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Emergency Med > 11 - Electrolyte Imbalance > Flashcards

11 - Electrolyte Imbalance Flashcards

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1
Q

Potassium imbalances

A
  • Extra-cellular K rises as pH decreases

- Medicines, GI issues, renal problems and pH changes are primary causes of imbalances

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2
Q

Hypokalemia causes

A
  • Diuretics
  • GI losses (diarrhea)
  • Alkalosis
  • Low magnesium
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3
Q

Hypokalemia signs and symptoms

A
  • Cramps or fatigue
  • Paresthesias
  • Dysrhythmias, flat t waves, ST depression
  • She has never been able to see flat T waves or high T waves from high or low potassium
  • Ileus (belly ache, nausea)
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4
Q

Hypokalemia treatment

A
  • ***Replace slowly (PO or IV)
  • ***If you give it fast, heart problems, burning IV and arrhythmias
  • 3.5 – 5 is normal; admit if below 2.5
  • Oral replacement is usually adequate and less risky (20 -40 meq K in a liter ok…more IV and nurses get very nervous plus burns)
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5
Q

Hyperkalemia causes

A
  • Hemolysis - #1 cause of high K result ***
  • Meds
  • Metabolic Acidosis
  • As the acidosis is corrected, K will go back into the cell leading to hypokalemia
  • Renal failure #1 true medical reason ***
  • Rhabdomyolsis
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6
Q

Hyperkalemia signs and symptoms

A
  • Hyper-reflexia, paresthesia, weakness
  • Tented T waves***
  • V-fib, heart block, death
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7
Q

Hyperkalemia treatment

A
  • Albuterol
  • Lasix
  • Insulin + glu
  • Calcium gluconate, calcium chloride
  • Kayexalate (not so much anymore)
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8
Q

When does one check potassium?

A
  • Often before surgery (not always)
  • Renal issues
  • Meds
  • Part of BMP(chem 7)
  • Rhabdo concerns
  • GI issues
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9
Q

Hypoglycemia

A
  • BS
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10
Q

Treatment of hypoglycemia

A
  • Sugar
  • Glucagon (IM or IV) - Hypoglycemia, Cocaine overdose, Food caught in the throat (smooth muscle relaxer)
  • This one you can treat quickly…don’t give them oral if they can’t swallow (hard candy)
  • If known diabetic and don’t know BS – give sugar
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11
Q

Hyperglycemia

A
  • Reasons beyond diabetes (steroids, stress, infection)
  • Increased glucose levels cause delay in healing/decreased mortality in hospital if managed
  • Very high sugar – feel cruddy for days, panting
  • Serious consequence is DKA
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12
Q

DKA

A
  • Acute, deadly consequence of DM (usually type I)
  • Frequently follows GI illness (or is GI illness part of DKA?)
  • Give fluids, fluids and more fluids
  • Then give insulin; when BS hits 250, give glucose
  • Add potassium (starts high, decreases with rx)
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13
Q

**How do you know if it is DKA? **

A
  • Clinically – tachypnic…trying to blow off acids by panting and getting rid of CO2 - Patient will be PANTING ***
  • Sweaty and vomiting
  • Confused or anxious or combative or nonresponsive
  • ABGs will show low pH, low CO2, low bicarb
  • Blood/urine + ketones
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14
Q

Hyperosmotic hyperglycemic state (HHS)

A
  • Type II diabetic equivalent to DKA
  • Sugars not as high – treatment the same
  • People can be just as sick as in DKA
  • Glu >600, Osmo>320, ph >7.3, bicarb >15, not many ketones
  • “I don’t see this as much, not as common, but the treatment is the same”
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15
Q

When do you check sugars?

A
  • Screens (FMH, age, surgery)
  • Acutely- confusion, N/V
  • Part of BPM
  • Chronically, vision changes, wt loss, polydipsia, neuropathy
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16
Q

Calcium imbalances

A
  • Regulated by PTH, vitamin D and calcitonin
  • Need liver, kidney, skin and GI system for balance
  • Phosphorus and calcium inversely related
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17
Q

Hypocalcemia causes

A
  • Meds
  • Metabolic disorders
  • Surgical mishap (parathyroid glands)
  • Pancreatitis (low Ca bad sign), CA
  • Renal/liver problems (via vitamin D)
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18
Q

