(2) Common problems in acute care

Question 1

Hyponatremia - evaluation

Answer 1

Most common electrolyte abnormality

Urine sodium - normal 10-20
Serum osmolality - normal 275-285
Clinical status

Question 2

Urine sodium > 20

Answer 2

suggests kidney issue

Question 3

Urine sodium < 10

Answer 3

suggests problem outside of kidney

Question 4

Isotonic Hyponatremia - s/s and treatment

Answer 4

Pseudohyponatremia
- occurs with extreme HLD, high protein leves
s/s - asymptomatic - usually found on labs

Treatment - cut down on fat

Question 5

Hypotonic Hyponatremia - assessment

Answer 5

Serum osmo < 280
Are they hyper/hypovolemic?
If Hypervolemic - assess for extrarenal salt loss or renal salt wasting?

Question 6

Any time in acute care you see diarrhea, what should you test for?

Answer 6

C-difficile

Question 7

Hypovolemic Hypotonic Hypernatremia
w/ urine sodium < 10
Causes (3)

Answer 7

Dehydration
Diarrhea
Vomiting or prolonged NGT suctioning

Question 8

Hypovolemic Hypotonic Hypernatremia
w/ urine sodium > 20
Causes (3)

Answer 8

Low volume - kidneys cannot conserve NA

• • Diuretics**
• • ACE inhibitors
• • Mineralocorticoid deficiency

Question 9

Hypervolemic Hypotonic Hypernatremia
MOST COMMON
Causes (3)

Treatment

Answer 9

Any Edematous states
-- CHF
-- Liver disease
-- Advanced renal failure
Treatment - restrict fluids

Question 10

Hypertonic Hyponatremia
serum osmo is?
Most common cause?

Answer 10

Serum osmo > 290

Hyperglycemia - usually HHNK

Question 11

Hyponatremia management?

Answer 11

Treatment based on cause
Hypervolemic - fluid restriction 
Hypovolemic - give IVF - normal saline
Symptomatic - give NS with loop diuretic
CNS symptoms - consider 3% and lasix

Question 12

What rate do you administer 3% saline to a hyponatremic patient?

Answer 12

slow and calculated

Question 13

Hypernatremia

Management

Answer 13

Usually due to excess water loss

Depends on cause
Hypovolemia – NS followed by half
Euvolemia – D5W
Hypervolemia - D5W and lasix or dialysis

Question 14

Normal potassium levels

Answer 14

3-5.5

Question 15

Normal sodium levels

Answer 15

135-145

Question 16

Hypokalemia - causes

Answer 16

Diuretics
Alkalosis
GI loss
Excess renal loss

Question 17

Elevated serum epinephrine in trauma patients may contribute to:

Answer 17

Hypokalemia

Question 18

Hypokalemia - s/s (4)

Answer 18

Muscular weakness
Fatigue
Muscle cramps - legs hurt early afternoon
Constipation

Question 19

Severe Hypokalemia s/s (4)

Answer 19

Severe < 2.5

• • flaccid paralysis
• • tetany
• • hyporeflexia
• • rhabdomyolosis

Question 20

Hypokalemia - diagnostics

Answer 20

Decreased amplitude on ECG
Broad T waves
Prominent U waves
multifocal PVCs, V-tach, V-fib

Question 21

Hypokalemia managemet

Answer 21

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

Question 22

Hyperkalemia - causes

Answer 22

excess intake 
renal failure 
drugs - NSAIDS 
hypoaldosteronism
cell death
acidosis - shifts extracellular

Question 23

At what rate does K increase with drop in pH?

Answer 23

0.7 mEq/L for every 0.1 drop in pH

Question 24

If you replace K 3 times in 8 hours and potassium doesn’t move, what is likely the issue?

Answer 24

Hypomagnesemia

Question 25

Hyperkalemia - diagnosis

Answer 25

ECG - tall peaked T-waves

Question 26

Hyperkalemia - management

Answer 26

Kayexalate

Insulin 10 U regular with D50

Question 27

How does insulin and d50 reduce K?

Answer 27

It pushes it into the cell.

Question 28

Why is Calcium important?

Answer 28

Important as a mediator of neuromuscular and cardiac function

Question 29

What is normal ionized calcium

Answer 29

4.5-5.5 mg/dl and does not vary with albumin level

Question 30

Hypocalcemia

Answer 30

Pancreatitis
Renal failure
Severe trauma
Blood transfusions

Question 31

Hypocalcemia

Answer 31

Increased DTR
Trousseau’s sign - Caropopedal spasm
Chvostek’s - cheek blink

Question 32

Hypercalcemia

Answer 32

Sluggish

• • Fatigue
• • muscle weakness
• • Depression
• • Anorexia
• • N/V
• -Constipation

Question 33

Severe Hypercalcemia

Answer 33

Can cause coma and death

> 12 is considered a medical emergency

Question 34

Hypercalcemia treatment

Answer 34

Calcitonin
Dialysis
If > 12 NS infusion with loop diuretic

Question 35

HYPOcalcemia management

Answer 35

ABG - check pH 
Acute - Calcium gluconate
Chronic - Oral supplements
-- Vitamin D
-- Aluminum hydroxide

Question 36

If a patient has a normal calcium level (8.5-10.5 mg/dl) but a low albumin, what does this suggest?

Answer 36

Hypercalcemia - because 50% of calcium is bound to albumin

Question 37

Corrected calcium formula

Answer 37

total Ca + 0.8 or (4-serum albumin)

Question 38

What is Chvostek’s sign?

Answer 38

twitching of the facial muscles in response to tapping over the area of the facial nerve

Hypocalcemia

Question 39

What is Trousseau’s sign?

Answer 39

Blood pressure cuff around arm for 3 minutes will induce spasm in the forarm and hand

Hypocalcemia

Question 40

Acid-base imbalances

Respiratory Acidosis

Answer 40

pH < 7.35

Question 41

pH - 7.28
CO2 - 50
Bicarb - 25

Answer 41

Respiratory acidosis

• Lethargic
• Overdose

Treatment - ventilation, narcan

Question 42

pH 7.50
CO2 - 25
Bicarb 25

Answer 42

Respiratory alkalosis
- Hyperventilation

Treatment - sedation

Question 43

pH < 7.35
CO2 - 35-45
Bicarb < 22

Answer 43

Metabolic acidosis

Question 44

Anion Gap

Answer 44

{Na + K} - {HCO3 + Cl}

Question 45

Higher the anion gap

Answer 45

The more acutely ill the patient is

Question 46

Acetazolamide - Diamox

Answer 46

Metabolic alkalosis

Question 47

“ROME”

Answer 47

Respiratory opposite

Metabolic equal