Scoring systems, classifications and criteria Flashcards
Revised Cardiac Risk Index (Lee) and Original Cardiac Risk Index (Goldman)
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)
Acute Physiology, Age and Chronic Health Evaluation (APACHE)
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, GCS
Lab (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
POSSUM
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 accurately
V-POSSUM – vascular surgery
Cr-POSSUM – colon cancer resection
Richmond Agitation-Sedation Scale (RASS)
+4 to -5
+4 combative
+3 very agitated
+2 agitated
+1 restless
0 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).
Atrial fibrillation (CHA2DS2VASc and HAS-BLED)
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-BLED HTN (SBP>160) Abnormal renal/liver function Stroke Bleeding Labile INR Elderly Drugs/alcohol
3 or more = high risk, caution and regular review
Liver scores (Child-Pugh, MELD, Maddrey’s discriminant function, CLIF-SOFA, ISHEN)
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 encephalopathy
Type 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.
PONV (Apfel)
- 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%).
Obstructive Sleep Apnoea (STOP-BANG and Epworth)
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 M Gender (male)
0-2 low risk
3-4 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 Scale 8 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
Structured modified Brice interview for awareness
- What was the last thing you remembered before you went to sleep?
- What was the first thing you remembered after your operation?
- Can you remember anything in between?
- Can you remember if you had any dreams during your operation?
- What was the worst thing about your operation?
Asked postop, at 24h and 30d later.
MUST (Malnutrition Universal Screening Tool) - BAPEN
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
Difficult airway (Modified Mallampati)
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.
Laryngoscopy (Cormack and Lehane)
Grade 1: Full view of glottis
Grade 2a: Partial view of glottis
Grade 2b: Only posterior extremity of glottis seen or only arytenoid cartilages
Grade 3: Only epiglottis seen
Grade 4: Neither glottis nor epiglottis seen
Grade 2b+ predicts difficult intubation.
Perioperative nerve injuries (Seddon, Sunderland)
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)
Hypersensitivity reactions (Gell and Coombs)
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
Adverse drug reactions
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)
Serotonin syndrome (Hunter criteria)
Having taken a serotonergic agent and presenting with one of more of: Clonus Agitation Diaphoresis Tremor Hyperreflexia Hypertonia Pyrexia
Duke Activity Status Index
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
Le Fort fractures
1 - horizontal
2 - pyramidal
3 - transverse
Maastricht classification of DCD
1 - DOA 2 - 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.
Sedation (ASA)
- 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)
Pulmonary hypertension (WHO)
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 disease Group 3: chronic lung disease Group 4: thromboembolic disease Group 5: unclear/multifactorial e.g. SCD
Cardiac disease in pregnancy (WHO)
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
Composite airway scoring systems (Wilson Sum Risk Score and Simplified Airway Risk Index)
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
Simplified Acute Physiology Score (SAPS)
Developed as simplification of APACHE
I-III, III most commonly used
20 variables
Worst values in first hour of ICU admission
Sequential Organ Failure Assessment (SOFA) and qSOFA
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 <15 2 or more = poor prognosis
Mortality Prediction Model (MPM)
I-II
Outcome prediction at 24, 48 and 72 hrs
AAA scores (Hardman Index and Glasgow Aneurysm Score (GAS))
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.
European System for Cardiac Operative Risk Evaluation (EuroSCORE)
Euroscore 20 or higher = too high risk for AVR, consider TAVI
CAM-ICU (Confusion Assessment Method for ICU)
(RASS to be -3 or above)
- Acute change or fluctuating course
- Inattention (SAVE A HAART) - >2 errors
- RASS anything other than 0
- 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).
