What are the four primary acid-base disorrders?
Metabolic Acidosis
Metabolic Alkalosis
Respiratory Acidosis
Respiratory Alkalosis
Respiratory acid-base disorders bring primary changes in ___ and secondary (compensatory) changes in _____.
CO2
HCO3-
Metabolic acid-base disorders bring primary changes in ___ and secondary (compensatory) changes in _____.
HCO3-
CO2
What primary acid-base disorder is indicated by the ABG below….
7.21/30/100/15
A. Metabolic Acidosis
B. Metabolic Alkalosis
C. Respiratory Acidosis
D. Respiratory Alkalosis
A. Metabolic Acidosis
What is the compensatory response in a metabolic acidosis?
Decrease CO2 concentration through hyperventilation
What processes can result in a Metabolic acidosis?
Lactic Acidosis DKA Ingestion (Methanol, Ethylene Glycol, ASA) Renal Failure Diarrhea (HCO3- Loss)
What primary acid-base disorder is indicated by the ABG below….
7.50/50/100/30
A. Metabolic Acidosis
B. Metabolic Alkalosis
C. Respiratory Acidosis
D. Respiratory Alkalosis
B. Metabolic Alkalosis
What is the compensatory response in metabolic alkalosis?
Increased CO2 concentration through hypoventilation
What processes can lead to metabolic alkalosis?
- TPN Administration
- Vomiting (H+ loss)
- Loop diuretics
- HCO3- Administration
What primary acid-base disorder is indicated by the ABG below….
7.14/56/100/27
A. Metabolic Acidosis
B. Metabolic Alkalosis
C. Respiratory Acidosis
D. Respiratory Alkalosis
C. Respiratory Acidosis
What is the compensatory response in a respiratory acidosis?
Increased HCO3- buffering in the kidneys
What processes can lead to a respiratory acidosis?
Alveolar hypoventilation V/Q mismatch Alterations in CNS respiratory drive Respiratory muscle fatigue Pulmonary disease Mechanical ventilation
If an intubated and mechanically ventilated patient developed a respiratory acidosis, would this be the result of hypoventilation or hyperventilation?
How could this be corrected?
Hypoventilation (The patient is not breathing fast enough)
This can be corrected through increasing the ventilation rate
What primary acid-base disorder is indicated by the ABG below….
7.56/25/100/18
A. Metabolic Acidosis
B. Metabolic Alkalosis
C. Respiratory Acidosis
D. Respiratory Alkalosis
D. Respiratory Alkalosis
What is the compensatory response to a respiratory alkalosis?
Decreased HCO3- production in the kidneys
Is respiratory alkalosis commonly due to hypoventilation or hyperventilation?
Hyperventilation
What processes can cause respiratory alkalosis?
- Pain
- CVA
- Anxiety
- Trauma (Flail Chest)
- Hypoxemia, Altitude
- Pulmonary Edema
- Heart Failure
- Sepsis
- Mechanical Ventilation
- Over-correcting Metabolic acidosis
What are causes of a WAGMA (Wide anion gap metabolic acidosis)?
MUDPILES
Methanol Uremia (renal failure) Diabetic ketoacidosis Propylene glycol Infection, inborn errors of metabolism Lactic acidosis Ethylene glycol Salicylate
A 65 y.o. male s/p CABG is intubated and placed on ventilation in the ICU. Following intubation, an ABG is drawn which shows…..
7.27/55/250/25(-2)/100%
What is the primary acid/base disorder?
Is this likely a result of?
How could this be corrected?
Respiratory Acidosis
This is likely a result of hypoventilation (holding onto too much CO2)
Increase the ventilation rate
A 40 y.o female involved in a single vehicle MVA arrives in the ED. On exam she is found to have a fail chest. As respiratory failure seems imminent, she is intubated. Following intubation, an ABG is drawn which shows….
7.54/24/370/22/100%
What is the primary acid/base disorder?
Is this likely a result of?
How could this be corrected?
Respiratory Alkalosis
This is likely due to mechanical hyperventilation. (Losing too much CO2)
Decrease the ventilation rate
A 6 y.o. male is brought into the ED complaining of emesis, abdominal pain, and polyuria. A UA is ordered which shows a large amount of glucose and the presence of ketones. This is concerning and prompts an ABG draw, which shows…..
7.25/16/131/7/99%
What is the primary acid/base disorder?
What is the likely underlying condition this patient has?
How are they trying to compensate?
Metabolic Acidosis
This patient likely has undiagnosed DM and is now presenting in DKA
He was trying to compensate by hyperventilating and ‘blowing down’ his CO2 levels
_______ are IV fluids that contain water, dextrose, Na+, Cl-, and other electrolytes
Crystalloids
______ _____ contain mostly Na+ and Cl- but also have lactate, K+, and Ca2+
Lactated Ringer’s (LR)
______ contain packed red blood cells, pooled human plasma (5% albumin, 25% albumin), semisynthetic glucose polymers (dextran), and semisynthetic hydroxyethyl starch (hetastarch)
Colloids
Are colloids more likely to remain in the intravascular space or the interstitial space?
Intravascular
Why should colloids be avoided in patient who are requiring fluid resuscitation (ie: dehydration)?
Colloids will draw water out of the interstitial space
When would symptoms of intravascular fluid depletion likely manifest?
Once 15% (750 mL) of blood volume is lost
What is the recommended ‘fluid’ of choice in fluid resuscitation?
Crystalloids
What are the signs and symptoms of intravascular fluid depletion?
