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Electrolyte Abnormalities + DI + SIADH Flashcards

1
Q

What is K normally excreted for

A

Exchange for Na

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2
Q

What is a fatal level of K

A

> 7

Cause fatal arythmia - asystole / VF / cardiac arrest

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3
Q

What can cause hyperkalaemia

A

Decreased excretion
Increased K out of cells
Endocrine
Other

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4
Q

What causes decreased excretion

A 
Renal failure - AKI or CKD
ACEI / ARB 
NSAID
Heparin e.g. enoxoparin 
Spirnolactone (K sparing diuretic)
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5
Q

What causes increased K out of cells

A

Tumourlysis
Rhabdomyolysis
Metabolic acidosis - as K shifted out in exchange for H
BB - salbutamol used to treat

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6
Q

What are endocrine causes

A

Addison’s (hypo adrenal)

  • Increased K as decreased excretion
  • Low Na as decreased reabsorption
  • Low BP as low Na
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7
Q

What are other causes

A

Massive blood transfusion

Type 4 renal tubular acidosis seen with DM or CKD

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8
Q

What are symptoms of hyperkalaemia

A 
Weakness
Fast irregular pulse
Chest pain
SOB 
Paplitations
Dizzy
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9
Q

What do you need if symptomatic

A

U+E
ECG
Urgent dialysis / haemofiltration

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10
Q

How do you investigate

A 
DRABC
Stop all meds that cause 
Bloods - U+E 
ABG / VBG for K - repeat 
ECG for arrhythmia
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11
Q

What does ECG show

A 
Tall tented T waves
P wave widens
PR disappears
P wave disappears
Broad QRS
AV block 
Sinus brady or slow AF
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12
Q

