Emergency Medicine Rotation

HEART Score

• Purpose: Predicts 6-week risk of major adverse cardiac event(s) (MACE) in patients with chest pain.

• History:

• EKG: nonspecific repolarization changes (+1), ST deviation (+2)

• Age: <45 (0), 45-64 (+1), >65 (+2)

• Risk factors: 1-2 RFs (+1), >3 RFs or atherosclerotic dz (+2)

  • HTN, Hyperchol, DM, obesity (BMI >30), smoking, +FH,

  • Atherosclerotic dz (prior MI, PCI/CABG, CVA/TIA, or PAD)

• Troponin: 1-3x normal limit (+1), >3x normal limit (+2)

• Score:

  • <3: Low risk- discharge

  • 4-6: Intermediate risk- observe

  • >7: High risk- admit

Wells’ Criteria for PE

• Purpose: risk of PE

• S/Sx of DVT

• PE is #1 Dx or equally likely

• HR >100

• Immobilization >3 d or surgery w/in prior 4 wk

• Previously diagnosed PE or DVT

• Hemoptysis

• Malignancy w/ tx w/in 6 mos or palliative

• Score:

  • <2: Low probability - PERC Rule

  • 2-6: Intermediate probability - D-dimer

  • >6: High probability - CT PA

PERC Rule

• Purpose: Rule out PE in patients w/ low Wells’ Score (PE risk)

• <50 yo

• HR <100

• O2 >95%

• No hemoptysis

• No unilateral leg swelling

• No estrogen use

• No prior DVT or PE

• No surgery/trauma requiring hospitalization w/in 4 wks

• Score:

  • Does not meet criteria - D-dimer if low-risk

  • Meets all criteria - rules out PE

Wells’ Criteria for DVT

• Purpose: risk of DVT

• Active cancer (tx or palliative w/in 6 mos)

• Bedridden >3 d or surgery w/in 12 wk

• Unilateral calf swelling >3 cm

• Collateral (nonvaricose) superficial veins present

• Entire leg swollen

• Localized tenderness along the deep venous system

• Pitting edema

• Paralysis, paresis, or recent plaster immobilization of the LE

• Previously documented DVT

• Alternative dx to DVT as likely or more likely (-2)

• Score:

  • <0: Unlikely - D-dimer to r/o

  • 1-2: Increased risk - D-dimer to r/o

  • >3: High risk - Venous US

NIH Stroke Scale (NIHSS)

• Purpose: Quantifies stroke severity + monitors for neuro changes

• 1a: Level of consciousness

• 1b: Ask what is your age and what is the month?

• 1c: Command blink your eyes and squeeze my hand.

• 2: Horizontal gaze/EOM

• 3: Visual fields

• 4: Facial palsy

• 5: Motor arms

• 6: Motor legs

• 7: Limb ataxia- FNF/heel-shin

• 8: Sensation- sharp/dull

• 9: Language/aphasia

• 10: Dysarthria (ex. slurring)

• 11: Extinction/inattention

• Score:

  • 0 = No stroke

  • 1-2 = Minor stroke

  • 5-14 = Moderate stroke

  • >15 = Severe stroke

  • Time is brain. Consult Neuro. Non-contrast CT Head w/in 20 mins of arrival.

CHA₂ DS₂ VASc Score

• Purpose: Stroke risk for patients w/ atrial fibrillation

• CHF

• HTN

• A₂ >75 yo

• DM

• S₂ Stroke/TIA/thromboembolism

• Vascular (MI, PAD, or aortic plaque)

• Age 65-74 yo

• Sex (F +1)

• Score:

  • 0 = no anticoagulation

  • 1 = oral anticoagulation or antiplatelet

  • 2 = oral anticoagulation (DOACs or warfarin, not ASA)

CURB-65 Score

• Purpose: Pneumonia severity

• Confusion

• BUN >19 mg/dL (>7 mmol/L urea)

• RR >30

• Systolic BP <90 or Diastolic BP <60

• Age >65 yo

• Score:

  • 0-1 = Low risk - outpatient care

  • 2 = Intermediate risk - inpatient v. observation admission

  • >3 = High risk - inpatient admission (consider ICU if >4)

Ddx for “Abd pain”

1. AAA

2. Ectopic pregnancy

3. Appedicitis

4. Bowel Obstruction

5. Perforated viscus

6. Mesenteric Ischemia

7. Pancreatitis

8. Cholecystitis/Biliary Dz

9. Nephrolithiasis

10. Sepsis/Intra-abdominal infection

Ddx for “shortness of breath”

1. PE

2. ACS/MI

3. HF/Pulmonary Edema

4. Asthma or COPD Exacerbation

5. PNA

6. Pneumothorax

7. Anaphylaxis

8. Upper airway obstruction- angioedema or FB

9. Metabolic acidosis- DKA or sepsis

10. Sepsis

11. Arrhythmia- a fib

12. Aortic stenosis, aortic regurg, mitral stenosis, mitral regurg

Ddx for “chest pain”

1. ACS- unstable angina or MI

2. PE

3. Aortic dissection

4. Tension pneumothorax

5. Pericardial tamponade

6. Esophageal rupture (Boerhaave)

7. PNA

8. Pericarditis- relieved by sitting + leaning forward

9. GERD

10. Costochondritis

11. Arrhythmia/Aortic stenosis

Workup: VS, EKG, Troponin, BNP, CXR, CBC/CMP

Infectious Endocarditis

Peripheral Sx: FROM JANE

Fever (MC)

Roth spots- retinal hemorrhages w/ pale centers

Osler nodes- Painful (ouchy) nodules on palms/fingers

Murmur- new or changing

Janeway lesions- Painless macules on palms/soles

Anemia

Nail-bed hemorrhage- splinter hemorrhages

Emboli

Dx: Modified Duke Criteria

Tx:

• Native valve - anti-staph PCN + ceftriaxone

  • If MRSA suspected - vancomycin + ceftriaxone

• Prosthetic valve - vancomycin + gentamicin + rifampin

• Fungal - amphotericin B

• If high-risk pt undergoing high-risk procedure, prophylaxis w/ amoxicillin 2g PO 1 hr prior.

Beck’s Triad

1. Hypotension- decreased BP

2. Muffled heart sounds- distant

3. Elevated neck veins- distended jugular veins (JVD)

Dx: Pericardial tamponade

• EKG: electrical alternans + low-voltage QRS

• CXR: ‘water-bottle/canteen’ heart

• Echo = gold standard - RV collapse

Tx: pericardiocentesis

R and R’ in V4-V6

LBBB

R and R’ in V1-V3

RBBB

New York Heart Failure Classification

• Class I: w/o limitation of physical activity

• Class II: slight limitation. comfortable at rest.

• Class III: marked limitation. comfortable at rest.

• Class IV: complete limitation. discomfort at rest.

Tx:

• Systolic L HF - ACEI + BB + Loop diuretic (ex. furosemide/Lasix)

• Diastolic HF - ACEI + BB or CCB

Ddx for “palpitations”

• Anxiety

• Electrolyte abnormality- hypokalemia or hypomagnesemia

• Hyperthyroidism

• Ischemic heart disease

• Ingestion of stimulant(s)- cocaine, amphetamines, caffeine

• Medications- digoxin, BB, CCB, hydralazines, diuretics, minoxidil

• Pheocytochromocytoma

• Hypoglycemia in DM1

• MVP

• A fib

• WPW Syndrome

• Sick sinus syndrome

• PSVT