Amy Rynes, MSN, FNP-BC, CFRN Laurie Smith, Paramedic, FPC You only get three… Selecting lab values with meaning for five critical patients. Amy Rynes, MSN, FNP-BC, CFRN Laurie Smith, Paramedic, FPC

Objectives 1. To gain a greater understanding of lab values in relationship to the patient complaint. 2. Knowing when to ask for particular lab values that may drive or change your practice. 3. Advantages and disadvantages to retesting lab values after interventions.

Disclosures No affiliations with product companies. No financial disclosures.

Case Study One “Oh help me… I drank too much”

45 yo F Abdominal Pain ETOH on board PMH: 1.Chronic ETOH 2. HTN 3.Hyperlipidemia 45 yo F Abdominal Pain ETOH on board

Social Hx: ½ Pack a Day smoker ETOH daily Allergies: PCN Toradol Ibuprofen

Meds: None VS: Temp 37.2 (99) HR: 110 NSR RR: 20 BP: 146/86 SpO2: 94% RA

Treatments Pre Hospital: IV NS (Bloody IV Start) Oxygen Zofran BS 145

Hospital Interventions Labs CT Chest Xray Fentanyl Zofran

What do you want to know?

#1 AST Liver Failure Alcohol, Skeletal Muscle, Drugs

Sodium 129 mmol/L (135-145) Potassium 3. 8 mmol/L (3. 5-5 Sodium 129 mmol/L (135-145) Potassium 3.8 mmol/L (3.5-5.1) Chloride 102 mmol/L (98-107) CO2 21 mmol/L (22-29) AGAP 20 mmol/L (10-20) Alkaline Phosphatase 87 unit/L (46-118) Glucose Lvl 156 mg/dL (70-139) Creatinine 1.10 mg/dL (0.60-1.10) EGFR 60 mL/min/1.73m BUN 26 mg/dL (6-21) Calcium Lvl 8.6 mg/dL (8.6-10.3) Protein Total 7.3 gm/dL (6.3-7.9) Albumin Lvl 4.3g/dL (3.5-5.0) AST 344unit/L (8-43) ALT 215 U/L (7-45) Bili Total 4.0 mg/dL (- < = 1.2) PT 12.9 seconds (8.7-11.8) INR 2.3 INR (0.0-5.0) PTT 26.4 seconds (25.6-35.0)

#2 ALT Liver Failure Non-Alcoholic, Hepatitis, HELLP

Sodium 129 mmol/L (135-145) Potassium 3. 8 mmol/L (3. 5-5 Sodium 129 mmol/L (135-145) Potassium 3.8 mmol/L (3.5-5.1) Chloride 102 mmol/L (98-107) CO2 21 mmol/L (22-29) AGAP 20 mmol/L (10-20) Alkaline Phosphatase 87 unit/L (46-118) Glucose Lvl 156 mg/dL (70-139) Creatinine 1.10 mg/dL (0.60-1.10) EGFR 60 mL/min/1.73m BUN 26 mg/dL (6-21) Calcium Lvl 8.6 mg/dL (8.6-10.3) Protein Total 7.3 gm/dL (6.3-7.9) Albumin Lvl 4.3g/dL (3.5-5.0) AST 344 unit/L (8-43) ALT 215 U/L (7-45) Bili Total 4.0 mg/dL (- < = 1.2) PT 12.9 seconds (8.7-11.8) INR 2.3 INR (0.0-5.0) PTT 26.4 seconds (25.6-35.0)

#3 PT/INR Liver Failure Prolonged PT, INR, aPTT Poor prediction of risk of bleeding TEG or ROTEM (not available in remote centers) NO FFP

