Peripartum Cardiomyopathy.

Victoria L Morris, Carolina Mendoza, Gowri S Stevens, Jessica L Wilson, Adeola A Kosoko
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Heart failure with reduced ejection fraction and/or reduced systolic function diagnosed in patients during the last month of pregnancy or up to five months following delivery defines PCCM.1 Another broader definition from the European Society of Cardiology defines PPCM as heart failure that occurs \"towards the end of pregnancy or in the months following delivery, where no other cause of heart failure is found.\"2 Though PPCM occurs worldwide, most data is extracted from the United States (incidence 1:900 to 1:4000 live births), Nigeria, Haiti, and South Africa.3,4Risk factors for PPCM include pre-eclampsia, multiparity, and advanced maternal age. Unfortunately, the complete pathophysiology of PPCM remains unclear. However, it is important for emergency physicians to be aware of this rare diagnosis because though 50-80% of women with PPCM may eventually recover normal left ventricle systolic function,5 positive outcomes depend on timely recognition of PPCM as a disease and the appropriate management of heart failure. Symptomatic PPCM is an emergent condition that requires an attentive and knowledgeable emergency medicine physician for rapid recognition and treatment. A simulation of this rare condition can give residents the experience of identifying and managing this disease that they might not otherwise see personally during their training.</p><p><strong>Educational objectives: </strong>By the end of this simulation session, learners will be able to: 1) initiate a workup of a pregnant patient who presents with syncope, 2) accurately diagnose peripartum cardiomyopathy, 3) demonstrate care of a gravid patient in respiratory distress due to peripartum cardiomyopathy, 4) appropriately manage cardiogenic shock due to peripartum cardiomyopathy.</p><p><strong>Educational methods: </strong>This simulation was conducted as a high-fidelity medical simulation case followed by a debriefing. 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引用次数: 0

Abstract

Audience: This simulation is appropriate for emergency medicine (EM) residents of all levels.

Introduction: Peripartum cardiomyopathy (PPCM) is a rare, idiopathic condition that occurs in the mother around the time of childbirth. Heart failure with reduced ejection fraction and/or reduced systolic function diagnosed in patients during the last month of pregnancy or up to five months following delivery defines PCCM.1 Another broader definition from the European Society of Cardiology defines PPCM as heart failure that occurs "towards the end of pregnancy or in the months following delivery, where no other cause of heart failure is found."2 Though PPCM occurs worldwide, most data is extracted from the United States (incidence 1:900 to 1:4000 live births), Nigeria, Haiti, and South Africa.3,4Risk factors for PPCM include pre-eclampsia, multiparity, and advanced maternal age. Unfortunately, the complete pathophysiology of PPCM remains unclear. However, it is important for emergency physicians to be aware of this rare diagnosis because though 50-80% of women with PPCM may eventually recover normal left ventricle systolic function,5 positive outcomes depend on timely recognition of PPCM as a disease and the appropriate management of heart failure. Symptomatic PPCM is an emergent condition that requires an attentive and knowledgeable emergency medicine physician for rapid recognition and treatment. A simulation of this rare condition can give residents the experience of identifying and managing this disease that they might not otherwise see personally during their training.

Educational objectives: By the end of this simulation session, learners will be able to: 1) initiate a workup of a pregnant patient who presents with syncope, 2) accurately diagnose peripartum cardiomyopathy, 3) demonstrate care of a gravid patient in respiratory distress due to peripartum cardiomyopathy, 4) appropriately manage cardiogenic shock due to peripartum cardiomyopathy.

Educational methods: This simulation was conducted as a high-fidelity medical simulation case followed by a debriefing. It could potentially be adapted for use as a low-fidelity case or an oral boards exam case.

Research methods: The educational content and clinical applicability of this simulation was evaluated by oral and written feedback from participant groups at a large three-year emergency medicine residency training program. Each participant completed the case and the facilitated debriefing afterwards. Case facilitators also provided their personal observations on the implementation of the simulation.

Results: The participants gave the simulation positive feedback (n=18). Seventeen EM residents and one pediatric emergency medicine (PEM) fellow participated in the feedback survey. Learners overall agreed (18.75%) or strongly agreed (81.25%) that participating in this simulation would improve their performance in a live clinical setting.