4AT
Acute onset or fluctuating course
Attention (months backwards)
Alertness
AMT4 (age, DOB, place, year)
Score 4 or above significant (each item has several points)
ABCD2 score for TIA
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
NYHA
1: asymptomatic on ordinary activity
2: 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
King’s College Hospital liver transplant criteria
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 oedema Rising vasopressor requirements Major psychiatric comorbidity
Traumatic Brain Injury
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
Encephalopathy (West Haven and World Health Congress of Gastroenterology)
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
Cardiomyopathy
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)
American Spinal Injury Association (ASIA) impairment scale for spinal injury
A: complete
B: incomplete - sensory function preserved
C: incomplete - motor function partially preserved (MRC <3)
D: incomplete - motor function partially preserved (MRC >3)
E: normal
MRC grades 1-5
Specific cord syndromes: anterior cord, posterior cord, central cord, Brown-Sequard, conus medullaris, cauda equina
Bone Cement Implantation Syndrome
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 RFs ASA 3/4 COPD Diuretics Warfarin
Clinical Pulmonary Infection Score (CPIS) for VAP
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).
Evan’s score/PRST (awareness)
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.
Berlin criteria (ARDS)
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.
LSCS categories
Cat 1 - immediate threat to life of woman or fetus; decision to delivery interval (DDI) <30m
Cat 2 - maternal or fetal compromise but not immediately life threatening; DDI <75m
Cat 3 - no compromise but for early delivery
Cat 4 - elective, at time to suit woman and unit
Types of myocardial infarction
- Spontaneous atherosclerotic plaque rupture
- Supply/demand mismatch
- Sudden cardiac death
- PCI-related
5 CABG-related
KDIGO (Kidney Disease: Improving Global Outcomes)
[Basically a combination of previous RIFLE and AKIN criteria]
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 >12h
Stage 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.
Fitness for thoracic surgery
FEV1>2 for pneumonectomy
FEV1>1.5 for lobectomy
If not –> V/Q
ppo FEV1 > 40% ok
If not –> CPET
VO2 max >15 and AT >11 desirable, below this is high risk/consider non-operative options
CAGE questionnaire
Cut down
Angry
Guilty
Eye opener
(2 or more significant)
COPD
FEV1:FVC <0.7
Reversibility <12%
FEV1 >80 - mild 50-80 moderate 30-50 severe <30 very severe (NICE/GOLD criteria)
BMI
<18.5 underweight 18.5-25 normal 25-30 overweight 30-35 obese 35-55 morbidly obese >55 supermorbidly obese
SAH scoring systems
WFNS
1- GCS 15, no motor deficit
2 - GCS 13/14, no motor deficit
3 - 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 blood 2 - diffuse, no clot +/or layer <1mm 3 - localised clot +/or layer >1mm 4 - intracerebral or intraventricular clots
Other = Hunt and Hess (clinical features).
Revised Baux score (burns)
Age + % TBSA (+17 if inhalational injury)
> 140 considered unsurvivable
(Original did not include inhalational injury component. A P-Baux score exists for paediatrics.)
Burn severity
Superficial - erythema, pain Partial thickness (superficial or deep) - erythema, pain, blistering Full thickness - charring, white, painless
Burns unit referral criteria
BSA>10% adults, >5% children (2/3rd degree) NAI (children or adults) Associated traumatic injuries Pregnancy Special areas - hands, feet, perineum Inhalational injury Chemical or electrical burns
Hypovolaemic shock
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.
Weaning indices
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.
Apgar
Appearance (colour) Pulse Grimace Activity Respiration
Each scored 0-2
Done at 1 and 5 mins post birth
7 or more is normal
WHO performance status
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
GI bleed (Rockall, Glasgow-Blatchford)
Glasgow-Blatchford - Hb, urea - HR, BP - Syncope, malaena - Cardiac failure, liver disease Score 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
Early warning scores
- NEWS
- PEWS
- MEOWS
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.
Pancreatitis
- Severity (Glasgow, Atlanta, Balthazar)
- Diagnostic (IAP)
- Prognostic (Ranson)
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.