Sodium 129 mmol/L (135-145) Potassium 3. 8 mmol/L (3. 5-5 Sodium 129 mmol/L (135-145) Potassium 3.8 mmol/L (3.5-5.1) Chloride 102 mmol/L (98-107) CO2 21 mmol/L (22-29) AGAP 20 mmol/L (10-20) Alkaline Phosphatase 87 unit/L (46-118) Glucose Lvl 156 mg/dL (70-139) Creatinine 1.10 mg/dL (0.60-1.10) EGFR 60 mL/min/1.73m BUN 26 mg/dL (6-21) Calcium Lvl 8.6 mg/dL (8.6-10.3) Protein Total 7.3 gm/dL (6.3-7.9) Albumin Lvl 4.3g/dL (3.5-5.0) AST 344 unit/L (8-43) ALT 215 U/L (7-45) Bili Total 4.0 mg/dL (- < = 1.2) PT 12.9 seconds (8.7-11.8) INR 2.3 INR (0.0-5.0) PTT 26.4 seconds (25.6-35.0)

What are you going to do and how will this change your practice? Fluids Medications Blood/FFP? EPOC

Case Study Two “My back hurts”

53 yo Male CPR in progress Missed Dialysis PMH: 1. End Stage Renal 2. HTN 3. DM 4. Hyperlipidemia 5. CAD 6. Asthma 53 yo Male CPR in progress Missed Dialysis

Social Hx: ½ Pack a Day smoker No ETOH Allergies: None

Meds: Lisinopril Insulin ASA Albuterol Simvastatin VS: Temp 37.2 (99) HR: VF RR: Assisted BP: None SpO2: Failed BG 213

Treatments Pre Hospital Pt not intubated 2 18g IV 1 Shock Delivered CPR in Progress PE: JVD Rales Bilateral Pitting Edema

Treatments Pre Hospital: #8 ET 24 at Lip Lucas Devise Applied ACLS Calcium BiCarb

Hospital Treatments Labs CT? Insulin D-50 Albuterol Dialysis?

What do you want to know?

#1 Creatinine/GFR Renal Failure GFR Calculated from Creatinine Multiple stages (Less than 30mg/day for three of more months)

Sodium 137 mmol/L (135-145) Potassium 6. 0 mmol/L (3. 5-5 Sodium 137 mmol/L (135-145) Potassium 6.0 mmol/L (3.5-5.1) Chloride 97 mmol/L (98-107) CO2 28 mmol/L (22-29) AGAP 12 mmol/L (10-20) Alkaline Phosphatase 25 unit/L (46-118) Glucose Lvl 315 mg/dL (70-139) Creatinine 7.42 mg/dL (0.60-1.10) EGFR 8 mL/min/1.73m BUN 39 mg/dL (6-21) Calcium Lvl 10.5 mg/dL (8.6-10.3) Protein Total 6.4 gm/dL (6.3-7.9) Albumin Lvl 3.6 g/dL (3.5-5.0) AST 25 unit/L (8-43) ALT 7 U/L (7-45) Bili Total 0.4 mg/dL (- < = 1.2)

#2 Calcium Renal Failure Hypercalcemia (long standing) can lead to calcification, degeneration and necrosis of the tubular cells Acute hypercalcemia directly shortens the myocardial action potential ST-segment elevation (mimics STEMI)

Sodium 137 mmol/L (135-145) Potassium 6. 0 mmol/L (3. 5-5 Sodium 137 mmol/L (135-145) Potassium 6.0 mmol/L (3.5-5.1) Chloride 97 mmol/L (98-107) CO2 28 mmol/L (22-29) AGAP 12 mmol/L (10-20) Alkaline Phosphatase 25 unit/L (46-118) Glucose Lvl 315 mg/dL (70-139) Creatinine 7.42 mg/dL (0.60-1.10) EGFR 8 mL/min/1.73m BUN 39 mg/dL (6-21) Calcium Lvl 10.5 mg/dL (8.6-10.3) Protein Total 6.4 gm/dL (6.3-7.9) Albumin Lvl 3.6 g/dL (3.5-5.0) AST 25 unit/L (8-43) ALT 7 U/L (7-45) Bili Total 0.4 mg/dL (- < = 1.2)

