Gen - Scoring Systems

Question 1

Revised Cardiac Risk Index (Lee) and Original Cardiac Risk Index (Goldman)

Answer 1

RCRI (Lee 1999)- 6 factors - IHD, CCF, CVD, IDDM, CKD, high risk surgery (suprainguinal vascular, intraperitoneal or thoracic) - Risk of cardiac death, non-fatal MI and non-fatal cardiac arrest = 0.4% (0 risk factors), 0.9% (1), 6.6% (2), 11% (3 or more) - Does not cover all cause mortality or complications beyond inpatient stay; underestimates risk in vascular surgery OCRI (Goldman 1977) - RFs: S3 (11), elevated JVP (11), MI last 6/12 (10), ECG atrial ectopics or not SR (7), ECG >5 ventricular ectopics/min (7), age >70 (5), emergency procedure (4), intrathoracic/intra-abdo/aortic surgery (3), poor general status/metabolic/bedridden (3) - Score <6 = 0.2% mortality, 1% morbidity- 6-12 = 7% morbidity - 13-35 = 14% morbidity - >26 = 78% morbidity, 56% mortality Other (more cumbersome but ?more accurate) risk calculators include: - Gupta MICA NSQIP (MI/Cardiac Arrest) - ACS-NSQIP (American College of Surgeons National Surgical Quality Improvement Program)

Question 2

Acute Physiology, Age and Chronic Health Evaluation (APACHE)

Answer 2

APACHE I-IV, but II most widely used Score 0-71 on 12 variables (APACHE 4 has 129 variables!) Score >25 is roughly 35% or 55% mortality (operative vs non-operative) Basis: 3 factors influence outcome in critically ill patients: chronic background disease, patient reserve, severity of acute illness Based on the most abnormal measurements in the first 24 hours of ICU stay Describes case mix, workload Discriminates between survivors and non-survivors and can predict LoS Significant burden of data entry Problems: lead-time bias (patients referred to tertiary centre have their mortality underestimated) Acute variables (A) Clinical (5): HR, RR, MAP, temperature, GCSLab (7): HCt, WBC, Na+, K+, creatinine, arterial pH, PaO2

Chronic variables (B) Cirrhosis, heart failure, ESRF, chronic resp disease, immunocompromise 

Age (C) Then A + B + C gives final score out of 71

Question 3

POSSUM

Answer 3

Physiology and Operative Severity Score for enUmeration of Mortality 12 acute physiological parameters (surgery and severity of surgery)Meant to predict death but was found to over predict P-POSSUM – Portsmouth: predicts hospital mortality more accuratelyV-POSSUM – vascular surgeryCr-POSSUM – colon cancer resection

Question 4

Richmond Agitation-Sedation Scale (RASS)

Answer 4

+4 to -5 +4 combative +3 very agitated +2 agitated +1 restless0 alert and calm -1 drowsy (eyes closed; on name calling/command, sustained eye opening and eye contact >10s) -2 light sedation (eye opening and eye contact but not sustained) -3 moderate sedation (any response to voice but no eye contact) -4 deep sedation (any movement to stimulation) -5 unrousable (no response) Alternatives = Ramsey Sedation Scale (1-6), Riker Sedation Agitation Scale (1-7) and Motor Activity Assessment Scale (0-6).

Question 5

Atrial fibrillation (CHA2DS2VASc and HAS-BLED)

Answer 5

CHA2DS2VASc CCF, HTN, age>75, DM, stroke, vascular disease, age>65, sex category (female) 1 = 1.3% risk, 9 = 15.2% risk 0 or 1 = low risk; aspirin no longer recommended 2+ = warfarin/NOAC

HAS-BLEDHTN (SBP>160) Abnormal renal/liver function Stroke Bleeding Labile INR ElderlyDrugs/alcohol

3 or more = high risk, caution and regular review

Question 6

Liver scores (Child-Pugh, MELD, Maddrey’s discriminant function, CLIF-SOFA, ISHEN)

Answer 6

Child-Pugh: albumin, bilirubin, INR, ascites, encephalopathy each scored 1-3 (score 5-15). Class A: 5-6 (100% 1y survival), B: 7-9 (80%), C: 10-15 (45%). Model for End-Stage Liver Disease (MELD): bilirubin, INR, creatinine, Na+ (latter added 2016). Range 1-40, natural logarithmic. Suitability for TIPSS/transplant (need MELD >15 to list). PELD in children. UKELD in UK. Maddrey: PT, bilirubin. Score > 32 in alcoholic hepatitis suggests poor prognosis and possible benefit from steroids. Bilirubin + 4.6 x (PT - control PT) CLIF-SOFA: for AoC liver failure - general ICU survival prognostication. ISHEN: International Society for Hepatic Encephalopathy and Nitrogen metabolism classification of hepatic encephalopathyType A - Acute liver failure Type B - Bypass (porto-systemic) Type C - Cirrhosis ALF scores: O’Grady, Brennan, Japanese systems. All based on time from jaundice to encephalopathy.

Question 7

PONV (Apfel)

Answer 7

• Female (strongest RF) * Non-smoker* Previous PONV and/or motion sickness * Opiates postop

  PONV risk:0 factors: 10% 1: 20% 2: 40% 3: 60% 4: 80% 

  Overall PONV incidence = 30%. Any single antiemetic reduces PONV risk by 25% (RRR). Propofol TIVA reduces it by 30%. Rescue tx should be of a different class; a second dose of ondansetron is same as giving placebo. Metoclopramide 10mg does nothing - need 25-50mg. New antiemetics: neurokinin-1 antagonists (aprepitant) - reduces PONV by 80% but expensive. POVOC score for children (surgery duration ≥30 min, age ≥3, strabismus surgery, hx/Fhx PONV - 9%, 10%, 30%, 55%, 70%).

Question 8

Obstructive Sleep Apnoea (STOP-BANG and Epworth)

Answer 8

Snoring (loud) Tired in daytime (has to be present to call it 'OSA syndrome' and justify NIV) Observed apnoea Pressure (HTN) BMI >35 Age >50 Neck circumference >16" F / >17" cm MGender (male)

0-2 low risk3-4 intermediate 5+ high risk Other RFs not included: alcohol, smoking, pregnancy, low exercise, surgical patient, unemployed, craniofacial syndromes, neuromuscular disease. Prevalence 5-10% adults, 2:1 M.

