• 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.

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

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

Management

Suggested management (clinician must consider additional clinical information including hemodynamic stability and 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.

.

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Literature

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

Baseline Cardiovascular Risk Assessment in Cancer Patients Scheduled to Receive Cardiotoxic Cancer Therapies (Anthracycline Chemotherapy) – Online Calculator

Baseline cardiovascular risk assessment in cancer patients scheduled to receive cardiotoxic cancer therapies (Anthracycline Chemotherapy)…

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National Institutes of Health Stroke Scale (NIHSS) – Online calculator

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Charlson Comorbidity Index (CCI) Online Calculator

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

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

Date of assessment

---

Age *

<50 years

50–59 years

60–69 years

70–79 years

≥80 years

Myocardial infarction *

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

No

Yes

Congestive heart failure *

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

No

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)

No

Yes

Cerebrovascular accident or Transient ischemic attack *

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

No

Yes

Dementia *

Chronic cognitive deficit

No

Yes

Chronic obstructive pulmonary disease *

No

Yes

Connective tissue disease *

No

Yes

Peptic ulcer disease *

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

No

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 *

No

Yes

Moderate to severe chronic kidney disease *

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

No

Yes

Solid tumor *

None

Localized

Metastatic

Leukemia *

No

Yes

Lymphoma *

No

Yes

AIDS *

No

Yes

---

Charlson Comorbidity Index

10-year survival

Details:

Reset

* Required

VariablePointsAge <50…

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Multiple Myeloma Diagnostic Criteria – Online Calculator

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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:

Reset

* Required

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

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

Revised Multiple Myeloma International Staging System (R-ISS) – prognostication tool for myeloma patients based on…

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Multiple Myeloma International Staging System (ISS) Online Calculator

Multiple Myeloma International Staging System (ISS) prognosticates the severity of multiple myeloma based on routinely…

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Сообщение Focused Assessment with Sonography for Trauma (FAST): Online Calculator появились сначала на ClinCaseQuest.

Maximum Allowable Blood Loss (ABL) Without Transfusion formula helps with determining when to transfuse a patient if blood count values are not immediately available.

Maximum Allowable Blood Loss (ABL) Without Transfusion calculated based on formula:

ABL = [EBV x (Hi-Hf)] / Hav, where EBV = body weight, kg x average blood volume*, mL/kg and other variables are as follows:

*Average blood volume by age:

Transfusion triggers vary by patient and clinical presentation.

Patients with hemoglobin concentrations below 6 g/dL almost always require transfusion. In stable patients with hemoglobin values 6-10 g/dL, the decision whether to transfuse is based on an evaluation of clinical status; patients with values above 10 g/dL rarely require transfusion unless they are unstable or have signs/symptoms consistent with continued hemorrhage.

During blood loss, dilution of remaining hemoglobin occurs as intravascular volume is maintained by fluid shifts and administration of fluids. Consider transfusing if estimated blood loss exceeds calculated allowable blood loss.

Estimating blood loss intraoperatively can be done via direct measure of blood in suction canister along with measuring soiled sponges.

This method is only an estimate to measure blood loss. Patient vitals and clinical signs should be evaluated clinically first.

Capacity by sponge type:

• 4x4s: ~10 mL blood
• Gauze sponges (Ray-Tec):~10-20 mL blood
• Laparotomy (lap) sponges: ~50-100 mL blood

Consider timing of blood loss. Acute blood loss may not present with a drop in hemoglobin. Always monitor clinical metrics such as hemodynamics and respiratory status along with anticipated blood loss.

The trigger to transfuse varies by patient.

The maximum allowable blood loss equation was developed by Jeffrey Gross based on an accepted equation for blood loss and incorporating a correction for isovolumetric hemodilution using a mathematical differential.

Gross in 1983 showed that a blood loss greater than 20% of estimated blood volume will cause the maximum allowable value to be inaccurate.

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Literature

1. Gross JB. Estimating Allowable Blood Loss Corrected for Dilution. Anesthesiology 58.2 (1983): 277-280.
2. Practice Guidelines for blood component therapy: A report by the American Society of Anesthesiologists Task Force on Blood Component Therapy.
3. Practice guidelines for blood transfusion: a compilation from recent peer-reviewed literature. American Red Cross.