Hypocalcemia signs and symptoms

A
  • ***Tetany/muscle spasm
  • Seizures
  • Fractures
  • Decreased cardiac output
  • ***Chvostek sign (tap facial nerve)
  • ***Trousseau sign (inflate BP cuff/carpal spasm)
  • LOW calcium = spasms
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19
Q

Hypocalcemia

A
  • ***Always check an albumin prior to saying someone is hypocalcemia
  • ***If they have a low albumin, it causes the calcium to be low
  • Add .8 of Ca to every 1.0 decrease in albumin
  • Albumin of 2, calcium of 7
  • (4 – 2) X 8 = 1.6 add to 7 = 8.6 real calcium level
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20
Q

Hypocalcemia treatment

A
  • Treat underlying cause
  • Replace slowly (tums works)
  • HCTZ
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21
Q

Hypercalcemia causes

A
  • PTH
  • Meds (thiazides)
  • Cancers
  • Metabolic (high thyroid, low phos)
  • Immobilization
  • PTH and CA account for 90%
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22
Q

Hypercalcemia signs and symptoms

A
  • Muscle weakness
  • Fatigue
  • Nausea
  • Bone pain
  • Anorexia
  • Has to be pretty high to get symptoms
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23
Q

Hypercalcemia treatment

A
  • Calcitonin
  • IV phosphorus
  • Lasix
  • Bisphosphonates
  • IVF
  • Dialysis
24
Q

When does one check Ca+?

A
  • Osteoporosis
  • Part of most BMPs now
  • Concern of parathyroid disease
  • Cardiac arrhythmias
25
Q

Sodium imbalances

A
  • Essential in water/volume balance
  • Influenced by thirst, ADH, renal-angiotensin
  • Increased osmo (280-300) stimulates thirst and ADH
  • Hypovolemia stimulated Na absorption
26
Q

Hyponatremia signs and symptoms ***

A
  • Confusion***
  • Nausea/vomiting*
  • Cramps*
  • Often no s/s (especially if chronic)*
27
Q

3 types of hyponatremia

A
  • Hypovolemic
  • Euvolemic
  • Hypervolemic
28
Q

Hypovolemic hyponatremia

A 
Easiest to figure out – pt is dehydrated, but has lost salt > water
o	GI losses
o	Exercise
o	Burns
o	Pancreatitis
o	Meds
29
Q

Hyponatremia treatment

A
  • Correcting the fluid loss usually takes care of it – give isotonic saline (NS)
30
Q

Euvolemic hyponatremia

A
  • HARDEST to figure out
  • Volume is ok, sodium low
  • Psychogenic (or drinking too much H2O)
  • Hypertriglycerides
  • Hyperglycemia
  • SIADH
  • Meds
  • Infection
  • Adrenal or thyroid disorders
31
Q

Pseudohyponatremia

A
  • Low Na secondary to increase in lipids
32
Q

Transitional hyponatremia

A
  • Secondary to hyperglycemia (Na goes into cells to equalize osmolality)
  • Na decreases 1.6 meq for every 100 mg/dl increase in glucose
  • Na will correct when glucose does
33
Q

SIADH

A
  • Syndrome of inappropriate antidiuretic hormone secretion
  • A big cause of euvolemic hyponatremia (1/3 of low sodium)
  • Low plasma osmolality, high urine osmolality, plus high urine Na
34
Q

Causes of SIADH

A
  • Cancers (oat cell, small cell, ovarian, lymphoma) can secrete ADH
  • Infection
  • Trauma
  • Meds (prozac, TCAs, anti-seizure, chronic alcohol)
35
Q

SIADH treatment

A
  • Fluid restriction
  • Oral Na
  • Democlocycline
36
Q

New treatment option

A
  • Vaptans – ADH receptor antagonists
  • Works because fixing SAIDH is a slow process, this speeds it up
  • All you need to know is that it is an ADH receptor antagonist ***
37
Q

Hypervolemic hyponatremia

A
  • Caused by CHF, renal disorders or liver cirrhosis
  • Treat with water restriction – tough to fix because they often have fluid but not in vessels – some add loops + fluids
  • With these, often have to improve the underlying cause
38
Q

Replacing sodium

A
  • If you replace sodium too quickly, can get central pontine myelinolysis**** (irreversible)
  • Use NS unless having acute neurological symptoms like seizures
  • If critical symptoms, then can use 3% saline – Oral better bet
  • KNOW THIS – BOARD QUESTION
  • Two things to correct very slowly = potassium and sodium
39
Q

Hypernatremia

A
  • Not common
  • Can be from fluid loss, meds, renal impairment, burns
  • See anxiety, tremor, spasticity, seizure
40
Q

