Acid-Base / Electrolytes / Fluids Flashcards by Zachary Schulz

What are the four primary acid-base disorrders?

Metabolic Acidosis
Metabolic Alkalosis
Respiratory Acidosis
Respiratory Alkalosis

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Respiratory acid-base disorders bring primary changes in ___ and secondary (compensatory) changes in _____.

CO2

HCO3-

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Metabolic acid-base disorders bring primary changes in ___ and secondary (compensatory) changes in _____.

HCO3-

CO2

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What primary acid-base disorder is indicated by the ABG below….

7.21/30/100/15

A. Metabolic Acidosis
B. Metabolic Alkalosis
C. Respiratory Acidosis
D. Respiratory Alkalosis

A. Metabolic Acidosis

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What is the compensatory response in a metabolic acidosis?

Decrease CO2 concentration through hyperventilation

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What processes can result in a Metabolic acidosis?

Lactic Acidosis
DKA
Ingestion (Methanol, Ethylene Glycol, ASA)
Renal Failure
Diarrhea (HCO3- Loss)

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What primary acid-base disorder is indicated by the ABG below….

7.50/50/100/30

A. Metabolic Acidosis
B. Metabolic Alkalosis
C. Respiratory Acidosis
D. Respiratory Alkalosis

B. Metabolic Alkalosis

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What is the compensatory response in metabolic alkalosis?

Increased CO2 concentration through hypoventilation

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What processes can lead to metabolic alkalosis?

TPN Administration
Vomiting (H+ loss)
Loop diuretics
HCO3- Administration

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What primary acid-base disorder is indicated by the ABG below….

7.14/56/100/27

A. Metabolic Acidosis
B. Metabolic Alkalosis
C. Respiratory Acidosis
D. Respiratory Alkalosis

C. Respiratory Acidosis

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What is the compensatory response in a respiratory acidosis?

Increased HCO3- buffering in the kidneys

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What processes can lead to a respiratory acidosis?

Alveolar hypoventilation
V/Q mismatch
Alterations in CNS respiratory drive
Respiratory muscle fatigue
Pulmonary disease
Mechanical ventilation

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If an intubated and mechanically ventilated patient developed a respiratory acidosis, would this be the result of hypoventilation or hyperventilation?

How could this be corrected?

Hypoventilation (The patient is not breathing fast enough)

This can be corrected through increasing the ventilation rate

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What primary acid-base disorder is indicated by the ABG below….

7.56/25/100/18

A. Metabolic Acidosis
B. Metabolic Alkalosis
C. Respiratory Acidosis
D. Respiratory Alkalosis

D. Respiratory Alkalosis

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What is the compensatory response to a respiratory alkalosis?

Decreased HCO3- production in the kidneys

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Is respiratory alkalosis commonly due to hypoventilation or hyperventilation?

Hyperventilation

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What processes can cause respiratory alkalosis?

Pain
CVA
Anxiety
Trauma (Flail Chest)
Hypoxemia, Altitude
Pulmonary Edema
Heart Failure
Sepsis
Mechanical Ventilation
Over-correcting Metabolic acidosis

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What are causes of a WAGMA (Wide anion gap metabolic acidosis)?

MUDPILES

Methanol
Uremia (renal failure)
Diabetic ketoacidosis
Propylene glycol
Infection, inborn errors of metabolism
Lactic acidosis
Ethylene glycol
Salicylate

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A 65 y.o. male s/p CABG is intubated and placed on ventilation in the ICU. Following intubation, an ABG is drawn which shows…..

7.27/55/250/25(-2)/100%

What is the primary acid/base disorder?

Is this likely a result of?

How could this be corrected?

Respiratory Acidosis

This is likely a result of hypoventilation (holding onto too much CO2)

Increase the ventilation rate

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A 40 y.o female involved in a single vehicle MVA arrives in the ED. On exam she is found to have a fail chest. As respiratory failure seems imminent, she is intubated. Following intubation, an ABG is drawn which shows….