What should you do if haemodynamically unstable

A

Dialysis

Haemofiltration

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13
Q

When do you treat urgently

A

K >6.5

ECG + K>6

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14
Q

How do you treat

A

Stop cause / drugs
Calcium gluconate / cholride
Insulin dextrose
Salubtamol

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15
Q

What dose calcium gluconate

A

10% 10 mls IV injection

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16
Q

What does it do

A

Stabilise myocardium if ECG changes

Gives 30-60 minute protection

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17
Q

What dose of insulin dextrose

A

50ml 50% 10 units insulin dextrose

Then infusion

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18
Q

What does it do

A

Shift K internally
Dextrose counteract sugar loss
Must monitor for hypo

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19
Q

What does of salbutamol

A

5-10mg neb
Tachy can limit use
Unlicensed

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20
Q

What can you use if K not that high

A

Calcium resonium

Used more in CKD to bring down over a few days

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21
Q

What do you do if this fails

A

Dialysis / anion exchange

Need to cure cause by getting patient to pee

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22
Q

Why are diuretics not really used

A

Cause hypovolaemia

DO NOT use unless overloaded as well

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23
Q

How do you prevent

A

Low K
Stop ARB / spironolactone
Treat cause

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24
Q

How do you treat renal tubular acidosis

A

HCO3

Flucotisone

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25
What is emergency hypokalaemia
<2.5
26
What is most common causes of hypokalaemia (usually associated alkalosis as K is exchanged with H but can be due to acidosis)
D+V Diuretic Incorrect IV fluid replacement
27
What causes increased loss
Diuretic D+V Laxatives Pyloric stenosis
28
What are endocrine causes
Cushing's | Conn's
29
What are other causes
``` Alkalosis - K shifted in and H out Insulin / salbutamol excess Steroid use Type 1 and 2 renal tubular acidosis Tubular defect - Barter Mg deficiency - must exclude and Rx Hypokalamic periodic paralysis ```
30
What are the symptoms of hypokalaemia
``` Weakness Hypotonia Hyporeflexia Cramps Tetany Palpitations Light headed Constipation ```
31
What does hypokalaemia predispose you too
Digoxin toxicity | Careful if on diuretic
32
What does ECG show
U wave Prolonged QT and PR ST depression Absent T
33
What will urine potassium show
If renal loss = high | If extra renal e.g. D+V then low
34
What should you do if renal loss
BP
35
If BP high
``` Endocrine or renal artery stenosis Renin-angiotensin ratio High in stenosis Normal in endocrine Measure cortisol / creatinine ```
36
If BP normal
Mg | HCO3 levels
37
Acidosis
Tubular acidosis
38
Alkalosis
Tubular defect | Diuretic
39
How do you treat
``` Correct cause Oral K if mild IV K if severe <2.5-3 or symptomatic e.g. 40mmol in 500ml saline x 2 If not that low then could give 40mmol in 1l bag Monitor in cardiac area Consider K sparing diuretic ```
40
When would you not give K
If oliguric Or as fast bolus - no more than >10mmol / hour Try to dilute provided no CI e.g. HF
41
What is best indication of long standing K on diuretic
HCO3
42
What is most common cause of hypernatraemia
Water loss > Na loss Dehydration Fluid loss with no replacement - D+V / burns Incorrect IV fluids
43
Other causes
DI - decreased ADH so increased water loss Osmotic diuresis in diabetic coma Conn's - Primary aldosteronism as increased reabsorption
44
What are symptoms of hypernatraemia
``` Lethargy Thirst Weakness Irritable Confusion Coma Seizure Dehydration ```
45
What is important in bloods
Increased Na Increased albumin Increased urea suggestive of dehydration Urine osmolarity
46
What else should you do
Water deficit calculator to work out
47
What wil dehydration have
High urine osmolality as trying to conserve water
48
What will DI have
Low osmolarity as no ADH so water just washed out
49
How do you treat hypernatraemia
Oral rehydration Glucose 5% slow IV guided by output and plasma Na 0.9% saline if hypovolaemia
50
What should you avoid
Hypertonic
51
What do you need to do with regards to fluid and how fast do you go and why
Replace deficiency Replace ongoing loss and insensible Replace slowly no > than 0m5 as risk of cerebral oedema (seizure / coma / death)
52
When would you suspect primary aldosteronism (Conn's)
K down BP up Alkalosis
53
What does dehydration always have
High Na | Not the same as hypovolemia
54
What is most common
Hyponatraemia <130mmol | Either water excess or sodium depletion
55
What is important with regards to hyponatraemia
FLUID STATUS Doesn't mean Na depletion Can just be overloaded so dilutes
56
What causes hypovolaemic (dehydrated) hyponatraemia Urine Na >20
``` Diuretic Addison's Renal failure Osmolar diuresis -hyperglycaemia TURP Syndrome ```
57
What causes hypovolaemic (Dehydrated) but urine Na <20 so lost other than kidney as kidney tried to hold on to Na / osmolarity high
``` D+V Fistula Burn Obstruction - 3rd space loss Trauma CF Heat in extra sport = ongoing ADH release ```
58
What can D+V cause
Low or high Na
59
What drugs should you consider stopping / cause SIADH
``` Diuretic SSRI PPI - omeprazole (beware with SSRI in elderly) TCA Sulphonamides Carbmazepine ACEI ```
60
What causes hypervolaemic hyponatraemia - diltued NA
``` Nephrotic HF Liver cirrhosis Renal failure Polydipsia ```
61
What causes euvolaemic hypo
SIADH Severe hypothyroid Glucose-corticoid insufficiency
62
What suggests SIADH
High urine osmolality and Na as less water excreted so concentrates Think known cancer
63
What are symptoms of hyponatrameia
``` Confusion Headache ANorexia Nausea Malaise Irritable Weakness CNS distubrance Deceased CNS Seizure Encephalopathy ```
64
What is a medical emergency
Rapid changes or acute
65
How should you investigate
Fluid balance Urine osmolarity Serum osmolarity
66
What are baseline bloods for cause
``` Glucose Lipids TFT LFT -ve Short Synacthen for Addison Urine Na+K ```
67
How do you test for Addison