Diabetes insipidus

A
  • ADH failure
  • Either central or renal
  • Water wasting – get hypotonic urine
  • Meds (lithium, demeclocycline)
  • Note: Opposite of SAIDH – you’re peeing out a lot of water
41
Q

Treatment of diabetes insipidus

A
  • Central – DDVAP

- Nephrogenic – thiazide diuretics

42
Q

Hypernatremia

A
  • Treat with fluids

- If replace too quickly, can get brain swelling***

43
Q

When to check sodium

A
  • Part of BMP
  • Confusion
  • Muscle cramps, burns, illness
44
Q

Magnesium

A

Increased levels cause N/V, weakness, hypotension, diminished DTR
o Renal, iatrogenic (pre-eclampsia, asthma, torsades de pointes), rhabdo
o Read on your own

Decreased levels causes muscle cramps, hyper reflexes, psychosis, arrhythmias
o Illness, renal issues, malnutrition, EtOH can lead to decreased levels

45
Q

Giving a fluid bolus

A
  • ***Done for clinical dehydration or to correct vital signs
  • ***Always use isotonic (NS or LR)
  • ***A bolus is only a bolus if it is given quickly (wide open does not equal bolus)
  • A bolus is squeezing the bag until it is all in – Within 20 minutes
46
Q

How much to bolus?

A
  • ***In children, it is 20 ml/kg
  • May repeat 3 times, rarely worry about CHF
  • Adults – more eyeball the volume
47
Q

Maintenance fluid needs

A
  • Weight Volume/hr
  • 1st 10 kg 4 ml/kg/hr
  • 2nd 10 kg +2 ml/kg/hr
  • Any above +1 ml/kg/hr
48
Q

Urine output

A
  • In children, want 1-2 ml/kg/hr

- In adults, .5-1 ml/hr (

49
Q

Buzz words for boards

A
  • Hyperkalemia – Tented t waves, cardiac issues
  • Hyponatremia – confusion, central pontine myelinolysis
  • Hypocalcemia – tetany (physical tests that cause spasms) 9
50
Q

Case study 1 – Edith

A

Patient presentation
o Elderly woman with confusion
o Recently started Prozac

Deadly causes of confusion
o Stroke
o Sepsis
o Trauma

Common causes of confusion 
o	Infection (UTI, pneumonia, cellulitis) 
o	Electrolyte (hyponatremia) 
o	Medication (changing 4-5 meds)
51
Q

Case study ROS

A

ROS
o Dizzy, loss of appetite
o Nausea, no vomiting
o Urinary “problems” (incontinence, has to go all the time, no blood)
o No fever or chills
o Last time she ate was yesterday
o She has not had this before
o She has not had falls, but feels unsteady
o No chest pain, no SOB, no recent weight loss

Medications
o	Lisinopril (get basic labs -  BMP) 
o	Levothyroxine (order TSH) 
o	Prozac (can cause confusion, can cause sodium issues)

Physical exam
o Neuro exam (no signs of stroke)

52
Q

Case study labs

A

EKG = Normal

CBC (WBC = 14.2, Hbg = 12, Hct = 36, Platelets = 350)

o	UA (Positive nitrites, Positive leukocytes, Positive blood, Ketones) 
o	BMP (with liver enzymes = CMP) - Sodium = 123 (135-145)
o	TSH = 1.2 
o	Lactic acid (shows if they’re septic) = 0.6
53
Q

Case stud cause

A 
o	Likely UTI caused the hyponatremia 
o	Serum osmolality = 253 (low) 
o	Urine osmolality = 980 
o	Urine Na = 99 
o	This means all the sodium is going from the serum into the urine (called SIADH)
54
Q

Hyperkalemia case

A
  • Patient skipped dialysis - Potassium is not pulled off, so they are hyperkalemia

Potassium
o 3.5-5.1 mEq/L (she said 3.5 to 5.5)
o Even if potassium is just a little high, we get concerned

55
Q

Dialysis

A

o Best thing for her

o But not always possible at rural hospitals

56
Q

Other treatment

A

o Diuretics
o Calcium gluconate
o Glucose and insulin, which puts potassium back into the cell
o Albuterol puts potassium back into the cell = short term fix, but still helpful

57
Q

Fluids

A

o Give fluids (low BP) – first priority to get her BP up and keep her alive
o Give diuretics (to get rid of the fluids)

Emergency Med (14 decks)

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