Hy 2211 Help these fugitives!

[tommyk]

Hy 2211 Help these fugitives!
A group of inmates from a high security prison broke free in a closed metal truck in the middle of summer. When apprised by radio that U.S. Marshals are on their trail, the smugglers abandoned their charges in the middle of the desert, in the locked truck, with little water to drink. The victims are found and rescued 5 days later. One of them is brought to the emergency department, awake and alert, with obvious clinical signs of severe dehydration and a serum sodium concentration of 160 mEq/L. What are you going to do?? Hint: Again, the patient is awake and alert.
1-Leave them to die, because they supposedly broke the law.
2-5 L of 5% dextrose in water (D5W) over 2-3 days
3-5 L of D5W over 5-10 hours
4-5 L of 5% dextrose in half normal saline (D5 1/2 NS) over 5-10 hours
5-10 L of normal saline over 2-3 days
6-10 L of D5 1/2 NS over 5-10 hours
7-10 L of Lactate Ringers over 5 hours
8-10 kg of cyanide IV over 10 minutes



































































































































a) answer IS number 5. It is the most common, most reliable, most correct.. A rough guideline to quantify water loss is that every 3 mEq/L that the serum sodium concentration is above normal, represents about 1 L of water deficit. With a value of 160 we can assume a water deficit of about 5 L. There is no advantage to the patient in remaining severely volume contracted for several days, thus the replacement should aim for correction in a matter of 5-10 hours rather than 2 or 3 days. However, because his loses were incurred slowly (over 5 days), his brain has had a chance to adapt to the tonicity change (he is indeed awake and alert). Thus, the tonicity correction should not happen with the same speed with which the volume is going to be corrected. That delay is achieved by choosing a fluid that is not pure water, but one that has some sodium in it to dampen the effect on tonicity. Half normal saline is a good choice. L of D5W over 2 or 3 days would be safe from the viewpoint of slowly correcting the tonicity, but it would unnecessarily prolong the state of volume depletion. L of D5W over 5-10 hours could well be deadly, because it would revert the tonicity to normal at a rate too fast for the brain to follow, which is a volume replacement well beyond what is needed. The other options are just sadistic, remember, a life is a life….

[md90]

I chose #4, 5L of D5.45NS over 5-10 hours... but from your answer I'm believing that it's only half normal saline which is not any of the answer choices. Am I understanding right? Thank you.

[ilovetahira]

I also agree with md90, there are two chices with 1/2 NS with DW, one with 10 liters and other 5 liters. so I also pick 5 liters as 10 liters in a 5-10 hrs is too much in current situation.

[jameslynton]

Once again TommyK has a really tricky question here - you have to consider the impact of the 5% dextrose not just the normal saline on the human body. I will not give you my answer because I will tell you a story about dehydration. In WWII there was a group of English army soldgers lost in the north african desert. The ran out of water & food. Later they found bee hives - many soldger ate the honey. Other did not. The ones that ate the honey died before the villager could give them water. Why? This question requires you to think of the system as a "whole". 5% dextrose is normal Dextrose what will it do in a situation of concetrated blood sodium.

[jameslynton]

If the sodium Na+ is high what has happened to the K+, I think lactated ringers is the way to go. They are already pumping glycose from the liver, Lactated Ringers will have K+ also to help balance the Nervious system. Lactate will help stablize and buffer the blood as it returns to normal. I am going with #7. Who is right TK?

[Unregistered55]

whos this guy jameslynton who hasnt even started med school yet, and why he acting like he knows everything???!!!???

[tommyk]

Hy 2213 Thanks for responding to heatstroke, it is SO high yield…
It is so common, esp. if you “match” along the southern U.S. or in urban setting where proper air conditioning may not be found. If you are presented in the ER with a patient (peds, elderly, or median age), do you know just how to treat him/her? I heard this is a popular favorite question because it demonstrates such a common chief complaint…esp. as we approach warmer weather!!! Again, how do you treat a heatstroke patient? Think of the original workup, tests, and as I mentioned, what types of fluids? (Again, choose NS as the answer for the fluid part)













































































a) Think first of how the patient will present:

