Clinical Decision Rules to Know / Memorize

Question 1

PECARN CT Head

Answer 1

Age < 2
- GCS <=14, altered mental status or altered mental status
- LOC > 5 seconds
- Occipital, parietal or temporal hematoma or palpable skull fracture (age <2)

• Not acting “normally” (age < 2)
• Vomiting or severe headache (age > 2)
• Severe mechanism (MVC with ejection, death of another passenger, rollover, pedestrian / bike hit by car, fall from > 3 ft or high- impact by object

Age > 2:
- Any LOC in > 2
- Signs of basilar skull fracture (age > 2)
If GCS 15 and no signs of skull fracture and other feature +, can observe vs image in a joint decision making

Question 2

Canadian CT Head

Answer 2

Only applies to GCS 13-15 with LOC, amnesia of event or witnessed disorientation.
Age > 16
No blood thinners
Seizure after event

High Risk Features:
- Age > 65
- GCS < 15 at 2 hours post
- >2 episode vomit
- Any signs of basal skull fracture
- Open or depressed skull fracture

Medium Risk:
- Retrograde amnesia for 30 minutes
- Dangerous mechanism

Question 3

SAH Rule

Answer 3

Inclusion:
- Age > 15, new severe atraumatic headache, max intensity within 1 hr
Exclusion:
- Focal neuro deficit, prior aneurysm, prior SAH, known tumors, chronic headaches (3 or more in last 6 months that are similar)

Rule out criteria - NONE of:
1) Age > 40
2) Neck pain or stiffness
3) Witnessed LOC
4) Onset with exertion
5) Thunderclap (peak at onset)
6) Limited neck flexion on exam.

Question 4

Well’s DVT

Answer 4

Stasis:
- Paralysis Paresis or
- Plaster immobilization
- Bedridden or Sx in last 12 weeks

Thrombophilia:
- Active cancer
- Previous DVT

Physical Signs of Obstruction:
- Calf swelling > 3 cm
- Entire leg swollen
- Local tenderness on deep venous system
- Pitting edema on symptomatic leg only

Alternative Dx as likely (-2)

If score 0 or less: D-Dimer.
If 1-2, D-dimer
If 3 or higher: Need US. (D-dimer for risk-stratification only)

Question 5

Wells PE

Answer 5

Signs of DVT
PE #1 Diagnosis
HR > 100
Hemoptysis
Active cancer
Recent Sx or immobilization
Previous DVT or PE

Actions:
If < 4 then D-Dimer < 500 to r/o
If > 4 moderate - CT-PE

Question 6

PERC

Answer 6

If Any Present, Cannot Rule Out PE

Age > 50

HR >100
O2 sat < 95%
Hemoptysis
DVT signs

OCP / Hormone Use
Prior DVT /PE
Recent sx or trauma

Question 7

YEARS PE

Answer 7

PE most likely dx
Signs of DVT
Hemoptysis

If none, D-Dimer < 1000 rule out.

If any positive in NON-Pregnant: D-Dimer < 500 rule out

If pregnant: As above, but complete compression US and anticoagulate if abnormal.
CTPA if N doppler and D-Dimer > 500

Question 8

HEART

Answer 8

Inclusion: > 21 years old with symptoms suggestive of ACS.

History
ECG (N, non-specific repolarization i.e. LBBB, LVH, ST depression
Age <45, 45-64, >65
Risk Factors (DM, CAD, DLD, BMI > 30, Smoker, FMHx with CAD < 65 yrs, prior MI, PCI or CABG)
Troponin (Normal, 1-3x normal, 3 x Normal)

0,1,2 points for each category

<3 points low risk, DC at 3 hours if repeat trop negative
>3 high risk, consult to cardio

Question 9

PARC (peds appendicitis)

Answer 9

Age > 5 with pain < 96 hours
-Setting (community vs peds ED)
-Sex
- Duration (< 24, 24-48, 48-96)
- WBC
- Neutrophils
- Pain with walking
- Max tender in RLQ
- Abdo guarding
- History of migration to RLQ

Question 10

SIRS Criteria

Answer 10

2 or more of:

Temp <36 or >38
HR > 90
RR 22 or PaCO2 < 32
WBC <4 or > 12 or 10% bands

Question 11

Ottawa Ankle

Answer 11

Age > 2
Rule out if:
- Able to ambulate after injury or in the ED
OR
- No pain at:
Posterior 6 cm of med/lat malleoulus
Navicular
Base of 5th

Question 12

Ottawa Knee

Answer 12

Image if:
Age >55
Isolated patellar tenderness
Tenderness at fibular head
Unable to flex to 90 deg
Unable to weight bear immediately and in ED.

Question 13

CURB-65

Answer 13

Confusion
Urea > 7
RR > 30
sBP < 090 or diastolic < 60
Age >65

Question 14

NEXUS (can use in pediatric C-Spine)

Answer 14

Focal Neuro Deficit
Midline spinal tenderness
Altered LOC
Intoxicated
Distracting Injuries present

Question 15

Canadian C-Spine

Answer 15

Exclusion if:
GCS <15, < 16 yrs, unstable, non-trauma, acute paralysis, known vertebral disease, previous C-Spine Sx.

High Risk:
- Greater 65
- High energy mechanism 9> 3ft, axial load, MVC, ATV, bicycle
- Extremity parasthesia

Low Risk:
- Seated in ED
- Ambulatory at any time
- Delay onset neck pain
- No midline tenderness
- Simple rear-end

If able to actively rotate 45 degrees can remove collar.