Scoring systems Flashcards
Pancreatitis
BISAP, RANSONS, CT Severity Index
BISAP
- predicts mortality risk
- can be done in ED
- more recent than ranson
RANSONS
- mortality risk estimation
- based on initial and 48 hour lab values
CTSI
- based on CT without contrast
severity of acute pancreatitis
- combination of 2 scores (Balthazar and Pancreatic necrosis)
BISAP
Mortality risk in acute pancreatitis
B-I-S-A-P
BUN > 25mg/dL (8.9mmol/L)
Impaired mental status (disorientation, lethargy, somnolence, coma or stupor)
SIRS citeria (2+ of temp/HR/RR/WBC)
Age > 60yrs
Pleural effusion present
Interpretation
0 = <1% mortality risk
3 = mortality significantly increased
5 = 22% mortality
RANSONS
Mortality in acute pancreatitis
Based on initial and 48 hour labs
On admission
- WCC > 16
- Age > 55
- Glucose > 10
- AST > 250
- LDH > 350
At 48 hours into admission:
- Hct drop > 10% from admission
- BUN increase > 1.79mmol/L from admission
- Calcium < 2
- Arterial pO2 < 60mmHg
- Base deficit (24-HCO3) > 4mg/dL
- fluid needs > 6L
3+ on admission - severe pancreatitis likely
CTSI
CT severity Index - acute pancreatitis
Grading of pancreatitis
A: normal pancreas = 0
B: enlarged pancreas = 1
C: inflammatory changes in pancreas and peripancreatic fat = 2
D: ill-defined single peripancreatic fluid collection = 3
E: two or more poorly defined peripancreatic fluid collections = 4
PLUS
Pancreatic necrosis score None = 0 < 30% = 2 30-50% = 4 > 50% = 6
Interpretation
0-3 = mild acute pancreatitis
4-6 = moderate acute pancreatitis
7-10 = severe acute pancreatitis
NB - correlates well with other pancreatitis scores, so imaging not always necessary to assess severity of pancreatitis.
Orlowski Score
Prognostication in drowning
Poor prognosis associated with
3 - age < 3yrs 5 - submersion > 5mins 7 - initial pH < 7.1 9 - GCS 9 10 - initial resus/CPR delayed by > 10minutes
Glasgow-Blatchford Score
Risk of upper GI bleeding. Elements include
- BUN
- Hb
- SBP
- HR
- presentation with malena
- presentation with syncope
- known hepatic disease
- known heart failure
Cholecystitis on USS
- gallbladder wall > 3mm
- pericholycystic fluid/hyperaemia
- distended gallbladder > 4cm diameter/ >10cm long
- sonographic murphy’s sign
- gallstones
- air in gallbladder (emphysematous cholecystitis)
Normal diameter of CBD = <8mm
Killip Class
Risk stratification in AMI
I - no clinical signs of heart failure. Mortality 6%
II - crackles in lungs, S3, elevated JVP. Mortality 17%
III - frank acute pulmonary oedema. Mortality 38%
IV - cardiogenic shock, or hypotension + evidence of peripheral vasoconstriction (oliguria, cyanosis, sweating). Mortality 81%.
Duke criteria
For infective endocarditis.
