Electrolytes 2 Flashcards

1
Q

Evaluation of Hyponatremia

  • After initial steps of a thorough H&P, evaluate fluid status and then get which 4 labs first?
  • Which 2 labs second?
A
  • 1st: UA sodium, UA osmolality, serum osmolality, CMP
  • 2nd: TSH, serum cortisol
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2
Q

Tx of Hyponatremia

  • If Na is <125 or symptomatic, what is the tx?
  • ___ hyponatremia must be managed w/ extreme care
  • Rapid increase in serum sodium can lead to _______
  • Use of _____ is reserved for severe symptomatic cases
  • What is the “traditional” treatment of chronic hyponatremia? to induce what?
  • _____ are a newer class of tx agents which are vasopressin receptor antagonists
A
  • Hospitalize!
  • Chronic
  • Cerebral pontine myelinolysis (CPM)
  • Hypertonic solutions (3% NaCl)
  • Demeclocycline / to induce nephrogenic diabetes insipidus
  • “Vaptans”
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3
Q

Tx of Hyponatremia

  • In pts w/ severe symptomatic hyponatremia, the rate of sodium correction should be ____ in the first 24 hrs and ___ or less in 48 hours.
  • ****If CHRONIC hyponatremia, should try to keep it ___ or less in the first 24 hours*****
A
  • 6-12 mEq/L
  • 18 mEq/L
  • 8 mEq/L
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4
Q

When correcting Hyponatremia, how often should you be checking serum sodium as you are replacing it (to make sure not overcorrecting)?

A

q2h

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5
Q
  • Poorly understood entity characterized by focal demyelination in the pons and extra-pontine areas
  • Is it reversible?
  • Dysarthria, dysphagia, seizures, AMS, quadriparesis, hypotension begin ___ after over-correction of hyponatremia
A

Central Pontine Myelinolysis (CPM)

  • Irreversible
  • 1-3 days after
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6
Q

Which condition?

  • A hypertonic disorder due to serum sodium >145 mEqL
  • “Too little water relative to salt”
  • Clinical features due to brain shrinkage secondary to increased ECF osmolality
A

Hypernatremia

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7
Q

3 causes of Hypernatremia

A
  • Too little dietary water
  • Too much dietary salt
  • Excessive water loss from the body
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8
Q

4 causes of Hypernatremia

A
  • GI losses: elderly / infants w/ diarrhea
  • Skin loss: sweating, fever
  • Renal loss
  • Drug related: diuretics, lithium (can induce nephrogenic diabetes insipidus)
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9
Q

Clinical features of what condition?

  • Often asymptomatic
  • Thirst
  • AMS / weakness
  • Neuromuscular irritability
  • Focal neurologic deficits
  • Seizures or coma
A

Hypernatremia

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10
Q

Symptoms of Hypernatremia are related to rate of onset. If hypernatremia develops slowly, sxs will be ____.

A

Less dramatic

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11
Q

Normal Response to Hypernatremia

  • In response to hypernatremia, the body’s homeostatic mechanisms will normally do what 2 things?
  • The vast majority of cases of hypernatremia are due to _____.
A
  1. Create thirst / increase fluid intake
  2. Maximally concentrate urine to prevent further water loss
  • Water loss (GI tract, skin, renal)
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12
Q

Which condition?

  • Non-osmotic urinary water loss in setting of elevated serum sodium: urine is dilute when it should be concentrated (the collecting ducts are impermeable to water - water is not reabsorbed)
A

Diabetes Insipidus

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13
Q

Which type of diabetes insipidus?

  • Due to impaired secretion of antidiuretic hormone (ADH)
  • Also called _____.
  • Typically treated w/ _____
A
  • Central DI
  • Neurogenic DI
  • Desmopressin (often an inhaled dDAVP nasal spray or IV DDAVP)
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14
Q

Which type of diabetes insipidus?

  • Lack of kidney response to ADH, causing continued water loss even though patient is low on water.
  • Adequate ADH is present
A

Nephrogenic DI

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15
Q

Nephrogenic Diabetes Insipidus can be genetic or acquired.

  • Acquired is typically from which 4 things?
  • What is the treatment?
A
  • Chronic renal insufficiency
  • Tubulointerstitial renal disease
  • Amyloidosis
  • Lithium toxicity

Tx:

  • Thiazide diuretic
  • Amiloride (K sparing diuretic)
  • Chlorpropamide (antidiabetic oral agent)
  • NSAIDs have been tried (including Indomethacin)
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16
Q

Tx of Hypernatremia

  • ____ if severe
  • Stop water loss
  • Replace water deficit in what 3 ways? w/ what fluid?
  • Do not replace too rapidly, especially is the hypernatremia is _____. Why?
  • It is okay to correct rapidy if what?
A
  • Hospitalize
  • Oral, NG tube, IV w/ hypotonic fluids
  • present for several days (can cause seizures, brain damage, CPM)
  • Tx Rapid: If hypernatremia developed acutely
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17
Q

In order to replace free water in hypernatremia, you need to calculate what?

