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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 54
Gilbert Program in Medical Simulation Simulation Casebook Harvard Medical School Draft of the 1 st edition (2011), updated 3/2/12 VIII. Development and Deployment This case was developed as part of a graduate-level science course (college, PhD students), and has been deployed as a recurrent course offering. IX. Authors/Contributors Case drafted by Julia Khodor, Ph.D. with Emily Hayden, M.D.; additional contributions and updates by the Gilbert Simulation Team. Compiled and formatted by Elan Guterman. Reviewed and edited with references by Jeffrey Siegelman, M.D. and Zoë Howard, M.D. 55
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