CCT / CBL Mix Flashcards
Definition of hyperkalaemia:
Serum potassium concentration >5.3mmol/L.
How to classify different causes of hyperkalaemia?
Causes of hyperkalaemia may be broken down into causes of impaired excretion of potassium from the kidney, increased release of potassium from cells, and “pseudohyperkalaemia” / artefact.
Skim the list of hyperkalaemia due to impaired excretion:
- Acute kidney injury
- Chronic kidney disease
- ACE inhibitors or angiotensin receptor blockers
- Potassium-sparing diuretics (e.g. spironolactone)
- NSAIDs
- Heparin/low molecular weight heparin (which inhibits aldosterone release)
- Ciclosporin
- High dose trimethoprim
- Hypoaldosteronism (e.g. renal tubular acidosis type 4)
- Addison’s disease
Skim the list of hyperkalaemia due to increased release from cells:
- Lactic acidosis
- Insulin deficiency
- Rhabdomyolysis
- Tumour lysis syndrome
- Massive haemolysis
- Digoxin toxicity (NB: This can be precipitated by hypokalaemia)
- Beta-blockers.
Artefact causes of hyperkalaemia:
Important to think about when in a primary care setting.
- Haemolysis (traumatic venepuncture, prolonged tourniquet use, fist clenching)
- Delayed analysis (K+ leaks out of red blood cells)
Suspect this when:
- A mild rise in potassium with all other U&E results normal
- Consider spurious results in absence of:
- Acute illness (e.g. AKI, acidosis)
- Co-morbidities (elderly, renal, endocrine, CCF)
- Causative medications
Talk through the ECG changes seen in hyperkalaemia in order of severity.
- 5mmol = Tall tented T-waves.
- 6mmol = P waves flatten / Prolonged PR.
- 7mmol = Wide QRS
- 8mmol = Sine wave pattern
- 8mmol = Can cause Vfib
What is ‘severe’ hyperkalaemia?
> 6.5mmol K+
How to treat severe hyperkalaemia?
Treat K+ >6.5mmol/L or any ECG changes with the following;
- Give 10ml of 10% calcium gluconate (or chloride) over 10 mins - this is cardioprotective.
- Intravenous insulin (10U soluble insulin) in 25g GLUCOSE (50mL of 50% or 125ml of 20% glucose) - insulin causes intracellular K+ shift and glucose to required to prevent hypoglycaemia.
- Nebulised salbutamol - also causes intracellular K+ shift.
- Calcium resonium increases K+ excretion into urine (MH)
Loop diuretics can also be used (but longer to act).
Dialysis if not responding to treatment.
SIADH causes what?
Euvolemic hyponatraemia
How is SIADH managed?
Management revolves around offloading this excess water:
- Fluid restriction (up to 750ml/day) and treat underlying cause.
- ADH antagonists (e.g. tolvaptan, deomeclocycline).
- Oral sodium and furosemide.
How does the urine change in patients with SIADH?
The urine becomes more concentrated as less water is excreted by the kidneys.
Therefore patients with SIADH have a “high urine osmolality” and “high urine sodium”.
Symptoms of SIADH:
- Headache
- Fatigue
- Muscle aches and cramps
- Confusion
- Severe hyponatraemiacan cause seizures and reduced consciousness
There is no reliable test for SIADH, therefore it is a diagnosis of exclusion.
- what other investigations should be done?
- Negativeshort synacthen testto excludeadrenal insufficiency
- No history of diuretic use
- No diarrhoea, vomiting, burns, fistula or excessive sweating
- No excessive water intake
- Nochronic kidney diseaseoracute kidney injury
What is an important complication of treating hyponatraemia?
Central pontine myelinolysis(CPM) is also (and more accurately) known as “osmotic demyelination syndrome”. It is usually a complication of long term severe hyponatraemia(< 120 mmols/l) being treated too quickly (> 10 mmol/l increase over 24 hours).
Dietary advice for a patient with CF?
High calorie, high fat, with pancreatic enzyme supplementation for every meal.
What are the genetics of fragile x?
X-linked on FMR gene
CGG repeat disorder.
What are the features of fragile x syndrome?
Long face, prominent forehead and chin, protruding ears, large testes, flat feet, mitral valve prolapse.
Autism and anxiety.
How should challenging behaviour and intellectual disability be assessed?
- Developemental history
- Response to previous interventions for challenging behaviour
- Independent living skills / occupational ability
- History of trauma / change in life events
- Relationship with carers / family
- Sensory profile
- Environment
How should people with challenging behaviour be managed? OSCE
MDT
PBS (positive behavioural support)!!
Treat underlying health issues
Staff training and communication guidelines
Adapt environment
Establish diagnoses and prescribe psychotropic medication where appropriate.
What does PBS (positive behavioural support) aim to do?
Increase domestic activity skills, engagement and quality of life.
Increase community inclusion.
Improve physical health and management.
Preventative strategies to avoid the behaviour and reactive strategies during crisis.
Define challenging behaviour:
Behaviour can be described as challenging when it is of such an intensity, frequency or duration as to threaten the quality of life and or the physical safety of the individual or others and is likely to lead to responses that are restrictive, aversive or result in exclusion.
Investigations for someone presenting with challenging behaviour: OSCE
Abdo exam - to rule out constipation.
Sensory tests - hearing and sight.
Otoscopy to rule out infection.
Bloods - FBC (anaemia) U&E’s, LFT’s, TFT’s, Bone profile (hypocalcemia), B12.
Urine Dipstick - rule out UTI
H.pylori-causing pain
Dental check.
May consider a CT head if acute behavioural change.
What are the 5 principles when assessing capacity?
- Principle 1: A presumption of capacity.
- Principle 2: Individuals being supported to make their own decisions.
- Principle 3: Unwise decisions.
- Principle 4: Best interests.
- Principle 5: Less restrictive option.
What is the two stage test of capacity and what criteria are tested to assess capacity?
- Does the person have an impairment of their mind or brain?
- Does the impairment mean the person is unable to make a specific decision when they need to?
The Mental Capacity Act 2005 states a person is unable to make a decision if they cannot
- Understand
- Retain
- Evaluate
- Communicate