Epworth Sleepiness Scale8 situations are rated on chance of falling asleep/dozing during them (0-3). Up to 10 normal 11-14 mild 15-18 moderate 19+ severe daytime sleepiness

NB: other types of sleep apnoea: central and mixed (i.e. central and obstructive). Investigations - Home overnight oximetry and oxygen desaturation index (ODI >5/15/30 correlates with AHIs of the same values) - Polysomnography

Question 9

Structured modified Brice interview for awareness

Answer 9

1. What was the last thing you remembered before you went to sleep?2. What was the first thing you remembered after your operation?3. Can you remember anything in between?4. Can you remember if you had any dreams during your operation?5. What was the worst thing about your operation?Asked postop, at 24h and 30d later.

Question 10

MUST (Malnutrition Universal Screening Tool) - BAPEN

Answer 10

Three factors scored 0-2- BMI: >20 (0), 20-18.5 (1), <18.5 (2) - Unintentional weight loss in last 3-6/12: <5% (0), 5-10% (1), >10% (2)- If acutely ill AND no nutrition (or likely not to have) for >5 days = 2 Total score: 0 - low risk, routine care 1 - medium risk, monitor diet 2+ - high risk, refer to dietician, monitor diet

Question 11

Difficult airway (Modified Mallampati)

Answer 11

Class I: Soft palate, uvula, fauces, pillars Class II: Soft palate, uvula, fauces Class III: Soft palate, base of uvula Class IV: Only hard palate Class III/IV predicts difficult intubation but only 5% prove to be so.

Question 12

Laryngoscopy (Cormack and Lehane)

Answer 12

Grade 1: Full view of glottisGrade 2a: Partial view of glottisGrade 2b: Only posterior extremity of glottis seen or only arytenoid cartilagesGrade 3: Only epiglottis seen Grade 4: Neither glottis nor epiglottis seenGrade 2b+ predicts difficult intubation.

Question 13

Perioperative nerve injuries (Seddon, Sunderland)

Answer 13

Seddon Class 1 - neuropraxia (temporary, physiological) Class 2 - axonotmesis (relative loss of continuity, can regenerate) Class 3 - neurotmesis (total severance, surgery required) Sunderland is similar but with 5 classes (class 3 is split into three)

Question 14

Hypersensitivity reactions (Gell and Coombs)

Answer 14

Type 1 (immediate): IgE-mediated mast cell degranulation e.g. anaphylaxis, allergic asthma Type 2 (cytotoxic): IgG/M antibodies e.g. haemolytic anaemia, HIT, Graves, MG Type 3 (immune complex): complex deposition in vessels e.g. RA, SLE Type 4 (delayed): T cell mediated e.g. contact dermatitis

Question 15

Adverse drug reactions

Answer 15

Type A: 90%. Predictable, dose-related, can happen to any pt. e.g. diarrhoea from abx, gastritis from NSAIDs. Type B: 10%. Dose-unrelated, unpredictable, idiosyncratic hypersensitivity reactions, occurring in susceptible pts. Subdivided into hypersensitivity reactions 1-4. (Also WHO classification: 6 groups)

Question 16

Serotonin syndrome (Hunter criteria)

Answer 16

Having taken a serotonergic agent and presenting with one of more of: Clonus AgitationDiaphoresis Tremor Hyperreflexia Hypertonia Pyrexia

Question 17

Duke Activity Status Index

Answer 17

1-4 METs: dressing, eating, walking on the flat 4: climbing one flight of stairs (18-21 steps; traditional marker of fitness for major surgery; equivalent to VO2 max 15ml/kg/min) 5-7: moderate function (two flights of stairs without stopping) 8-11: carrying shopping upstairs, cycling, jogging, swimming Golf - with buggy 2 METs, walking 4 METs! 1 MET = 3.5ml O2 consumption/kg/min (70kg, 40yo man at rest) Poor: <4 METs Moderate: 4-7 Excellent: >7

Question 18

Le Fort fractures

Answer 18

1 - horizontal 2 - pyramidal 3 - transverse

Question 19

Maastricht classification of DCD

Answer 19

1 - DOA2 - unsuccessful resuscitation 3 - anticipated cardiac arrest 4 - cardiac arrest in brain dead donor 5 - unexpected arrest in ICU patient

Only 3 and 4 are controlled modes. Uncontrolled modes can only be considered in transplant centres. Difference = decision for donation is made after rather than before death.

Question 20

Sedation (ASA)

Answer 20

• Minimal (anxiolysis; ABC maintained) * Moderate (conscious sedation; purposeful verbal contact maintained; ABC maintained)* Deep (rousable to pain; may require AB assistance, C maintained) * GA (unrousable; AB +/- C support required)

Question 21

Pulmonary hypertension (WHO)

Answer 21

MPAP>25mmHg at rest. Mod >35, >50 severe. Group 1 is PAH (arterial), others are PH (venous).

Group 1: pulmonary arterial HTN of any cause (e.g. inherited - BMPR2 mutation, CTDs, drugs, portal HTN, congenital heart disease)  Group 2: left heart diseaseGroup 3: chronic lung disease Group 4: thromboembolic disease Group 5: unclear/multifactorial e.g. SCD

Question 22

Cardiac disease in pregnancy (WHO)

Answer 22

1 - low risk, no increase in mortality, up to mild increase in morbidity e.g. repaired A/VSD, uncomplicated PDA 2 - 5-15% increased mortality e.g. unoperated A/VSD, repaired TOF/COA 3 - 25-50% increased mortality e.g. Fontan, mechanical valve. Relative CI for pregnancy, expert MDT involvement required. 4 - extremely high risk, pregnancy CI e.g. primary PHTN, Eisenmenger’s, LVEF<30%, NYHA 3/4, severe AS/MS

Question 23

Composite airway scoring systems (Wilson Sum Risk Score and Simplified Airway Risk Index)

Answer 23

Wilson Sum Risk Score - Weight, head and neck movement, jaw movement, receding mandible, buck teeth - Score 4 or more predicts 90% of difficult intubations SARI- MO, thyromental distance, MP, neck movement, underbite, body weight, intubation history - Score 4 or more = difficulty predicted

