High temperatures Heat stroke Strenuous exercise Seizures Toxin ingestion Infection renal failure and possible multiorgan failure. One key finding is urine dipstick showing blood but urine microscopy not identifying red blood cells. Serum markers, such as creatinine kinase, then can be measured. The level of creatinine kinase elevation directly correlates with the risk of renal failure. Left untreated, early complications include hyperkalemia, hypocalcemia, possible cardiac arrest, and arrhythmia. Approximately 15% of patients later develop acute renal failure, which carries a high risk of future morbidity and mortality. Early institution of aggressive IV hydration with normal saline can reverse the hypovolemia and prevent precipitation of the myoglobin within the tubules. Some experts advocate the addition of IV sodium bicarbonate to alkalinize the urine, which may further decrease the toxicity and precipitation of myoglobin to the tubules. Others advocate the use of mannitol. an osmotic agent. Some patients may require hemodialysis. Diuretics, however, may worsen the situation and are not indicated.
|55.1] A 22-year-old man presents to the emergency room 30 minutes after smoking crack cocaine with the complaint of crushing substernal chest pain. His ECG shows early repolarization with a heart rate of 116 but no other changes, and his cardiac troponin levels are negative. His urine drug screen is positive for cocaine. Which of the following is the best next step?
A. Give the patient acetaminophen for pain and discharge home
B. Treat with IV metoprolol to reduce the heart rate to <60 bprn
C. Administer aspirin, sedation, and nitrates
D. Administer thrombolytics and admit to the coronary care unit
E. Give flumazenil to reverse the action of the cocaine
[55.2] A 35-year-old marathon runner has been training for his next run and is brought to the emergency room after collapsing on the road. His temperature is 108°F. and he is tachypneic and lethargic. Urine dipstick shows large blood, but no red blood cells are seen on microscopy. Which of the following interventions would be least useful in his management?
A. Immediate aggressive IV hydration with normal saline
B. Immediate cooling by spraying with cool water and using cold packs
C. Obtain blood culture and immediately start IV antibiotics
D. Monitor his airway and provide supplemental oxygen
E. Check serum electrolyte levels, including potassium and calcium, and treat accordingly
[55.1J C. The patient should be given oxygen, aspirin, sedation, and nitrates for vasodilation and will require some evaluation for an acute coronary syndrome. Beta-blockers are relatively contraindicated because they can worsen vasoconstriction. There is no indication for thrombolytics. Flumazenil is the antagonist for benzodiazepines and would have no effect on cocaine.
[55.2] C. The patient is likely suffering from exertional heat stroke and resulting rhabdomyolysis. Each of the interventions is appropriate, except C, because the hyperthermia likely does not represent infection.
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