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Emergency Medicine > Metabolic Emergencies > Flashcards

Metabolic Emergencies Flashcards

1
Q

Common causes of electrolyte disturbances:

A
  1. Shifts in third space losses (fluid lost to circulation). (seen as edema in extremities)
  2. NG losses, vomiting, diarrhea, drains, blood loss.
  3. Medications. (diuretics)
  4. Pre-existing deficits:
    - NPO for OR
    - Bowel preps.
  5. lab error/hemolysed specimen (suspect if pt looks normal)

*good hx taking is essential

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2
Q

What are normal lab values for
Na
K

A

Na: 135-145mEq/L
K: 3.5-5

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3
Q

Some electrolytes may appear falsely elevated or low: What electrolytes can cause this together

A
  • Med Calc App.
    1. Corrected Calcium for Albumin.
    2. Corrected Sodium for Glucose.
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4
Q

Na problem: “It’s not a salt problem, it’s a water problem.”

  • hyper:
  • hypo:
A
  • hyper: loosing too much water

- hypo: hanging on to too much water

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5
Q

Signs and sx of hypernatremia

A
  1. Restlessness,
  2. extreme thirst,
  3. lethargy,
  4. seizures,
  5. AMS,
  6. tremors.
  7. May have fever.
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6
Q

Causes of hypernatremia

A
  1. Dehydration
  2. diarrhea
  3. Vomitting
  4. NG tube suction
  5. excessive sweating
  6. burns
  7. neurogenic diabetes inspidus
  8. Fistulas
  9. high glucose in DKA
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7
Q

Work up of hypernatremia

A
  1. BMP- – look for other lab abnormalities along with Na+
  2. Serum osmolality
  3. Urine osmolality
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8
Q

What is the treatment of hypernatremia

A
  1. Increase free water intake.
  2. LR or NS to correct volume deficit with circulatory/volume compromise (low BP)
  3. IVF: D5W, ¼ NS or ½ NS
  4. Goal < 12 mEq /L per day correction.
  5. If >150 then consider admitting for correction of Na+
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9
Q

Complications of rapid correction of hypernatremia

A
  1. seizures
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10
Q

Signs and sx of hyponatremia

A
  1. Na <135
  2. Headache,
  3. cramps,
  4. N/V,
  5. ileus,
  6. lethargy,
  7. confusion,
  8. weakness,
  9. seizures (less than 119 worry about this),
  10. coma.
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11
Q

Causes of hyponatremia

A
  1. drinking too much water (dilutional)
  2. vomiting
  3. Burns
  4. pancreatitis
  5. excess diuretics (esp. thiazide)
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12
Q

Work up of hyponatremia

A
  1. Check urine osmolality and urine sodium.
  2. Check serum osmolality.
  3. Figure out if hypertonic, hypotonic or isotonic hyponatremia.
  4. Figure out if hypervolemic, hypovolemic, euvolemic hyponatremia.
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13
Q

Helpful in determining etiology of hyponatremia.

If its low, helps determine further pathway for stratification and treatment

A

Serum osmolality

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14
Q

what are the values for:

  1. normal serum osmolality
  2. hypotonic hyponatremia
  3. hypertonic hyponatremia
A

Normal range is 275-295 mOsm/kg (mmol/kg).

Hypotonic hyponatremia <280 mOsm/kg
*dry looking

Hypertonic hyponatremia >285 mOm/kg
*wet looking

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15
Q

Common causes of hyponatremic hypervolemic

A
  1. wet looking
  2. CHF
  3. cirrhosis
  4. nephrotic syndrome
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16
Q

Common causes of hyponatremic hypovolemic

A
  1. renal solute loss
  2. dehydration
  3. diuretics
  4. burns
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17
Q

Treatment for hyponatremia hypovolemia

A

give fluids: normal saline

*if severe consider hypertonic saline, slowly

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18
Q

Treatment for hyponatremia hypervolemia

A

fluid restriction

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19
Q

Treatment for hyponatremia Euvolemic

A

fluid restriction- primarily free water restriction

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20
Q

treatment of hyponatremia

A
  1. Correct underlying cause.
  2. Diuretics or fluid restriction or both.
  3. Goal < 12 mEq / L per day correction.
  4. Goal 1 mEq/L/h for first 3-4 hours or until sx resolve otherwise do not correct faster than 0.5 mEq/L/h.

