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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 d. Exercise hyperthermia e. Important metabolic abnormalities in rhabdomyolysis (hyperkalemia, hypocalcemia, hyperphosphatemia, metabolic acidosis) b. Etiology: exercise, drugs, medications (ACE inhibitor, HCTZ, statins), direct muscle injury, seizure, DKA, infections, heat related syndromes, myopathies c. Pathophysiology i. necrosis of striated muscles ii. ARF: major theories (volume depletion resulting in renal ischemia, direct tubular injury) d. Treatment i. IVF resuscitation: volume repletion and to establish a diuresis ii. Management/diagnosis of underlying cause iii. Serial measurements important (serum potassium, calcium, phosphate, and creatinine, urine pH, urine output iv. Discuss indications for dialysis v. Discuss theory behind urine alkalinization (although no longer recommended over aggressive IV fluid resuscitation vi. Discuss EKG findings/management of hyperkalemia e. Complications i. Cardiac arrest, acute renal failure VIII. Development and Deployment This case was developed for independent study sessions for first and second year medical students. Variants have been deployed as part of “transition to the wards” integration curricula for rising third year medical students. IX. Authors/Contributors Case drafted by Rami Ahmed, D.O, with 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. 86
Gilbert Program in Medical Simulation Simulation Casebook Harvard Medical School Draft of the 1 st edition (2011), updated 3/2/12 X. Appendix A: Lab Values BASIC METABOLIC PANEL Reference Range Sodium 147 135-147 mmol/L Potassium 7.0 3.5-5.2 mmol/L Chloride 110 95-107 mmol/L CO 2 12 22-30 mmol/L Urea Nitrogen (BUN) 85 7-20 mg/dL Creatinine 4.8 0.5-1.2 mg/dL Glucose 100 60-110 mg/dL CHEMISTRY TESTS Reference Range Lactate 2.2 0 – 1.5 mEq/L Creatine Kinase 21,000 25 – 200 IU/L HCG 0 0 – 5 IU/L COMPLETE BLOOD COUNT Reference Range WITH DIFFERENTIAL Male Female White Blood Cell (WBC) 22,000 4,500 - 10,000 K/uL Neutrophils (%) 65 54 – 62% Band forms (%) 4 3 - 5 (>8% indicates L shift) Basophils (%) 0.35 0 – 1% 0 - 0.75% Eosinophils (%) 2 0 – 3% 1 – 3% Lymphocytes (%) 24 24 – 44% 25 – 33% Monocytes (%) 4 3 – 6% 3 – 7% Hemoglobin (HGB) 15.0 13.5 - 16.5 g/dL 12.0 - 15.0 g/dL Hematocrit (HCT) 45.0 41 – 50% 36 – 44% 87
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