Supportive and Preventive Medicine

Clinical prediction rules to help determine the probabil-

ity of HIT (e.g., 4Ts score) have been developed. Patients

with a low 4Ts score (0–3) have a very low probability

of HIT (Answer D is correct). Direct thrombin inhibi-

tors are the agents of choice for anticoagulation in acute

HIT because they have no cross-reactivity with heparin.

Initiating these agents in those with a low probability of

HIT could lead to an unnecessary increase in bleeding

risk (Answer B is incorrect). If the 4T score revealed an

intermediate or high risk of HIT, the first step would

be to ensure that all forms of heparin are discontin-

ued, including flushes and heparin-coated catheters

(Answer C is incorrect). The next step would be to initi-

ate an alternative form of anticoagulation (Answer A is

incorrect).

Answer: C

General considerations in the critically ill patient at

the end of life include minimizing uncomfortable or

unnecessary procedures, tests, and treatments, includ-

ing fingersticks, Foley catheters, and routine vital signs

(Answers A, B, and D are incorrect). Symptom man-

agement of pain and anxiety, fever, cough, secretions,

nausea and vomiting, and delirium should be considered

in the dying patient (Answer C is correct).