideline: from falsely declaring emergency to denying reperfusion in a high-risk population. Are the Sgarbossa Criteria ready for prime time? Am Heart J. 2013 Sep;166(3):409-13. doi: 10.1016/j.ahj.2013.03.032. Epub 2013 Aug 6. PubMed PMID: 24016487. https://pubmed.ncbi.nlm.nih.gov/24016487/

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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

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]]> 4Ts Score System for Heparin-Induced Thrombocytopenia https://clincasequest.hospital/4ts-score-for-hit/ Fri, 16 Jul 2021 08:31:00 +0000 https://clincasequest.hospital/?p=29788 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…

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]]> 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.

Thrombocytopenia:
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 5–10 OR platelet fall ≤1 day (prior heparin exposure within 30 days)
Consistent with days 5–10 fall, but not clear; onset after day 10 OR fall ≤1 day (prior heparin exposure 30–100 days ago)
Platelet count fall <4 days without recent exposure

Thrombosis or other sequelae:
New thrombosis OR skin necrosis; acute systemic reaction post-IV heparin bolus
Progressive OR recurrent thrombosis; non-necrotizing skin lesions; suspected thrombosis (not proven)
None

Other causes for thrombocytopenia:
None apparent
Possible
Definite



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.
ThrombocytopeniaPlatelet 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/l0
Timing of platelet count fallClear 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 exposure0
Thrombosis or other sequelaeNew 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
 None0
Other causes for thrombocytopeniaNone apparent+2
 Possible+1
 Definite0

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.

ScoreRisk stratificationProbability of HIT
≤3 pointslow probability for HIT≤5% in original study, <1% in meta-analysis
4-5 pointsintermediate probability for HIT~14%
6-8 pointshigh 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:

Category2 points1 point0 points
ThrombocytopeniaPlatelet count fall > 50% AND platelet nadir ≥ 20 ×109/lPlatelet count fall 30%–50% OR platelet nadir 10–19 ×109/lPlatelet count fall < 30% OR platelet nadir < 10 ×109/l
Timing of platelet count fallClear 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 sequelaeNew thrombosis (confirmed) OR skin necrosis at heparin injection sites OR acute systemic reaction after intravenous heparin bolusProgressive or recurrent thrombosis OR nonnecrotizing (erythematous) skin lesions OR suspected thrombosis (not proven)None
Other causes for thrombocytopeniaNone apparentPossibleDefinite

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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]]> ABCD2 Score System for stroke risk assessment after suspected TIA, online calculator https://clincasequest.hospital/abcd2-score-stroke-risk/ Wed, 14 Jul 2021 11:39:00 +0000 https://clincasequest.hospital/?p=29794 ABCD2 Score System estimates the risk of stroke after a suspected transient ischemic attack (TIA). The ABCD2 score can help physicians to provide risk stratification stroke…

Сообщение ABCD2 Score System for stroke risk assessment after suspected TIA, online calculator появились сначала на ClinCaseQuest.

]]> ABCD2 Score System estimates the risk of stroke after a suspected transient ischemic attack (TIA). The ABCD2 score can help physicians to provide risk stratification stroke in patients presenting with a TIA. Patients with a low risk of stroke could undergo outpatient diagnostic tests. Patients with moderate and high risk should be hospitalized for careful diagnosis.

Age ≥ 60 years:
No
Yes

BP ≥ 140/90 mmHg Initial BP. Either SBP ≥ 140 or DBP ≥ 90:
No
Yes

Clinical features of the TIA:
Unilateral weakness
Speech disturbance without weakness
Other symptoms

Duration of symptoms:
<10 minutes
10-59 minutes
≥ 60 minutes

History of diabetes:
Yes
No


Patient’s score Range Risk group Stroke Risk Recommendation
0 0 0 0 0

The addition of the selected points is required.

CriteriaValuePoints
Age ≥ 60 yearsY/N+1
BP ≥ 140/90 mmHgY/N+1
Clinical features of the TIAUnilateral Wwakness+2
 Speech disturbance without weakness+1
 Other symptoms0
Duration of symptoms< 10 minutes0
 10-59 minutes+1
 ≥ 60 minutes+2
History of diabetesY/N+1

Multiple studies have shown that as the ABCD2 score increases the risk of a subsequent stroke also increases.