2 major OR 1 major + 3 minor OR 5 minor
MAJOR
- POS BC of typical pathogen, from 2+ cultures
- evidence of endocardial involvement on echo (vegetation, abscess, new regurgitation, new partial dehiscence of prosthetic valve)
MINOR
- predisposition (heart disease, IVDU)
- fever > 38
- vascular phenomena (arterial emboli, septic pulmonary infarcts, mycotic aneurysms, conjunctival haemorrhages, janeway lesions)
- immunological phenomena (osler’s nodes, roth spots, rheumatoid factor)
- microbiological evidence (single + BC of typical pathogen)
- echo findings (consistent with IE but doesn’t meet major criteria)
CRUSADE score
Post-MI bleeding risk. Elements:
- HR
- SBP
- Haematocrit
- creatinine clearance
- sex
- signs of CHF at presentation
- history of vascular disease
- history of diabetes mellitus
San Francisco Syncope Rule
CHESS
C - CCF H - Hct < 30% E - ECG abnormal S - short of breath S - SBP < 90mmHg at triage
All negative = low risk
Any positive = not low risk
Framingham
For diagnosis of heart failure
MAJOR - 2 or more (or 1 + 2 minor)
- APO
- cardiomegaly
- hepatojugular reflex
- neck vein distension
- PND or orthopnoea
- Pulmonary rales
- S3 gallop rhythm
MINOR
- ankle oedema
- SOBOE
- hepatomegaly
- nocturnal cough
- pleural effusion
- tachycardia > 120
NYHA
Classification in heart failure
Class
I - no limitation of physical activity
II - slight limitation in physical activity
III - marked limitation in physical activity
IV - symptoms at rest and discomfort with any physical activity
ACC/AHA Staging for Heart Failure
A - high risk of heart failure but no symptoms and no structural heart disease
B - structural heart disease but no symptoms of failure
C - structural heart disease + symptoms of heart failure
D - refractory heart failure requiring specialised interventions
Charcot triad and Reynold’s pentad for Cholangitis
Charcot triad
- RUQ pain
- fever
- jaundice
Reynold’s pentad
- RUQ pain
- fever
- jaundice
- shock
- altered sensorium
Tokyo guidelines for acute cholangitis
Provides diagnostic criteria and severity grading
PART A: Systemic inflammation
- fever and/or shaking chills
- lab data: evidence of inflammatory response (WCC < 4 or > 10 and/or CRP > 1)
PART B: Cholestasis
- jaundice (total bilirubin > 2)
- lab data: abnormal LFTs (>1.5x STD)
PART C: Imaging
- biliary dilatation
- evidence of the aetiology on imaging (stricture, stone, stent, etc)
Quick SOFA score (qSOFA)
Risk of death or prolonged ICU admission in sepsis
- SBP < 100mmHg
- RR > 22
- GCS 14 or less
ABCD2
Estimates risk of stroke after suspected TIA
A - age 60+ (1)
B - blood pressure either SBP 140+ or DBP 90+ (1)
C - clinical features of the TIA
- unilateral weakness (2)
- speech disturbance without weakness (1)
- other symptoms (0)
D - duration of symptoms
- 60+ minutes (2)
- 10-59mins (1)
- <10 mins (0)
D - history of diabetes (1)
INTERPRETATION
Low risk = 0-3
Moderate risk = 4-5
High risk = 6-7
Stroke scores
FAST-ED
- to determine emergency destination, stroke triage
ROSIER
- also about early detection and appropriate triage
RACE
NIHSS
- severity score
HINTS
Head impulse
- if PERIPHERAL, patient’s eyes keep moving with head, then saccade back (positive test)
- if CENTRAL, patient’s eyes keep focussed on you (negative test)
Nystagmus
- no/unidirectional suggests peripheral
- phase changing to beat in direction of gaze suggests central
Test of Skew
patient looks at your nose, you cover one of their eyes
rapidly uncover the eye and look to see if it realigns
if the eye moves –> CENTRAL “vertical disconjugate gaze”
if the eye does not move (no skew deviation) - peripheral cause
CHADSVASC
CCF HTN Age > 75 Diabetes mellitus Vascular disease - previous stroke, TIA, embolism Gender - female
HASBLED
HTN > 160 SBP
Abnormal renal function or liver function
Stroke - prior history
Bleeding - predisposition or prior major bleeding
Labile INR
Elderly (>65)
Drug or alcohol use, medications predisposing to bleeding (antiplatelet, NSAID)
TIMI Score
Estimates mortality for patients with unstable angina and NSTEMI
Features
- age 65+
- 3+ CAD risk factors (HTN, cholesterol, DM, FHx, smoker)
- known CAD >50% stenosis
- ASA use past 7 days
- severe angina 2+ episodes in the past 24 hours
- ST changes > 0.5mm
- positive TnI
all score 1 each
if 0-1 total = low risk of adverse outcome (death, MI, urgent revascularisation)
Other chest pain scores
EDACS
- identify patients at low risk of MACE
- potential for early discharge from ED if low risk (with serial TnIs + ECGs)
HEART
- also assessing risk of MACE in patients presenting with symptoms suggestive of ACS
Australian Heart Foundation Risk Stratification of Chest Pain
HIGH RISK
- ST elevation
- positive troponin
- ongoing/repetitive chest pain
- persistent ST depression or TWI in 2 contiguous leads
- HD compromise (SBP < 90; killip class >1, and/or new onset MR)
- syncope
- sustained VT
- known poor LV systolic function LVEF <40%
- AMI/PCI/CABG within the past 6 months
INTERMEDIATE RISK
- 2 or more symptomatic episodes within 24 hours
- prior regular aspirin use within the past 7 days
- age 65+
- CKD - egfr < 60
- known diabetes
- known CAD - prior MI w/LVEF > 40%, prior PCI/CABG, coronary lesion >50%
- two or more of: HTN, FHx, active smoking, dyslipidaemia
LOW RISK
- normal ECG
- normal TNI
- age < 40yrs
- absence of known CAD
- atypical symptoms
- symptoms resolved
Stanford and DeBakey
STANFORD
A - ascending aorta. Can extend distally. Usually needs surgery
B - only involves aorta beyond left subclavian. Conservative management.