*admit if Na is below 125

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21
Q

What is a complication of too rapid correction of hyponatremia

A

Central pontine myelinolysis

brain swelling

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22
Q

Sx of Central pontine myelinolysis

A
  1. confusion
  2. horizontal gaze paralysis
  3. weakness
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23
Q

what is SIADH

A

syndrome of inappropriate antidiuretic hormone

*Important cause of euvolemic hyponatremia

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24
Q

Causes of SIADH

A
  1. CNS disorders,
  2. some cancers (small cell)
  3. drug induced.
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25
Q

how do you diagnose SIADH

A
  1. Low Na+ with low Osmolality
  2. Renal excretion of sodium
  3. Euvolemic state
  4. Absence of other causes low Na+
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26
Q

Important cause of euvolemic hyponatremia.

A

SIADH

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27
Q

EKG changes for Na abnormlaitiy

A

NO EKG CHANGES

*often has AMS

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28
Q

Signs and sx of hyperkalemia

A
  1. Muscle weakness,
  2. paralysis,
  3. n/v/d,
  4. abdominal cramping,
  5. cardiac arrhythmias (palpitations),
  6. cardiac arrest.

*associated with metabolic acidosis

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29
Q

Causes of hyperkalemia

A
  1. Iatrogenic overdose,
  2. blood transfusion (rate dependent)
    3 renal failure,
  3. hemolysis or tissue injury,
  4. diuretics (K+ sparing- spironolactone)
  5. lab error*
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30
Q

EKG changes w/ hyperkalemia

A
  1. peaky T waves
  2. depressed ST segments
  3. Prolonged PR interval
  4. wide QRS
  5. Bradycardia–> can progress to Vfib and aystole
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31
Q

What are critical values for hyperkalemia

A

Critical values: > 6.0 – emergency treatment warranted (esp if EKG changes)

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32
Q

Urgent treatment for hyperkalemia

A
  1. EKG monitor.
  2. IV calcium (cardioprotective).
  3. NaHCO3 (drives K back intracellularly)– don’t use in diabetics
  4. Glucose + insulin
  5. Albuterol
  6. Dialysis
  7. Kayelxalate- help stool out K+
  8. Furosemide- help urinate out K+
  9. admit to hosptial

7 and 8 do not help immediately help stool and urinate out the K+

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33
Q

Non-urgent treatment of hyperkalemia

A
  1. Kayelxalate- help stool out K+
  2. Furosemide- help urinate out K+
  3. admit to hosptial
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34
Q

Signs and sx of hypokalemia

A
  1. Weakness,
  2. tetany,
  3. N/V,
  4. ileus,
  5. paraesthesias.
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35
Q

Causes of hypokalmeia

A
  1. Diuretics,
  2. certain Abx (anti-fungal, aminoglycosides),
  3. albuterol,
  4. diarrhea,
  5. intestinal fistula,
  6. vomiting,
  7. insulin,
  8. DKA.
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36
Q

EKG changes seen w/ hypokalemia

A
  1. flatted T waves
  2. U waves
  3. ST segment depression
  4. PACs
  5. Torsades
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37
Q

tx of hypokalemia

A
  1. correct hypomagneisum**
  2. Replace orally whenever possible
  3. KCl IV for severe cases.
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38
Q

What is the normal value for Ca

A

8.5-10.3mg/dL

39
Q

Always correct for __ with Ca abnormality

A

albumin

*can look falsely low

40
Q

Signs and sx of hypercalcemia

A
  1. Stones,
  2. Bones,
  3. Abdominal Groans,
  4. Psychic Overtones/depression
41
Q

Causes of hypercalcemia

A
  1. Calcium IV,
  2. hyperPTH*,
  3. mets,
  4. pagets disease,
  5. addisons disease,
  6. acromegaly,
  7. neoplasm**,
  8. sarcoid.
42
Q

