Electrolytes – Capstone Dr. Dan Grace

Hyperkalemia

Causes: #1 cause hemolysis followed by renal failure, acidosis, cell death, drugs (ACE/ARBS)

Sxs: Abd pain, diarrhea, chest pain, muscle weakness/numbness, n/v, palpitations

EKG changes: variable depending on K; peaked T waves then P flattens and PR lengthens, conduction abnormalities and bradycardia – prolonged QRS up to sine wave, then cardiac arrest

Treatment: stabilize cardiac membrane with calcium gluconate, shift K into cells via 5-10 U regular insulin with 1-2 D50 amps, albuterol neb, sodium bicarb (esp if acidotic), Get rid of K via lasix if properly hydrated, dialysis.

Hypokalemia

Causes: chronic ETOH, malnutrition, diuretics, vom/diarrhea, hyperventilating, alkalosis

Sxs: cramping, weakness

EKG changes: U waves, flattening/loss of T waves, tornadoes, AV block, brady, PVCs

Deficit: For every 0.3 meq/L below 3.5, 100 meq deficit, replace with KCl PO if can, or IV; also have Effer-K, K phos at no more than 60 meq at at time

Hypernatremia

Causes: unreplaced water losses, decreased water intake or excessive Na intake

Sxs: HA, n/v, confusion/AMS, seizure, coma

Treatment: Depends on sxs, mild symptomatic (if euvolemic consider 1/2NS), severe with seizure/coma (D5W), Free water deficit on MDCalc [(serum Na – 140)/140] x 0.6body weight in kg. Don’t correct more than 0.5/hr.

Hyponatremia

Causes: vomiting, diarrhea, diuretics, drinking too much water, dehydration, heart/kidney/liver problems, inadequate salt intake – generally classified into hypovolemic, euvolemic, or hypervolemic

Sxs: dizziness, fatigue, HA, confusion, nausea, seizures

Repletion: no more than 0.5 meq/hr and 8meq/day to avoid osmotic demyelination syndrome. Give hypertonic saline 3% for seizure, coma 100 -150 cc over 10 min, can repeat x 1

Other electrolytes important in ED

Hypercalcemia: bones, stones, groans, psychiatric overtones; Tx if 12-14 with sxs or >14; fluid resuscitate, lasix if fluid overload, calcitonin is faster than bisphosphonates

Hypophosphatemia: anemia, bruising, seizure, coma, constipation, muscle weakness; usually caused by DKA, refeeding, malabsorption, ETOH; tx with NaPhos or KPhos PO or IV

Environmental Kahoot – Dr. Dan Grace

-Killerbees more likely to swarm and sting multiple times

-Acute Mountain Sickness – descend; Acetazolamide works by causing primary metabolic acidosis

-Ruptured TM following ascent from scuba diving – antibiotic drops and ear precautions

-Difference b/t heat stroke/exhaustion = neuro sxs

-Iguana bite – cipro

-ARDS after wet drowning due to water washing away surfactant

Toxic Smoothie – Dr. Bosse

-Digoxin toxicity is only time you do not want to use calcium for hyperkalemia

-Cyanide toxicity: lactate level. Tx with hydroxycobalamin. Other tx: nitrite (causes methemoglobinemia which then scavenges cyanide); thiosulfate, cyanokit (amyl nitrite, sodium nitrite, sodium thiosulfate)

-Antihypertensive overdose: hypotension possible but not common with ACE-I OD

-Few toxins cleared by HD: lithium, toxic alcohols, salicylates, theophylline

Geriatrics Lecture – Mentation

-Normal aging: slowed, need more time.

-Confusion, problems with judgement not normal

-Dementia progresses over years vs delirium acute change in things like attention, falling asleep, disorganized thinking or altered level of consciousness

-Delirum causes – several, but think of infection, meds, seizures, intracranial bleed, NPH

-Can use ADEPT Tool to assess change in mental status

-Use smaller doses of medications for elderly

-If need meds for agitation ex: Haldol 0.5 mg (IV,IM,PO), Seroquel 12.5 mg, Olanzapine 2.5-5 mg, Risperidone 0.25-0.5 mg

Decompensated Cirrhosis – Dr. McGee

-Have high index of suspicion for cirrhosis – use clues from exam and labs

-Search for underlying etiology of portosystemic encephalopathy, GIB, etc.

-Diagnose and treat SBP: diagnostic paracentesis with >250 PMNs, Ceftriaxone 2g Q24 hrs, Alubmin 1.5g/kg on day 1 reduces mortality

-GIB: early GI consult; varies 15-30% risk of death. 2 large bore IVs, cultures, ceftriaxone (or broader), keep Hb around 7. correcting INR with FFP not recommended, transfuse if plt <50 K, cryo for fibrinogen <100. Protonix, octreotide. Blakemore tube if needed.

-Hepatorenal Syndrome: High index of suspicion, Cirrhosis and Cr >1.5. If cirrhotic with AKI, use albumin 5% if hypovolemic, 25% if euvolemic/hypervolemic, non ICU midodrine and octreotide; if ICU levo with MAP >85.

-Medications to AVOID: Never NSAIDs, if opiates needed then fentanyl > Hydromorphone > morphine, avoid benzos as much as possible; can give Tylenol up to 2 g/day