Risk Score to Predict QTc Prolongation in Hospitalized Patients

For patients with COVID-19, we are using drugs that prolong QT-interval.  The risk of life-threatening arrhythmias from QT prolongation may be higher.  This article reports a scoring system to identify patients that are at risk for QT prolongation.

The study found that the following factors predicted QTc prolongation:  female, sepsi, LV dysfunction, administration of QT-prolong drug, >= 2 QT prolonging drugs, loop-diuretic, age >68, serum K <3.5, admitting ATc >450ms.

A risk score was developed.  Risk was classified as low (score of 0-6), moderate (7-10) and high (11-21).

 

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A high risk score >11 was associated with 74% Sn and 77% Sp (PPV 79% NPV 76) for predicting QTc prolongation.  Incidence of QTc prolongation 15% in low risk, 37% in moderate risk and 73% in high risk.

 

 

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Reference:

Tisdale, J., Jaynes, H., Kingery, J., Mourad, N., Trujillo, T., Overholser, B., & Kovacs, R. (2013). Development and Validation of a Risk Score to Predict QT Interval Prolongation in Hospitalized Patients. Circulation: Cardiovascular Quality And Outcomes, 6(4), 479-487. doi: 10.1161/circoutcomes.113.000152

Risk for Cerebrovascular Injury after Blunt Trauma

There are two criteria used to screen patients with blunt trauma of cerebrovascular injury:  the Denver and Memphis criteria
Denver Criteria

1. LeForte II or III fracture pattern

2. Cervical spine fracture or subluxation

3. Basilar skull fracture with involvement of the carotid canal

4. DAI with GCS <6

5.  Near hanging with anoxic brain injury
Memphis Criteria:

1. Cervical spine fracture

2.  LeForte II or III facial fracture

3.  Basilar skull fracture with involvement of the carotid canal

4.  Horner’s syndrome

5.  Neurologic deficit not explained by imaging studies

6.  Neck soft-tissue injury (seatbelt sign, hematoma, or hanging)

Weaning Parameters

Weaning parameter values typically used to predict weaning outcome

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Hemodynamic and respiratory parameters used to determine readiness for spontaneous breathing trial

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Hemodynamic and respiratory parameters used to determine an unsuccessful spontaneous breathing trial

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Hemodynamic and respiratory parameters used to determine readiness for spontaneous breathing trial in neurosurgical patients

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Reference:

Layon, A. Joseph, Andrea Gabrielli, and William Friedman. Textbook Of Neurointensive Care. London: Springer London, 2013. Print.

NEXUS Criteria for C-spine Injury

N.E.X.U.S. = National Emergency X-ray Utilization Study

Utility:  if criteria fulfilled, low risk for spinal injury and c-spine can be cleared without the need for imaging

NEXUS Criteria:

  • Normal level of alertness
  • Not intoxicated
  • No midline cervical spine tenderness
  • No other painful injuries that may distract the patient from a less painful (but broken) neck
  • No focal neurologic deficits

Only if patient fulfills all 5 criteria – then forego imaging.  Otherwise, proceed with imaging.

Mnemonic: NSAID (neuro deficit, spinal tenderness, AMS, intoxication, distracting injury)

National Emergency X Radiography Utilization Study NEXUS Criteria Emergency Medicine Practice.JPG

 

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Reference:

Hoffman, Jerome R et al. “Selective Cervical Spine Radiography In Blunt Trauma: Methodology Of The National Emergency X-Radiography Utilization Study (NEXUS)”. Annals of Emergency Medicine 32.4 (1998): 461-469. Web.

RIFLE Criteria for Acute Kidney Injury

The table below shows the RIFLE (Risk Injury Failure Loss End stage) classification scheme for acute kidney injury.

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This system has a separate criteria for creatinine and urine output.  If the patient’s condition falls under two different levels, then the worse classification should be used.

RIFLE-FC = denotes ‘acute-on-chronic’ disease.

RIFLE-FO = when RIFLE-F classification is reached by urine output criteria only

 

Checklist:  AKI work-up

  • Urinary sediment
  • Urinalysis
  • exclude obstruction
  • review of meds
  • rhabdomyolysis: creatine kinas, free myoglobin
  • vasculitis: CXR, blood smear, measurement of nonspecific inflammatory markers, specific antibodies (anti-GBM, ANCA, anti-DNA, anti-smooth muscle)
  • TTP: LDH, haptoglobin, unconjugated bilirubin, free hemoglobin
  • Cryoglobulins
  • Bence-Jones proteins
  • Renal biopsy

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References

Bersten, Andrew D, and Neil Soni. Oh’s Intensive Care Manual. London: Elsevier Health Sciences UK, 2013. Print.