Drive potassium into the cells and remove excess #3 Potassium Renal Failure Drive potassium into the cells and remove excess Causes decreased action potential within the membrane as it is in the extracellular space Increased potassium stimulates aldosterone, enhances sodium reabsorption and indirectly enhances potassium secretion in the principal cell

Sodium 137 mmol/L (135-145) Potassium 6. 0 mmol/L (3. 5-5 Sodium 137 mmol/L (135-145) Potassium 6.0 mmol/L (3.5-5.1) Chloride 97 mmol/L (98-107) CO2 28 mmol/L (22-29) AGAP 12 mmol/L (10-20) Alkaline Phosphatase 25 unit/L (46-118) Glucose Lvl 315 mg/dL (70-139) Creatinine 7.42 mg/dL (0.60-1.10) EGFR 8 mL/min/1.73m BUN 39 mg/dL (6-21) Calcium Lvl 10.5 mg/dL (8.6-10.3) Protein Total 6.4 gm/dL (6.3-7.9) Albumin Lvl 3.6 g/dL (3.5-5.0) AST 25 unit/L (8-43) ALT 7 U/L (7-45) Bili Total 0.4 mg/dL (- < = 1.2)

What are you going to do and how will this change your practice? Fluids Medications Albuterol Calcium (30-60 min) Rhythm Review EPOC

Case Study Three “Sugar Everywhere”

PMH: DM HTN Hypothyroidism 47 yo Male Weakness Chills Back Pain

ALLERGIES: None MEDS: Regular Insulin Lisinopril Hydrochlorothiazide Levothryroxine

Social HX: Non- smoker No ETOH No Drugs

PE: VS: T37.9 (100.2) HR 125 RR 22 BP 95/60 O2 97% Clear Lungs Dry Mucous Membranes Moves all extremities Clammy Ectopy Noted VS: T37.9 (100.2) HR 125 RR 22 BP 95/60 O2 97%

Treatments Pre Hospital 2 18g IV 1L NS Oxygen

Treatments Hospital 2nd L NS in 10 min K Rider Correct Electrolytes Insulin gtt?

What do you want to know?

Diabetic Ketoacidosis #1 Potassium Diabetic Ketoacidosis High or low? Why?

Sodium 127 mmol/L (135-145) Potassium 2. 9 mmol/L (3. 5-5 Sodium 127 mmol/L (135-145) Potassium 2.9 mmol/L (3.5-5.1) Chloride 89 mmol/L (98-107) CO2 21 mmol/L (22-29) AGAP 26 mmol/L (10-20) Alkaline Phosphatase 126 unit/L (46-118) Glucose Lvl 685 mg/dL (70-139) Creatinine 1.2 mg/dL (0.60-1.10) EGFR 50 mL/min/1.73m BUN 34 mg/dL (6-21) Calcium Lvl 7.9 mg/dL (8.6-10.3) Protein Total 6.3 gm/dL (6.3-7.9) Albumin Lvl 3.3g/dL (3.5-5.0) AST 21 unit/L (8-43) ALT 13 U/L (7-45) Bili Total 0.6 mg/dL (- < = 1.2)

Diabetic Ketoacidosis #2 Calcium Diabetic Ketoacidosis High or Low? Why? How is the action potential of the cells increased?

Sodium 127 mmol/L (135-145) Potassium 2. 9 mmol/L (3. 5-5 Sodium 127 mmol/L (135-145) Potassium 2.9 mmol/L (3.5-5.1) Chloride 89 mmol/L (98-107) CO2 21 mmol/L (22-29) AGAP 26 mmol/L (10-20) Alkaline Phosphatase 126 unit/L (46-118) Glucose Lvl 685 mg/dL (70-139) Creatinine 1.2 mg/dL (0.60-1.10) EGFR 50 mL/min/1.73m BUN 34 mg/dL (6-21) Calcium Lvl 7.9 mg/dL (8.6-10.3) Protein Total 6.3 gm/dL (6.3-7.9) Albumin Lvl 3.3g/dL (3.5-5.0) AST 21 unit/L (8-43) ALT 13 U/L (7-45) Bili Total 0.6 mg/dL (- < = 1.2)