Baseline Cardiovascular Risk Assessment in Cancer Patients Scheduled to Receive Cardiotoxic Cancer Therapies (Anthracycline Chemotherapy) – Online Calculator

July 3, 2023

Baseline cardiovascular risk assessment in cancer patients scheduled to receive cardiotoxic cancer therapies (Anthracycline Chemotherapy)…

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National Institutes of Health Stroke Scale (NIHSS) – Online calculator

June 22, 2023

The National Institutes of Health Stroke Scale (NIHSS) is a scale designed to assess the…

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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

---

Age *

<50 years

50–59 years

60–69 years

70–79 years

≥80 years

Myocardial infarction *

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

No

Yes

Congestive heart failure *

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

No

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)

No

Yes

Cerebrovascular accident or Transient ischemic attack *

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

No

Yes

Dementia *

Chronic cognitive deficit

No

Yes

Chronic obstructive pulmonary disease *

No

Yes

Connective tissue disease *

No

Yes

Peptic ulcer disease *

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

No

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 *

No

Yes

Moderate to severe chronic kidney disease *

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

No

Yes

Solid tumor *

None

Localized

Metastatic

Leukemia *

No

Yes

Lymphoma *

No

Yes

AIDS *

No

Yes

---

Charlson Comorbidity Index

10-year survival

VariablePointsAge <50…

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

January 17, 2023

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Multiple Myeloma International Staging System (ISS) Online Calculator

January 16, 2023

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Сообщение Maximum Allowable Blood Loss (ABL) Without Transfusion: Online calculator появились сначала на ClinCaseQuest.

*Known history of ischemic heart disease, cerebrovascular disease, peripheral arterial disease, congestive heart failure, severe pulmonary hypertension, or severe obstructive intracardiac abnormality (eg, severe aortic stenosis, severe mitral stenosis, or severe hypertrophic obstructive cardiomyopathy).

NB! The RCRI score should be used with caution in patients requiring urgent surgery, as this scale is not well validated in this population.

The revised cardiac risk index for preoperative risk accurately risk-stratifies patients and helps patients understand individualized risk prior to undergoing surgery, which can be helpful in discussions of informed consent.

In patients with elevated risk (RCRI ≥1, age ≥65, or age 45-64 with significant cardiovascular disease), helps direct further preoperative risk stratification (e.g. with serum NT-proBNP or BNP) and determine appropriate cardiac monitoring post-op (ECG, troponins).

*Known history of coronary artery disease, cerebral vascular disease, peripheral artery disease, congestive heart failure, severe PHTN or a severe obstructive intracardiac abnormality (e.g. severe aortic stenosis, severe mitral stenosis, or severe hypertrophic obstructive cardiomyopathy).

Interpretation:

According to the 2016 CCS Perioperative Guidelines:

• If the RCRI is ≥1, the patient’s age is ≥65, or they are between 45-64 with significant cardiac disease*, the next step is to measure the patient’s NT-ProBNP or BNP if this is available at your institution.
• If the NT-ProBNP is ≥300 ng/L or BNP is ≥92 ng/L, then there should be an EKG ordered in the PACU and troponins should be measured daily for 48-72 hours.
• If, after risk stratification, the NT-ProBNP is <300 ng/L or BNP <92 ng/L, no routine postoperative cardiac monitoring is warranted.
• If the institution does not have these assays available, then all patients should be monitored with an EKG in the PACU and troponin measurements daily for 48-72 hours if they meet one of the following: RCRI ≥1, age ≥65, or age 45-64 with the aforementioned cardiac disease.*

*Known history of coronary artery disease, cerebral vascular disease, peripheral artery disease, congestive heart failure, severe PHTN or a severe obstructive intracardiac abnormality (e.g. severe aortic stenosis, severe mitral stenosis, or severe hypertrophic obstructive cardiomyopathy).

The data supporting the use of NT-ProBNP/BNP comes from a large 2014 meta-analysis of 18 studies with a total of 2,477 patients (Rodseth 2014). This study, which was in agreement with multiple previous meta-analyses, noted that for those patients with a pre-operative NT-ProBNP of <300 ng/l or BNP <92 ng/l, the rate of 30-day postoperative non-fatal MI or Death was 4.9% (3.9%-61%), and was 21.8% (19.0%-24.8%) in those with pre-operative NT-ProBNP is ≥300 ng/L or BNP is ≥92 ng/L.

RCRI score easy to use by any involved specialty, including general internal medicine, cardiology, anesthesia, or surgery, and very well validated. It can be used in the inpatient or outpatient preoperative setting.

