Hip / Open Fracture Preop Risk Stratification

Hip/Open fracture Ortho Pre-Op Evaluation - Risk Stratification for surgery

High risk conditions: [no high risk condition from list below]
Unstable angina: new or increasing
MI: <45 days MI or <12 months, UNLESS seen by cardiology and recommended mgmt was implemented
CHF: new or worsening heart failure symptoms
Arrhythmia: 2nd or complete heart block, Ventricular arrhythmias, HR <45, Afib with RVR
Valve: severe valve stenosis or regurgitation accompanied by new or worsened symptoms or loud systolic murmur
Acute hyponatremia: Na<130
Hypertensive urgency: >180/120 mmHg
Preop hypotension: <90 SBP, <65 MAP

Revised Cardiac Risk Index (RCRI) for Intraoperative Risk: 
1. Isolated hip fracture is not a high-risk surgery: 0 points 
2. History of Ischemic heart disease [0][1] point 
3. History of CHF [0][1] point 
4. History of Cerebrovascular disease [0][1] point
5. Pre-operative treatment with insulin [0][1] point 
6. Pre-operative creatinine >2mg/dL [0][1] point
Total [ ] points, if RCRI < 2 NO FURTHER TESTING INDICATED

[RCRI>2:]
[elevated risk, METS >4, NO FURTHER TESTING indicated]
[elevated risk, METS <4, NO FURTHER TESTING as it would not impact decision to do surgery]
[elevated risk, METS unknown, NO FURTHER TESTING as it would not impact decision to do surgery]
[elevated risk, METS <4, FURTHER TESTING would impact decision to do surgery, consider cardiology consult]

Metabolic Equivalent Values (METS)
[RCRI <2, assessment not indicated in hip fracture algorithm]
[walking slowly = 2]
[walking normally = 3]
[walking briskly = 5]
[walking/hiking/jogging = 8]

Echo:
[Not indicated]
[Indicated for:] [new enlarged cardiac silhouette] [CHF or valve disease if not stable] [moderate valve disease if no echo in 1yr] [diastolic murmur] [grade II-III murmur] [dyspnea of unknown cause] [elevated PA pressure (>40mmHg mild, 50-60 moderate, >60 severe] 
[Not required pre-op: ordered for post-op mgmt, ok to proceed with surgery before results are available]
[Required pre-op: ordered urgently and discussed with cardiology on call for pre-op eval for surgery planned <24hrs from admit time]

EKG: for h/o CAD, males > 45, females >55.
[Afib, rate controlled]
[Afib with RVR, consult cardiology, check echo]
[2nd or complete heart block, consult cardiology]
[Ventricular arrhythmia, consult cardiology]
[HR <45, consult cardiology]
[Reviewed and unremarkable]
CXR:
[PNA noted, IV abx initiated]
[CHF pattern noted. Diuresis, Repeat CXR ordered STAT 0400, will f/u]
[Reviewed:] []
[HCG:]
[Not indicated, >50 yrs old or s/p hysterectomy]
[Indicated: urine quantitative neg]
[Indicated: urine quantitative positive, urine qualitative ordered STAT and OBGYN consulted, will f/u with recs]
T&S:
[reviewed][ordered STAT]
Blood thinners: []last dose: [time]
-continue dual antiplatelet therapy
-reverse coumadin per protocol
-stop DOAC
Last meal/PO intake: []
Code status: [Full code][DNR/DNI ][Unable to obtain due to AMS]

CBC: [Leukocytosis noted, UA wnl, CXR no acute process, likely reactive to trauma, repeat CBC ordered 0400, will f/u.] [Leukocytosis noted, workup complete, IV abx initiated.] [Hgb <8, PRBC on hold for OR.] [Plt <50, plt on hold for OR.] [Unremarkable]

BMP: [hyperkalemia: likely hemolyzed sample, STAT repeat K+ ordered, will f/u.] [AKI, creat elevated, IVFs, avoid nephrotoxic agents, repeat renal panel ordered for 0400, will f/u.] [CKD with hyperkalemia, K+ corrected repeat K+ ordered for 0400, will f/u.] [Severe hyponatremia, nephrology consulted, repeat Na ordered for 0400, will f/u]

Coags: [INR corrected, STAT INR ordered for 0400, will f/u.] [Unremarkable]

Assessment/Plan: Based on the hospital’s Geriatric Hip Fracture algorithm, and additional information, patient is [low][increased] risk for intra-operative cardiac events.
[Recommend proceed with surgery. The benefit of early surgery (prevention of complications related to immobility) outweigh the cardiac risks that might be prevented]

[Recommend delaying surgery. The patient has elevated risk and further pre-operative cardiac testing would impact decision to do surgery. Case discussed with cardiology oncall for urgent pre-operative evaluation as surgery planned for <24hrs from time of admission].



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**This algorithm is based on Medical Center of Plano Geriatric Hip Fracture Guideline 9/2018 and HCA hip alert protocol. 
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