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Electrolyte and Metabolic Disturbances Electrolyte and Metabolic Disturbances
Electrolyte and Metabolic Disturbances Electrolyte and Metabolic Disturbances
Disturbances
®
Objectives
Review causes and clinical manifestations of severe
electrolyte disturbances
Outline emergent management of electrolyte disturbances
Ureterosigmoidostomy
No acid-base disorder
Mg deficiency
Drugs
Hyperkalemia
Severe hyperkalemia is a medical emergency
Neuromuscular signs (weakness, ascending
paralysis, respiratory failure)
Progressive ECG changes (peaked T waves,
flattened P waves, prolonged PR interval,
idioventricular rhythm and widened QRS
complex, “sine wave” pattern, V fib)
Hyperkalemia
tubular unresponsiveness
Renal failure
GFR < 10 -20% of normal
Hyperkalemia
Treatment
Stop potassium!
Get and ECG
Hyperkalemia with ECG changes is a medical
emergency
Hyperkalemia
Treatment
Firstphase is emergency treatment to counteract the
effects of hyperkalemia
IV Calcium
Temporizing treatment to drive the potassium into the cells
glucose plus insulin
Beta2 agonist
NaHCO3
Hyperkalemia
Treatment
Therapy directed at actual removal of potassium
from the body
sodium polystyrene sulfonate (Kayexalate)
dialysis
Hypocalcemia
Calcium chloride or gluconate
Bolus + continuous infusion
Hypercalcemia
Rehydration with normal saline
Loop diuretics
Other Electrolyte Disorders
Hypophosphatemia
Replacement iv for level < 1 mg/dL (0.32
mmol/L)
Hypomagnesemia
Emergent administration over
5–10 mins
Less urgent administration over
10–60 mins
Hypoglycemia
5 Causes
too much insulin
not enough food
increased physical activity
illness
injury
Signs and Symptoms of
Hypoglycemia
Faster onset than DKA
Early signs: Headache, Hunger, Mild agitation
Blood sugar below 50-70 mg/dL
hallucinations
or nervousness or outright hostility
cold sweat and tachycardia common but not required
Blood sugar blow 20 -50 mg/dL
convulsions and loss of consciousness
as sugar drops the convulsions stop but coma persists
Treatment of Hypoglycemia
High flow Oxygen
Early IV access if patient not verbal
D50 after blood glucose determination
Should be administered in patients with less than
60-70 mg/dL
Treat the patient, not the glucometer, may need
to administer in patients with higher readings
Make sure the IV is patent since extravasation
causes necrosis of the surrounding area
Hyperglycemic Syndromes
MET 40 ®
Thyroid Storm
Exaggerated manifestations of
hyperthyroidism
Supportive measures
Specific measures
Propylthiouracil or methimazole
Propranolol
Dexamethasone or hydrocortisone
MET 47 ®
Key Points
Important Concepts
Concentrations
Compartments
Contents
Volumes
Rates of gain & loss
Intake Excretion
ICF
28L
Intake Excretion
ICF
26L
Intake Excretion
ICF
28L
TOTAL 42
Loss of 2L of isotonic fluid,
e.g. blood, fistula fluid
ECF ECF
14L 12L
- 2L of isotonic fluid
ICF ICF
28L 28L
Note :
Loss is from ECF
No change in [Na]
No fluid redistribution
Loss of 3L of hypotonic fluid,
e.g. insensible loss
- 3L of hypotonic fluid
ECF
ECF ECF
14L
11L 13L
Note :
Greater loss from ICF than ECF
Small increase in [Na]
Fluid redistribution between ECF & ICF
Gain of 2L of isotonic fluid,
e.g. saline drip
ECF ECF
14L 16L
+ 2L of isotonic fluid
ICF ICF
28L 28L
Note :
Gain is to ECF
No change in [Na]
No fluid redistribution
Gain of 3L of hypotonic fluid,
e.g. water, dextrose
+ 3L of hypotonic fluid
ECF ECF
ECF
14L 17L
15L
ICF ICF
ICF
28L 30L
28L
Note :
Greater gain to ICF than ECF
Small decrease in [Na]
Fluid redistribution between ECF & ICF
Summary
Water & electrolyte metabolism central to much acute clinical care
Multitude of causes of disturbances & many important effects
Most clinical problems can be solved using a common sense
approach to the concepts of
volumes
compartments
contents
concentrations
input /output