Diabetic Ketoacidosis #3 Glucose Diabetic Ketoacidosis Elevated How fast should it be corrected? Kids/Adults

Sodium 127 mmol/L (135-145) Potassium 2. 9 mmol/L (3. 5-5 Sodium 127 mmol/L (135-145) Potassium 2.9 mmol/L (3.5-5.1) Chloride 89 mmol/L (98-107) CO2 21 mmol/L (22-29) AGAP 26 mmol/L (10-20) Alkaline Phosphatase 126 unit/L (46-118) Glucose Lvl 685 mg/dL (70-139) Creatinine 1.2 mg/dL (0.60-1.10) EGFR 50 mL/min/1.73m BUN 34 mg/dL (6-21) Calcium Lvl 7.9 mg/dL (8.6-10.3) Protein Total 6.3 gm/dL (6.3-7.9) Albumin Lvl 3.3g/dL (3.5-5.0) AST 21 unit/L (8-43) ALT 13 U/L (7-45) Bili Total 0.6 mg/dL (- < = 1.2)

What are you going to do and how will this change your practice? Fluids Medications Electrolytes Rhythm Review EPOC

Case Study Four “Where is my leg?”

Traumatic Amputation of Right leg PMH: None 32 yo Female Traumatic Amputation of Right leg

ALLERGIES: Unknown MEDS: Unable to obtain

PE: VS: HR 125 RR 24 BP 80/40 SpO2 97% RA Decreased Right Lung Moves all intact extremities Clammy VS: HR 125 RR 24 BP 80/40 SpO2 97% RA

Treatments Pre Hospital 2 18g IV 1L NS Oxygen Intubated RSI Blood TXA?

What do you want to know?

#1 Hemoglobin Trauma “Normal Ranges” Athletes High Altitudes Smoker African – American Chronic Disease Older Adults Female 11.6 – 12.3 g/dL Male 13.0 – 14.2 g/dL

Hgb 11. 5 g/dL Hct 33. 3% WBC 4. 6 x 10 (9)/L RBC 3 Hgb 11.5 g/dL Hct 33.3% WBC 4.6 x 10 (9)/L RBC 3.77 x 10 (12)/L MCV 104.2 fL RDW 13.2% Platelet 140 x 10 (9)/L Neutro Absolute 2.01 x 10(9)/L Lymph Absolute 1.49 x 10 (9)/L Mono Absolute 0.99 x 10 (9)/L Eos Absolute 0.08 x 10 (9)/L Baso Absolute 0.07 x 10(9)/L Differential (Auto)

Packed spun volume of blood that consists of intact RBCs #2 Hematocrit Trauma “Packed Cell volume” Packed spun volume of blood that consists of intact RBCs % 3 x Hemoglobin

Hgb 11. 5 g/dL Hct 33. 3% WBC 4. 6 x 10 (9)/L RBC 3 Hgb 11.5 g/dL Hct 33.3% WBC 4.6 x 10 (9)/L RBC 3.77 x 10 (12)/L MCV 104.2 fL RDW 13.2% Platelet 140 x 10 (9)/L Neutro Absolute 2.01 x 10(9)/L Lymph Absolute 1.49 x 10 (9)/L Mono Absolute 0.99 x 10 (9)/L Eos Absolute 0.08 x 10 (9)/L Baso Absolute 0.07 x 10(9)/L Differential (Auto)

#3 Platelet Trauma For each 10 to 12 units of transfused RBCs are associated with a 50 percent fall in the platelet count.