Results:

Total scoreRisk groupStroke Risk
Recommendation
0-3Low Risk• 2-Day Stroke Risk: 1.0%
• 7-Day Stroke Risk: 1.2%
• 90-Day Stroke Risk: 3.1%  		• Arrange expedited evaluation as an outpatient with the goal of obtaining the relevant studies and consultations within 24 hours.
• Consider further imaging modalities including MRI and carotid ultrasound as outpatient.
• Consider consulting Neurology to help determine whether the patient would benefit from further inpatient evaluation or to expedite outpatient follow-up when appropriate.      
4-5Moderate Risk• 2-Day Stroke Risk: 4.1%
• 7-Day Stroke Risk: 5.9%
• 90-Day Stroke Risk: 9.8%		• Admit patient for further evaluation to the hospital.
• Consult Neurology.
• Consider obtaining an MRI and other appropriate vascular and embolic imaging.    
6-7High Risk• 2-Day Stroke Risk: 8.1%
• 7-Day Stroke Risk: 11.7%
• 90-Day Stroke Risk: 17.8%		• Admit patient for further evaluation to the hospital.
• Consult Neurology.
• Consider obtaining an MRI and other appropriate vascular and embolic imaging.    
  • A prospective observational study of 637 patients presenting to the ED found that the ABCD2 score did not add incremental value beyond an ED evaluation that included central nervous system and carotid artery imaging in the ability to risk-stratify patients with transient ischemic attack in the study’s cohort. (Stead 2010)
  • In this population of patients with TIA patients, a rapid ED-based outpatient protocol that included early carotid imaging and treatment when appropriate, found that the rate of stroke was independent of ABCD2 risk stratification. (Stead 2010)

Limitations:

The ABCD2 score should not be used as a substitute for clinical judgement or decision making. The ABCD score was developed in an outpatient setting (not in emergency departments!). It has been shown to have lower accuracy when ABCD2 score used by non-specialists (primary care or emergency physicians).

Patients with a low baseline risk of stroke (≤ 2%) with a low ABCD2 score (0-2) are at low risk for having a stroke within the next 7 days (0.4-0.8%). In this population of patients with TIA patients, rapid emergency department-based outpatient diagnostic tests are recommended.

In centers where computed tomography and carotid ultrasound studies are performed in collaboration with a stroke service, adding assessment based on the ABCD2 score to the evaluation appears unnecessary.

Based on the the poor performance of the ABCD2 score system in the emergency department setting, combined with difficulties in arranging the necessary imaging and specialty follow-up within 24-hour window, that most emergency department physicians were likely to choose to perform a rapid evaluation of TIA patients (imaging, possible neurology consultation) regardless of the ABCD2 score.

Literature
Johnston SC, Rothwell PM, Nguyen-Huynh MN, Giles MF, Elkins JS, Bernstein AL, Sidney S. Validation and refinement of scores to predict very early stroke risk after transient ischaemic attack. Lancet. 2007 Jan 27;369(9558):283-92. https://pubmed.ncbi.nlm.nih.gov/17258668/
Josephson SA, Sidney S, Pham TN, Bernstein AL, Johnston SC. Higher ABCD2 score predicts patients most likely to have true transient ischemic attack. Stroke. 2008 Nov;39(11):3096-8. doi: 10.1161/STROKEAHA.108.514562. Epub 2008 Aug 7. https://pubmed.ncbi.nlm.nih.gov/18688003/
Rothwell PM, Giles MF, Flossmann E, Lovelock CE, Redgrave JN, Warlow CP, Mehta Z. A simple score (ABCD) to identify individuals at high early risk of stroke after transient ischaemic attack. Lancet. 2005 Jul 2-8;366(9479):29-36. https://pubmed.ncbi.nlm.nih.gov/15993230/
Sanders LM, Srikanth VK, Blacker DJ, Jolley DJ, Cooper KA, Phan TG.Performance of the ABCD2 score for stroke risk post TIA: meta-analysis and probability modeling. Neurology. 2012 Sep 4;79(10):971-80. doi: 10.1212/WNL.0b013e31825f9d02. Epub 2012 Jun 13. PubMed PMID: 22700810. https://pubmed.ncbi.nlm.nih.gov/22700810/
Stead LG, Suravaram S, Bellolio MF, Enduri S, Rabinstein A, Gilmore RM, Bhagra A, Manivannan V, Decker WW. An assessment of the incremental value of the ABCD2 score in the emergency department evaluation of transient ischemic attack. Ann Emerg Med. 2011 Jan;57(1):46-51. doi: 10.1016/j.annemergmed.2010.07.001. Epub 2010 Sep 19. PubMed PMID: 20855130. https://pubmed.ncbi.nlm.nih.gov/20855130/
Perry JJ, Sharma M, Sivilotti ML, Sutherland J, Symington C, Worster A, Émond M, Stotts G, Jin AY, Oczkowski WJ, Sahlas DJ, Murray HE, MacKey A, Verreault S, Wells GA, Stiell IG. Prospective validation of the ABCD2 score for patients in the emergency department with transient ischemic attack. CMAJ. 2011 Jul 12;183(10):1137-45. doi: 10.1503/cmaj.101668. Epub 2011 Jun 6. PubMed PMID: 21646462. https://pubmed.ncbi.nlm.nih.gov/21646462/