DeBAKEY
1 - entire aorta
2 - confined to ascending aorta
3 - descending aorta distal to subclavian artery
Sgarbossa criteria
- concordant ST elevation > 1mm in any lead
- concordant ST depression > 1mm in any of V1-3
- discordant ST elevation > 5mm
SMART COP
Risk of death and need for ICU
S - SBP < 90mmHg M - multilobar CXR involvement A - albumin > 35 R - resp rate > 25 (or > 30 if older than 50yrs) T - tachycardia > 125 C - confusion, acute onset O - oxygen low (<93% if under 50, < 90% if over 50) P - pH < 7.35 (arterial)
Predicts risk of needing IRVS + 30 day mortality
5-6 = high risk
7+ = very high
CURB 65
Predicts need for admission
C - acute onset confusion U - uraemia (> 7mmol/L) R - resp rate > 30 B - systolic Blood pressure < 90 or DBP < 60 65 - age 65+
0-1 = appropriate for OPD; 30 day mortality < 3% 2 = 9% mortality; inpatient care 3-5 = 15-40% mortality; consider ICU
Wells
Estimate probability of PE
7 features
- clinical signs and symptoms of DVT (3)
- an alternative diagnosis less likely than PE (3)
- HR > 100 (1.5)
- immobilisation 3+ consecutive days/surgery in the past 4/52 (1.5)
- previous objectively diagnosed PE or DVT (1.5)
- haemoptysis (1)
- malignancy (Rx within past 6/12, or palliative) (1)
0-1 = low risk - consider PERC +/- D dimer 2-6 = moderate risk; consider D dimer or CTPA >6 = high risk - D dimer not recommended
PERC
PE Rule Out Criteria (need to be low risk for PE on Wells)
8 criteria
- age < 50
- pulse < 100
- SpO2 > 95% RA
- absence of unilateral leg swelling
- absence of haemoptysis
- no recent trauma or surgery
- no prior history of VTE
- no exogenous oestrogen exposure
All negative = no need for further workup
Simplified PESI score
PE Severity Index
- Age > 80
- history of cancer
- chronic cardiopulmonary disease
- HR > 110
- SBP < 100
- arterial oxygen saturation < 90%
If NO to all –> not high risk. Consider outpatient therapy.