At the same time, the RCRI score includes a limited number of risk factors it includes, in part because the original studies could not include a sufficient number of patients for every important risk factor (e.g. underestimates hemodynamic and cardiovascular outcomes in valvular disease).

NB! Other patient important outcomes that are not assessed by this tool include:

• risk of stroke,
• major bleeding,
• prolonged hospitalization,
• ICU admission.

Alternative perioperative cardiac risk scores like the Myocardial Infarction and Cardiac Arrest (MICA) Score and the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) Score have been validated only retrospectively and therefore underestimate the risk of myocardial ischemia compared with the RCRI, which has been validated by multiple studies over the past 15 years including a very large 2010 systematic review (24 studies and 792,740 patients) which found moderate discrimination in predicting major perioperative cardiac complications.

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Literature

1. Goldman L, Caldera DL, Nussbaum SR, Southwick FS, Krogstad D, Murray B, Burke DS, O’Malley TA, Goroll AH, Caplan CH, Nolan J, Carabello B, Slater EE. Multifactorial index of cardiac risk in noncardiac surgical procedures. N Engl J Med. 1977 Oct 20;297(16):845-50. https://pubmed.ncbi.nlm.nih.gov/904659/
2. Lee TH, Marcantonio ER, Mangione CM, Thomas EJ, Polanczyk CA, Cook EF, Sugarbaker DJ, Donaldson MC, Poss R, Ho KK, Ludwig LE, Pedan A, Goldman L. Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery. Circulation. 1999 Sep 7;100(10):1043-9. https://pubmed.ncbi.nlm.nih.gov/10477528/
3. VISION Pilot Study investigators, Devereaux PJ, Bradley D, Chan MT, et al. An international prospective cohort study evaluating major vascular complications among patients undergoing noncardiac surgery: the VISION Pilot Study. Open Med. 2011;5(4):e193-200. https://pubmed.ncbi.nlm.nih.gov/22567075/
4. Ausset S, Auroy Y, Lambert E, et al. Cardiac troponin I release after hip surgery correlates with poor long-term cardiac outcome. Eur J Anaesthesiol. 2008;25(2):158-64. https://pubmed.ncbi.nlm.nih.gov/17666156/
5. Sheth T, Chan M, Butler C, et al. Prognostic capabilities of coronary computed tomographic angiography before non-cardiac surgery: prospective cohort study. BMJ. 2015;350:h1907. https://pubmed.ncbi.nlm.nih.gov/25902738/
6. Ford MK, Beattie WS, Wijeysundera DN. Systematic review: prediction of perioperative cardiac complications and mortality by the revised cardiac risk index. Ann Intern Med. 2010;152(1):26-35. http://www.ncbi.nlm.nih.gov/pubmed/20048269
7. Fleisher LA, Beckman JA, Brown KA, et al. ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery) Developed in Collaboration With the American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, and Society for Vascular Surgery. J Am Coll Cardiol. 2007;50(17):1707-32. https://pubmed.ncbi.nlm.nih.gov/17950159/
8. Duceppe E, Parlow J, Macdonald P, et al. Canadian Cardiovascular Society Guidelines on Perioperative Cardiac Risk Assessment and Management for Patients Who Undergo Noncardiac Surgery. Can J Cardiol. 2017;33(1):17-32. https://pubmed.ncbi.nlm.nih.gov/27865641/
9. Fleisher LA, Fleischmann KE, Auerbach AD, et al. 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;130(24):2215-2245. https://pubmed.ncbi.nlm.nih.gov/25085962/
10. Rajagopalan S, Croal BL, Bachoo P, Hillis GS, Cuthbertson BH, Brittenden J. N-terminal pro B-type natriuretic peptide is an independent predictor of postoperative myocardial injury in patients undergoing major vascular surgery. J Vasc Surg. 2008;48(4):912-7. https://pubmed.ncbi.nlm.nih.gov/18586440/
11. Rodseth RN, Biccard BM, Le manach Y, et al. The prognostic value of pre-operative and post-operative B-type natriuretic peptides in patients undergoing noncardiac surgery: B-type natriuretic peptide and N-terminal fragment of pro-B-type natriuretic peptide: a systematic review and individual patient data meta-analysis. J Am Coll Cardiol. 2014;63(2):170-80. https://pubmed.ncbi.nlm.nih.gov/24076282/
12. Devereaux PJ, Duceppe E, Guyatt G, et al. Dabigatran in patients with myocardial injury after non-cardiac surgery (MANAGE): an international, randomised, placebo-controlled trial. Lancet. 2018;391(10137):2325-2334. https://pubmed.ncbi.nlm.nih.gov/29900874/