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]]> The Glascow Coma Scale https://clincasequest.hospital/glascow-coma/ Sat, 26 Jun 2021 07:07:56 +0000 https://clincasequest.hospital/?p=29303 The Glascow Coma Scale, GCS is a scale for assessing impaired consciousness and coma in children older than 4 years and adults. On the scale,…

Сообщение The Glascow Coma Scale появились сначала на ClinCaseQuest.

]]> The Glascow Coma Scale, GCS is a scale for assessing impaired consciousness and coma in children older than 4 years and adults.

On the scale, the condition is assessed by the sum of points based on three parameters: Eye response (E – from 1 to 4), Verbal response (V – from 1 to 5) and Motor response (M – from 1 to 6). Thus, the minimum number of points is 3 (third degree coma), the maximum is 15 (clear consciousness).

Registration time:


Eye response, E:
Spontaneously
To verbal command
To pain
No eye opening

Verbal response, V:
Oriented
Confused
Inappropriate words
Incomprehensible sounds
No verbal response

Motor response, M:
Obeys commands
Localizes pain
Withdrawal from pain
Flexion to pain
Extension to pain
No motor response


Patient’s score Patient’s assessment Level of consciousness
0 0 0
ParameterResponsePoints
Eye response, ESpontaneously4
To verbal command3
To pain2
No eye opening1
Verbal response, VOriented5
Confused4
Inappropriate words3
Incomprehensible sounds2
No verbal response1
Motor response, MObeys commands6
 Localizes pain5
 Withdrawal from pain4
 Flexion to pain3
 Extension to pain2
 No motor response1

In the Glasgow scale, clinical signs are differentiated according to their severity, which is reflected in points. To obtain information about the degree of change in consciousness, the points are summed up. The greater the sum of points, the less the degree of inhibition of brain function, and on the contrary – the less this sum, the deeper the coma.

Levels of consciousnessGCS (in points)
Consciousness is clear15
Moderate stun13-14
Deep stun11-12
Sopor9-10
Coma I degree7-8
Coma II degree5-6
Coma III degree3-4

GCS  designed for use in serial assessments of patients with coma from either medical or surgical causes. The GCS is commonly used in the pre-hospital and acute care setting as well as during hospitalization to evaluate mental status in both traumatic and non-traumatic clinical presentations.

In the care of an individual patient, the ratings of the three criteria in the Scale should be assessed, monitored, reported, and communicated separately.

The combined Score is an index of the severity impairment and is useful as a summary of a patient’s condition, in classifying groups of different severity and for triage. The Score cannot be calculated if one or other of the component criteria is not testable.

The GCS has been shown to have statistical correlation with a broad array of adverse neurologic outcomes, including brain injury, need for neurosurgery, impaired recovery and mortality.

Besides, the GCS has been incorporated into numerous guidelines and assessment scores (e.g. ACLS, ATLS, APACHE I-III, TRISS and WNS SAH Grading Scale).

In some patients, it may be impossible to assess one or more of the three components of the coma scale. The reasons include the next, but are not limited to:

  • Eye: local injury and/or edema.
  • Verbal: intubation.
  • All (eye, verbal, motor): sedation, paralysis, and ventilation eliminating all responses. 

If a component is untestable, a score of 1 should not be assigned. In this circumstance, summation of the findings into a total Glasgow Coma Score is invalid.

The 3 parts of the Glasgow Coma Scale are charted independently, and the position can be recorded as “NT” (not testable or not applicable –“NA”), with an option of indicating the reason, e.g. “C” for eye closure and “T” for intubation

The GCS score can be indicative of how critically ill a patient is.

Trauma patients presenting with GCS <15 warrant close attention and reassessment.

A declining GCS is concerning in any setting and should prompt assessment of the airway and possible intervention.

Conversely, a GCS of 15 should not be taken as an indication that a patient (trauma or medical) is not critically ill. Decisions about the aggressiveness of the management and treatment plans should be made based on clinical presentation and context and not in any way overridden by the GCS score.

Clinical management decisions should not be based solely on the GCS score in the acute setting.

If a trauma patient has a GCS ≤8 and there is clinical concern that they are unable to protect their airway or that they have an expected worsening clinical course based on exam or imaging findings, then intubation can be considered.

