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Houseman (break your leg) > Biochemistry abn > Flashcards

Biochemistry abn Flashcards

1
Q

Hypernatremia

A 
DDx
- DEHYDRATION
- Endocrine (Cushing, Conn's)
- Iatrogenic (meds)
==================================
Document 1. GC/ seizure, 2. fluid status
Aim decrease Na 10-12mmol/D

Mx

  • Low salt diet
  • CHECK DRUG: W/H NaCl, NaHCO3, Na supplement
  • IVF 1/2:1/2 500mL q6H - q12H
  • RECHECK RFT q6H - q12H

Symptomatic / Na >160: D5 + ICU
Na <160: D5
Na <150: keep obs

  • If decreasing rate fast: slow down transfusion rate
  • If decreasing rate slow: IV D5 500mL q8H-q12Hp
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2
Q

Hyponatremia

A

DDx

  • Pseudohyponatremia: normal/ H serum osm > glc, paraprotein, TG
  • hypovolemic: GI/ third space/ renal (diuretics)
  • euvolemic: SIADH/ hypoT4/ addison/ drinking too much water
  • hypervolemia: CHF, cirrhosis, hypoALB, nephrotic
  • # Think SIADH: low serum osm, high urine osm, urine Na >40, TFT/cortisol normalDocument 1. GC/ seizure, 2. fluid status

Ix to order

  • DAT
  • Neuroobs q4H (Na<120)
  • Blood x TSH, spot cortisol, osm
  • Urine x osm, sodium *urine osm/ Na not low : kidney/ ADH prob
  • CXR
  • +- CT brain if Na <120

Mx to order

  • hypovolemic: NS
  • euvolemic: FR (<1.2L - 1.5L) +- NaCl
  • hypervolemic: FR + lasix
  • NaCl PO 900mg BD/TDS
  • or NaCl PO 1800mg BD/TDS
  • If Na <120, call MO; IV hydrocortisone 100mg q8H, think addison crisis
  • If Na <110, consult ICU
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3
Q

HyperK

A

CHECK hemolysis

K 5-6

  • ECG (Peaked T >5mm in limb; >10mm in chest, shorten QT, ST depression)
  • Resonium A/C 15g PO/PR q6H x3 (A = Na, C = Ca)
  • Recheck RFT afterwards

K >6

  • ECG + cardiac monitor (Prolong PR, Widen QRS, Loss of P wave, Sine wave pattern (QRS blended with T), PEA/VF)
  • IV Calcium gluconate 10% 10mL over 3min x1, repeat q10min till sinus
  • DI drip: D50 50mL + actrapid 10U q30mins x1 (last 2H)
  • resonium A/C 15mg PO/PR q6H (if R/T, give PR)
  • Recheck RFT afterwards, H’stix

W/H K supplement, ACEI/ARB/spironolactone, amiloride, moduretic

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4
Q

HypoK

A

Find cause
- Think diuretics, vomiting, cushing’s, theophylline, high colostomy output

Special cases
- HD/ anuria: <2.5 (repeat urgent + ECG, PO KCl 0.5-1g x1), otherwise keep obs
- CAPD: replace as normal
- IPD (1x - 2x/ week): UO +: replace cautiously; UO- : = HD
- IF MI/ arrhythmia: aim K>4!!!!
===============================
Ix
- Drug history, w/h dose causing hypoK (thiazide)
- Bicarbonate (N: transcellular shift/ drugs; meta alkalosis: Conn/ Cushing/ iduretics; meta acidosis: GI loss e.g. diarrhea/ DKA/ RTA)
- If metabolic alkalosis: spot K, paired serum K, 24H urine x K (rarely done)

Treat HypoK

  • 2.8-3.5
  • –> KCl syrup PO 2000mg q2H x 1-3 (expect 0.2 rise per dose)
  • —> (persistent) Slow K PO 600mg daily/BD/TDS, check Mg next blood
  • 2.5-2.8
  • —> CHECK IF HD/ anuria (if HD, no replacement)
  • —> ECG
  • —> KCl 10mmol in 100mL water q1H-q2H x1
  • —> KCl syrup 3000mg PO q2H x4
  • —> Maintenance K: oral K 600mg daily/ 10-20mmol to each pint IVF
  • —> recheck RFT, Mg afterwards
  • <2.5
  • —> CHECK IF HD (if HD, repeat K; 0.5-1g PO KCl x1 if still <2.5)
  • —> ECG, symptoms of LL weakness
  • —> KCl 20mmol in 100mL water q1H-q2H x1
  • —> KCl syrup 3000mg PO q2H x3
  • —> Recheck RFT, Mg afterwards