EKG changes w/ hypercalcemia

A
  1. Short QT interval

2. Prolonged PR interval

43
Q

Tx of hypercalcemia

A
  1. volume expansion with NS,
  2. diuresis with furosemide.
  3. hospitalize pts w/ ionized Ca >3.0
44
Q

signs and sx of hypocalcemia

A
  1. Chvostek’s and Trousseau sign,
  2. increased DTRs,
  3. confusion, abdominal cramps,
  4. stridor,
  5. laryngospasm,
  6. seizures,
  7. tetany,
  8. psych abnormalities (paranoia, depression, hallucinations)
45
Q

causes of hypocalcemia

A
  1. Short bowel syndrome,
  2. intestinal bypass,
  3. sepsis,
  4. acute pancreatitis,
  5. diuretics,
  6. renal failure,
  7. hypoMg,
  8. rhabdo
46
Q

EKG findings w/ hypocalcemia

A
  1. Prolonged QT
47
Q

What is Chvostek’s sign

A

facial spasm when taping facial nerve

*associated w/ hypocalcemia

48
Q

What is Trousseau sign

A

wrist curls w/ BP taking?

*associated w/ hypocalcemia

49
Q

Treatment of hypocalcemia

A
  1. IV or PO calcium (acute vs chronic)- make sure to correct for albumin before tx!!
  2. may need to correct magnesium
  3. if acute and symptomatic- admit to hospital

*PO if chronic, IV if acute

50
Q

what are normal magnesium values

A

1.8-3.0 mg/dL

51
Q

Signs and sx of hypermagnesium

A
  1. Resp failure,
  2. CNS depression,
  3. decreased DTRs
52
Q

Causes of hypermagnesium

A
  1. TPN
  2. renal failure
  3. IV magnesium
  4. taking too many antacids or laxatives?
53
Q

Tx of hypermagnesium

A
  1. Calcium gluconate IV,
  2. NS + furosemide
  3. dialysis.
  4. admit if symptomatic
54
Q

EKG changes w/ hypermagnesium

A

*similar to hyperK

  1. prolonged QT
  2. wide QRS
  3. peaked T waves
  4. bradycardia
55
Q

Signs and sx of hypomagensium

A
  1. Increased DTRs,
  2. tetany,
  3. asterixis–wrist flapping motion
  4. tremor,
  5. Chvostek,
  6. ventricular ectopy
56
Q

causes of hypomagnesium

A
  1. TPN,
  2. decreased Ca,
  3. renal failure,
  4. diarrhea, vomiting,
  5. gastric suctioning,
  6. aminoglycosides
  7. CHRONIC ALCOHOL ABUSE!
57
Q

treatment of hypomagnesium

A
  1. MgSO4 IV (acute)
  2. Mg oxide PO (chronic)
  3. admit if symptomatic
58
Q

glucose emergencies are most commonly found in who

59
Q

Signs and sx of hypoglycemia

A
  1. Altered mental status,
  2. neurologic deficits,
  3. seizures,
  4. coma.
    Milder symptoms:
  5. shakiness,
  6. nausea,
  7. sweats / clammy,
  8. lightheadedness.
60
Q

causes of hypoglycemia

A
  1. Generally related to diabetes medications and change in diet / missed meal.
  2. Infection,
  3. endocrine disorders,
  4. malnutrition,
  5. drugs / alcohol.
61
Q

treatment of hypoglycemia

A
  1. IV dextrose (50 cc of 50% glucose = 25 g glucose).
  2. Fruit juice if pt alert / able to eat.
  3. Glucagon IM if no IV access.
  4. Monitor…duration dependent on duration of hypoglycemic medication patient is taking.
    May need to admit.
62
Q

what is considered hyperglycemia

A

> 200 w/ sx

63
Q

Signs and sx of hyperglycemia

A
  1. Classically: 3 P’s: polyuria, polydypsia, polyphagia
  2. Fatigue / weakness,
  3. blurry vision,
  4. dehydration,
  5. lightheadedness,
  6. headache.
64
Q

causes of hyperglycemia

A
  1. Infections,
  2. medication non-compliance,
  3. new diagnosis DM
  4. MI
65
Q

treatment of hyperglycemia

A
  1. IVF- aggressive fluid rehdyration
  2. potassium replacement
  3. insulin at 0.1mg/kg/hr IV drip, when K is normal
  4. Manage trigger
  5. tx pain and nausea
66
Q

complicatoins of hyperglycemia

A
  1. DKA

2. HHS

67
Q

“Most common acute life-threatening complication of diabetes.”