7.54/24/370/22/100%

What is the primary acid/base disorder?

Is this likely a result of?

How could this be corrected?

Respiratory Alkalosis

This is likely due to mechanical hyperventilation. (Losing too much CO2)

Decrease the ventilation rate

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A 6 y.o. male is brought into the ED complaining of emesis, abdominal pain, and polyuria. A UA is ordered which shows a large amount of glucose and the presence of ketones. This is concerning and prompts an ABG draw, which shows…..

7.25/16/131/7/99%

What is the primary acid/base disorder?

What is the likely underlying condition this patient has?

How are they trying to compensate?

Metabolic Acidosis

This patient likely has undiagnosed DM and is now presenting in DKA

He was trying to compensate by hyperventilating and ‘blowing down’ his CO2 levels

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_______ are IV fluids that contain water, dextrose, Na+, Cl-, and other electrolytes

Crystalloids

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______ _____ contain mostly Na+ and Cl- but also have lactate, K+, and Ca2+

Lactated Ringer’s (LR)

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______ contain packed red blood cells, pooled human plasma (5% albumin, 25% albumin), semisynthetic glucose polymers (dextran), and semisynthetic hydroxyethyl starch (hetastarch)

Colloids

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Are colloids more likely to remain in the intravascular space or the interstitial space?

Intravascular

Why should colloids be avoided in patient who are requiring fluid resuscitation (ie: dehydration)?

Colloids will draw water out of the interstitial space

When would symptoms of intravascular fluid depletion likely manifest?

Once 15% (750 mL) of blood volume is lost

What is the recommended 'fluid' of choice in fluid resuscitation?

Crystalloids

What are the signs and symptoms of intravascular fluid depletion?

1. Tachycardisa 2. Hypotension 3. Orthostatic 4. AKI (Increased BUN/sCr) 5. Dry Mucus Membranes 6. Decreased Skin Turgor 7. Reduced Urine Output 8. Dizziness

____ water is also referred as D5W and is metabolized to water and CO2 in the body

Free Water (D5W)

What THREE things are considered when adjusting maintenance fluids?

1. Input 2. Output 3. Insensible Loss

Which 'fluid' is commonly used for maintenance fluids? A. Crystalloids B. Colloids C. Free Water (D5W)

C. Free Water (D5W)

Increased osmolarity would likely result in fluid shift ______ (out of/into the cell, cell _______ (hydration/dehydration and _______ (shrinkage/growth)

Out of Dehydration Shrinkage

Decreased osmolarity would likely result in fluid shift ______ (out of/into the cell, cell _______ (hydration/dehydration) and _______

Into Hydration Hemolysis

In what THREE ways can fluid be classified in terms of osmolarity?

1. Hypertonic (Water out of the cells) 2. Isotonic 3. Hypotonic (Water into the cell)

What are TWO common uses for hypertonic saline?

1. TBI with increased ICP and MAP | 2. Symptomatic Hyponatremia (AMS, Coma)

When should hypertonic saline be AVOIDED?

1. Chronic Asymptomatic Hyponatremia 2. Hyponatremia with Hyperglycemia (ex: DKA) 3. Hyponatremia with Hypovalemia (ex: CHF)

What is the maximal safe amount of change in serum Na+ levels over 24 hours?

10-12 mmol/L

What are common complications of hypertonic saline?

1. Hypokalemia 2. Hyperchloremic Acidosis 3. Hypernatremia 4. Phlebitis 5. Heart Failure (Fluid Overload) 6. Osmotic Demyelination Syndrome (Rapid Correction of Hyponatremia) 7. Hypotension (Rapid Administration)

What are complications of IV hypotonic fluids?

1. Hemolysis of cells | 2. Death

IVF with an osmolarity less than ____ mOsm/L should be AVOIDED

150 mOsm/L

________ hyponatremia is caused by excess Na+ and fluid, but the fluid excess predominates

Hypervolemic Hyponatremia

________ hyponatermia normal total body Na+ but excess fluid, appears diluted

Normovolemic Hyponatremia

_________ hyponatremia is a deficit of both fluid and Na+ but total Na+ is decreased more than total body water

Hypovolemic Hyponatremia

What is an example of a disease or process(es) that can cause hypervolemic hyponatremia? Normovolemic? Hypovolemic?