If NPO, use infusion

  1. Max infuse 40mmol K/H
  2. Simultaneously only 20mmol K on drip stand (e.g. not 20mmol K in 100 water AND 10mmol K in 500mL NS tgt)
  3. Max IV K 40-120mmol/ day
  • 3-3.5
  • —> Add 10mmol K to each pint IVF
  • —> 10 mmoL in 500mL NS q6-8H
  • —> recheck RFT mane
  • 2.8-3
  • —> Add 20mmol K to each pint IVF
  • —> 20mmol in 500mL NS q6-8H
  • —> Recheck RFT mane
  • <2.5
  • —> ECG
  • —> KCl 20mmol in 100mL water q1-2H x1
  • —> Add 20mmol K to each pint IVF
  • —> 20mmol in 500mL NS q6-8H
  • —> Recheck RFT, Mg afterwards
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5
Q

Hypomagnesium

A
  • Treat if + hypoK, hypoCa, arrhythmia
  • ECG
  • 4mL 50% MaSO4 in 100mL NS infuse 30 min
  • +- 10mL 50% MgSO4 in 500mL NS over 6H
  • +- Mg trilisilate PO 10mL TDS daily
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6
Q

HyperCa

A

DDx

  • Malignancy, PTH (young, ESRD), dehydration, drugs (Ca sup, VitD, thiazide), TB/ milk alkaline syndrome/ hypoerT4 (bone turnover)
    1. ALB and calculate adj calcium: adj Ca = 0.02 * (40-patient alb in g/L) + serum Ca
    2. check ionized calcium
  • Treat acc to investigation (PTH, Thyroid, vitD)

> 3.0
ECG, cardiac monitoring
Document symptoms (CNS), fluid status
Drug chart (off calcium supp/ Vit D)
Rehydration by NS 500mL q6-8H if not overload
Pamidronate 60-90mg in 500mL NS over 4H x 1 (onset 1-2D): not for eGFR <30
Salmon calcitonin 4U /kg IMI/ SC Q12H (onset 2-3H)
Lasix (for fluid overload)
Recheck Ca till Ca <3.0
Ca>4.0 / ECG changes: consult ICU
W/H calcium supplement

Mild hyperCa
Fluid overload, drugs
Underlying cause
Rehydration by NS
Pamidronate 30-60mg in 500mL NS if persistent

Calcium of malig (usu >3)
—-> IV NS 500mL q6-8H
—-> recheck RFT
—–> Pamidronate 30-80mg in 500mL NS infused over 4-6H
—-> (if fail) #Zometa 4mg in 100mL NS over 15mins
# If CrCl >60: 4mg, CrCl 50-60: 3.5mg, CrCl 40-49: 3.3mg, CrCl 30-39: 3mg
—-> recheck Ca 3/7, each dose of bisphosphonate last 3/52

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7
Q

HypoCa

A
  • +-ECG, symptoms (numb/twitching)
  • IV infusion calcium gluconate 10% 10mL in 100mL NS over 30mins/ IV calcium gluconate 10% 10mL over 3-5mins
  • PO caltrate 1500mg daily or tds or qid
  • Vit D supp if vit d def
    »» vit d3 1000IU daily
    »» alphacalcidol (renal fail, liver ok)
    »» rocaltrol (renal fail liver fail, postparathyroidectomy in esrd)
    THINK renal failure (PO4 retention), post parathyroidectomy (hungry bone), vit d def, liver ds, consumption (pancreatitis rhabdo hyperpo4 in tumor lysis), hypoPTH, hypoMg

Renal failure

  • CAPD regimen from low Ca to normal Ca
  • +- caltrate 600 (Ca and VitD supp) 1500mg PO daily
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8
Q

