Dehydration

Question 1

Definition of Dehydration vs. Hypovolemia

Answer 1

Dehydration: loss of water without sodium or potassium -> in the absence of volume repletion may lead to hypernatremia

Hypovolemia: loss of isotonic fluid leading to a reduction of plasma volume

Question 2

5 symptoms in adult

Answer 2

Fatigue, weakness, malaise, thirst, postural dizziness
Altered mental status, lethargy
Oliguria
Increased thirst

Question 3

5 signs in adult

Answer 3

Orthostatic vitals (HR↑ >30bpm, sBP ↓> 20 or dBP ↓> 10mmHg)
Tachycardia, tachypnea
Dry mucosa
Diminished skin turgor
Sunken eyes
Skin turgor
Capillary refill >3s

Question 4

Clinical Features of Hypovolemic Shock

Answer 4

hypotension, tachycardia, peripheral vasoconstriction, oliguria, AMS

Question 5

Clinical Features of Pediatric Hypovolemia

Answer 5

Increased Thirst
Restless
Irritability
Lethargy
Loss of consciousness
Sunken eyes fontanelle
Absence of tears
Weight Loss
Fewer wet diapers

Question 6

% volume / weight loss in mild, moderate and severe hypovolemia

Answer 6

Mild dehydration – 3-5% weight loss
Moderate dehydration – 6-9% weight loss
Severe dehydration - >9% weight loss

Question 7

5 risk factors

Answer 7

fever 
vomit 
diarrhea
Decreased Cognitive Function
Reduced Oral Intake
Absence or altered thirst mechanism
Diuretics

Question 8

Dehydration Risk Screening Tool: DEHYDRATIONS

Answer 8

D: diuretics
E: end of life
H: high fever
Y: yellow urine turned dark
D: dizziness (orthostatics)
R: reduced oral intake
A: axilla dry
T: tachycardia
I: incontinence
O: oral problems
N: neurologic impairment
S: sunken eyes LR 3.7
**Dry mucus membranes LR 3.1**
**Abnormal skin turgor LR 3.5**

Question 9

Measurements / Physical Exam features of adult

Answer 9

BP – Hotn
HR – tachycardia
RR – tachypnea
Orthostatics: Pulse increased by 30, SBP increase by 20, DBP increase by 10
Volume status – less reliable in elderly:
Dry axilla LR 2.8
Moist mucus membrane / tongue WITHOUT furrow LR -0.3
Cap refill
Skin turgor

Question 10

Clinical features of mild pediatric

Answer 10

Physical Exam findings normal

Question 11

Clinical features of moderate pediatric

Answer 11

Tachycardia 
normal – low SBP 
\+/- tachypnea 
dry buccal mucosa 
sunken anterior fontanelle 
reduced skin turgor 
cool skin 
reduced urine output 
irritable

Question 12

Clinical features of severe pediatric

Answer 12

Rapid / Weak / absent pulse
Low SBP
Tachypnea or decreased / absent breath
Parched buccal mucosa
Markedly sunken fontanelle
Markedly sunken eyes
Tenting of skin
Skin cool, mottles, acrocyanotic 
Anuria
Grunting / lethargy / coma

Question 13

What serum and urine measurements?

Answer 13

Elevated Cr
Elevated hematocrit
Acid Base disturbance 
Electrolyte Abnormalities 
Elevated LFTs and Troponins
Low Urine Na

Question 14

What additional imaging?

Answer 14

POCUS: IVC <1cm diameter and obvious collapse

Question 15

Fluid management of mild - moderate

Answer 15

Oral rehydration if the best option for both peds and adults

Question 16

Indications for IV fluids

Answer 16

Severe Dehydration:
Inability to tolerate PO intake
Inability to administer ORT
Persistent vomiting 
Electrolyte abnormalities where ORT cannot be monitored

Question 17

Fluid resuscitation of the unstable adult (what / how much)

Answer 17

1-2 x 500cc – 1 L bolus crystalloid

Question 18

Fluid resuscitation of the unstable pediatric (what / how much)

Answer 18

1-2 x 20 cc / kg bolus crystalloid

Question 19

Pediatric Maintenance Fluid: what and how much?

Answer 19

4:2:1 Rule (4 ml / kg for first 10 kg, 2 ml / kg for 2nd 10 kg, 1 ml / kg for each kg > 20)
0.9% NS with 5% dextrose
Consider 10-20 mEq of KCL per each L of fluid to avoid hypokalemia

Question 20

Adult Maintenance Fluid: what / how much

Answer 20

80 cc / hr of ½ NS in 5% dextrose with 20 mlEq of KCL for each L fluid

Question 21

4 etiology / treatment of the underlying cause

Answer 21

Meds -> stop or reduce
Hyperglycemia -> fluids / insulin per DKA / HHS pathway
Infection -> antipyretics and abx
Emesis -> anti-emetics and identification / treatment of underlying cause

Question 22

5 risk factors for dehydration in pregnancy

Answer 22

gHTN / preeclampsia
gDM
Preterm birth
Oligohydramnios
LFBW

Question 23

Objective measures to follow while rehydrating someone

Answer 23

BP
Weight
Serum glucose
Sodium
Urea
Creatining 
Potassium 
GFR