Decision Rules Flashcards
HEART Score
History Slightly suspicious0 Moderately suspicious+1 Highly suspicious+2 EKG 0 points normal 1 point: No ST deviation but LBBB, LVH, repolarization changes (e.g. digoxin); 2 points: ST deviation not due to LBBB, LVH, or digoxin Age <45. 0 45-64. +1 ≥65. +2 Risk factors: HTN, hypercholesterolemia, DM, obesity (BMI >30 kg/m²), smoking (current, or smoking cessation ≤3 mo), positive family history (parent or sibling with CVD before age 65); atherosclerotic disease: prior MI, PCI/CABG, CVA/TIA, or peripheral arterial disease No known risk factors0 1-2 risk factors+1 ≥3 risk factors or history of atherosclerotic disease+2 Initial troponin ≤normal limit0 1–3× normal limit+1 >3× normal limit+2 Scores 0-3: 0.9-1.7% risk of adverse cardiac event. In the HEART Score study, these patients were discharged (0.99% in the retrospective study, 1.7% in the prospective study) Scores 4-6: 12-16.6% risk of adverse cardiac event. In the HEART Score study, these patients were admitted to the hospital. (11.6% retrospective, 16.6% prospective) Scores ≥7: 50-65% risk of adverse cardiac event. In the HEART Score study, these patients were candidates for early invasive measures. (65.2% retrospective, 50.1% prospective) A MACE (Major Adverse Cardiac Event) was defined as all-cause mortality, myocardial infarction, or coronary revascularization.
PECARN
PECARN criteria •Paediatric Emergency Care Applied Research Network •the only prospectively validated paediatric head injury decision rule •patients with none of the following criteria do not require a head CT •patients with one criteria may require a head CT, however clinical judgement should be applied -usually a more prolonged period of observation is required, rather than an immediate CT Exclusions •GCS <14 •trivial mechanism -e.g. ground level fall -walking or running into stationary object -no features of head trauma except scalp abrasions and lacerations •penetrating trauma •known brain tumour •pre-existing neurological disorder complicating assessment •presence of a ventricular shunt •presence of a bleeding disorder Children 2 -18 years of age Criteria •abnormal mental status -agitation -somnolence -repetitive questioning -slow response to verbal communication •any or suspected loss of consciousness •vomiting •severe headache •severe injury mechanism -motor vehicle collision with patient ejection, death of another passenger, or rollover -pedestrian or bicyclist without helmet struck by motor vehicle -fall > 1.5m (5 feet) for children aged 2 years or older -head struck with a high-impact object -the least useful of the criteria and can probably be omitted from the decision rule -0.6% of those aged 2 years or older have clinically important brain injury when present as an isolated criteria •signs of basilar skull fracture Results •97-99% sensitive •45-60% specific for clinically important brain injury, the composite end point of -death from traumatic brain injury -neurosurgery -intubation > 24 hours -hospital admission > 2 nights Children < 2 years of age Criteria •abnormal mental status -GCS <14 -agitation -somnolence -repetitive questioning -slow response to verbal communication -not acting normally according to parent •severe injury mechanism -motor vehicle collision with patient ejection, death of another passenger, or rollover -pedestrian or bicyclist without helmet struck by motor vehicle -fall > 0.9m (3 feet) for children < 2 years of age -head struck with a high-impact object -0.3% of those aged < 2 years have clinically important brain injury when present as an isolated criteria •palpable or unclear skull fracture •occipital, parietal or temporal scalp haematoma Results •sensitivity of 98.6-100% for clinically important brain injury •specificity of 53.7%
ALVARADO Score
M - Migration of pain
A - anorexia
N - nausea/vomiting
T - tenderness RIF (2)
R - rebound tenderness
E - elevated WCC
L - leukocytosis (2)
S - shift of white blood cells to the left
Score >/= 9 in males and 10 in females = 100% sensitive
SADPERSONS
S: Male sex → 1
A: Age 15-25 or 59+ years → 1
D: Depression or hopelessness → 2
P: Previous suicidal attempts or psychiatric care → 1
E: Excessive ethanol or drug use → 1
R: Rational thinking loss (psychotic or organic illness) → 2
S: Single, widowed or divorced → 1
O: Organized or serious attempt → 2
N: No social support → 1
S: Stated future intent (determined to repeat or ambivalent) → 2
RANSON Criteria
At admission:
Age in years > 55 years
WBC count > 16000 cells/mm3
Blood glucose > 11.11 mmol/L (> 200 mg/dL)
Serum AST > 250 IU/L
Serum LDH > 350 IU/L
Within 48 hours:
Serum calcium < 2.0 mmol/L (< 8.0 mg/dL)
Hematocrit fall > 10%
Oxygen (hypoxemia PaO2 < 60 mmHg)
BUN increased by 1.8 or more mmol/L (5 or more mg/dL) after IV fluid hydration
Base deficit (negative base excess) > 4 mEq/L
Sequestration of fluids > 6 L
Interpretation
If the score ≥ 3, severe pancreatitis likely.
If the score < 3, severe pancreatitis is unlikely
Or
Score 0 to 2 : 2% mortality
Score 3 to 4 : 15% mortality
Score 5 to 6 : 40% mortality
Score 7 to 8 : 100% mortality
Revised Trauma Score (RTS)
Glasgow Coma Scale (GCS)score
4: 13-15
3: 9-12
2: 6-8
1: 4-5
0: 3
systolic blood pressurescore
4: >90
3: 76-89
2: 50-75
1: 1-49
0: 0
respiratory ratescore
4: 10-29
3: >30
2: 6-9
1: 1-5
0: 0
Calculation
Glasgow coma scale score + systolic blood pressure score + respiratory rate score
Interpretation
lower score indicates higher severity
RTS <4 proposed for transfer to trauma center
Pros
useful during triage to determine which patients need to be transported to a trauma center
Cons
can underestimate injury severity in patients injured in one system