Question 24

Simplified Acute Physiology Score (SAPS)

Answer 24

Developed as simplification of APACHE I-III, III most commonly used 20 variables Worst values in first hour of ICU admission

Question 25

Sequential Organ Failure Assessment (SOFA) and qSOFA

Answer 25

Originally designed/validated in sepsis 6 organs and grades of organ function (score 0-4 for CVS, RS, neuro, renal, liver, haem) Single marker for each system: BP/inotropes, PFR, GCS, creat/UO, bili, plt. Daily and composite scores possible Tracks morbidity - use worst value of the day Used in trials to analyse secondary endpoints SOFA score which increases in first 48h is a/w higher risk of death SOFA 2 or greater = 10% mortality SOFA 2 or greater + lactate >2 + inotrope requirement to keep MAP>65 = 40% mortality

qSOFA (to identify early sepsis outside ICU setting) - RR >22 - SBP <100  - GCS <152 or more = poor prognosis

Question 26

Mortality Prediction Model (MPM)

Answer 26

I-II| Outcome prediction at 24, 48 and 72 hrs

Question 27

AAA scores (Hardman Index and Glasgow Aneurysm Score (GAS))

Answer 27

For ruptured AAA outcome prediction. 5 factors.Age>76, creat>190, Hb<9, ischaemic ECG, LOC after hospital arrival. Score of 2 or more = >80% mortality. GAS is an alternative, similar categories, can be used in both elective and emergency repair.

Question 28

European System for Cardiac Operative Risk Evaluation (EuroSCORE)

Answer 28

Euroscore 20 or higher = too high risk for AVR, consider TAVI

Question 29

CAM-ICU (Confusion Assessment Method for ICU)

Answer 29

(RASS to be -3 or above) 1. Acute change or fluctuating course2. Inattention (SAVE A HAART) - >2 errors 3. RASS anything other than 0 4. Disorganised thinking (4 yes/no Qs and 1 command) - >1 error CAM-ICU positive if 1 + 2 and either 3 or 4 are present. Alternatives = 4AT or Intensive Care Delirium Screening Checklist (ICDSC).

Question 30

4AT

Answer 30

Acute onset or fluctuating course Attention (months backwards) AlertnessAMT4 (age, DOB, place, year) Score 4 or above significant (each item has several points)

Question 31

ABCD2 score for TIA

Answer 31

Age >60 (1) BP >140/90 (1) Clinical - unilateral weakness (2), speech difficulty alone (1) Duration - <10m (0), 10-60m (1), >1h (2) DM (1) 2-day stroke risk 0-3 - 1% 4-7 - 4% (admit) 8-13 - 8% (admit) Need CT brain, ECG, echo, carotid Dopplers, bloods inc glucose and lipids

Question 32

NYHA

Answer 32

1: asymptomatic on ordinary activity2: mild symptoms on ordinary activity 3: moderate symptoms but comfortable at rest 4: severe symptoms, symptomatic at rest By EF: normal 60-70, mild 40-50, moderate 30-40, severe <30

Question 33

King’s College Hospital liver transplant criteria

Answer 33

Paracetamol: - Arterial pH <7.3 24h post adm (or <7.25 if had NAC)Or all of: - Grade 3/4 encephalopathy - Creatinine >300 - INR >6.5 (PT>100s) Or: - Lac >3.5 at 4h or >3 at 12h

Non-paracetamol: - INR>6.5 (PT>100s) Or any three of: - INR>3.5 (PT>50s) - Age<10 or >40 - Non-hepatitis A/B aetiology - Bilirubin>300 - Jaundice to encephalopathy interval >7 days

(alternative = ALFED - acute liver failure early dynamic model for prognostication) Therefore, avoid correcting coagulopathy if pt not bleeding and needs to meet criteria to be listed for transplant.

CIs to emergency LTx Uncontrolled sepsis Severe cerebral oedemaRising vasopressor requirements Major psychiatric comorbidity

Question 34

Traumatic Brain Injury

Answer 34

Minor: GCS 13-15; mortality 0.1%Moderate: GCS 9-12; mortality 10%Severe: GCS <9; mortality 40% Poor prognostic factors: lower GCS, age >45, comorbidities, other injuries, duration that ICP>20, mx in non-neuro centre

Question 35

Encephalopathy (West Haven and World Health Congress of Gastroenterology)

Answer 35

West Haven 0 - subclinical 1 - mild impairment (sleep disturbance, reduced attention, mild confusion) 2 - moderate impairment (lethargy, disorientation, personality change, ataxia) 3 - severe impairment (somnolence or agitation, nystagmus, clonus, upgoing plantars, dysarthria) 4 - coma, with or without response to painful stimuli, decorticate or decerebrate posturing ISHEN- Type A (acute) - acute liver failure, typically with cerebral oedema - Type B (bypass) - caused by porto-systemic shunting without intrinsic liver disease - Type C (cirrhosis) - in patients with cirrhosis; subdivided into episodic, persistent and minimal encephalopathy

Question 36

Cardiomyopathy

Answer 36

Primary - intrinsic - Genetic e.g. HCM (aut dom, variable penetrance and variable expressivity) - Acquired e.g. PPCM Secondary - extrinsic (primary pathology outside the myocardium) e.g. ischaemic (CAD), metabolic (amyloidosis), neuromuscular (MD), toxicity (doxorubicin)

Question 37

American Spinal Injury Association (ASIA) impairment scale for spinal injury

Answer 37

A: completeB: incomplete - sensory function preserved C: incomplete - motor function partially preserved (MRC <3) D: incomplete - motor function partially preserved (MRC >3) E: normalMRC grades 1-5 Specific cord syndromes: anterior cord, posterior cord, central cord, Brown-Sequard, conus medullaris, cauda equina

Question 38

Bone Cement Implantation Syndrome

Answer 38

Grade 1: SpO2 <94% or BP drop >20% Grade 2: SpO2 <88% or BP drop >40% or LOC Grade 3: CV collapse requiring CPR

Major RFsASA 3/4COPDDiuretics Warfarin

Question 39

Clinical Pulmonary Infection Score (CPIS) for VAP

Answer 39

5 factors:- Temperature - Secretions- PFR- WBC- CXR Each max score 2. Total score 6 or more suggests VAP but poorly sensitive and specific. Other VAP scores: CDC, HELICS VAP organisms: Gram negs = PHAKE (Pseudomonas, Haemophilus, Acinetobacter, Klebsiella, Enterobacter); also sometimes Gram pos (staph/strep).

