Decision Rules And Clinical Scoring Systems By Chris Krause

Front 1

What is the Canadian C Spine Rule?

Back 1

Inclusion criteria: For alert stable trauma patients where C-spine injury is a concern.
Exclusion criteria: Altered mental status, age under 16, acute neurological symptoms (e.g. paralysis), known C-spine disease or injury.

The rule has 2 steps - first, assess for high risk factors that require automatic Xray. Then, if none are present, assess for low-risk criteria that would allow clinical testing of the neck.

HIGH RISK FACTORS:
1) Age >65
2) Paresthesias in extremities
3) Dangerous mechanism* (1) fall from >3 feet or >5 stairs; 2) axial load to head (e.g. diving); 3) High speed MVC (>100 km/hr) or ejection, or rollover; 4) motorized recreational vehicle; 5) bicycle or pedestrian vs car)

IF ANY - then X ray - IF NONE - go to low-risk factors.

LOW-RISK FACTORS:
1) Simple read-end MVC (i.e. not hit at high speeds, not high by a much larger vehicle, not pushed into oncoming traffic)
2) Sitting position in ED
3) Ambulatory at ANY time
4) Delayed onset of neck pain
5) Absence of midline tenderness.

IF ANY - then take off collar and examine - IF NONE - X ray.

If eligible to be examined, and can rotate head 45 degrees in each direction - CLEARED.
IF UNABLE - X-ray.

Front 2

What is the Canadian CT Head Rule?

Back 2

Remember 5 Inclusion/Exclusion criteria:
- must be a trauma case
- must be a minor head injury (GCS 13-15)
- Only applies to age > 16
- exclude any OBVIOUS open skull fracture
- exclude anticoagulated patients or those with bleeding problems

5 Features High Risk for Intervention
1) GCS <15 at 2 hours post injury
2) Suspected open or depressed skull fracture
3) Any sign of basal skull fracture (there are 4)
4) 2 or more episodes of vomiting
5) Age >= 65

2 Features Medium Risk for Brain Injury
1) Amnesia before impact >30 minutes
2) Dangerous mechanism (there are 3)
- pedestrian vs car
- ejection
- fall from >= 3 feet or >= 5 stairs

Front 3

What are the Wells DVT Criteria?

Back 3

Each of the 10 items is assigned one point.

1) Active cancer
2) Bedridden recently >3 days or surgery within the past month.
3) Calf diameter >3cm greater than other leg.
4) Collateral superficial veins present.
5) Entire leg swollen.
6) Localized tenderness along deep vein system.
7) Pitting edema, worse in affected leg.
8) Recent paralysis, plaster, or paresis of affected leg?
9) Previous history of DVT.
10) Other diagnosis more likely than DVT - MINUS TWO POINTS.

If sum of the score is 2 or more, investigate for DVT.

Front 4

What is the modified Wells Score for PE?

Back 4

1) Signs / symptoms of DVT - 3 points
2) Heart rate > 100 bpm - 1.5 points
3) Immobilization or surgery in past 4 weeks - 1.5 points
4) Previous PE or DVT - 1.5 points
5) Hempotysis - 1 point
6) Active cancer - 1 point
7) No other Dx more likely than PE - 3 points

Score of 0-4 - PE unlikely
Score of 5 or more - PE likely

Front 5

What is the PERC Rule?

Back 5

A list of criteria, the absence of ALL of which allows you to discharge a patient with suspected PE without ANY further workup (i.e. no D-dimer).

There are 8 Items:
1) Age > 50
2) Initial HR > 100
3) Initial O2 sat < 94%
4) Unilateral leg swelling
5) Hemoptysis
6) Recent surgery
7) History of VTE
8) Estrogen use

Mnemonic: HAD CLOTS - Hormone use, Age >50, DVT/PE in the past, Coughing up blood, Leg swelling, O2 sats <94%, Tachycardia, Surgery.

Front 6

What are the Ottawa Ankle (and Foot) Rules?