A

Water deficit

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18
Q
  • Major intracellular cation
  • Renal excretion is the major route of elimination
  • Regulation of renal ___ excretion and total body ___ balance occurs in the distal nephron
  • Aldosterone causes increased renal excretion
A

Serum Potassium

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19
Q

Which condition?

  • Nearly 98% of body’s K is intracellular
  • Total body K stores of approximately 50 mEq/kg
  • 20% of hospitalized pts are _____
  • 80% of pts who are receiving diuretics become ____.
A

Hypokalemia

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20
Q

Clinical presentation of which condition?

  • Weakness, fatigue
  • Muscle cramps
  • Hyporeflexia
  • Flaccid paralysis (ascending)
  • Hypercapnia
  • Which one is most important (not listed here)****
A

Hypokalemia

  • Cardiac arrhythmias
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21
Q

T/F

  • K can be replaced more rapidly than Na
A

True

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22
Q

4 ECG findings of Hypokalemia

A
  • Flattened T waves
  • Prominent U waves
  • Premature Ventricular Contractions (PVC’s)
  • Depressed ST segments
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23
Q

Hypokalemia mnemonic

hYpOkalemia U CRAMP

A
  • U waves
  • Cramping
  • Resp failure / rhabdomyolysis
  • Anorexia, N/V
  • Muscle weakness
  • Paralysis
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24
Q

