Aouthmany Shaza, Siano Alyssa, Russ De Ante', Bustillo Mark
University of Toledo College of Medicine, Department of Emergency Medicine, Toledo, OH.
J Educ Teach Emerg Med. 2020 Jan 15;6(1):S24-S45. doi: 10.21980/J89Q0M. eCollection 2021 Jan.
The aim of this simulation is to educate emergency medicine interns, residents and advanced providers on the recognition, diagnosis, and management of heparin-induced thrombocytopenia (HIT). Communication, teamwork, and crisis resource management are incorporated into the case.
Heparin-induced thrombocytopenia is a life-threatening complication of heparin exposure (eg, unfractionated heparin, low molecular weight [LMW] heparin) that occurs in a small percentage of patients exposed.1 It results in a consumptive coagulopathy in which the clotting cascade is inappropriately activated, leading to a low platelet count yet hypercoagulable state. HIT is associated with mortality rates of 20-30%, with a similar percentage of patients becoming subsequently disabled due to severe complications including limb amputation, multi-system organ failure, stroke or other causes of morbidity.2 Heparin-induced thrombocytopenia often presents 5 to 15 days after starting heparin treatment, and with more outpatients being treated with heparin products, it is likely that a first-line provider, such as an emergency medicine physician, would be the first clinician to encounter these patients. The combination of thrombocytopenia and hypercoagulability, along with the rarity of the disease, can make this difficult to diagnose and puts the first line clinician at risk for mismanagement. It is important to be familiar with the signs and symptoms of HIT and to refrain from starting heparin or platelets upon discovery of thrombosis or thrombocytopenia because it will lead to severe and rapid patient deterioration. Therefore, the ability to quickly recognize and treat this condition properly is an essential skill for emergency medicine physicians. Our goal is to create a simulated case that familiarizes emergency providers to this condition so they can be comfortable diagnosing and managing it in a real clinical scenario.
After completing this simulated case, participants will be able to: Obtain a detailed history that includes recent medications, medical, surgical, and social history to evaluate for HIT risk factors.Perform an adequate neurovascular exam including evaluation of motor function, sensation, skin color, pulses, and capillary refill.Order appropriate laboratory testing and imaging for diagnosis of thrombocytopenia and arterial occlusion, including bed side doppler or ultrasound.Discuss and recognize the symptoms of HIT and the contraindications of platelet and heparin administration in the emergency department.Avoid administration of heparin in the emergency department setting and recognize that platelets may worsen thrombus formation and lead to limb amputation.2Select appropriate medications for treatment and determine appropriate disposition for a patient presenting with HIT.Demonstrate interpersonal communication with patient and family.Recognize that HIT with thrombosis is a potential complication in hospitalized patients and outpatient settings and is associated with high mortality rates.
This is a high-fidelity simulation case that allows participants to diagnose and treat HIT in a safe environment. The case is followed by a debriefing and small group discussion to review patient care skills, medical knowledge, interpersonal communication, and practice-based learning and improvement.
The educational content and efficacy were evaluated by oral feedback and a debriefing session immediately after completion of the simulation. Participants were provided with an evaluation at the completion of the debriefing session to provide qualitative feedback on the simulation case. A quality Likert Scale was used for the evaluation.
Post-simulation feedback resulted in positive reception, and learners found it useful to run through a high-risk case potentially seen in the emergency department. Out of the 21 participants, 14 responded to the evaluation. Feedback was overwhelmingly positive with the majority rating the simulation as excellent or good. The simulation improved awareness of the symptoms of HIT and contraindications of immediate platelet and/or heparin initiation upon vessel occlusion and thrombocytopenia discovery. Heparin-induced thrombocytopenia, pain control, resuscitation efforts, coagulation disorders, history taking, undifferentiated patient, arterial occlusion, hematology, emergency medicine simulation.
本次模拟的目的是对急诊医学实习生、住院医师和高级医疗人员进行肝素诱导的血小板减少症（HIT）的识别、诊断和管理方面的培训。沟通、团队合作和危机资源管理融入到了该病例中。
肝素诱导的血小板减少症是肝素暴露（如普通肝素、低分子[LMW]肝素）的一种危及生命的并发症，在一小部分接受肝素治疗的患者中发生。它会导致一种消耗性凝血病，其中凝血级联反应被不恰当地激活，导致血小板计数降低但处于高凝状态。HIT的死亡率为20%至30%，有相似比例的患者随后因严重并发症而致残，包括肢体截肢、多系统器官衰竭、中风或其他发病原因。肝素诱导的血小板减少症通常在开始肝素治疗后5至15天出现，并且随着越来越多的门诊患者接受肝素产品治疗，一线医疗人员，如急诊医学医生，很可能是首批接诊这些患者的临床医生。血小板减少症和高凝状态的结合，以及该疾病的罕见性，可能使其难以诊断，并使一线临床医生面临管理不当的风险。熟悉HIT的体征和症状，并且在发现血栓形成或血小板减少症时避免使用肝素或血小板，这一点很重要，因为这会导致患者病情严重且迅速恶化。因此，快速识别并正确治疗这种病症的能力是急诊医学医生的一项基本技能。我们的目标是创建一个模拟病例，使急诊医疗人员熟悉这种病症，以便他们在实际临床场景中能够自如地进行诊断和管理。
完成这个模拟病例后，参与者将能够：获取详细病史，包括近期用药、医疗、手术和社会史，以评估HIT风险因素。进行充分的神经血管检查，包括评估运动功能、感觉、皮肤颜色、脉搏和毛细血管再充盈情况。为诊断血小板减少症和动脉闭塞安排适当的实验室检查和影像学检查，包括床边多普勒检查或超声检查。讨论并识别HIT的症状以及急诊科血小板和肝素给药的禁忌证。在急诊科环境中避免使用肝素，并认识到血小板可能会使血栓形成恶化并导致肢体截肢。选择合适的药物进行治疗，并确定HIT患者的适当处置方式。展示与患者及其家属的人际沟通。认识到伴有血栓形成的HIT是住院患者和门诊患者中的一种潜在并发症，且与高死亡率相关。
这是一个高保真模拟病例，使参与者能够在安全环境中诊断和治疗HIT。病例之后是总结汇报和小组讨论，以回顾患者护理技能、医学知识、人际沟通以及基于实践的学习与改进。
在模拟完成后，通过口头反馈和总结汇报环节对教育内容和效果进行评估。在总结汇报环节结束时，为参与者提供一份评估表，以提供关于模拟病例的定性反馈。使用质量李克特量表进行评估。
模拟后的反馈得到了积极回应，学习者发现演练一个急诊科可能遇到的高风险病例很有用。在21名参与者中，14人回复了评估。反馈绝大多数是积极的，大多数人将模拟评为优秀或良好。该模拟提高了对HIT症状以及在发现血管闭塞和血小板减少症时立即启动血小板和/或肝素的禁忌证的认识。肝素诱导的血小板减少症、疼痛控制、复苏努力、凝血障碍、病史采集、未分化患者、动脉闭塞、血液学、急诊医学模拟。