Question 40

Evan’s score/PRST (awareness)

Answer 40

P - pressure (SBP)R - rate (HR) S - sweating T - tears Each scored 0-2 so total is 0-8. Non-specific, very variable between pts, inadequate alone.

Question 41

Berlin criteria (ARDS)

Answer 41

Timing - within 1/52 of known insult Imaging - bilateral opacities not fully explained by effusions/collapse Not fully explained by cardiac failure/fluid overload Mild: PFR 39.9 down to 26.6kPa (27% mortality) Moderate: 26.6 down to 13.3kPa (32% mortality) Severe: <13.3kPa (45% mortality) All with PEEP at least 5 cmH2O Higher mortality if a/w sepsis, alcohol abuse or advanced age. Lower with trauma.

Question 42

LSCS categories

Answer 42

Cat 1 - immediate threat to life of woman or fetus; decision to delivery interval (DDI) <30mCat 2 - maternal or fetal compromise but not immediately life threatening; DDI <75mCat 3 - no compromise but for early deliveryCat 4 - elective, at time to suit woman and unit

Question 43

Types of myocardial infarction

Answer 43

1. Spontaneous atherosclerotic plaque rupture2. Supply/demand mismatch 3. Sudden cardiac death 4. PCI-related 5 CABG-related

Question 44

KDIGO (Kidney Disease: Improving Global Outcomes) [Basically a combination of previous RIFLE and AKIN criteria]

Answer 44

Stage 1: creat 1.5-1.9x baseline, UO <0.5ml/kg/h for 6-12h Stage 2: creat 2-2.9x baseline, UO <0.5ml/kg/h for >12hStage 3: creat 3x baseline, UO <0.3ml/kg/h for >24h or anuria >12h or RRT Note that once the creat starts to rise, at least 50% of renal function is already lost. CKD stage 1-5 is based on GFR. UOP is the most sensitive indicator of successful weaning from CRRT (>400ml/24h unaided by diuretics). Restarting filter = poorer outcomes.

Question 45

Fitness for thoracic surgery

Answer 45

FEV1>2 for pneumonectomy FEV1>1.5 for lobectomy If not –> V/Q ppo FEV1 > 40% okIf not –> CPET VO2 max >15 and AT >11 desirable, below this is high risk/consider non-operative options

Question 46

CAGE questionnaire

Answer 46

Cut down Angry Guilty Eye opener(2 or more significant)

Question 47

COPD

Answer 47

FEV1:FVC <0.7 Reversibility <12%

FEV1 >80 - mild 50-80 moderate 30-50 severe<30 very severe (NICE/GOLD criteria)

Question 48

BMI

Answer 48

<18.5 underweight 18.5-25 normal 25-30 overweight 30-35 obese35-55 morbidly obese>55 supermorbidly obese

Question 49

SAH scoring systems

Answer 49

WFNS1- GCS 15, no motor deficit 2 - GCS 13/14, no motor deficit3 - GCS 13/14 with motor deficit 4 - GCS 7-12 with or without motor deficit 5 - GCS 3-6 with or without motor deficit

Fisher 1 - no blood2 - diffuse, no clot +/or layer <1mm3 - localised clot +/or layer >1mm 4 - intracerebral or intraventricular clots

Other = Hunt and Hess (clinical features).

Question 50

Revised Baux score (burns)

Answer 50

Age + % TBSA (+17 if inhalational injury) >140 considered unsurvivable (Original did not include inhalational injury component. A P-Baux score exists for paediatrics.)

Question 51

Burn severity

Answer 51

Superficial - erythema, pain Partial thickness (superficial or deep) - erythema, pain, blistering Full thickness - charring, white, painless

Question 52

Burns unit referral criteria

Answer 52

BSA>10% adults, >5% children (2/3rd degree) NAI (children or adults) Associated traumatic injuries Pregnancy Special areas - hands, feet, perineumInhalational injury Chemical or electrical burns

Question 53

Hypovolaemic shock

Answer 53

I: up to 750ml/15% blood volume; all parameters normal II: 750ml-1.5L/15-30%; HR/DBP/RR/cap refill start to rise III: 1.5-2L/30-40%; BP starts to drop, GCS affected IV: >2L/>40%; BP falls, HR very high, drowsy Fluid challenge: responders, non-responders, partial responders.

Question 54

Weaning indices

Answer 54

VC >10-15ml/kg VT >5ml/kg MIP > -30 PFR>300 RSBI (RR/VT) <80 predicts success, >105 failure P.01 (normal = 1.5cmH2O)

(Also CROP, IEQ, WI, IWI) Weaning is simple in 70%, difficult (up to 3 attempts) or prolonged.

Question 55

Apgar

Answer 55

Appearance (colour) Pulse Grimace Activity Respiration

Each scored 0-2 Done at 1 and 5 mins post birth 7 or more is normal

Question 56

WHO performance status

Answer 56

0: normal, unrestricted 1: strenuous activity restricted 2: able to self-care but not work, in bed <50% waking hours 3: limited self-care, in bed >50% waking hours 4: disabled, bed/chairbound 5: dead

Question 57

GI bleed (Rockall, Glasgow-Blatchford)

Answer 57

Glasgow-Blatchford - Hb, urea - HR, BP- Syncope, malaena - Cardiac failure, liver diseaseScore 6+ = 50% risk of needing intervention Score 0 = could manage as outpt Mainly for use in ED to plan timing of endoscopy; not validated in ICU population

Rockall - Pre-scope (out of 7): age, comorbidity, shock - Post-scope (out of 11): the above + diagnosis, scope evidence of recent bleed Score <3 good, >8 bad outcome

Question 58

Early warning scores- NEWS- PEWS- MEOWS

Answer 58

Aggregated parameter track and trigger systems. Degree of physiological derangement is weighted and reflected in the score. Parameters: RR, SpO2, HR, BP, temperature, AVPU Identifies pts at risk of deterioration, so that medical teams can identify problem and treat accordingly 1-4 low - RN review 5-6 medium (or any one RED score) - doctor/NP review 7+ high - critical care review NEWS is a good predictor of unplanned ICU admission.