3 mechanisms which cause Hypokalemia

A
  • Transcellular shifts
  • Renal losses
  • Extrarenal losses
25
**Which mechanism causing Hypokalemia?** * Drugs: insulin, caffeine, bronchodilators, theophylline * Delirium tremens * Hyperthyroidism * Metabolic alkalosis (all lead to increase beta-adrenergic activity which causes K to shift \_\_\_\_\_)
**Transcellular Shifts** * K shifts out of blood stream and into the cells
26
**Renal Losses causing Hypokalemia** * ___ are the most common cause * Aldosterone facilitates K excretion in the _____ therefore, high aldosterone states such as Hyperaldosteronism and Cushing's can lead to hypokalemia * Renal tubular acidosis types 1&2
* Diuretics * distal tubules
27
* What are 3 extrarenal losses causing Hypokalemia? * Which one causes metabolic alkalosis, which further promotes renal potassium loss?\*
* Vomiting & diarrhea * Burns * Magnesium deficiency * \*vomiting, NG suction
28
**Tx of Hypokalemia** * Replace K and if possible tx underlying cause * ___ monitoring if inpatient * ____ replacement is preferred method * IV reserved for those not able to eat * If giving IV potassium via peripheral IV (not central line), include ____ with it because why? * Never ____ IV potassium!!
* Telemetry * Oral potassium (better absorption) * Lidocaine, it burns and can destroy veins * Push, should be given slowly
29
**How do you replace potassium?** * For every 0.1 mEq/L below 4mEq/L, give ___ mEq/L
10
30
**Special Circumstances of Tx of Hypokalemia** * ______ is important in potassium reuptake, and if low can hinder replacement of potassium * draw Mg if hypokalemia is severe/resistant * Hypokalemia precipitates ____ toxicity
* Hypomagnesemia * Digoxin
31
**Which condition?** * In absence of renal failure or other identifiable causes, is actually quite rare * Relatively asymptomatic * Muscle weakness * begins in legs, acsends to trunk/arms * "ascending flaccid paralysis" * _ECG changes show what?_
**Hyperkalemia** * Potentially life threatening arrhythmias * Seen in 50% of patients * _Peaked T waves\*\*_ * Widened QRS * Junctional rhythm * Ventricular fibrillation
32
Mnemonic for Hyperkalemia "A FACT"
* Arrhythmias * Flaccid paralysis * Ascending muscle weakness * Conduction abnormalities * T waves
33
2 "factitious" causes of Hyperkalemia (Pseudohyperkalemia)
* Hemolysis * Repeated fist clenching w/ tourniquet in place (poor venipuncture technique)
34
3 causes of Hyperkalemia from Impaired K excretion
* **Renal failure** * **Mineralocorticoid deficiency** * Addison's Disease * Hypoaldosteronism * **Renal tubular dysfunction**
35
5 drugs which can cause Hyperkalemia
* K sparing diuretics * ACE inhibitors * ARBs * NSAIDs * Bactrim
36
3 ways increased inake of K can cause Hyperkalemia
* Increased dietary intake of K containing foods * Taking too much PO potassium * Taking too much IV potassium
37
**Other causes of Hyperkalemia** * 3 conditions which move K from intracellular to extracellular spaces
* Tissue damage (rhabdomyolysis) * Acidosis * Decreased insulin
38
2 emergent treatment options for tx of Hyperkalemia
* **IV Calcium** * **Maneuvers to shift K from ECF to ICF** * Sodium bicarbonate (IV push) * Insulin IV + D50W (given w/ dextrose)
39
**Which emergent tx of Hyperkalemia?** * Less than 5 mins onset of action * Lasts 60 minutes * Reduces threshold potential of cardiac myocytes, restoring the normal gradient with the resting membrane potential which is distorted by hyperkalemia
IV Calcium
40
**Which emergent tx of Hyperkalemia?** * IV push to increase pH * Action within 5 mins * Lasts 15-30 mins * Typically start with 1 amp = 50 mEq
Sodium Bicarbonate | (shifts K from ECF to ICF)
41
Other potential options for emergent tx of Hyperkalemia (3)
* Nebulized albuterol * IV Lasix * Dialysis
42
**Which "less urgent" tx of Hyperkalemia?** * Exchanges Na for K in the gut * Decreases total body K * Causes lots of horrible diarrhea * Onset 2-12 hours, available PO or PR * Lowers K level by 0.5 for every gram given **What are 2 other less urgent tx options?**
Kayexalate * Lasix (and other loop & thiazide diuretics) * Correct underlying cause
43
Measure of total Ca is ___ + \_\_\_\_
Free (ionized) + protein bound
44
Serum calcium is used to evaluate metabolism and monitor patients w/ what 3 things?
* Hyperparathyroidism * Malignancies * Renal Failure
45
Calcium has an inverse relationship with what chemical compound?
Phosphate
46
* 99% of Ca is located where in the body? * ECF Calcium * 50% is \_\_\_\_ * 10% is \_\_\_\_\_ * 40% is \_\_\_\_
Bone * 50% is free (ionized) * 10% is complexed * 40% is protein bound
47
**Which form of calcium?** * Physiological active form, unaffected by serum albumin levels * Free to participate in cellular function * role in neuromuscular activity, cardiac function, and blood clotting
Ionized
48
**Which form of Calcium?** * Citrate added to blood to prevent clotting
**Complexed** (chelated with substances such as citrate)
49
**Which form of Calcium?** * When serum albumin is low, Ca level will also be low * Albumin and Calcium should be measured silmultaneously
Protein - bound (albumin)
50
**Calcium Physiology** * Calcium is absorbed through ____ under influence of \_\_\_\_\_ * Stored where? * Excreted by what organ? * Regulated by what 3 things?
* GI tract / Vitamin D * Bone * Kidney * PTH / Vit D / Calcitonin
51
A decrease in serum Calcium triggers the release of ___ from the parathyroid gland, which acts to increase Ca in the blood by doing what 3 things?
PTH * Activating Vit D (to increase Ca absorption in gut) * Promoting bone resorption (release Ca from bone) * Increasing Ca uptake in the kidneys (Promotes conservation)
52
An increase in serum Calcium triggers the release of ____ from the thyroid gland, which acts to decrease Ca in blood by doing what?
Calcitonin * Inhibiting bone resorption
53
If calcium levels are high, what should you be concerned about?
Malignancy
54
Sxs of Hypercalcemia "Has a cute saying to remember"
**"Stones, bones, abdominal moans, and psychiatric groans"** * Kidney stones * Bone pain * Abd pain, N/V, anorexia, constipation * Effects of nervous system, lethargy, fatigue, memory loss, psychosis, depression
55
What 2 things cause 90% of hypercalcemia?
* Malignancy * Primary hyperparathyroidism
56
Which 4 medications can cause hypercalcemia?
* Thiazide diuretics * Lithium * Antacids * Vitamin A analogs (accutane)
57
**Evaluation of Hypercalcemia** * PTH is increased with \_\_\_\_\_ * PTH is suppressed in \_\_\_\_\_
* Increased in primary hyperparathyroidism * Suppressed in malignancy
58
* What is the #1 therapy / tx of Hypercalcemia? * What are 3 other tx options?
* _\*\*#1: Volume expansion (normal saline)_ * **Calcitonin** (used to lower levels rapidly) * **Pamidronate** (usually given to cancer pts) * **Zoledronic Acid** (Zometra - replaced Pamidronate as a 1st line therapy for malignancy)