Back 6

Ottawa Ankle Rule - A patient requires an X-ray of the ankle only if the following conditions are met:

Pain in the ankle PLUS at least one of:
- tenderness of the posterior edge of the distal 6cm of lateral OR medial malleolus
- inability to weight bear BOTH on-scene and in the ED (4 steps).

Ottawa Foot Rule - a patient requires an X-ray of the foot only if they have pain in the mid-foot zone and at least one of the following:
- Bony tenderness over the navicular bone.
- Bony tenderness at the base of the 5th metatarsal.
- Inability to weight bear on scene AND in the ED (4 steps).

Front 7

What are the NEXUS criteria and how does the rule compare to Canadian C-spine Rule?

Back 7

NEXUS consists of 5 criteria. Unless a patient fulfills them all, Xrays are required.

It is less specific than the CCR but it is validated in a pediatric population (how young? LOOK THIS UP)

The 5 criteria spell NSAID:
N - Neurology - i.e. no neurological deficit
S - Stable and alert - i.e. normal level of consciousness
A - Absence of midline tenderness
I - Intoxication - i.e. NO intoxication
D - Distraction - i.e. NO distracting injuries

Front 8

Provide a list of suicide risk factors.

Back 8

The mnemonic SAD PERSONS lists 10 risk factors:
S - Sex - male.
A - Age - older age.
D - Depression - history of depression.
P - Previous attempt.
E - Ethanol abuse.
R - Rational thinking loss, i.e. psychotic features.
S - Social supports - lack of support system.
O - Organized plan.
N - No spouse.
S - sickness - any kind of chronic illness or disease.

Front 9

What are the SIRS Criteria?

Back 9

SIRS = Systemic Inflammatory Response Syndrome.

It is fulfilled if 2 of the following 4 criteria are met:

1) Core temperature of greater than 38.3 or less than 36.

2) Heart rate greater than 90 beats/minute in the absence of an external cause.

3) Mean respiratory rate >20, or PaCO2 <32.

4) Leukocyte count greater than 12,000 or less than 4,000, or greater than 10% immature bands.

Front 10

What is the PECARN rule for children at very low risk of clinically-important brain injuries?

Back 10

Note that this rule has not been independently validated (only validated in the same study population).

Two categories: Children under 2, and children over 2.

There are THREE HIGH RISK Criteria for Children under 2:
1) GCS=14; 2) Other sign of altered mental status; 3) Palpable skull fracture
--> All these children need CTs (risk of ciTBI 4-5%)

There are FOUR MEDIUM RISK Criteria for children under 2:
1) Non-frontal hematoma; 2) LOC less than 5 seconds; 3) Not acting normally per parent; 4) Severe mechanism* (defined as high mechanism MVC -including rollover; struck by car without helmet; fall > 3-5 feet; or head struck by high impact object).
--> Consider CT vs observation for these (risk of ciTBI ~1% - most of these are in the extremely young or those with multiple or severe symptoms).

There are THREE HIGH RISK Criteria for children over 2:
1) GCS=14; 2) Other signs of altered mental status; 3) Signs of basal skull fracture.
--> All these children need CT (risk of ciTBI 4-5%).

There are FOUR MEDIUM RISK Criteria for children over 2:
1) History of LOC; 2) History of vomiting; 3) Severe headache; 4) Severe mechanism of injury* (defined as high mechanism MVC - including rollover; struck by car without helmet; fall > 3-5 feet; or head struck by high impact object).
--> Consider CT vs observation for these (risk of ciTBI ~1%, most of which are in patients with multiple or severe symptoms).

Patients without ANY of the above features --> NO CT. Risk of radiation from CT scan greater than risk of missed ciTBI.

Front 11

What are the Centor Criteria for pharyngitis?

How does the score guide management?

Back 11

A scoring system to assess the likelihood that a given sore throat is strep throat. It has four elements:

1) Tonsillar exudate
2) Tender anterior cervical nodes
3) Absence of cough
4) Fever

In the modified Centor criteria you add a point for age 3-15, and subtract one for age over 44.

If the score is 0-1: no testing, no treatment.

If the score is 2-3: throat swab, treat if positive.

If the score is 4-5: Throat swab, can begin treatment immediately if you so desire (risk of strep throat ~50%).