Question 59

Pancreatitis- Severity (Glasgow, Atlanta, Balthazar) - Diagnostic (IAP) - Prognostic (Ranson)

Answer 59

Modified Glasgow score for severity (PANCREAS) - PaO2<8- Age>55 - Neuts (WBC>15)- Ca<2- Renal (urea>16) - Enzymes (ALT/AST>200 / LDH>600) - Alb<32 - Sugar (glu>10) Score 3+ = severe, should go to critical care. Atlanta criteria (modified determinant-based criteria) - Mild: no necrosis or organ failure - Moderate: sterile necrosis and/or transient organ failure- Severe: either infected necrosis or persistent organ failure- Critical: both infected necrosis and persistent organ failure Where organ failure = SOFA>2 and persistent organ failure = >48h.

International Association of Pancreatology/American Pancreatic Association criteria (IAP/APA) diagnostic criteria 2 out of 3 of: - clinical: upper abdo pain - biochemical: amylase/lipase >3x ULN - radiological: CT/MR/US supportive

Ranson score for prognosis (non-gallstone associated)11 parameters- 5 on admission (age>55, glu>11, WBC>16, LDH>350 AST>250) - 6 at 48h (Hct drop>10%, urea rise>1.8, PaO2<8, base deficit>-4 (i.e. more negative), fluid sequestration>6L, Ca<2) Score 0-2 - 2% mortality 3-4 - 15%5-6 50% >6 100% Separate Ranson criteria exist for gallstone disease (generally higher numbers). APACHE is a good outcome predictor in pancreatitis, i.e. high risk of death >25. Balthazar CT severity index: predicts M and M based on appearances of pancreas/degree of necrosis.

Question 60

Injury Severity Score and RSS

Answer 60

ISS - anatomical system 6 regions each scored out of 6 (minor to unsurvivable) The 3 worst scores are each squared then summed Max score 75 A 6 in any region automatically converts score to 75 Major trauma = ISS >15 RSS - physiological system

Question 61

Warkentin 4T HIT score

Answer 61

Thrombocytopenia (2 = >50% fall)Timing (2 = day 5-10)Thrombosis (2 = proven new) The exclusion of other causes (2 = no others) Each scored 0-2 so max score 80-3 low probability 4-5 intermediate6+ high Mod-high = send HIT screen (ELISA for anti-heparin PF4 abs and functional testing) Plt transfusion is CI in HIT Urgent anticoagulation with alternative agent Type I - non-immune, less severeType II - immune-mediated

Question 62

Levels of evidence (literature) GRADE system (Grading of Recommendations Assessment, Development and Evaluation)

Answer 62

Levels of evidence 1a: systematic review or meta-analysis1b: RCT 2a: non-randomised controlled trial 2b: quasi-experimental e.g. cohort study 3: descriptive e.g. case-control 4: expert opinion GRADE Recommendations are made based on the above + quality markers in the original research: - Quality of evidence: A-D (high/moderate/low/very low) - Strength of recommendation: 1 = recommendation (strong), 2 = suggestion (weak) - Final outcomes can be 1A, 1B, 1C, 1D, 2A, 2B, 2C, 2D or ungraded

Question 63

Types of data

Answer 63

Categorical - Nominal (blood groups) - Ordinal (ASA grade) Numerical - Discrete (no. of pts) - Interval (centigrade) - Ratio (Kelvin) - Continuous (weight)

Question 64

SPRINT hip fracture audit 2014 recommendations

Answer 64

1. Consultant/SAS anaesthetist2. Consider neuraxial in all pts 3. Spinal using heavy bupivacaine <10mg with pt bad hip down 4. Intrathecal opioids - fentanyl only 5. Sedation - midazolam or propofol 6. Always give supplemental O2 7. Consider gas induction 8. SV rather than IPPV 9. Consider nerve blocks in all pts 10. Do not combine GA/neuraxial 11. Avoid hypotension 12. Assess all for BCIS

Question 65

Duke criteria for endocarditis

Answer 65

Major: - Positive BC x2 for typical organism or persistently +ve BC - Echo evidence of vegetation/abscess/new dehiscence or regurg of valvular prosthesis Minor: - IVDU/predisposing cardiac condition - Fever>38C- Vascular phenomena (major arterial emboli, septic pulmonary infarcts, mycotic aneurysm, ICH, conjunctival haemorrhage, Janeway lesions - Immunological phenomena (glomerulonephritis, Osler’s nodes, Roth spots, RhF +ve) - Microbiological evidence (+ve BC not meeting major criteria) - Echo consistent but not meeting major criteria Need 2 major, 1 major + 3 minor, or 5 minor.

Question 66

Aortic dissection (Stanford and DeBakey)

Answer 66

StanfordType A: ascending (encompasses DeBakey 1 and 2) - aortic root replacement Type B: descending (DeBakey 3) - BP control and possibly endovascular tx DeBakey

Type 1 (60%): starts in ascending aorta, goes to aortic arch and often distally beyondType 2 (10%): starts in ascending aorta and is confined thereType 3 (30%): starts in descending aorta, rarely extends proximally but may extend distally 

Also Svensson - defines type

Question 67

NIH Stroke Scale, FAST, ROSIER (Recognition of Stroke in the Emergency Room)

Answer 67

NIHSS: complicated. 11 domains. Total score between 0-42. >16 = strong possibility of death <6 = likely good recovery FAST: face, arms, speech, test/time.

ROSIER - asymmetric facial weakness- asymmetric arm weakness - asymmetric leg weakness - speech disturbance - visual field defect Each score 1 (LOC/syncope or seizure activity score -1)If score >0 stroke is likely.

