Feature

Playing by the Rules: Using Decision Rules Wisely Part 2, Nontraumatic Conditions

Emergency Medicine. 2018 December;50(12):1-14

References

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30. Hess EP, Perry JJ, Calder LA, et al. Prospective validation of a modified Thrombolysis In Myocardial Infarction risk score in emergency department patients with chest pain and possible acute coronary syndrome. Acad Emerg Med. 2010;17(4):368-375.

31. Macdonald SPJ, Nagree Y, Fatovich DM, ad Brown SGA. Modified TIMI risk score cannot be used to identify low-risk chest pain in the emergency department: a multicenter validation study. Emerg Med J. 2014;31:281-285.

32. Hess EP, Agarwal D, Chandra S, et al. Diagnostic accuracy of the TIMI risk score in patients with chest pain in the emergency department: a meta-analysis. CMAJ. 2010;182(10):1039-1044.

33. Than, M, Cullen L, Aldous S, et al. 2-Hour accelerated diagnostic protocol to assess patients with chest pain symptoms using contemporary troponins as the only biomarker: the ADAPT trial. JACC. 2012;59(23):2091-2098.

34. Carlton EW, Khattab A, Greaves K. Identifying patients suitable for discharge after a single-presentation high-sensitivity Troponin result: a comparison of five established risk scores and two high-sensitivity assays. Ann Emerg Med. 2015;66(6):635-645.

35. Poldervaart JM, Langedijk M, Backus BE, et al. Comparison of the GRACE, HEART and TIMI score to predict major adverse cardiac events in chest pain patients at the emergency department. Int J Cardiol. 2017;227:656-661.

36. Nieuwets A, Poldervaart JM, Reitsma JB, et al. Medical consumption compared for TIMI and HEART score in chest pain patients at the emergency department: a retrospective cost analysis. BMJ Open. 2016;6:e010694.

37. Wells PS, Ginsberg JS, Anderson DR, et al. Use of a clinical model for safe management of patients with suspected pulmonary embolism. Ann Intern Med. 1998;129:997-1005.

38. Wells PS, Anderson DR, Rodger M, et al. Derivation of a simple clinical model to categorize patients’ probability of pulmonary embolism: increasing the model’s utility with the SimpliRED D-dimer. Thromb Haemost. 2000;83(3):416-420.

39. Wells PS, Anderson DR, Rodger M, et al. Excluding pulmonary embolism at the bedside without diagnostic imaging: management of patients with suspected pulmonary embolism presenting to the emergency department by using a simple clinical model and D-dimer. Ann Intern Med. 2001;135:98-107.

40. Wolf SJ, McCubbin TR, Feldhaus KM, Faragher JP, Adcock DM. Prospective validation of Wells’ criteria in the evaluation of patients with suspected pulmonary embolism. Ann Emerg Med. 2004;44:503-510.

41. Chagnon I, Bounameaux H, Aujesky D, et al. Comparison of two clinical prediction rules and implicit assessment among patients with suspected pulmonary embolism. Am J Med. 2002;113:269-275.

42. Christopher Study Investigators. Effectiveness of managing suspected pulmonary embolism using an algorithm combining clinical probability, D-dimer testing, and computed tomography. JAMA. 2006;295:172-179.

43. Kline JA, Mitchell AM, Kabrhel C, Richman PB, Courtney DM. Clinical criteria to prevent unnecessary diagnostic testing in emergency department patients with suspected pulmonary embolism. J Thromb Haemost. 2004;2:1247-1255.

44. Kline JA, Courtney DM, Kabrhel C, et al. Propsective multicenter evaluation of the pulmonary embolism rule-out criteria. J Thromb Haemost. 2008;6:772-780.

45. Penaloza A, Soulie C, Moumneh T, et al. Pulmonary embolism rule-out criteria (PERC) rule in European patients with low implicit clinical probability (PERCEPIC): a multicenter, prospective, observational study. Lancet Haematol. 2017;4:e615-e621.

46. Freund Y, Cachanado M, Aubry A, et al. Effect of the Pulmonary Embolism Rule-Out Criteria on subsequent thromboembolic events among low-risk emergency department patients. The PROPER randomized clinical trial. JAMA. 2018;319(6):559-566.

47. Hugli O, Righini M, Le Gal G, et al. The pulmonary embolism rule-out criteria (PERC) rule does not safely exclude pulmonary embolism. J Thromb Haemost. 2011;9:300-4.

