SIMULATION CASEBOOK - MyCourses

Gilbert Program in Medical Simulation
Simulation Casebook
Harvard Medical School Draft of the 1 st edition (2011), updated 3/2/12
Aggressive IV fluid resuscitation
Thiamine administration
Dextrose/glucose administration
Correct electrolyte imbalances
Imaging as indicated (CXR)
2. Potential complications/errors path(s):
Failure to administer dextrose/glucose
Failure to administer IVF
Failure to recognize acidosis
3. Program debugging: N/A
VII.
Debriefing Plan
A. Method of debriefing: Group with multimedia teaching materials
B. Debriefing materials: See Appendix C
C. Potential debriefing topics
1. Team dynamics
a. Leadership
b. Collaboration
c. Communication
d. Professionalism
2. Didactic material
a. Presentation/Etiology
i. Appropriate differential diagnosis
ii. Abdominal pain, nausea/vomiting is common and nonspecific
iii. Breath can have fruity odor, indicating ketonemia
iv. Understanding respiratory compensation
b. Pathophysiology
i. Emphasize NADH/NAD ratio, normal glucose, depleted carbohydrate
and protein stores, elevated fatty acids
ii. Compare and contrast with DKA and starvation ketosis
iii. Understand why glucose can be low/high/normal
iv. Understand why ketonuria but little/no glucosuria
v. Importance to consider and distinguish among ethanol, methanol and
ethylene glycol toxicity
vi. Anion gap: Na - (Cl + HCO 3 )
c. Treatment
i. Proper laboratory evaluation – considering all etiologies of metabolic
acidosis, consider evaluating for osmolar gap
ii. Need for vitamin supplementation (thiamine), careful repletion of
electrolytes
iii. Discussion of thiamine before glucose and potential to increase the risk
of precipitating Wernicke’s encephalopathy/Korsakoff’s syndrome
(evidence for/against)
iv. Avoidance of insulin administration for the ketosis
v. Avoidance of bicarbonate administration for the acidosis
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