Discussion: Peripartum cardiomyopathy is a low frequency, high acuity illness that requires a synthesis of the learner's knowledge of complex physiology, navigation of logistical and systems-based challenges, and advanced communication and leadership skills to ensure the best possible patient outcome. All EM physicians will be expected to expertly manage this illness after completion of an EM training program, yet not every EM resident will encounter this type of patient during training. Supplementing the EM resident's standard training with this simulation experience provides a psychologically and educationally safe space to learn and possibly make mistakes without causing patient harm. Practically all residents were able to correctly diagnose the patient with a cardiomyopathy even if they were not familiar with the diagnosis of "peripartum cardiomyopathy." The residents particularly enjoyed the case to explore concepts of benefits and risks of medical therapeutics (ie, positive pressure ventilation, vasopressors/inotropes) and safe practice for the gravid patient. This case and the associated high yield debriefing session were effective teaching tools for emergency medicine residents about PPCM.

Topics: Medical simulation, peripartum cardiomyopathy, pregnancy, respiratory failure, cardiogenic shock, emergent cesarian section.

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围产期心肌病。
观众:本模拟适合所有级别的急诊医学(EM)住院医师。围生期心肌病(PPCM)是一种罕见的特发性疾病,发生在母亲分娩前后。在妊娠最后一个月或分娩后5个月内诊断出的伴有射血分数降低和/或收缩功能降低的心力衰竭定义为PCCM.1欧洲心脏病学会的另一个更广泛的定义将PPCM定义为“在妊娠末期或分娩后几个月内未发现其他心力衰竭原因的心力衰竭”。虽然PPCM发生在世界各地,但大多数数据来自美国(发病率1:90至1:4000活产)、尼日利亚、海地和南非。不幸的是,PPCM的完整病理生理机制尚不清楚。然而,急诊医生必须意识到这种罕见的诊断,因为尽管50-80%的PPCM女性最终可能恢复正常的左心室收缩功能,但积极的结果取决于及时认识到PPCM是一种疾病,并对心力衰竭进行适当的管理。有症状的PPCM是一种紧急情况,需要一个细心和知识渊博的急诊医生快速识别和治疗。这种罕见情况的模拟可以给住院医生提供识别和管理这种疾病的经验,否则他们在培训期间可能不会亲自看到。教育目标:在模拟课程结束时,学习者将能够:1)开始对出现晕厥的孕妇进行检查,2)准确诊断围产期心肌病,3)演示因围产期心肌病导致呼吸窘迫的孕妇的护理,4)适当处理围产期心肌病引起的心源性休克。教学方法:本模拟以高保真医学模拟案例的形式进行,然后进行汇报。它可能被用作低保真案例或口头委员会考试案例。研究方法:在一个大型的三年急诊医学住院医师培训项目中,通过参与者群体的口头和书面反馈来评估该模拟的教育内容和临床适用性。每个参与者都完成了案例和随后的辅助汇报。个案协调员也提供了他们对模拟实施的个人观察。结果:参与者给予模拟正反馈(n=18)。17名急诊住院医师和1名儿科急诊医师参与了反馈调查。学习者总体上同意(18.75%)或强烈同意(81.25%)参加这个模拟会提高他们在现场临床环境中的表现。讨论:围产期心肌病是一种低频率、高敏度的疾病,需要学习者综合掌握复杂的生理学知识、应对后勤和系统挑战的能力,以及先进的沟通和领导技能,以确保患者的最佳预后。所有的急诊医生在完成急诊培训项目后都应该熟练地管理这种疾病,但并不是每个急诊住院医师都会在培训期间遇到这种类型的病人。用这种模拟经验补充急诊住院医生的标准培训,提供了一个心理和教育上安全的空间,可以学习和可能犯的错误,而不会对患者造成伤害。几乎所有住院医师都能正确诊断心肌病患者,即使他们不熟悉“围产期心肌病”的诊断。住院医生们特别喜欢这个案例,因为它探讨了医学治疗的好处和风险(即正压通气、血管加压药/肌力药物)的概念,以及孕妇的安全做法。本案例及相关的高收益报告会是急诊医学住院医师关于PPCM的有效教学工具。主题:医学模拟,围产期心肌病,妊娠,呼吸衰竭,心源性休克,紧急剖宫产。
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