48. Theunissen JMG, Scholing C, van Hasselt WE, van der Maten J, ter Avest E. A retrospective analysis of the combined use of PERC rule and Wells score to exclude pulmonary embolism in the Emergency Department. Emerg Med J. 2016;33:696-701.

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50. Shapiro NI, Wolfe RE, Moore RB, Smith E, Burdick E, Bates DW. Mortality in Emergency Department Sepsis (MEDS) score: a prospectively derived and validated clinical prediction rule. Crit Care Med. 2003;31(3):670-675.

51. Shapiro NI, Howell MD, Talmor D, Donnino M, Ngo L, Bates DW. Mortality in Emergency Department Sepsis (MEDS) score predicts 1-year mortality. Crit Care Med. 2007;35(1):192-198.

52. Sankoff JD, Goyal M, Gaieski DF, et al. Validation of the Mortality in Emergency Department Sepsis (MEDS) score in patients with the systemic inflammatory response syndrome (SIRS). Crit Care Med. 2008;36(2):421-26.

53. Jones AE, Saak K, Kline JA. Performance of the Mortality in Emergency Department Sepsis score for predicting hospital mortality among patients with severe sepsis and septic shock. Am J Emerg Med. 2008;26(6):689-692.

54. Carpenter CR., Keim SM, Upadhye S, Nguyen HB. Risk stratification of the potentially septic patient in the emergency department: the Mortality in the Emergency Department Sepsis (MEDS) score. J Emerg Med. 2009;37(3):319-327.

55. Hermans MAW, Leffers P, Jansen LM, Keulemans YC, Stassen PM. The value of the Mortality in Emergency Department Sepsis (MEDS) score, C reactive protein and lactate in predicting 28-day mortality of sepsis in a Dutch emergency department. Emerg Med J. 2012;29(4):295–300.

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The greater the number of points, the higher the risk for imminent stroke, from low (0-3 points) to moderate (4-5 points) to high (6-7 points). The initial retrospective internal validation study found that the low, moderate, and high groups correlated to 7-day stroke risk of 1.2%, 5.9%, and 11.7%, respectively. Subsequently, the ABCD2 score was rapidly incorporated into institutional and national protocols for assessing risk for stroke and featured prominently in the 2009 American Heart Association guidelines on TIA, which recommend hospitalization for a score of 3 or greater.^4,5

More recently, a multicenter prospective external validation study of more than 2000 TIA patients found that using the American Heart Association recommended cutoff of 3 or greater resulted in a sensitivity of 94.7% for detecting those patients who sustained a stroke within 7 days, but a specificity of only 12.5%.⁶ The investigators concluded that a specificity this low would require “almost all” of the TIA patients in their cohort (87.6%) to be admitted to the hospital—even though only 3.2% of their patients had a stroke within 90 days.⁶ Even when examined at other cutoff scores, the investigators found the ABCD2 score to have poor accuracy.⁶

Comment: Decreasing resource utilization is a laudable goal, but it does not appear that the ABCD2 score provides much guidance on which TIA patients can safely go home. Moreover, the increasing availability of advanced imaging and tele-neurology consultation in the ED have changed the landscape of TIA and stroke care. Many EPs have since argued that the ABCD2 score adds little to their evaluation.⁷

Abdomen

Alvarado Score

There are multiple clinical prediction rules for appendicitis. Among the most commonly utilized by EPs and surgical consultants are the Alvarado score and the Appendicitis Inflammatory Response Score. The Alvarado score was derived in 1986 based on a retrospective review of 305 abdominal pain patients of whom 227 (aged 4 to 80 years) had appendicitis.8 Factors were identified and weighted, which can be recalled through the mnemonic MANTRELS:

Migration of pain to the right lower quadrant: 1 point
Anorexia or acetone in urine: 1 point
Nausea or vomiting: 1 point
Tenderness in the right lower quadrant: 2 points
Rebound tenderness: 1 point
Elevation of the temperature > 37.3°C: 1 point
Leukocytosis >10K X 109/L: 2 points
Shift to the left of neutrophils (>75%): 1 point

The original article posited that a score of 5 or 6 was “compatible” with the diagnosis of acute appendicitis—necessitating further observation for possible appendicitis—and that higher scores indicated an increasing probability of disease.⁸ Of note, the rule has also been adapted for clinical settings where differentials are not easily obtainable with the left shift criterion removed; this is known as the modified Alvarado score and calculated out at a maximum of 9.⁹