68
Q

Deficiency of insulin –> hyperglycemia with the formation of ketoacids.

A

DKA

more common w/ Type 1 than type 2

69
Q

Signs and sx of DKA

A
  1. 3 P’s, tachypnea,
  2. dehydration and
  3. confusion.
  4. N/V in about 25% and c/o abdominal pain.
  5. Kussmaul’s respirations: rapid deep breathing.
  6. Ketone breath: fruity or acetone-like odor.
  7. onset of sx tend to be rapid
70
Q

causes of DKA

A
  1. Infection
  2. Injury / Trauma
  3. Cardiac origin (MI or ACS)
  4. Neurologic origin (TIA or CVA)
  5. Alcohol or other drug abuse
  6. GI illness: pancreatitis, gastroenteritis, GI bleeding
  7. Medications (steroids) including non-compliance or inability to afford medications.
71
Q

Lab findings for DKA

A
  1. Glucose > 250 mg/dL
  2. BUN / Creatinine may be elevated d/t dehydration.
  3. Ketones in serum or urine (add on Beta hydroxybutyrate* or Acetoacetate)
  4. pH < 7.3
  5. Serum bicarbonate < 15 mEq / L (LOW)
  6. Serum osmolality > 340 mOsm/kg
  7. Anion gap > 10.
    [Na] – ([Cl] + [HCO3]) = anion gap
72
Q

Work up of DKA

A
  1. Fingerstick glucose
  2. CBC, BMP, Mg, Phos
  3. EKG (consider also cardiac monitor)
  4. Serum beta-hydroxybutyrate and UA for ketones
  5. ABG (or VBG)

Additional work up to find / treat the source:
Cardiac markers, cultures (blood, urine, wound) if suspect infection, imaging (CT head, CXR, limb eval osteomyelitis), other.
* as indicated*

73
Q

Treatment of DKA

A
  1. 2 PIVs, cardiac monitor, cycling vital signs.
  2. Fluid resuscitation.
  3. electrolyte replacement
  4. insulin therapy: – generally insulin infusion +/- bolus.
  5. Frequent re-evaluations and lab re-checks.
  6. Treat the cause.
  7. Admit to ICU.
74
Q

how do you fluid resusitate w/ DKA

A

1 to 1.5 L NS over first hour then….

Correct ½ of fluid deficit over first 8 hours then the remaining ½ over the next 24 hours.

75
Q

how do you replace electrolytes w/ DKA

A

K+ < 3.3 WITHHOLD insulin until K improved.

K+ 3.3 – 5.0 give 20-30 mEq KCl / liter IVF.

K+ > 5.0, hold potassium and follow Q 1 h K+ for possible repletion

76
Q

What is HHS

A
  • Hyperosmolar Hyperglycemic State (HHS)
  • Life threatening complication of diabetes. (HIGH MORTALITY ~20%)

-Generally occurs in older patients with Type 2 DM and carries a higher mortality than DKA.

77
Q

What are predisposing factors for HHS?

A

generally the same as DKA but pt population often > 65.

78
Q

Signs and sx of HHS

A
  1. 3 P’s
  2. generalized weakness
  3. confusion (to coma)
  4. VERY dehydration (9L deficit)

**NO ABDOMINAL PAIN (AS SEEN W/ DKA)

79
Q

Lab findings of HHS

A
  1. Serum glucose > 600.*
  2. Profound dehydration (up to 9L deficit).*
  3. Prominent glucosuria.
  4. Generally small or absent ketones (urine or serum).*
  5. Serum bicarbonate > 15 mEq / L
  6. pH > 7.3
  7. Variable anion gap (usually < 10).
  8. Serum osmolality 320-380 mOsm/kg.
  9. Electrolytes: K+ generally normal or low. BUN/ creatinine markedly elevated.
80
Q

treatment of HHS

A
  1. 2 PIVs, cardiac monitor, cycling vital signs.
  2. Fluid resuscitation.
  3. K+ replacement if needed.
  4. Insulin therapy – generally insulin infusion +/- bolus.
  5. Frequent re-evaluations and lab re-checks.
  6. Treat the cause.
  7. Admit to ICU.