Think:
Heat exhaustion
Weakness
Vomiting
Orthostatic pulse and blood pressure changes
Tachycardia
Assume that any patient presenting with an elevated temperature, signs of CNS dysfunction, and a history of heat exposure has heatstroke and treat immediately.
CNS dysfunction includes seizure, coma, delirium, bizarre behavior, opisthotonus, hallucinations, decerebrate rigidity, cerebellar dysfunction, oculogyric crisis, and fixed and dilated pupils.
Coagulation disorders include disseminated intravascular coagulation (DIC) and result in signs such as purpura, conjunctival hemorrhage, melena, bloody diarrhea, hemoptysis, hematuria, myocardial bleeding, and CNS hemorrhage.
Skin findings may range from warm and dry to diaphoretic. Many individuals with temperatures higher than 41°C are sweating diffusely. Anhydrosis typically is a late finding in heatstroke and is more common in classic than in exertional heatstroke.
Respiratory symptoms include tachypnea, alkalosis, and respiratory decompensation secondary to acute respiratory distress syndrome (ARDS).
Genitourinary symptoms include hematuria, oliguria, or anuria that may occur as signs of acute renal failure.
Unlike malignant hyperthermia and neuroleptic malignant syndrome, heatstroke is not characterized by muscular rigidity. Muscle cramps or flaccidity may be noted.
As we discussed above, the primary cause is failure of thermoregulation due to heat stress. But always KEEP IN MIND the “weird” stuff, like MALIGNANT HYPERTENSION and THYROID STORM. Boards can DEFINITELY fool you if you do not know these COLD.
If they ask you what LABS you would order, what will you say? Think again ORGANIZED and SYSTEM based:
As Dr Goljan said to me, the liver “does everything”. So get hepatic transaminases: These are elevated almost universally in heatstroke. Reconsider the diagnosis of heatstroke if aspartate aminotransferase (AST) and alanine aminotransferase (ALT) levels are within the reference ranges.
CBC, prothrombin time (PT), activated partial thromboplastin time (aPTT), fibrinogen, and platelets: These tests may provide evidence of coagulation disorders and hemoconcentration.
Electrolytes, BUN, and creatinine: Evaluate for acute renal failure, acid-base disorders, uremia, and hyperkalemia.
Blood glucose: Hypoglycemia may occur because of increased use of glucose or hepatic damage leading to impaired gluconeogenesis.
Creatine kinase (CK): The CK level is elevated in rhabdomyolysis, especially in exertional heatstroke.
Arterial blood gases (ABGs): These measurements are useful to evaluate acid-base status, pulmonary function, and tissue oxygenation. Nonexertional cases typically have respiratory alkalosis, while exertional cases may have both respiratory alkalosis and lactic acidosis.
Do NOT forget a Urinalysis
Proteinuria, hematuria, myoglobinuria, or granular casts provide evidence of acute renal failure or rhabdomyolysis.
Urine specific gravity typically is increased. Did you know as Dr. Goljan said to me how important a urine analysis is????

Do NOT forget to get a chest radiography
Perform chest radiography (CXR) to evaluate for ARDS, aspiration, and pneumonia.
CXR may be useful in excluding differential diagnoses (eg, thermal myocardial dysfunction, which may result in a pulmonary edema pattern on CXR film despite dehydration).
Also, the brain is definitely affected… so get or “pick” a CT scan of the head
Evaluate for CNS edema and hemorrhage.
This test is important to exclude differential diagnoses in patients with altered level of consciousness.
Do not forget also a rectal thermometer probe for constant core temperature monitoring.
As far as meds go, they may ask you what meds NOT to give. Think about it. First thing is “eliminate” the anti-cholinergics! Do you really want to STOP sweating in a patient with hyperthermia??? Use your common sense too.. Avoid several drugs, including those anticholinergics (decrease sweating), alpha-adrenergic agonists (increase peripheral resistance without increasing cardiac output), and antipyretics.
There are a lot of management questions like giving them an “ice bath” and stuff, but that is more Step 2 than Step 1. But listen carefully, Board is heavy on Most Commons, D5 (Dextrose in water), as Dr. Goljan said to me, is basically giving them only water…95% is pure H20. Since tonicity is the problem too, the best choice is Normal Saline. OK? It is so readily available, you do not have to do calculations, and it WILL work, and you will see in clinics when YOU ALL become a doctor, that NS is used. I know others “could” be used, but normal saline is in every single hospital room and you will see it hanging on just about everyone’s bed. Yeah, yeah, I know Lactate Ringer’s could work, but usually pick that when you are given a case of like someone in an abdominal surgical trauma, where pH is more important. Again, NS is the best answer. Trust me on this…
Now, what the boards MAY FOOL you on is, HOW MUCH normal saline is needed. It is a Step 1 question, not only for Step 2. In fact, I will admit that I PERSONALLY on my own test got a “How much Normal Saline in liters?” needed to be given to a patient, and I had to consider the Total Body Water, Intracellular place, Extracellular space, etc. KNOW fluids COLD. Recall, we are mostly “fluids.”… eh? J Love, Tommy

[tommyk]

Dear md90 and the other smarties,

After MUCH thought and talking to my team (Team A) in IM, I can accept 5% Dextrose in half normal saline over about 5 hours. Normal saline will work and is so often used because of cost and availability, and it is so easy to administer. BUT, you all make a GREAT SMART point. Again, after much thought, the 5% Dextrose in half normal saline over 5 hours should be acceptable.

Sincerely,
Your beloved brother, Tommyk :D