Question 68

SMART-COP (prediction of ventilation/vasopressor requirement in CAP)

Answer 68

S: SBP <90 (2 points) M: multilobar involvement (1) A: albumin <35 (1)R: RR >25 if under 50, or >30 if over 50 (1) T: tachycardia >125 (1)C: confusion (new) (1) O: O2 low (SpO2 <93 or PFR <333 if under 50, or SpO2 <90 or PFR <250 if over 50) (2) P: pH <7.35 arterial (2)

0-2 low risk 3-4 risk 1 in 8 5-6 risk 1 in 37+ risk 2 in 3

Question 69

Light’s criteria

Answer 69

Pleural fluid:serum protein >0.5Pleural fluid:serum LDH >0.6 Pleural fluid LDH >2/3 ULN for serum 1 or more = exudateUseful in critical illness when albumin often low Transudate: “failures’ - heart/liver/renal, PE, low albumin. Caused by increased capillary hydrostatic pressure or reduced plasma oncotic pressure. Exudate: infection, ca, RA, pancreatitis. Caused by increased capillary permeability or decreased lymphatic absorption from pleural space. SAAG>11g/L predicts the pt to have portal HTN, with 97% accuracy - “transudate” <11 predicts no portal HTN - “exudate”

Question 70

Virchow’s triad

Answer 70

• FLOW: Venous stasis – e.g. immobility, proximal venous obstruction* FLUID: Hypercoagulable state – e.g. trauma, dehydration, pregnancy, thrombophilia* VESSELS: Vessel wall damage – e.g. previous DVT

Question 71

Weaning predictors

Answer 71

RSBI <105 (only valid if PEEP and PS are 0)

Question 72

Post cardiac arrest goals

Answer 72

SpO2 94-98% Normocapnoea Glucose 4-10 TTM at 36C for 24h then rewarm by 0.25C per hour. Avoid T>38C for 72h post ROSC Angio/PCI if STEMI or other causes of arrest excluded

Question 73

Weaning criteria

Answer 73

A: patentB: FiO2<0.4, PEEP<8, PS<10, adequate drive, able to clear secretions and comply with physio C: stable D: GCS sufficient E: original pathology resolved, no procedures needing sedation/GA in near future

Question 74

Levels of inpatient careLevels of ICU

Answer 74

Inpatient care0 - normal ward based 1 - ward based with additional monitoring/intervention requirements, needing ICU outreach input, or step down from level 2/3 (1:4 min nursing)2 - single organ failure, pre or postop care or step down from level 3 (1:2.5) 3 - advanced airway or 2+ organ support (1:1) ICUs (Australasian classification) 1 - basic/immediate/short term support 2 - high standard general ICU care 3 - tertiary referral unit

Question 75

CURB65 for CAP

Answer 75

Confusion Urea >7RR>30BP<90 systolic/60 diastolicAge 65 or over

Mortality 0 - 0.7%1 - 3.2% 2 - 13.0% 3 - 17.0% 4 - 41.5% 5 - 57.0%

Question 76

Hepatorenal syndrome criteria (International Club of Ascites)

Answer 76

• Cirrhosis with ascites- Creatinine >133 - No improvement in creat after at least 48h of diuretic withdrawal and volume expansion with albumin (1g/kg/day up to max 100g/day) - Absence of shock - No current/recent nephrotoxins - Absence of intrinsic renal disease (i.e. proteinuria >4.5g/day, microhaematuria, abnormal renal USS)Type 1 HRS Rapidly progressive - doubling of baseline creat <2/52 Often related to SBP Often a/w acute circulatory compromise and rapid hepatic decompensation Poor prognosisType 2 HRS Slower onset Spontaneous a/w refractory ascites

Question 77

Grading of oesophageal varices by endoscopic appearance (Jalan and Hayes 2000)

Answer 77

Grade 1 - small, well epithelialised, disappear on insufflation of the oesophagus. No tx indicated. Grade 2 - intermediate, between grade 1 and 3. Grade 3 - large varices which occlude the lumen. Grade 2/3 require portal pressure reduction by non-selective BB +/- banding.

Question 78

Abdominal compartment syndrome

Answer 78

Normal IAP = 5-7mmHg Intra-abdominal HTN = >12mmHg Abdominal compartment syndrome = >20mmHg (or abdominal perfusion pressure <50mmHg) with associated organ failure Grade 1: 12-15Grade 2: 16-20 Grade 3: 21-25Grade 4: >25 i.e. grades 1/2 are IAHTN (treat medically) and 3/4 are ACS (consider surgical laparostomy if medical control failing or IAP>30). Renal perfusion is compromised at IAP>15; anuria is typical at IAP>30.

Question 79

ASA score

Answer 79

ASA 1 - no organic, biochemical, physiological or psychiatric disease. Mortality 0.1% ASA 2 - mild/moderate systemic disease. 0.7% ASA 3 - severe, not incapacitating. 3.5% ASA 4 - constant threat to life. 18.3% ASA 5 - moribund, resuscitative effort. 93.3% ASA 6 - brain dead donor Suffix ‘E’ added to identify emergency cases in which delay would increase risk of loss of life or limb.

Question 80

Brain Trauma Foundation indications for invasive ICP monitoring

Answer 80

Severe TBI + abnormal CT Mod-severe TBI and neuro assessment impossible Severe TBI + normal CT but 2 out of 3 of: age >40, SBP<90, abnormal GCS motor response(Non-TBI indications: spontaneous ICH + coma, hypoxic brain injury (e.g. post arrest/near drowning), hepatic encephalopathy, intracranial infections)

Question 81

Lundberg waves

Answer 81

A: ICP 50-100 for 5-10m. Slow,, vasogenic waves due to reflex vasodilatation due to low MAP. Always pathological. B: ICP 20-30 above baseline for 30s-2m. Evidence of normal autoregulation. Absence post TBI is poor prognostic sign. C: 4-8m cycles. No clinical significance.

