(2) Common problems in acute care Flashcards
Hyponatremia - evaluation
Most common electrolyte abnormality
Urine sodium - normal 10-20
Serum osmolality - normal 275-285
Clinical status
Urine sodium > 20
suggests kidney issue
Urine sodium < 10
suggests problem outside of kidney
Isotonic Hyponatremia - s/s and treatment
Pseudohyponatremia
- occurs with extreme HLD, high protein leves
s/s - asymptomatic - usually found on labs
Treatment - cut down on fat
Hypotonic Hyponatremia - assessment
Serum osmo < 280
Are they hyper/hypovolemic?
If Hypervolemic - assess for extrarenal salt loss or renal salt wasting?
Any time in acute care you see diarrhea, what should you test for?
C-difficile
Hypovolemic Hypotonic Hypernatremia
w/ urine sodium < 10
Causes (3)
Dehydration
Diarrhea
Vomiting or prolonged NGT suctioning
Hypovolemic Hypotonic Hypernatremia
w/ urine sodium > 20
Causes (3)
Low volume - kidneys cannot conserve NA
- Diuretics**
- ACE inhibitors
- Mineralocorticoid deficiency
Hypervolemic Hypotonic Hypernatremia
MOST COMMON
Causes (3)
Treatment
Any Edematous states -- CHF -- Liver disease -- Advanced renal failure Treatment - restrict fluids
Hypertonic Hyponatremia
serum osmo is?
Most common cause?
Serum osmo > 290
Hyperglycemia - usually HHNK
Hyponatremia management?
Treatment based on cause Hypervolemic - fluid restriction Hypovolemic - give IVF - normal saline Symptomatic - give NS with loop diuretic CNS symptoms - consider 3% and lasix
What rate do you administer 3% saline to a hyponatremic patient?
slow and calculated
Hypernatremia
Management
Usually due to excess water loss
Depends on cause
Hypovolemia – NS followed by half
Euvolemia – D5W
Hypervolemia - D5W and lasix or dialysis
Normal potassium levels
3-5.5
Normal sodium levels
135-145
Hypokalemia - causes
Diuretics
Alkalosis
GI loss
Excess renal loss
Elevated serum epinephrine in trauma patients may contribute to:
Hypokalemia
Hypokalemia - s/s (4)
Muscular weakness
Fatigue
Muscle cramps - legs hurt early afternoon
Constipation
Severe Hypokalemia s/s (4)
Severe < 2.5
- flaccid paralysis
- tetany
- hyporeflexia
- rhabdomyolosis
Hypokalemia - diagnostics
Decreased amplitude on ECG
Broad T waves
Prominent U waves
multifocal PVCs, V-tach, V-fib
Hypokalemia managemet
2.5-4 give PO or 10 mEq/hr IV
< 2.5 or severe s/s may give 40 mEq/hr
– Give magnesium if refractory hypokalemia
Hyperkalemia - causes
excess intake renal failure drugs - NSAIDS hypoaldosteronism cell death acidosis - shifts extracellular
At what rate does K increase with drop in pH?
0.7 mEq/L for every 0.1 drop in pH
If you replace K 3 times in 8 hours and potassium doesn’t move, what is likely the issue?
Hypomagnesemia
Hyperkalemia - diagnosis
ECG - tall peaked T-waves
Hyperkalemia - management
Kayexalate
Insulin 10 U regular with D50
How does insulin and d50 reduce K?
It pushes it into the cell.
Why is Calcium important?
Important as a mediator of neuromuscular and cardiac function
What is normal ionized calcium
4.5-5.5 mg/dl and does not vary with albumin level
Hypocalcemia
Pancreatitis
Renal failure
Severe trauma
Blood transfusions
Hypocalcemia
Increased DTR
Trousseau’s sign - Caropopedal spasm
Chvostek’s - cheek blink
Hypercalcemia
Sluggish
- Fatigue
- muscle weakness
- Depression
- Anorexia
- N/V
- -Constipation
Severe Hypercalcemia
Can cause coma and death
> 12 is considered a medical emergency
Hypercalcemia treatment
Calcitonin
Dialysis
If > 12 NS infusion with loop diuretic
HYPOcalcemia management
ABG - check pH Acute - Calcium gluconate Chronic - Oral supplements -- Vitamin D -- Aluminum hydroxide
If a patient has a normal calcium level (8.5-10.5 mg/dl) but a low albumin, what does this suggest?
Hypercalcemia - because 50% of calcium is bound to albumin
Corrected calcium formula
total Ca + 0.8 or (4-serum albumin)
What is Chvostek’s sign?
twitching of the facial muscles in response to tapping over the area of the facial nerve
Hypocalcemia
What is Trousseau’s sign?
Blood pressure cuff around arm for 3 minutes will induce spasm in the forarm and hand
Hypocalcemia
Acid-base imbalances
Respiratory Acidosis
pH < 7.35
pH - 7.28
CO2 - 50
Bicarb - 25
Respiratory acidosis
- Lethargic
- Overdose
Treatment - ventilation, narcan
pH 7.50
CO2 - 25
Bicarb 25
Respiratory alkalosis
- Hyperventilation
Treatment - sedation
pH < 7.35
CO2 - 35-45
Bicarb < 22
Metabolic acidosis
Anion Gap
{Na + K} - {HCO3 + Cl}
Higher the anion gap
The more acutely ill the patient is
Acetazolamide - Diamox
Metabolic alkalosis
“ROME”
Respiratory opposite
Metabolic equal
