EM- metabolic emergencies

Question 1

what is “ketosis”?

Answer 1

Ketosis is a metabolic process that occurs when the body begins to burn fat for energy because it does not have enough carbohydrates to burn. During this process, the liver produces chemicals called ketones

Question 2

3 causes of hypoglycemia? ketosis

Answer 2

fasting
malabsorption, GE
increased utilization: exertion

Question 3

3 causes of hypoglycemia? non-ketosis

Answer 3

hyperinsulinism
adrenal insufficiency
congenital disorders
*also drugs, sepsis, hepatic failure

Question 4

hypoglycemia: S+S, PE

Answer 4

S+S: AMS; anxiety, shakiness, nausea, sweating
PE: confusion, diaphoresis, tremor
tachycardia, incr BP
obtundation, seizures

Question 5

what labs dx hypoglycemia?

Answer 5

glucose <50 mg/dL

Question 6

txt for hypoglycemia?

Answer 6

orange juice, snickers

IV D50: 1amp then 100 cal/hr for 2 hrs

Question 7

what is the pathophys if DKA?

Answer 7

liver has increased glucose production but peripheral tissues have decr. glucose uptake = hyperglycemia
–> osmotic diuresis and vol. depletion
liver rapidly increases ketogenesis (body NEEDs fuel) and Adipose releases free fatty acids = ketoacidosis
–> decreased alkali reserve and metabolic acidosis

Question 8

symptoms of DKA

Answer 8

Polydipsia, polyuria, weakness, nausea/vomiting, abdominal pain, weight loss

Question 9

PE findings for DKA: temp, HR, GI etc.

Answer 9

Hypothermia (hyper if infectious etio), tachycardia, tachypnea/hyperpnea (Kussmaul resps), ileus, maybe altered MS. 
acetone breath (fruity)

Question 10

4 Dx labs for DKA

Answer 10

Glucose >250 mg/dL
+ serum acetone
pH≤ 7.3
Anion gap >12

Question 11

what things can cause DKA?

Answer 11

increased cortisol
insulin omission (can’t use glucose)
inflammation; infection ; ischemia

Question 12

what things 5 can cause DKA?

Answer 12

increased cortisol
insulin omission (can’t use glucose)
inflammation; infection ; ischemia

Question 13

4 goals of DKA mgmt?

Answer 13

1. Volume resuscitate!!! 2L NaCl (for hypoperfused organs)
2. Correct AG acidosis
3. Target glucose: 150-200 mg/dL
4. Correct K+ and Mg2+

Question 14

if you give insulin to drive glucose into the cells, what electrolyte imbalance can you cause?

Answer 14

hypokalemia? so supplement with K+ if they might already be low in K+
(rather be high in K+ than low)

Question 15

how do you give fluids for DKA? (kinda weeds?)

Answer 15

1. 2L normal Saline for the 1st hour
2. Replace 50% of estimated TBW deficit over 8 hours
   CHANGE to D5 ½ NS @ 150 mL/hr when glucose <250 mg/dL

Question 16

DKA: If K _____ mEq/L, hold insulin until actively correcting K. what is your K+ goal?

Answer 16

< 3.3 mEq/L

Goal K+ = 4 - 5 mEq/L

Question 17

how often do you check glucose when resuscitating for DKA?

Answer 17

finger stick every hour
*Initial Goal: decr. Glucose by 50 - 75/hour
If glucose not decreasing by ≥ 50 mg/dL in 1st hour - double IV insulin rate

Question 18

do you give bicarb supplement for DKA?

Answer 18

only if pH <7

Question 19

what is the normal level of K+? what level is life threatening?

Answer 19

normal: 3.5- 5

life threatening: >7.5

Question 20

ekg findings of hyperkalemia?

Answer 20

peak T waves = hyperkalemia

BUT even if they have a normal EKG, if they have high K+ - still need to treat them

Question 21

what are the 3 mechanisms to hyperkalemia?

Answer 21

1. Excessive cellular release: rhabdo, burns, tumor lysis syndrome, crush injury, if theyve had a tourniquette on a long time
2. Excessive intake: KCL supplements
3. Insufficient excretion: AKI, CKD

Question 22

4 clinical causes of hyperkalemia?

Answer 22

1. renal insufficiency : DIALYSIS!!!
2. Meds (interferes w/excretion): ACEIs, ARBs, spironolactone, NSAIDs,
3. Mineralocorticoid deficiency: e.g. Addison’s
4. DKA (but you only wanna txt this with insulin)

Question 23

what is the most common cause of a hyperkalemia finding in lab results?

Answer 23

hemolysis from poor labs. Redo the lab sample if K+ >7 but no S+S

Question 24

K+ >7 causes what? what about >9?

Answer 24

> 7: conduction abnormalities and bradycardia

>9: Cardiac arrest due to… asystole, Vfib, PEA w/ bizarre wide complex rhythm

Question 25

3 part txt of hyperK+

Answer 25

#1 - Stabilize cardiac myocyte membranes
#2 - Drive the K back into the cells
#3 - Get rid of the excess

Question 26

what are 5 ways we drive K+ back into the cells?

Answer 26

1. 50g glucose (D50 ) w/ insulin (10 g) (5:1 ratio)
2. Beta agonists: Albuterol
3. bicarbonate - exchanges H+ inside the cell for K+ outside the cell (only if acidodic)
4. volume (saline) - if dialysis- careful
5. Mg + - drives K+ into the cell .

Question 27

what two ways do we get rid of the excess K+ ?

Answer 27

kayexelate (binds K+ into stool) and hemodialysis

Question 28

what do we do to stabilize the cardiac membrane?

Answer 28

give Ca+

Question 29

what level is considered hypoKalemia? severely low?

Answer 29

K+ < 3.5

severe if <2.5

Question 30

when are symptoms of Hypokalemia most likely present?

Answer 30

when there is a RAPID drop in K+ and it goes below 2.5

Question 31

What are 3 ways someone can get hypokalemia?

Answer 31

1. inadequate potassium intake (alcoholics/malnourished)
2. excessive loss of potassium
3. transcellular shift of potassium

Question 32

what is the most common cause of hypokalemia? most common drug-related cause?

Answer 32

• increased loss in the urine: increased urinary flow or delivery of sodium to distal nephron
• Diuretics

Question 33

GI loss of K+ (in the stool). when does this occur?

Answer 33

in pathological states where stool volume increases, as in cases of diarrhea

Question 34

how can transcellular shifts cause hypokalemia?

Answer 34

medications that cause transcellular potassium shifts:
stimulating cell membrane Na+/K+-ATPase and promoting K entry into cells
(insulin + glucose, albuterol)

Question 35

what ekg findings may indicate hypokalemia?

Answer 35

T flattening and inversion, Uwaves

Question 36

txt for hypokalemia?

Answer 36

For many patients, it is unnecessary to bring K+ levels back to normal during their ED stay
(but if you do have to, give K+Cl)
D/c HOME with instructions to eat foods that are high in potassium

Question 37

when would you need cardiac monitoring when repleting K+ via IV?

Answer 37

*When infused through a peripheral IV, K+ may be uncomfortable and result in a phlebitis
When the IV repletion rate is faster than 20 mEq/hour