Cortisol low | Short synapsin
68
How do you treat hyponatraemia
Correct cause | Replace Na and water at same rate
69
What do you do for asymptomatic and chronic
Fluid restrit Loop diuretic Can use ADH antagonist or hypertonic but rare
70
What do you do for acute severe symptomatic
``` Cautious rehydration to correct cerebral oedema Hypertonic 3% saline or Hartman 150ml over 15 min Repeat if no improvement With or without ADH antagonist Then determine fluid status ```
71
What should you not do and why
Correct more than 10mmol/l in 24 hours | Risk of central pontine myelinolysis as pulls water from brain cells
72
When would you consider furosemide
Not hypovolaemic
73
If hypovolaemic
0.9% saline
74
If hypervolaemic
Restrict Treat cause- CF / liver /r renal Have fluid intake < output if oedema / SIADH / renal failure
75
What do you do if seizure or coma
Hypertonic (1.8%) saline + furosemide | Aim for gradual increase to 125
76
What may happen if Na corrected rapid
HF Central pontine myelinolysis / Osmotic demyelination syndrome Correct no faster than 10mol in 24 hours
77
What does ADH antagonist do (Tolvaptan)
Promote water excretion No loss of electrolyte Effectie if hypervolaemic or euvolaemic but expensive
78
What can cause SIADH secretion
``` Tumour - SCLC / pancreas / gut Empyema CF Pneumonia / TB Drugs - SSRI / TCA / carbamazepine / cyclophosphamide / thiazide / CNS - meningitis / encephalitis / abscess / haemorrhage / stroke Post-op major surgery Head trauma ```
79
How do you Dx
``` Dx of exclusion as can't measure ADH Exclude other causes of hyponatraemia Assess fluid balance - euvolaemic Hypotonic hyponatraemia Urine osmolarity high - high urine Na as concentrated CXR CT head CAP Bronchoscopy ```
80
What is Furst formula
Used to see if fluid restriction would be helpful in Rx | <1 = restrict
81
What are other Rx for SIADH
``` Fluid restrict Demeclocycline - reduce responsiveness of collecting duct to ADH Tolvaptan Correct Na - aim target 130 Diuretic ```
82
What do you do if can't tell if SIADH
Adminster normal saline 1l over 12 hours Hypovolaemic responds SIADH will not or may worsen
83
What causes DI
Nephrogenic - insensitive to ADH | Cranial / central - deficient in ADH
84
What causes nephrogenic
``` Genetic = most common Hypercalcaemia Hypokalaemia Drugs - lithium Interstitial renal - pyelonephritis / sickle Chronic renal Post obstructive uropathy ```
85
What causes cranial
``` Idiopathic Brain tumour Head injury Pituitary tumour Craniopharyngioma Haemochromatosis / sarcoid Haemorrhoige Infection - meningoencephalitis ```
86
What are the symptoms
``` Polyuria Polydipsia As kidney's can't concentrate urine Nocturnal enuresis Dehydration Postural hypotension Symptoms of hypernatraemia Due to impaired water resoprotion ```
87
How do you Dx
High plasma osmolality Low urine osmolality Water deprivation test = test of choice - Doesn't affect urine osmolality as can't concentrate Can give synthetic ADH and see if respond - Will respond in central but not nephrogenic Do U+E, Ca, glucose to exclude DM MRI if central Exclude UTI
88
How do you Rx
Thiazide if nephrogenic - release more Na to lower plasma osmolality Low salt Low protein Desmopression if central - synthetic ADH
89
What are more common causes of polyuria
``` Diuretic Caffeien Alcohol DM Lithium HF Hypercalcaemia Hyperthyroid ```
90
How does metabolic acidosis cause hyperkalaemia
K and H ions fight to be exchanged for Na in distal tubule
91
What is hypokalaemia associated with
Alkalosis As K is taken into cells and H released So K loss
92
What can hypo be associated with
Acidosis e.g. renal tubular
93
Symptoms of osmotic demyelination syndrome / central pontine demyelinolysis
``` Confusion, headache, N+V Dysthria Dysphagia Paresis Seizure Coma ```
94
When should fluid intake be less than output in treatment of hyponatraemia
Oedematous states SIADH Renal failure Psychogenic polydipsia
95
Why should you replace fluid slowly in hypernatramia
Risk of cerebral oedema (seizure / coma) as brain loses electrolytes quickly whilst lowering of other electrolytes and water occurs more slowly
96
What causes hypo phosphate
``` Alcohl Acute liver failure DKA Refeeding Primary hyperparathyroid Osteomalacia ```
97
What are the consequences of hypophosphate
``` RBC haemolysis WBC / platelet dysfunction Muscle weakness Rhabdomyolysis CNS dysfunction ```
98
What causes raised ALP physiological
Growing child Pregnancy Heeling fracture
99
What causes pathological raised
``` Liver Osteomalcia Bone mets Pagets Renal failure Hyperparathyroid ```
100
What causes high Ca
Bone mets | Hyperparathyroid
101
What causes with low Ca
Osteomalacia | Renal failure
102
What are causes of hypocalcaemia
``` Vit D deficiency (osteomalacia) CKD Renal failure Hypoparathyroid (surgery / thyroiditis) Pseudohypoparathyroid (insensitive) Rehabdomyolysis Mg deficiency Massive blood transfusion Acute pancreatitis ```
103
What is calcium needed for
Muscle and nerve function
104
What does hypo cause
``` Tetany Parathesia Increased QT Trosseau Chvostek's ```
105
What is tetany
Twitching Cramping Spasm
106
If chronic
Depressoion | Cataracts
107
What is trousseau
Carpal spasm when brachial artery occluded when BP cuff above systolic Wrist flexion and fingers drawn in
108
What is Chvostek
Tapping paranoid causes facial muscles to twitch
109
How do you treat hypocalcaemia
IV calcium gluconate 10ml 10% 10 minutes if severe ECG Treat cause
110
How do you treat hypercalcaemia
Rehydration Normal saline 3-4l per day
111
What can be used after
Biphosphonates | Calcitonin - works quicker
112
What do you give if caused by sarcoid
Steroids
113
What can be used but careful
Loop diuretics if can't tolerate fluid but may worsen other electrolyte imbalances
114
What advise do you give
Advise good hydration | Avoid drugs that will worsen hypercalcameia
115
If correct hypernatraemia too fast
Cerebral oedema
116
If correct hyponatrameia too fast
Central pontine demyelinisys /
117
Causes of hypomagnesium
``` Diuretic PPI TPN Diarrhoea Chrons / UC Hypo K Hypo Ca due to reduced PTH Metabolic - Gilberts ```
118
Sx
ECG similar to hyperkalaemia Symptoms same as hypo calcium Exacerbates digoxin toxicity
119
Rx
Replace
120
If low phosphate
Add polyfuser

Renal / Urology (16 decks)

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