Hypervolemic: CHF Cirrhosis Normovolemic: SIADH Hypovolemic: Emesis, Diarrhea, Fever Third-Spacing Diuretics

How is hypervolemic hyponatremia treated?

1. Na+ / Water restriction 2. Treat underlying cause 3. Vasopressin receptor antagonist

How is normovolemic hypoonatremia treated?

1. Remove offending agent (If applicable) 2. Restrict fluids 3. Demeclocyline (Tx SIADH) 4. Vasopressin receptor antagonist

How is hypovolemic hyponatremia treated?

1. Fluid Resuscitation

What are common causes of hyponatremia

1. Increased ADH 2. Volume Depletion / Hypoperfusion 3. SIADH / Cortisol Deficiency 4. Medication (Diuretics, SSRIs) 5. Renal Failure

What are clinical manifestations of mild hyponatremia (120-125)? Moderate (115-120)? Severe (<115)?

Mild: Nausea, Malaise Moderate: HA, Lethargy, Obtundation, Confusion Severe: Delirium, Sz, Coma, Death

What are common symptom manifestation of hypernatremia (>145)

1. Lethargy, Weakness 2. Twitching, Sz 3. Coma 4. Death (Late/Severe)

What are common causes of hypernatremia?

1. Loss of Water (Fever, Burns, Infection) 2. Diabetes Insipidus) 3. Sodium Retention

What complications may occur if hypernatremia is corrected too rapidly?

Cerebral Edema Seizures Neurologic Damage Death

K+ is the primary ________ (intracellular/extracellular) cation while Na+ is the primary ________ (intracellular/extracellular) cation

Intracellular Extracellular

What are common causes of hypokalemia?

1. Increased pH 2. Insulin Load 3. Hypothermia 4. Increased GI Losses (vomiting, diarrhea, laxatives) 5. Diuretics 6. Hypomagnesemia

What are symptoms and manifestations of hypokalemia?

1. Muscle Weakness 2. Flattened T waves 3. Arrhythmias (Bradycardia, V Tach, V fib) 4. Rhabdomyolysis

How should a hypokalemic patient WITHOUT EKG chagnes be treated/managed?

PO K+ Supplementation

At what K+ should hypokalemia be treated with IV replacement? What else should be monitored?

< 2.5 These patients should likely have continuous EKG monitoring

What are common causes of hyperkalemia?

1. Increase K+ intake 2. Acidosis 3. Insulin Deficiency 4. Kidney Dysfunction

What are symptoms and manifestations of hyperkalemia?

1. Muscle Weakness / Paralysis 2. Peaked T-waves 3. V Fib is Possible 4. Additional Electrolyte abnormalities

When would urgent and immediate treatment of hyperkalemia be indicated?

1. K+ >6.5 2. Severe muscle weakness 3. EKC Change

What is used to prevent hyperkalemia induced arrhythmias?

IV Calcium

T/F: IV Ca2+ will decrease serum K+ levels

False It only antagonizes the effect of K+ on cardiac conduction

IV Ca2+ should be avoided in patients taking what anti-arrhythmic

Digoxin

Other than IV Ca2++, what additional 'primary' treatment options are available to treat hyperkalemia? What are the 'secondary' or additional treatment options are used to treat hyperkalemia?

Primary: 1. Insulin / Glucose 2. Sodium Bicarbonate (Avoid in renal disease) 3. Beta-2 Adrenergic Agonists (Avoid in coronary ischemia) Secondary: 1. Diuretics 2. Cation-resin Exchange 3. Dialysis 4. Kayexalate

What are common causes of hypomagnesemia (< 1.7)?