Baseline Cardiovascular Risk Assessment in Cancer Patients Scheduled to Receive Cardiotoxic Cancer Therapies (Anthracycline Chemotherapy) – Online Calculator

July 3, 2023

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National Institutes of Health Stroke Scale (NIHSS) – Online calculator

June 22, 2023

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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

---

Age *

<50 years

50–59 years

60–69 years

70–79 years

≥80 years

Myocardial infarction *

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

No

Yes

Congestive heart failure *

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

No

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)

No

Yes

Cerebrovascular accident or Transient ischemic attack *

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

No

Yes

Dementia *

Chronic cognitive deficit

No

Yes

Chronic obstructive pulmonary disease *

No

Yes

Connective tissue disease *

No

Yes

Peptic ulcer disease *

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

No

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 *

No

Yes

Moderate to severe chronic kidney disease *

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

No

Yes

Solid tumor *

None

Localized

Metastatic

Leukemia *

No

Yes

Lymphoma *

No

Yes

AIDS *

No

Yes

---

Charlson Comorbidity Index

10-year survival

VariablePointsAge <50…

Read More

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…

Read More

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

January 17, 2023

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Multiple Myeloma International Staging System (ISS) Online Calculator

January 16, 2023

Multiple Myeloma International Staging System (ISS) prognosticates the severity of multiple myeloma based on routinely…

Read More

Сообщение Revised Cardiac Risk Index for Pre-Operative Risk (RCRI) Online Calculator появились сначала на ClinCaseQuest.

The Physiological and Operating Severity Scale for Mortality and Morbidity (POSSUM) estimates morbidity and mortality in general surgery.

It can be used for both emergency and planned surgery. The POSSUM should be calculated when the decision to operate is made. The percentages can be shared with the patient when discussing the risks of the operation.

To score on the POSSUM scale is an addition of selected points.

Physiological score and operation severity score are weighted differently.

Severity of surgeries:

• Moderate: appendectomy, cholecystectomy, mastectomy, TURP
• Major: laparotomy, bowel resection, cholecystectomy w choledochotomy, peripheral vascular procedure or major amputation
• Major+: aortic procedure, abdominoperineal resection, pancreatic or liver resection, esophagogastrectomy

The POSSUM morbidity and mortality formulas are shown below:

• Morbidity ln[R/(1-R)] = – 5,91 + (0,16 x Physiological score) + (0,19 x operation severity score) (P<0,001).
• Mortality  ln [R/(1 –R)] = -7,04+ (0,13 x Physiological score) + (0,16 x operation severity score) (P <0,001).

Predicied versus observed rates for mortality and morbidity*

Morbidity was defined as any of the following:

• Wound haemorrhage: local haematoma requiring evacuation
• Deep haemorrhage: postoperative bleeding requiring re-exploration
• Chest infection: production of purulent sputum with positive

bacteriological cultures, with or without chest radiography changes or pyrexia, or consolidation seen on chest radiograph

• Woundinfection: wound cellulitis or the discharge ofpurulent exudate
• Urinary infection: the presence of z lo5 bacteria/ml with the presence of white cells in the urine, in previously clear urine
• Deep infection: the presence of an intra-abdominal collection confirmed clinically or radiologically.
• Septicaemia: positive blood culture
• Pyrexia of unknown origin: any temperature above 37°C for more than 24 h occurring after the original pyrexia following surgery (if present) had settled, for which no obvious cause could be found
• Wound dehiscence: superficial or deep wound breakdown
• Deep venous thrombosis and pulmonary embolus: when suspected, confirmed radiologically by venography or ventilation/perfusion scanning, or diagnosed at post mortem
• Cardiac failure: symptoms or signs of left ventricular or congestive cardiac failure which required an alteration from preoperative therapeutic measures
• Impaired renal function: arbitrarily defined as an increase in blood urea of > 5 mmol/l from preoperative levels
• Hypotension: a fall in systolic blood pressure below 90 mmHg for more than 2 h as determined by sphygmomanometry or arterial pressure transducer measurement
• “Any other complication”

The POSSUM was originally developed by Copeland and colleagues in 1991 to assess quality of care and provide a scoring system for surgical audit. Physiological and operative severity score data were obtained from 1,372 patients.