(Also consider
- pain controlled
- not distressed
- no bleeding risk
- good support and follow up)
Contraindications to Thrombolysis
As per QLD Health Thrombolysis in STEMI guideline
ABSOLUTE
- active bleeding or bleeding diatheses (excluding menses)
- suspected aortic dissection
- significant closed head or facial trauma within 3 months
- any prior ICH
- ischaemic stroke within 3 months
- known cerebral vascular lesion
- known malignant intracranial neoplasm
RELATIVE
- current anticoagulation
- non-compressible vascular puncture
- recent major surgery (<3 weeks)
- traumatic or prolonged CPR
- recent internal bleeding (within 4 weeks)/active PUD
- suspected pericarditis
- advanced liver/advanced metastatic cancer
- history of chronic, severe, poorly controlled HTN
- severe uncontrolled HTN SBP > 180/DBP > 110
- Ischaemic stroke > 3 months ago
- known intracranial abnormality not listed above
- dementia
- pregnancy or within 1 week post partum
Alvarado Score
Assist with clinical diagnosis of appendicitis
MANTRELS
M - migration of pain to RLQ A - anorexia N - nausea and vomiting T2 - tenderness in RLQ R - rebound pain E - elevated temperature L2 - leucocytosis S - shift of WBCs to the left
(all score 1 except T and L)
1-4: appendicitis unlikely
5-6: appendicitis possible
7-8: appendicitis probable
9-10: surgery indicated
Paediatric appendicitis score
For use in children aged 3-18 years
- RLQ tenderness to cough, percussion, or hopping (2)
- anorexia
- fever
- nausea or vomiting
- tenderness over RIF (2)
- leukocytosis with WCC > 10
- left shift
- migration of pain to the RLQ
(all score 1 except RLQ tenderness/pain)
0-3 = unlikely appendicitis 4-6 = consider imaging/surgical consult 7+ = likely appendicitis
Canadian CT head rule
Adults
GCS 13-15 plus at least one of
- loss of consciousness
- amnesia to the head injury event
- witnessed disorientation
EXCLUSION
- age < 16 years
- blood thinners
- seizure after injury
HIGH RISK criteria (Rules out need for NROS intervention)
- GCS < 15 at 2 hours post injury
- suspected open or depressed skull fracture
- any signs of basilar skull fracture (haemotympanum, raccoon eyes, Battle’s sign, CSF pyorrhoea)
- 2+ episodes of vomiting
- age 65+
MEDIUM RISK (Clinically important brain injury)
- retrograde amnesia to event > 30mins
- dangerous mechanism (ped v vehicle; ejection; fall from height)
NEXUS II HEAD rule
Head CT not required if none of the following are present:
- age 65+
- evidence of significant skull #
- scalp haematoma
- neurological deficit
- ALOC
- abnormal behaviour
- coagulopathy
- recurrent or forceful vomiting
NEXUS C Spine Rule
- Ages 1-101 included
- reduced sensitivity > 65
RULE
- ?focal neurological deficit present?
- midline spinal tenderness?
- altered LOC?
- intoxication?
- distracting injury?
Mnemonic NSAID N - neuro deficit S - spinal midline tenderness A - altered LOC I - intoxication D - distracting injury
Canadian C spine Rule
Exclusions
- age 65+
- extremity paraesthesia
- dangerous mechanism (fall >0.9m or 5 stairs; axial load injury; high speed MVA or rollover; bicycle collision; motorised recreational vehicle)
LOW RISK FACTORS PRESENT?
- sitting position in Ed
- ambulatory at any time
- delayed (not immediate) onset neck pain
- no midline tenderness
- simple rearend MVC
if yes to any of the above…
ABLE TO ACTIVELY ROTATE NECK 45d LEFT AND RIGHT?
cleared clinically if yes
PECARN
Inclusion: GCS 14+
UNDER 2 YEARS CT recommended if - GCS 14 - other signs of altered mental status (agitation, somnolence, repetitive questioning, slow response to verbal communications) - palpable skull #
Observation recommended if
- all of the above absent
- occipital or parietal or temporal scalp haematoma
- history of LOC 5+ seconds
- severe mechanism of injury
OVER 2 YEARS CT recommended for same reasons as above Observation recommended for - history of LOC - history of vomiting - severe mechanism of injury - severe headache
Kawasaki disease diagnostic criteria
Fever for at least 5 days
Plus FOUR of
- conjunctivitis
- lymphadenopathy (usually unilateral cervical, tender)
- rash
- lips and oral mucosa - hyperaemia, strawberry tongue, cracked
- extremeties - painful oedema, desquammation
NB
Irritability often also present, but not part of diagnostic criteria
Scarlet fever diagnosis
FEVER plus
- sore throat
- cervical lymphadenopathy
- strawberry tongue
- scarlet –> sandpaper rash (12-48 hours after onset of fever)
HSP diagnosis
typically 2-8 years old
recent URTI in ~50%
- NO FEVER
- Palpable purpura - gravity dependent
- arthritis/arthralgia (50-75%)
- abdominal pain (50%)
- renal involvement (haematuria, proteinuria, HTN) (25-50%)
HUS classic pentad
FAT-RN
F - fever A - anaemia T - thrombocytopaenia R - renal problems N - neurological problems (more likely in TTP) headache, confusion, seizures
**Resembles TTP (same pentad) but renal > neurological
Investigations
- MAHA
- ARF
- thrombocytopaenia
HUNT and HESS
Clinical grading of SAH
Grade 1 - asymptomatic/minimal headache, slight neck stiffness
Grade 2 = moderate-severe headache, neck stiffness, NO neurological features except CN palsy
Grade 3 = drowsy, minimal neuro deficit
Grade 4 = hemiparesis, stupor
Grade 5 = deep coma, decerebrate rigidity, moribund
WFNS
Clinical grading of SAH
Grade 1 = GCS 15, no motor deficit
Grade 2 = GCS 13-14, no motor deficit
Grade 3 = GCS 13-14, FOCAL neuro deficit
Grade 4 = GCS 7-12, with or without focal neuro
Grade 5 = GCS < 7, with or without focal neuro
Salter Harris
S-A-L-T-ER
1 - S - separated growth plate /slipped
2 - A - above growth plate (most common)
3 - L - beLow growth plate
4 - T - through growth plate (above and below)
5 - ER - ERasure of growth plate (squashed)
Aortic dissection classification
STANFORD
Type A = ascending aorta. Can extend distally ++. Surgery usually indicated.