Question 82

Asthma- Acute severe- Life-threatening- Near-fatal (BTS)

Answer 82

Acute severe - any one of: - PEFR 33-50% best or predicted - RR>25- HR>110- Cannot complete sentences Life-threatening - any one of: - PEFR<33% best or predicted - SpO2<92%/PaO2<8 - ‘Normal’ PaCO2 - Silent chest - Cyanosis - Poor respiratory effort - Hypotension - Arrhythmia - Exhaustion - Altered conscious level Near-fatal - Raised PaCO2 and/or requiring MV with high Paw

Question 83

Beck’s triad (cardiac tamponade)

Answer 83

Hypotension Distended neck vessels/raised JVPMuffled heart sounds

Question 84

Pelvic injuries - Young-Burgess- Tile

Answer 84

Young-Burgess- Anteroposterior compression - head-on collision - Lateral compression - side-on collision - Vertical shear injuries - head-on or fall from height- Combined mechanism Tile A: Rotationally and vertically stableB: Rotationally unstable, vertically stableC: Rotationally and vertically unstable

Question 85

Hypothermia

Answer 85

Mild: 35-32 Moderate: 32-28Severe: <28Swiss Staging SystemStage 1: conscious, shivering Stage 2: impaired consciousness, no shivering Stage 3: unconscious Stage 4: respiratory arrest, possible VF/asystoleStage 5: death

Question 86

Care bundles- Ventilator- CVC insertion - CVC maintenance - Trache

Answer 86

Ventilator care bundle (VAP prevention) - 6- Head up positioning - Chlorhexidine mouth care - Daily sedation hold- Peptic ulcer prophylaxis - VTE prophylaxis - Subglottic suction (included in UK) CVC insertion care bundle (CABSI prevention) - 5- Insertion checklist and documentation- Hand hygiene and maximal barrier precautions- Catheter site selection- Skin antisepsis- DressingCVC maintenance care bundle - 5- CVC still required? - Dressing intact and changed in last 7d - Chlorhex used to clean insertion site during dressing change - Hub decontamination prior to each access - Hand hygiene before and after each accessTrache care bundle - 6- Humidification - Suctioning - Inner tube care (2-4h) - Dressing and tapes (24h) - Cuff check - Bedside safety equipment

Question 87

ECMO referral criteria

Answer 87

Indications:- 16y or over- Potentially reversible SRF- No limitation to ongoing life-sustaining tx - Murray score 3 or more (or 2.5 or more if rapidly deteriorating) OR uncompensated hypercapnoea and pH<7.2 Contraindications:- Intracranial bleed (current or recent) - Other CI to anticoagulation - Ppeak>30 and/or FiO2>0.8 for >7d (relative)- Age >65 (relative) Typical patient characteristics- Severe hypoxaemia - Severe respiratory acidosis - Unable to achieve lung protective ventilation - Failure to rescue (e.g. proning/HFOV) - Air leak/BPF

Question 88

Five key principles of the Mental Capacity Act 2005 (came into force 2007)

Answer 88

1. Presumption of capacity 2. Support individuals to make their own decisions 3. Unwise decisions do not equal a lack of capacity And in patients without capacity: 4. Act in best interests 5. Take the least restrictive option

Question 89

Assessment of capacity

Answer 89

Two-stage functional test 1. Is there an impairment of/disturbance in the functioning of a person’s mind or brain? 2. Is the above sufficient to render the person non-capacitous to make a particular decision? i.e. can they understand, retain, weigh up and communicate (need all 4)? Capacity is time and decision-specific.

Question 90

Laboratory Risk Indicator for Necotizing fasciitis (LRINEC)

Answer 90

CRP >150 = 4 points WBC <15 = 0, 15-25 = 1, >25 = 2Hb >13.5 = 0, 11-13.5 = 1, <11 = 2 Na+ <135 = 2 Creat >141 = 2 Glu >10 = 1

Low risk: up to 5 Moderate: 6-7High: 8+ But 10% of ‘low risk’ category still had NF.

Question 91

Burns assessment

Answer 91

• Palmar surface area- Wallace rule of nines- Lund and Browder chart

Question 92

Modified Rankin score for neurodisability post stroke

Answer 92

0=asymptomatic 1=nosignificantdisabilitydespitesymptoms;fully functional2=slightdisability 3=moderatedisabilitybut can walk withoutassistance4=moderatelyseveredisability,unabletowalkwithoutassistance and needs help with ADLs 5=severedisability;bedridden,needing constant care6 = dead

Question 93

Clinical trial phases

Answer 93

Preclinical - in vitro/in vivo (animals)Phase 0 - human subtherapeutic/microdosing studies to observe pharmacokinetics (newish concept, often skipped) Phase 1 - healthy volunteers; safety and dosage; approx 70% drugs progress Phase 2 - patients with disease; efficacy and side effects; 33% progress Phase 3 - large RCTs of patients with disease; efficacy and monitoring for adverse reactions; 25-30% progress Phase 4 - postmarket surveillance

Question 94

Pulmonary embolism

Answer 94

Submassive - RV strain but no CVS compromiseMassive- RV dysfunction - SBP <90- Needing inotropes

Question 95

Sepsis care bundles (2015)- 3h- 6h

Answer 95

Three hour care bundle - 41. Measure lactate 2. Take blood cultures before abx 3. Broad spectrum abx 4. 30ml/kg crystalloid if hypotensive or lactate >4 Six hour care bundle - 35. If fluid unresponsive, start vasopressors and target MAP>65 6. If fluid unresponsive, reassess volume and perfusion status (clinical examination or two of: CVP, ScvO2, bedside CVS US or dynamic ax of fluid responsiveness with passive leg raise or fluid challenge) 7. Recheck lactate if initially elevated

Question 96

Oxford/Bamford stroke classification

Answer 96

TACS - total anterior PACS - partial anterior POCS - posterior LACS - lacunar

Question 97

Solid organ trauma

Answer 97

American Association for the Surgery of Trauma Organ Injury Scale Splenic I-IV Hepatic I-VI Depending on laceration size, haematoma size and state of vascular structures.

Question 98

SCORTEN score for TEN

Answer 98

7 factors

Age ≥40 HR ≥120 MalignancyBSA detachment ≥10% (at day 1)Urea >10Bicarb <20Glucose >14

5 or more = 90% mortality

Question 99

Full Outline of UnResponsiveness (FOUR score)

Answer 99

4 domains: eyes, motor, brainstem reflexes (pupils/corneal), breathing pattern. Each out of 4 so score out of 16. Can be applied equally to intubated/unintubated pts.