1. Impaired Absorption (UC, Diarrhea) 2. Alcoholism 3. Hypokalemia 4. Diuretics

What are signs and symptoms of hypomagnesemia?

Tetany, Twitching Arrhythmia HTN Sudden Death

What is a common cause of hypermagnesemia (>2.3)?

Renal Insufficiency

What are signs and symptoms of hypermagnesemia?

1. Nausea, Emesis 2. Bradycardia, Heart Block, Asystole 3. Respiratory Failure 4. Death

How is hypermagnesemia treated?

1. Discontinue Mg2+ containing medications 2. IVF and Diuretics is Asymptomatic 3. IV Ca2++ if cardiac symptoms 4. HD in the setting of kidney disease

What are common causes of hypophosphatemia (<2.5)?

1. Increased Renal Elimination (Diuretics) 2. Re-feeding Syndrome 3. Respiratory Alkalosis 4. DKA Treatment

What are common signs and symptoms of hypophosphatemia?

1. Tissue Hypoxia 2. Neurologic (Confusion, Sz, Coma) 3. Cardiopulmonary (Respiratory Failure, CHF)

What are common causes of hypomagnesemia (< 1.7)?

1. Impaired Absorption (UC, Diarrhea) 2. Alcoholism 3. Hypokalemia 4. Diuretics

What are signs and symptoms of hypomagnesemia?

Tetany, Twitching Arrhythmia HTN Sudden Death

What is a common cause of hypermagnesemia (>2.3)?

Renal Insufficiency

What are signs and symptoms of hypermagnesemia?

1. Nausea, Emesis 2. Bradycardia, Heart Block, Asystole 3. Respiratory Failure 4. Death

How is hypermagnesemia treated?

1. Discontinue Mg2+ containing medications 2. IVF and Diuretics is Asymptomatic 3. IV Ca2++ if cardiac symptoms 4. HD in the setting of kidney disease

What are common causes of hypophosphatemia (<2.5)?

1. Increased Renal Elimination (Diuretics) 2. Re-feeding Syndrome 3. Respiratory Alkalosis 4. DKA Treatment

What are common signs and symptoms of hypophosphatemia?

1. Tissue Hypoxia 2. Neurologic (Confusion, Sz, Coma) 3. Cardiopulmonary (Respiratory Failure, CHF)

What TWO diseases are commonly seen with hyperphosphatemia?

1. CKD | 2. Hypoparathyroidsm

T/F: Patient with hyperphosphatemia are typically asymptomatic

True

How is Hyperphosphatemia treated?

1. Dietary restrictions 2. Saline Infusion 3. Dialysis 4. Phosphate Binders (Calcium Carbonate, Calcium Acetate)

What are common causes of hypocalcemia?

1. CKD 2. Hypoparathyroidism 3. Vitamin D Deficiency 4. Alcoholism

What are some of the many treatment options for hypercalcemia?

1. Isotonic Saline Hydration 2. Calcitonin 3. Bisphosphonates 4. Loop Diuretics 5. Glucocorticoids 6. Dialysis

What are the acute hypocalcemia Sx?

Acute: Syncope CHF Angina

What are the neuromuscular hypocalcemia Sx?

``` Numbness Tingling Cramping Tetany Wheezing Hoarseness ```

What are the neurologic hypocalcemia Sx?

Irritability Fatigue Sz

What are the chronic dermatological hypocalcemia Sx?

``` Coarse Hair Brittle Nails Psoriasis Dry Skin Poor Dentition ```

What are the TWO most common causes of hypercalcemia?

1. Malignancy | 2. Hyperparathyroidism

What are the CNS Sx of hypercalcemia? GI Sx? Renal? Cardiac?

CHS: Lethargy, Weakness, Confusion GI: Constipation, Nausea Renal: Polyuria, Nocturia, Stones Cardiac: Syncope, Arrhythmia

What are some of the many treatment options for hypercalcemia?

1. Isotonic Saline Hydration 2. Calcitonin 3. Bisphosphonates 4. Loop Diuretics 5. Glucocorticoids