HypoPO4

A

Ddx
- inadequate intake (seriously ill), refeeding syndrome (fasting use fatty acid/ aa-> refeed use atp to synthesize glycogen fat protein), vit d def, hyperPTH, resp alkalosis, phosphate binder (caltrate alusorb savelemer)

<0.5

  • risk of hemolysis rhabdo resp fail
  • 5-10ml k2hpo4 in 100mL NS/D5 over 1-2H
  • or + 5ml k2hpo4 in each pint ivf q12H
  • beware hyperK

> 0.5

  • no tx (tx = metastatic calcification)
  • chronic: sandoz phosphate one tab qid x 2-3/7
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9
Q

AKI (sudden inc Cr/ urine <0.5mL/kg/H)

A
  • usu dehydration!
  • Fluid status
  • Bladder scan (if residual urine >350mL, foley to BSB/ flush foley)
  • NS 500mL q1-2H x1, then IVF q4-8H
  • Recheck RFT
  • Lasix 40mg q8H (???may need 1-3g/D to attain response)
  • Low dose dopamine 5mL/H to increase UO for med admin
  • If severe, not respond fluid challenge, no specific cause, workup cause
  • —> Blood x CBC, LRFT, bone, RG, ANCA, Anti-ANA, Anti-dsDNA, Anti-GBM, C3/C4, HBsAg, Anti-HCV, SPE, bence-jones protein, Ig pattern
  • —> urine x multistix, C/S
  • —> KUB, U USG urinary system
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10
Q

Deranged LFT

A
  • Check drug, cholangitis

Hepatitic picture (ALT> ALP)

  • blood x HBsAg, HBV DNA, AntiHCV, HAV, HEV, panadol level, GGT, AST, LDH, amylase, direct bilirubin, ammonia, INR
  • urine toxicology
  • W/H panadol, anti-TB, steroid
  • Treat complications (e.g. ascites, SBP, esophageal varices, encephalopathy, hepatorenal syndrome)
  • PO vitK1 10mg daily (deranaged INR >=1.5)/ IV vitK1 10mg q24H
  • IV albumin 20% 40g (1g/kg) q24H
  • Antiviral drug (entecavir 0.5mg daily PO)

Cholangitis picture (ALP> ALT)

  • NPO
  • Blood x HBsAg, HBV DNA, AntiHCV, HAV, HEV, GGT, AST, LDH, amylase
  • Blood c/s if fever >38
  • MSU C/S, multistix
  • CXR, AXr
  • antibiotics if fever
  • urgent USG HBP (CBD obstruction/ liver abscess)
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11
Q

Acidosis

A

pH <7.35

Metabolic: ALL LOW (pH, HCO3, CO2), base excess

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12
Q

Trop T/I increase

A
  • chest pain
  • vitals
  • ECG

Trop T
- <14: no action
- >14: repeat CK, TropT, CK, LDH, ECG q8H x3
»» double rise: MI
»» static/ downtrend: other cause (sepsis, renal failure, CHF)
- >1000: MI (often STEMI)

TropI
- <0.03: no action
- >0.03: repeat TropI, CK, LDH, ECG q8H x3
»» increasing trend: <0.3, repeat till downtrend
»» static/ downtrend: other cause
- >0.3: MI

Mx
NSTEMI: call MO before start enoxaparin
STEMI: call MO to for CCU bed

  • prop up
  • bed rest
  • cardiac monitor
  • O2 0-2L aim SaO2>=95%
  • aspirin 160mg PO stat x1, then 80mg PO daily
  • TNG 500mcg SL stat prn
  • +- enoxaparin 0.4mL SC q12H (bleeding hx)

still HTN/ chest pain

  • isoket (isosorbide dinitrate) infusion 50mg in 100mL NS, start with 4mL/H (0-10mL/H, max 20mL/H)
  • nitrocine 25mg in 100mL NS, start with 4mL/H
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13
Q

Deranged Fe profile, folate, B12

A

(can leave to MO)

Fe def

  • typically Fe L, Fe sat L, TIBC H
  • give FeSO4 300mg BD PO x4-8/52

Folate def
- Folate 5mg daily PO (after RO B12 def)

B12 def

  • B12 5000mcg IM alt day x 5doses, then B12 5000mcg IM q1-3month
  • RFT after 3rd dose (for hypoK)
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14
Q