The original POSSUM was modified to the Portsmouth POSSUM, or P-POSSUM, in 1998 by Prytherch and colleagues, who derived a more accurate prediction for the mortality component.

Both the POSSUM and P-POSSUM slightly overestimate both morbidity and mortality.

Since the original publication of POSSUM, the score has been modified and validated for numerous subtypes of surgeries and clinical scenarios, including:

• Colorectal surgery
• Vascular surgery
• Oncologic gastric surgery
• Hepatectomy
• Emergency laparotomy
• Orthopedic surgery

The original POSSUM was modified by researchers in Portsmouth who derived a more accurate prediction of mortality, and the P-POSSUM model is now more commonly used to calculate the mortality component.

The POSSUM data set excludes trauma patients, so POSSUM should NOT be used to predict morbidity and mortality after trauma surgery.

The POSSUM should NOT dictate the decision to operate, which is a clinical decision.

Physiological score should be calculated at the time of surgery, not at the time of admission.

The definitions of surgical procedures are guidelines only. Not all procedures are listed, and the closest approximation should be selected.

The POSSUM may overestimate risk in hepatopancreaticobiliary surgery.

Similar / alternative tools:

• There are procedure-specific models for colorectal surgery (CR-POSSUM), vascular surgery (Vascular-POSSUM), and esophagogastric surgery (O-POSSUM, O for oesophagogastric).
• APACHE II is a similar assessment tool but is applied to intensive care patients and only assesses the risk of mortality.
• The Surgical Apgar Score (SAS) offers similar estimates for morbidity and mortality.
• The POSSUM is more comprehensive than the SAS (which is calculated based on 3 parameters), but the SAS is more objective.
• The SAS uses intraoperative parameters exclusively, whereas the POSSUM uses preoperative parameters.
• The ACS NSQIP risk calculator is a newer, similar assessment. It has not yet been as rigorously validated as the POSSUM.
• Other disease-specific scores may be used to assess risk, e.g. Revised Cardiac Risk Index for Pre-Operative Risk.

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Literature

1. Copeland GP, Jones D, Walters M. POSSUM: a scoring system for surgical audit. Br J Surg 1991;78(3):355-60. https://pubmed.ncbi.nlm.nih.gov/2021856/
2. Prytherch DR, Whiteley MS, Higgins B, Weaver PC, Prout WG, Powell SJ. POSSUM and Portsmouth POSSUM for predicting mortality. Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity. Br J Surg 1998 Sep;85(9):1217-20. https://pubmed.ncbi.nlm.nih.gov/9752863/
3. Ramkumar T, Ng V, Fowler L, Farouk R. A comparison of POSSUM, P-POSSUM and colorectal POSSUM for the prediction of postoperative mortality in patients undergoing colorectal resection. Dis Colon Rectum. 2006 Mar;49(3):330-5. https://pubmed.ncbi.nlm.nih.gov/16421662/
4. Tez M, Yoldaş O, Gocmen E, Külah B, Koc M. Evaluation of P-POSSUM and CR-POSSUM scores in patients with colorectal cancer undergoing resection. World J Surg. 2006 Dec;30(12):2266-9. https://pubmed.ncbi.nlm.nih.gov/17103102/
5. Lam CM, Fan ST, Yuen AW, Law WL, Poon K. Validation of POSSUM scoring systems for audit of major hepatectomy. Br J Surg. 2004 Apr;91(4):450-4. https://pubmed.ncbi.nlm.nih.gov/15048745/
6. Mohil RS, Bhatnagar D, Bahadur L, Rajneesh, Dev DK, Magan M. POSSUM and P-POSSUM for risk-adjusted audit of patients undergoing emergency laparotomy. Br J Surg. 2004 Apr;91(4):500-3. https://pubmed.ncbi.nlm.nih.gov/15048756/
7. van Zeeland ML, Genovesi IP, Mulder JW, Strating PR, Glas AS, Engel AF. POSSUM predicts hospital mortality and long-term survival in patients with hip fractures. J Trauma. 2011 Apr;70(4):E67-72. https://pubmed.ncbi.nlm.nih.gov/21613973/
8. Chen T, Wang H, Wang H, Song Y, Li X, Wang J. POSSUM and P-POSSUM as predictors of postoperative morbidity and mortality in patients undergoing hepato-biliary-pancreatic surgery: a meta-analysis. Ann Surg Oncol. 2013 Aug;20(8):2501-10. https://pubmed.ncbi.nlm.nih.gov/23435569/
9. Copeland GP. The POSSUM System of Surgical Audit. Arch Surg. 2002;137(1):15-19. doi:10.1001/archsurg.137.1.15. http://jamanetwork.com/journals/jamasurgery/fullarticle/212013