Injury Severity Score and RSS
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
Warkentin 4T HIT score
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 8
0-3 low probability
4-5 intermediate
6+ 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 severe
Type II - immune-mediated
Levels of evidence (literature)
GRADE system (Grading of Recommendations Assessment, Development and Evaluation)
Levels of evidence
1a: systematic review or meta-analysis
1b: 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
Types of data
Categorical - Nominal (blood groups) - Ordinal (ASA grade) Numerical - Discrete (no. of pts) - Interval (centigrade) - Ratio (Kelvin) - Continuous (weight)
SPRINT hip fracture audit 2014 recommendations
- Consultant/SAS anaesthetist
- Consider neuraxial in all pts
- Spinal using heavy bupivacaine <10mg with pt bad hip down
- Intrathecal opioids - fentanyl only
- Sedation - midazolam or propofol
- Always give supplemental O2
- Consider gas induction
- SV rather than IPPV
- Consider nerve blocks in all pts
- Do not combine GA/neuraxial
- Avoid hypotension
- Assess all for BCIS
Duke criteria for endocarditis
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.
Aortic dissection (Stanford and DeBakey)
Stanford
Type 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 beyond Type 2 (10%): starts in ascending aorta and is confined there Type 3 (30%): starts in descending aorta, rarely extends proximally but may extend distally
Also Svensson - defines type
NIH Stroke Scale, FAST, ROSIER (Recognition of Stroke in the Emergency Room)
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.
SMART-COP (prediction of ventilation/vasopressor requirement in CAP)
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 3
7+ risk 2 in 3
Light’s criteria
Pleural fluid:serum protein >0.5
Pleural fluid:serum LDH >0.6
Pleural fluid LDH >2/3 ULN for serum
1 or more = exudate
Useful 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”
Weaning criteria
A: patent
B: 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
Virchow’s triad
- 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
Weaning predictors
RSBI <105 (only valid if PEEP and PS are 0)
Post cardiac arrest goals
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
Levels of inpatient care
Levels of ICU
Inpatient care
0 - 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
CURB65 for CAP
Confusion Urea >7 RR>30 BP<90 systolic/60 diastolic Age 65 or over
Mortality 0 - 0.7% 1 - 3.2% 2 - 13.0% 3 - 17.0% 4 - 41.5% 5 - 57.0%
Hepatorenal syndrome criteria (International Club of Ascites)
- 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 prognosis
Type 2 HRS
Slower onset
Spontaneous
a/w refractory ascites
Grading of oesophageal varices by endoscopic appearance (Jalan and Hayes 2000)
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.
Abdominal compartment syndrome
Normal IAP = 5-7mmHg
Intra-abdominal HTN = >12mmHg
Abdominal compartment syndrome = >20mmHg (or abdominal perfusion pressure <50mmHg) with associated organ failure
Grade 1: 12-15
Grade 2: 16-20
Grade 3: 21-25
Grade 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.
ASA score
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.
Brain Trauma Foundation indications for invasive ICP monitoring
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)
Lundberg waves
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.
Asthma
- Acute severe
- Life-threatening
- Near-fatal
(BTS)
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
Beck’s triad (cardiac tamponade)
Hypotension
Distended neck vessels/raised JVP
Muffled heart sounds
Pelvic injuries
- Young-Burgess
- Tile
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 stable
B: Rotationally unstable, vertically stable
C: Rotationally and vertically unstable
Hypothermia
Mild: 35-32
Moderate: 32-28
Severe: <28
Swiss Staging System
Stage 1: conscious, shivering
Stage 2: impaired consciousness, no shivering
Stage 3: unconscious
Stage 4: respiratory arrest, possible VF/asystole
Stage 5: death
Care bundles
- Ventilator
- CVC insertion
- CVC maintenance
- Trache
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
- Dressing
CVC 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 access
Trache care bundle - 6
- Humidification
- Suctioning
- Inner tube care (2-4h)
- Dressing and tapes (24h)
- Cuff check
- Bedside safety equipment
ECMO referral criteria
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
Five key principles of the Mental Capacity Act 2005 (came into force 2007)
- Presumption of capacity
- Support individuals to make their own decisions
- Unwise decisions do not equal a lack of capacity
And in patients without capacity:
- Act in best interests
- Take the least restrictive option
Assessment of capacity
Two-stage functional test
- Is there an impairment of/disturbance in the functioning of a person’s mind or brain?
- 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.
Laboratory Risk Indicator for Necotizing fasciitis (LRINEC)
CRP >150 = 4 points WBC <15 = 0, 15-25 = 1, >25 = 2 Hb >13.5 = 0, 11-13.5 = 1, <11 = 2 Na+ <135 = 2 Creat >141 = 2 Glu >10 = 1
Low risk: up to 5
Moderate: 6-7
High: 8+
But 10% of ‘low risk’ category still had NF.
