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Hypocalcemia
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0/6
Hypercalcemia
Hyperkalemia
100%
6/6
Hypokalemia
Hypomagnesemia
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A patient brought into the emergency department after a prolonged period of compression of his right upper extremity with an EKG significant for peaked T waves is indicative of crush syndrome leading to hyperkalemia. The mechanism of injury in crush syndrome is two-fold. Damage first occurs from the direct compression of the muscle fibers. Second, prolonged periods of compression cause ischemic damage to the muscle. This causes muscle cell death and lysis leading to metabolic imbalances such as hyperkalemia followed by organ failure. Sever et al. describe crush syndrome as the number one cause of casualty after mass disasters when excluding direct trauma. They note that patients can have high creatine kinase levels (up to 50,000 IU/L) along with elevated white blood cell counts (up to 20,000 cells/uL) and electrolyte imbalances. They note organ failure as the main culprit with renal failure being the most common cause due to the increased myoglobin in the bloodstream leading to myoglobinuria and hence, acute kidney injury. Rosedale et al. note that creatine kinase levels of below 1,000 IU/L is an important criteria for excluding the diagnosis of crush syndrome. They also note that it is important to act within 24 hours with fluids and correction of electrolyte abnormalities to reduce mortality and prevent organ failure in patients. Figure A shows an EKG with bradycardia and peaked T waves, significant for hyperkalemia. Illustration A showed an EKG with ST depression with inverted T waves and large U waves significant for hypokalemia. Incorrect Answers: Answer 1: Hypocalcemia would result in QT prolongation and does not normally result in T wave abnormalities. Answer 2: Hypercalcemia would result in QT shortening and does not normally result in T wave abnormalities. Answer 4: Hypokalemia would result in ST depressions with T wave inversions and prominent U waves as shown in Illustration A. Answer 5: Hypomagnesemia is normally associated with hypocalcemia and would result in QT prolongation without any abnormalities of the T waves.
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