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Interactive OSCE Checklist – Emergency care of a patient with chest pain – Acute Coronary Syndrome with ST-segment elevation and equivalents

May 14, 2022

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Date

Student name

Group, faculty

---

• Opening the consultation

Wash your hands and don PPE if appropriate

Introduce yourself to the patient including your name and role

Confirm the patient's name and date of birth

Explain the reason for the consultation

Obtain consent for counseling and care

• Availability of a defibrillator

Provide the availability of a defibrillator

Start ECG monitoring

• Presenting complaint

Use open questioning to explore the patient’s presenting complaint

• History of presenting complaint

Site: ask where the pain is

Onset: clarify when the pain first started and if it came on suddenly or gradually

Character: ask the patient to describe how the pain feels

Radiation: ask if the pain moves anywhere else

Associated symptoms: ask if there are any other associated symptoms

Time course: ask how the pain has changed over time

Exacerbating or relieving factors: ask if anything makes the pain worse or better

Severity: ask how severe the pain is on a scale of 0-10

• Past medical history

Screen for conditions that may be associated with chest pain

Ask about other medical diagnoses and previous surgical history

Ask if the patient has any allergies and if so, clarify what kind of reaction they had to the substance

• Drug history

Ask the patient is currently taking any prescribed medications or over-the-counter remedies

Ask the patient if they’re experiencing any side effects from their medication

• Physical examination

Assessment of general condition and vital functions according to the ABCDE algorithm

Visual assessment of the color of the skin, the presence of swelling of the cervical veins, and edema

Assessment of the state of the cardiovascular system

Assessment of the state of the respiratory system

Pulse oximetry to determine blood oxygen saturation (normal ≥ 95%)

Oxygen therapy (supporting saturation over 94-95%)

• Intravenous access

Intravenous access

Starting the infusion of Ringer's lactate solution

• Registration of a 12-channel ECG

Recording ECG

Assess the presence/absence of pathological ST-elevation according to formal STEMI criteria

Exclusion of other causes of benign ST-elevation in the presence of such ST-elevation – to exclude a possible non-coronary or acute coronary origin: early ventricular repolarization syndrome, left ventricular aneurysm, secondary ST-changes in LVH, recording artifacts, and others

Assessment of additional ECG patterns and conditions that may be caused by critical coronary artery occlusion (STEMI-equivalents) – in the absence of ST-elevation - make sure that there are no other signs of coronary artery occlusion (STEMI equivalents)

Identification of the localization of myocardial ischemia

Assess for the presence of right ventricular myocardial infarction

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

The timing of the increase in markers of myocardial damage

Analysis of other causes that may lead to increased markers of myocardial necrosis

• Making preliminary diagnosis

Criteria for ACS with ST-segment elevation (STEMI)

STEMI Equivalents

Localization

Killip score

• Drug therapy (basic)

Acetylsalicylic acid

Anticoagulant

Nitroglycerin

Beta-blocker

Administering solutions as needed

Pain relief

Midozalom administration for cocaine-induced STEMI

Concomitant therapy as needed

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

Primary PCI

Hospital thrombolysis followed by PCI

• Call the nearest reperfusion center

Activation of the intervention team of the reperfusion center

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

Choice of P2Y12 inhibitor for medical care

• Carrying out thrombolytic therapy as needed

Criteria for selecting patients for thrombolytic therapy

Evaluation of success criteria for fibrinolytic therapy

Choice of the drug for thrombolysis

Assessment of absolute contraindications for thrombolysis

Assessment of relative contraindications for thrombolysis

• Transportation to the nearest reperfusion center

Analysis of delays in the medical care of a patient with acute coronary syndrome

Monitoring of vital signs during the transfer

Pain management as needed

Reporting in the emergency department of the hospital during the patient's hospitalization

Total

Result:

Total: 0 / 62

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Сообщение POSSUM for Operative Morbidity and Mortality Risk – Online Calculator появились сначала на ClinCaseQuest.