In any patient, a rapidly declining or waxing and waning GCS is concerning and intubation should be considered in the context of the patient’s overall clinical condition.

Clinical management decisions should not be based solely on the GCS score in the acute setting.

The Glasgow scale is usually written in this form: “GCS 8 = E1 V4 M3 at 07:35“.

For more information on assessing a patient on the Glasgow Coma Scale, visit the official website. https://www.glasgowcomascale.org/

LITERATURE:
Teasdale G, Jennett B.Assessment of coma and impaired consciousness. A practical scale. Lancet. 1974 Jul 13;2(7872):81-4 https://pubmed.ncbi.nlm.nih.gov/4136544/
Moore L, Lavoie A, Camden S, Le Sage N, Sampalis JS, Bergeron E, Abdous B. Statistical validation of the Glasgow Coma Score.J Trauma. 2006 Jun;60(6):1238-43; discussion 1243-4 https://pubmed.ncbi.nlm.nih.gov/16766966/
“Reith FC, Van den brande R, Synnot A, Gruen R, Maas AI. The reliability of the Glasgow Coma Scale: a systematic review. Intensive Care Med. 2016;42(1):3-15 https://pubmed.ncbi.nlm.nih.gov/26564211/
Teasdale G, Jennett B. Assessment of coma and severity of brain damage. Anesthesiology. 1978;49:225-226 https://pubmed.ncbi.nlm.nih.gov/686455/
Teasdale G, Jennett B, Murray L, Murray G. Glasgow coma scale: to sum or not to sum. Lancet. 1983 Sep 17;2(8351):678 https://pubmed.ncbi.nlm.nih.gov/6136811/
Healey C, Osler TM, Rogers FB, Healey MA, Glance LG, Kilgo PD, Shackford SR, Meredith JW. Improving the Glasgow Coma Scale score: motor score alone is a better predictor. J Trauma. 2003 Apr;54(4):671-8; discussion 678-80 https://pubmed.ncbi.nlm.nih.gov/12707528/
Green SM. Cheerio, laddie! Bidding farewell to the Glasgow Coma Scale. Ann Emerg Med. 2011 Nov;58(5):427-30. doi: 10.1016/j.annemergmed.2011.06.009. Epub 2011 Jul 30 https://pubmed.ncbi.nlm.nih.gov/21803447/
Middleton PM. Practical use of the Glasgow Coma Scale; a comprehensive narrative review of GCS methodology. Australas Emerg Nurs J. 2012 Aug;15(3):170-83. doi: 10.1016/j.aenj.2012.06.002. Epub 2012 Aug 3. Review https://pubmed.ncbi.nlm.nih.gov/22947690/
Yeh DD. Glasgow Coma Scale 40 years later: in need of recalibration? JAMA Surg. 2014 Jul;149(7):734. doi: 10.1001/jamasurg.2014.47. No abstract available https://pubmed.ncbi.nlm.nih.gov/24899079/
Teasdale G. Forty Years on: Updating the Glasgow Coma Scale. Nursing Times. 2014; 110(42) https://cdn.ps.emap.com/wp-content/uploads/sites/3/2014/10/141015Forty-years-on-updating-the-Glasgow-coma-scale.pdf
Gill M, Windemuth R, Steele R, Green SM. A comparison of the Glasgow Coma Scale score to simplified alternative scores for the prediction of traumatic brain injury outcomes. Ann Emerg Med. 2005 Jan;45(1):37-42 https://pubmed.ncbi.nlm.nih.gov/15635308/
Haukoos JS, Gill MR, Rabon RE, Gravitz CS, Green SM. Validation of the Simplified Motor Score for the prediction of brain injury outcomes after trauma. Ann Emerg Med. 2007 Jul;50(1):18-24. Epub 2006 Nov 16 https://pubmed.ncbi.nlm.nih.gov/17113193/
Thompson DO, Hurtado TR, Liao MM, Byyny RL, Gravitz C, Haukoos JS. Validation of the Simplified Motor Score in the out-of-hospital setting for the prediction of outcomes after traumatic brain injury. Ann Emerg Med. 2011 Nov;58(5):417-25. doi: 10.1016/j.annemergmed.2011.05.033. Epub 2011 Jul 30 https://pubmed.ncbi.nlm.nih.gov/21803448/
Teasdale G, Maas A, Lecky F, Manley G, Stocchetti N, Murray G. The Glasgow Coma Scale at 40 years: standing the test of time. Lancet Neurol. 2014;13(8):844-54 https://pubmed.ncbi.nlm.nih.gov/25030516/

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Сообщение The Glascow Coma Scale появились сначала на ClinCaseQuest.

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