Thyroid profile

A

(can leave to MO)

  • check symptoms
  • check complications: thyroid storm, CHF, hypoK paralysis
  • deranged TSH, repeat TFT 6-8/52

TSH L

  • T4 L: secondary hypothyroidism
  • T4 N: subclinical hyperthyroidism, sick euthyroid
  • T4 H: primary hyperthyroidism

TSH N

  • T4 L: primary hypothyroidism
  • T4 N: normal
  • T4 H: primary hyperthyroidism

TSH H

  • T4 L: primary hypothyroidism
  • T4 N: subclinical hypothyroidism, sick euthyroid
  • T4 H: secondary hyperthyroidism

Primary hyperthyroidism: drugs, RAI, surgery

Primary/ secondary hypothyroidism:

  • thyroxine 50-100mcg daily PO
  • recheck TFT 6-8/52
  • RO adrenal insufficiency, cardiac ds
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15
Q

Stool clostridium difficile +

A
  • any diarrhea
  • contact precaution
  • Flagyl (metronidazole) 400mg PO TDS 1/52
  • symptoms control
    »» imodium (loperamide) PO 4mg stat, then 2mg tds-qid
    »» codeine PO 30mg tds for severe diarrhea
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16
Q

C/S +

A
  • fever
  • current Abx acc sensitivity
  • contamination?
    »» staph epidermiditis (usu contam), MRSA (repeat 2more C/S at diff site and time)
    »» MSU, sputum, tracheal aspirate, wound swab (await MO)

Blood C/S (usu accurate), strep/ gram- usu true infection

  • think IE, ECHO + ESBL
  • IV meropenem 500mg q8H

Urine C/S

  • check fever + WCC, both + usu true infection
  • PO augmentin 500mg q8H / PO nitrofurantoin 100mg BD for 5 days (uncomplicated cystitis, not renal impair/elderly)

Joint aspiration
- ALWAYS NPO, call MO!! (knee lavage, urgent consult ortho)

17
Q

HyperPO4

A

DDx

  • chronic renal failure
  • acute phosphate nephropathy (e.g. fleet)
  • tumor lysis
  • hemolysis/ rhabdomyoloysis
  • large tumor burden

Mx

  • low phosphate diet + phosphate binder (CaCO3, alusorb, sevelemer)
  • treat underlying caues
  • acute: dialysis
18
Q

HypoMg

A

Replace if

  1. severe hypoK/ hypoCa
  2. hyperreflexia
  3. arrhythmia

DDx

  • malnutrition/ refeeding syndrome
  • GI loss (diarrhea/ vomiting)
  • drugs (loop / thiazide, amphotericin B, aminoglycoside, PPI)
  • renal loss (diuretics, ATN polyuria phase, etc)

Mx
<0.5 (usu symptomatic)
- symptoms (numb/ twitching), reflex, ECG
- IV 50% MgSO4 5mL in 20mL NS/D5 over 15mins then in 50% MgSO4 100mL in 500mL NS/D5 over 6H
- if Torsades: IV MgSO4 1-2G in 10mL NS/D5 bolus
- repeat Mg

> 0.5 (usu asymptomatic)
- check renal failure (if renal fail, cautious to supple)
- drugs
- treat underlying cause
- oral supplement (ALL CAUSE DIARRHEA)
» Mg trisillicate PO 10mL TDS (poor oral bioavailibility)
» MgSO4 PO 5-10mL TDS (double bioava to triscillate)
» Mg L-lactate dihydrate PO 84-168mg Q12H (slow release, but $$)

19
Q

IVF

A

Plasma: 142 Na, 103 Cl, 4.5 K, 1.25 Mg, 2.5 Ca, 24 HCO3, 0.08 glc
NS: 154 Na, 154 Cl
D5: 5 glc
Hartman: 131 Na, 111 Cl, 5 K, 2 Ca, 29 HCO3 (CAUTION if hyperK/ renal fail)

Mx: 
stroke: NS
surgical: hartmann
hyperNa: 1/2 1/2 or D5
hypoK: hartman/ IVF + 10-20mmol K
hypoglc: D10

Houseman (break your leg) (23 decks)

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