Type B = only involves aorta beyond L subclavian artery. Conservative/medical Mx.
DeBAKEY
1 = entire aorta (60%)
2 = confined to ascending aorta (10-15%)
3 = descending aorta distal to subclavian artery (25-30%)
SCORTEN score
Severity index for TEN
one point for each:
- age > 40
- HR > 120
- presence of cancer or haematological malignancy
- epidural detachment involving BSA > 10% on day 1
- BUN > 10mmol/L (28mg/dL)
- glucose > 14mmol/L
- bicarbonate < 20 mEq/L
Predicts mortality 0-1 = 3.2% 2 = 12.1% 3 = 35.3% 4 = 58.3% 5+= 90%
Ottowa Subarachnoid Haemorrhage rule for headache evaluation
INCLUSION
- alert patient
- 15+ years old
- new severe atraumatic headache
- presenting within 14 days of headache
- no head trauma or fall in the previous 7 days
EXCLUSION
- new neurological deficits
- prior aneurysm
- prior SAH
- known brain tumour
- chronic recurrent headache (3+ headaches of the same character and intensity for 6+ months)
Why use
- 100% sensitive for SAH (rule out tool)
- 15% specific - not diagnostic
FEATURES
- age 40+
- neck pain or stiffness
- witnessed LOC
- onset during exertion
- thunderclap headache (pain peaking within 1 second)
- limited neck flexion on examination
if yes to any –> cannot exclude SAH; consider SAH workup
Difficult BVM - MOANS
M - mask seal (beard, blood on face, disruption of facial continuity)
O - obesity/obstruction (angioedema, abscess)
A - Age > 55
N - no teeth (leave dentures in place)
S - sleep apnoea/stiff lungs (COPD, asthma, ARDS, others)
Difficult laryngoscopy - LEMON
L - look externally (clinical gestalt, facial disruption, bleeding, small mouth, agitated patient)
E - evaluate 332 rule: mouth open, mandible, glottis
M - mallampatti score
O - obstruction/obesity (4 cardinal signs of upper airway obstruction = stridor, muffled voice, difficulty swallowing secretions, sensation of dyspnoea)
N - neck mobility - trauma, arthritis, AS. MILS.
Difficult extraglottic device - RODS
R - restricted mouth opening
O - obstruction
D - disrupted/distorted airway
S - stiff lung or C spine
Difficult cricothyrotomy - SHORT
S - surgery or other airway obstruction
H - haematoma (includes infection and abscess)
O - obesity
R - radiation distortion and other deformity
T - tumour
Paeds airway numbers
ETT size = age/4 + 4
at lips formula = age/2 + 12cm
SAD PERSONS
Suicide risk
S - male sex A - age < 19 or > 45 D - depression P - previous attempt E - excess alcohol or substance abuse R - rational thinking loss S - social supports lacking O - organised plan N - no spouse S - sickness
0-4 = low 5-6 = medium 7-10 = high
ARDS Severity
Mild = PaO2/FiO2 200-300. Mortality = 27%
Moderate = PaO2/FiO2 100-200. Mortality = 32%
Severe = PaO2/FiO2 < 100. Mortality = 45%
(PaO2 on PEEP on 5+)