Burns assessment
- Palmar surface area
- Wallace rule of nines
- Lund and Browder chart
Modified Rankin score for neurodisability post stroke
0=asymptomatic
1=nosignificantdisabilitydespitesymptoms;fully functional
2=slightdisability
3=moderatedisabilitybut can walk withoutassistance
4=moderatelyseveredisability,unabletowalkwithoutassistance and needs help with ADLs
5=severedisability;bedridden,needing constant care
6 = dead
Clinical trial phases
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
Pulmonary embolism
Submassive
- RV strain but no CVS compromise
Massive
- RV dysfunction
- SBP <90
- Needing inotropes
Sepsis care bundles (2015)
- 3h
- 6h
Three hour care bundle - 4
- Measure lactate
- Take blood cultures before abx
- Broad spectrum abx
- 30ml/kg crystalloid if hypotensive or lactate >4
Six hour care bundle - 3
- If fluid unresponsive, start vasopressors and target MAP>65
- 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)
- Recheck lactate if initially elevated
Oxford/Bamford stroke classification
TACS - total anterior
PACS - partial anterior
POCS - posterior
LACS - lacunar
Solid organ trauma
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.
SCORTEN score for TEN
7 factors
Age ≥40 HR ≥120 Malignancy BSA detachment ≥10% (at day 1) Urea >10 Bicarb <20 Glucose >14
5 or more = 90% mortality
Full Outline of UnResponsiveness (FOUR score)
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.
Canadian C-spine rules
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.
Frailty
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)
Multiple Organ Dysfunction Score (MODS)
7 systems scored 0-4
First measurement of the day
Pressure adjusted HR = (HR x CVP) / MAP
Therapeutic Intervention Scoring System (TISS)
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
Murray score
2 Ps, 2 Cs
Each scored 0-4
PFR >40/40-30/30-23/23-13/<13kPa
PEEP <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)
RCS clinical criteria for major GI and vascular surgery
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
Ann Arbor staging system - now replaced by Lugano
Ann Arbor Stage 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 disease
AA stage 3/4 = advanced disease
A/B (absence or presence of constitutional sx) applies only to HL.
Wells score for DVT
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
Wells score for PE
Clinical signs and symptoms of DVT: 3
Alternative 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
Ambulance Prioritisation Algorithm Inter-Hospital Transfer Protocol 2011
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)
Clinical Institute Withdrawal Assessment for Alcohol scale, revised (CIWA-Ar)
10 domains:
Nausea and vomiting Tremor Paroxysmal sweats Anxiety Agitation Tactile disturbance Auditory disturbance Visual disturbance Headache Altered sensorium
Score 10-14 give 25mg chlordiaz, or >15 50mg
Scored every 2h for 24h
Max 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
Pain scales in ICU
Behavioural Pain Score (BPS)
Critical Care Pain Observation Tool (CPOT)
Truelove and Witts - UC severity index
Bowel movements Blood in stool Temperature HR Anaemia ESR
Each domain has a mild/moderate/severe category
Guedel classification of the stages of anaesthesia (1937)
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
PEEP ladder (ARDSnet 2004)
FiO2 - PEEP
- 3 - 6
- 4 - 8
- 5 - 10
- 6 - 12
- 7 - 14
- 8 - 16
- 0 - 20
Post cardiac arrest neurological outcome
Cerebral Performance Categories 1 - full recovery/mild disability 2 - moderate disability 3 - severe disability 4 - PVS 5 - dead
Glasgow Outcome Scale
Same categories but backwards i.e. 5 is best
Lactic acidosis (Cohen and Woods)
Type A: tissue hypoxia
Low CO, severe anaemia, regional hypoperfusion
Type B: no tissue hypoxia
B1: disease-related e.g. DKA, AIDS
B2: drug/toxin-related e.g. cyanide, alcohols, HAART, metformin
B3: inborn errors of metabolism e.g. pyruvate dehydrogenase deficiency