Hgb 11. 5 g/dL Hct 33. 3% WBC 4. 6 x 10 (9)/L RBC 3 Hgb 11.5 g/dL Hct 33.3% WBC 4.6 x 10 (9)/L RBC 3.77 x 10 (12)/L MCV 104.2 fL RDW 13.2% Platelet 140 x 10 (9)/L Neutro Absolute 2.01 x 10(9)/L Lymph Absolute 1.49 x 10 (9)/L Mono Absolute 0.99 x 10 (9)/L Eos Absolute 0.08 x 10 (9)/L Baso Absolute 0.07 x 10(9)/L Differential (Auto)

What are you going to do and how will this change your practice? Fluids Medications Blood Tranexamic acid “competitively inhibits multiple plasminogen binding sites, decreasing plasmin formation and fibrinolysis” EPOC

Case Study Five “I have a fever”

PMH: Nursing home patient DM2 HTN CHF Hyperlipide mia Chronic Back pain HX of Diverticulitis 86 yo Female Fever Altered Mental Status

ALLERGIES: MEDS: HCTZ/Lisinopril Metformin ASA Nitro SL Simvastatin PCN Sulfa ARB’s Nickel Fish MEDS: HCTZ/Lisinopril Metformin ASA Nitro SL Simvastatin Hydrocodone Colace Albuterol Metoprolol Tylenol PM Bio Freeze Fentanyl Patch

VS: Temp 39.2 (100.4) HR 130 RR 28 BP 76/38 SpO2 92% RA PE: Confused Warm to touch Clammy Trace to 1+ edema (dependent) LS Course VS: Temp 39.2 (100.4) HR 130 RR 28 BP 76/38 SpO2 92% RA

Treatments Pre Hospital 2 18g IV 1L NS Oxygen Glucose

What do you want to know?

#1 WBC Sepsis

Hgb 11. 9 g/dL Hct 34. 3% WBC 26 x 10 (9)/L RBC 3 Hgb 11.9 g/dL Hct 34.3% WBC 26 x 10 (9)/L RBC 3.77 x 10 (12)/L MCV 104.2 fL RDW 13.2% Platelet 156 x 10 (9)/L Neutro Absolute 23.9 x 10(9)/L Lymph Absolute 0.8 x 10 (9)/L Mono Absolute 1.3 x 10 (9)/L Eos Absolute 0.08 x 10 (9)/L Baso Absolute 0.07 x 10(9)/L Differential (Auto)

Elevated creatinine may falsely elevate the lactate #2 Lactate Sepsis A serum lactate level ≥4 mmol/L is consistent with, but not diagnostic of, septic shock Elevated creatinine may falsely elevate the lactate

Hgb 11. 9 g/dL Hct 34. 3% WBC 26 x 10 (9)/L RBC 3 Hgb 11.9 g/dL Hct 34.3% WBC 26 x 10 (9)/L RBC 3.77 x 10 (12)/L MCV 104.2 fL RDW 13.2% Platelet 156 x 10 (9)/L Neutro Absolute 23.9 x 10(9)/L Lymph Absolute 0.8 x 10 (9)/L Mono Absolute 1.3 x 10 (9)/L Eos Absolute 0.08 x 10 (9)/L Baso Absolute 0.07 x 10(9)/L Differential (Auto) Lactate Acid 4.2 mM/l

#3 Blood Cultures Sepsis GET THEM!

What are you going to do and how will this change your practice? Fluids Medications Pressers Broad Spectrum Antibiotics EPOC

References Google Images Schrier, S. Approach to the adult patient with anemia. UpToDate. Jul 2016. Coates, T. Approach to the patient with neutrophilia. UpToDate. Jul 2016. Mount, D. Causes and evaluation of hyperkalemia in adults. UpToDate. Oct 2014. Okusa, M. Overview of the management of acute kideney injury (acute renal failure). UpToDate. Jan 2016. Mount, D. Treatment and prevention of hyperkalemia in adults. UpToDate. Jul 2015. Shane, E. Clinical manifestations of hypercalcemia. UpToDate. Aug 2016. Rosenberg, M. Overview of the management of chronic kidney disease in adults. UpToDate. Feb 2016. Shah, N. & Caldwell, S. Hemostatic abnormalities in patients with liver disease. UpToDate. Apr 2016. Friedman, L. Approach to the patient with abnormal liver biochemical and function tests. UpToDate. Nov 2015.