*High mortality!

81
Q

Describe the fluid resuscitation of HHS

A

1 to 1.5 L NS over first hour then….

Correct ½ of fluid deficit over first 8 hours then the remaining ½ over the next 24 hours.

82
Q

What is an anion gap

A

A measurement of the interval between the sum of ‘routinely measured’ cations minus the sum of the ‘routinely measured’ anions in the blood.

The anion gap = (Na+ + K+) - (Cl- + HCO3-)

*doesnt take into account glucose

83
Q

what is a normal anion gap

84
Q

diseases that have normal anion gap

A

HARDUPS:

  1. Hyperalimentation (TPN)
  2. Acetazolamide
  3. Renal Tubular Acidosis
  4. Diarrhea
  5. Uretero-enteric fistula
  6. Pancreatoduodenal fistula
  7. Spironolactone
85
Q

Causes of Elevated anion gap

A

CAT MUDPILES

  1. C-carbon monoxide, cyanide, CHF
  2. A-aminoglycosides
  3. T-teophylline, toluene (glue-sniffing)
  4. Methanol
  5. Uremia
  6. DKA (ketoacidosis)
  7. Paracetamol/acetaminophen, phenformin, paraldehyde
  8. Iron, inborn errors of metabolism
  9. Lactic acidosis
  10. Ethanol, ethylene glycol
  11. Salicylates (ASA)
86
Q

Causes of respiratory acidosis

A
  1. Hypoventilation** (pnemuothorax, pleural effusion, airway obstruction, parenchymal lung disease)
  2. Drug intox.*
  3. cardiac arrest*
  4. COPD*
87
Q

causes of respiratory alkalosis

A
  1. HYPERventilation (anxiety, fever, pain)
  2. asthma exacerbation
  3. PE
  4. high altitude
  5. ASA over dose

*resp. problem

88
Q

Causes of metabolic acidosis

A

**MUDPILES (gap) or HARDUPS (no gap)

  1. Loss of Bicarbonate:
    -Diarrhea, ileus, fistula, high-output ileostomy.
  2. Increase in acids:
    Lactic acidosis, ketoacidosis, renal failure, necrotic tissue.
89
Q

causes of metabolic alkalosis

A
  1. vomiting
  2. diarrhea
  3. NG suctioning

**volume loss with chloride depletion

90
Q

how to interpret an ABG

A
  1. look at pH and decide acidotic of alkalotic
  2. look at pCO2
    -low= alkalosis
    -high=acidosis
  3. look at HCO3
    -low=acidotic
    -high=alkalotic
  4. Start matching…
    -If pH low and pCO2 high: respiratory acidosis
    -If pH high and pCO2 low: respiratory alkalosis
    -If pH low and HCO3 low: metabolic acidosis
    -If pH high and HCO3 high: metabolic alkalosis
  5. Look for compensation…
    -Does pCO2 or HCO3 go in opposite direction?
    Indicates compensation.
  6. Look at pO2 to determine if patient is hypoxemic.
    If hypoxemic – address!
91
Q

-If pH low and pCO2 high: ___
-If pH high and pCO2 low: ___
If pH low and HCO3 low: ___
If pH high and HCO3 high: ___

A

respiratory acidosis

respiratory alkalosis

metabolic acidosis

metabolic alkalosis

92
Q

___ excess: excess or insufficient amount of bicarbonate in the system.

93
Q

A negative base excess indicates a ___ in the blood.

A

base deficit

94
Q

how do you document ABGs

A

pH/pCO2/pO2/HCO3/O2 Sat/BE

Emergency Medicine (22 decks)

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