Question 100

Canadian C-spine rules

Answer 100

Preconditions: alert (GCS 15) and stable High risk (imaging mandated)- Age >65- Parasthesia in extremities - Dangerous mechanism (fall from height, axial loading, high speed RTA, bicycle/motorised recreational vehicle collision) Low risk - Simple rearend RTA - Sitting in ED- Ambulatory at any time - Delayed onset neck pain - Absent midline C-spine tenderness If low risk and able to actively rotate neck 45 degrees left and right, imaging not required. If not, or if no low risk factors are present, imaging is required.

Question 101

Frailty

Answer 101

Frailty phenotype (Fried’s definition or Cardiovascular Health Study definition)3 or more of 5- Weakness (reduced grip strength)- Slowness (walking speed)- Low physical activity- Self-reported exhaustion- Unintentional weight loss (>4.5kg/y)

Other systems - Frailty index: cumulative deficits identified in a comprehensive geriatric assessment (70 item inventory, research tool) - Edmonton Frail Scale- Clinical Frailty Scale - PRISMA 7 questionnaire- Simple tests - timed up-and-go test (>10s to stand from a chair, walk 3m, turn round and sit down again), walking speed (>5s to walk 4m)

Question 102

Multiple Organ Dysfunction Score (MODS)

Answer 102

7 systems scored 0-4 First measurement of the day Pressure adjusted HR = (HR x CVP) / MAP

Question 103

Therapeutic Intervention Scoring System (TISS)

Answer 103

Nursing workload 7 areas of care - basic, ventilatory, CV, renal, neuro, metabolic, specific Total score 78 One nurse can provide 46 TISS points per shift Each TISS point is 10.6 mins of time

Question 104

Murray score

Answer 104

2 Ps, 2 Cs Each scored 0-4 PFR >40/40-30/30-23/23-13/<13kPaPEEP <5/6-8/9-11/12-14/>15cmH2O CXR - 1 point per quadrant infiltrated Compliance >80/80-60/60-40/40-20/<20ml/cmH2O 3 or more for ECMO referral (2.5 if rapid clinical deterioration)

Question 105

RCS clinical criteria for major GI and vascular surgery

Answer 105

Patients with any of the following have a predicted mortality of at least 5%: - Age >65- Shock of any cause - Age >50 and emergency/urgent/redo surgery, creat>130, DM or cardioresp disease

Question 106

Ann Arbor staging system - now replaced by Lugano

Answer 106

Ann ArborStage 1 - single region Stage 2 - two regions but confined to one side of diaphragm Stage 3 - both sides of diaphragm Stage 4 - disseminated

Lugano AA stage 1/2 = limited diseaseAA stage 3/4 = advanced disease A/B (absence or presence of constitutional sx) applies only to HL.

Question 107

Wells score for DVT

Answer 107

1 point for each of: Active cancer Paralysis, paresis or recent plaster immobilisation of the lower extremities Recently bedridden for 3 days or more or major surgery within 3/12 Localised tenderness Entire leg swollen Ipsilateral calf swelling >3cm greater than contralateral Ipsilateral pitting oedema Collateral superficial veins (non-varicose) Previous DVT Alternative diagnosis at least as likely: -2 points DVT likely: 2 or more points DVT unlikely: 0 or 1

Question 108

Wells score for PE

Answer 108

Clinical signs and symptoms of DVT: 3Alternative diagnosis less likely than PE: 3 HR >100: 1.5 Immobilisation for more than 3 days or surgery in the previous 1/12: 1.5 Previous VTE: 1.5 Haemoptysis: 1 Active cancer: 1 PE likely: 5+ points PE unlikely: 4 points or fewer

Question 109

Ambulance Prioritisation Algorithm Inter-Hospital Transfer Protocol 2011

Answer 109

Priority 1 - time critical for life-saving intervention (8m) Priority 2 - other life/limb saving treatment (<1h) Priority 3 - other (<4h) Priority 4 - non-clinical (<8h)

Question 110

Clinical Institute Withdrawal Assessment for Alcohol scale, revised (CIWA-Ar)

Answer 110

10 domains:

Nausea and vomiting TremorParoxysmal sweats Anxiety Agitation Tactile disturbance Auditory disturbance Visual disturbanceHeadacheAltered sensorium

Score 10-14 give 25mg chlordiaz, or >15 50mg Scored every 2h for 24hMax 300mg/24h Then reducing doses over next 2-5d - reduce by 20% of the first 24h dose each day In liver impairment, use lorazepam or oxazepam 1mg loraz = 25mg chlordiaz = 10mg diaz

Question 111

Pain scales in ICU

Answer 111

Behavioural Pain Score (BPS)| Critical Care Pain Observation Tool (CPOT)

Question 112

Truelove and Witts - UC severity index

Answer 112

Bowel movements Blood in stool TemperatureHR Anaemia ESR

Each domain has a mild/moderate/severe category

Question 113

Guedel classification of the stages of anaesthesia (1937)

Answer 113

Stage 1 - analgesia (start to LOC) Stage 2 - excitement (LOC to onset of automatic breathing) - loss of eyelash reflex but airway reflexes still active Stage 3 - surgical anaesthesia (4 planes) * Plane 1 - loss of eyelid reflex, pinpoint pupils * Plane 2 - loss of corneal reflex * Plane 3 - laryngeal reflexes depressed, normal pupils * Plane 4 - carinal reflex depressed, apnoea Stage 4 - coma

Question 114

PEEP ladder (ARDSnet 2004)

Answer 114

FiO2 - PEEP 0. 3 - 6 0. 4 - 8 0. 5 - 10 0. 6 - 120. 7 - 14 0. 8 - 16 1. 0 - 20

Question 115

Post cardiac arrest neurological outcome

Answer 115

Cerebral Performance Categories1 - full recovery/mild disability2 - moderate disability 3 - severe disability 4 - PVS 5 - dead

Glasgow Outcome Scale Same categories but backwards i.e. 5 is best

Question 116

Lactic acidosis (Cohen and Woods)

Answer 116

Type A: tissue hypoxiaLow CO, severe anaemia, regional hypoperfusion Type B: no tissue hypoxia B1: disease-related e.g. DKA, AIDSB2: drug/toxin-related e.g. cyanide, alcohols, HAART, metformin B3: inborn errors of metabolism e.g. pyruvate dehydrogenase deficiency