- Tachycardisa
- Hypotension
- Orthostatic
- AKI (Increased BUN/sCr)
- Dry Mucus Membranes
- Decreased Skin Turgor
- Reduced Urine Output
- Dizziness
____ water is also referred as D5W and is metabolized to water and CO2 in the body
Free Water (D5W)
What THREE things are considered when adjusting maintenance fluids?
- Input
- Output
- Insensible Loss
Which ‘fluid’ is commonly used for maintenance fluids?
A. Crystalloids
B. Colloids
C. Free Water (D5W)
C. Free Water (D5W)
Increased osmolarity would likely result in fluid shift ______ (out of/into the cell, cell _______ (hydration/dehydration and _______ (shrinkage/growth)
Out of
Dehydration
Shrinkage
Decreased osmolarity would likely result in fluid shift ______ (out of/into the cell, cell _______ (hydration/dehydration) and _______
Into
Hydration
Hemolysis
In what THREE ways can fluid be classified in terms of osmolarity?
- Hypertonic (Water out of the cells)
- Isotonic
- Hypotonic (Water into the cell)
What are TWO common uses for hypertonic saline?
- TBI with increased ICP and MAP
2. Symptomatic Hyponatremia (AMS, Coma)
When should hypertonic saline be AVOIDED?
- Chronic Asymptomatic Hyponatremia
- Hyponatremia with Hyperglycemia (ex: DKA)
- Hyponatremia with Hypovalemia (ex: CHF)
What is the maximal safe amount of change in serum Na+ levels over 24 hours?
10-12 mmol/L
What are common complications of hypertonic saline?
- Hypokalemia
- Hyperchloremic Acidosis
- Hypernatremia
- Phlebitis
- Heart Failure (Fluid Overload)
- Osmotic Demyelination Syndrome (Rapid Correction of Hyponatremia)
- Hypotension (Rapid Administration)
What are complications of IV hypotonic fluids?
- Hemolysis of cells
2. Death
IVF with an osmolarity less than ____ mOsm/L should be AVOIDED
150 mOsm/L
________ hyponatremia is caused by excess Na+ and fluid, but the fluid excess predominates
Hypervolemic Hyponatremia
________ hyponatermia normal total body Na+ but excess fluid, appears diluted
Normovolemic Hyponatremia
_________ hyponatremia is a deficit of both fluid and Na+ but total Na+ is decreased more than total body water
Hypovolemic Hyponatremia
What is an example of a disease or process(es) that can cause hypervolemic hyponatremia?
Normovolemic?
Hypovolemic?
Hypervolemic:
CHF
Cirrhosis
Normovolemic:
SIADH
Hypovolemic:
Emesis, Diarrhea, Fever
Third-Spacing
Diuretics
How is hypervolemic hyponatremia treated?
- Na+ / Water restriction
- Treat underlying cause
- Vasopressin receptor antagonist
How is normovolemic hypoonatremia treated?
- Remove offending agent (If applicable)
- Restrict fluids
- Demeclocyline (Tx SIADH)
- Vasopressin receptor antagonist
How is hypovolemic hyponatremia treated?
- Fluid Resuscitation
What are common causes of hyponatremia
- Increased ADH
- Volume Depletion / Hypoperfusion
- SIADH / Cortisol Deficiency
- Medication (Diuretics, SSRIs)
- Renal Failure
What are clinical manifestations of mild hyponatremia (120-125)?
Moderate (115-120)?
Severe (<115)?
Mild:
Nausea, Malaise
Moderate:
HA, Lethargy, Obtundation, Confusion
Severe:
Delirium, Sz, Coma, Death
What are common symptom manifestation of hypernatremia (>145)
- Lethargy, Weakness
- Twitching, Sz
- Coma
- Death (Late/Severe)
What are common causes of hypernatremia?
- Loss of Water (Fever, Burns, Infection)
- Diabetes Insipidus)
- Sodium Retention
What complications may occur if hypernatremia is corrected too rapidly?
Cerebral Edema
Seizures
Neurologic Damage
Death
K+ is the primary ________ (intracellular/extracellular) cation while Na+ is the primary ________ (intracellular/extracellular) cation
Intracellular
Extracellular
What are common causes of hypokalemia?
- Increased pH
- Insulin Load
- Hypothermia
- Increased GI Losses (vomiting, diarrhea, laxatives)
- Diuretics
- Hypomagnesemia
What are symptoms and manifestations of hypokalemia?
- Muscle Weakness
- Flattened T waves
- Arrhythmias (Bradycardia, V Tach, V fib)
- Rhabdomyolysis
How should a hypokalemic patient WITHOUT EKG chagnes be treated/managed?
PO K+ Supplementation
At what K+ should hypokalemia be treated with IV replacement?
What else should be monitored?
< 2.5
These patients should likely have continuous EKG monitoring
What are common causes of hyperkalemia?
- Increase K+ intake
- Acidosis
- Insulin Deficiency
- Kidney Dysfunction
What are symptoms and manifestations of hyperkalemia?
- Muscle Weakness / Paralysis
- Peaked T-waves
- V Fib is Possible
- Additional Electrolyte abnormalities
When would urgent and immediate treatment of hyperkalemia be indicated?
- K+ >6.5
- Severe muscle weakness
- EKC Change
What is used to prevent hyperkalemia induced arrhythmias?
IV Calcium
T/F: IV Ca2+ will decrease serum K+ levels
False
It only antagonizes the effect of K+ on cardiac conduction
IV Ca2+ should be avoided in patients taking what anti-arrhythmic
Digoxin
Other than IV Ca2++, what additional ‘primary’ treatment options are available to treat hyperkalemia?
What are the ‘secondary’ or additional treatment options are used to treat hyperkalemia?
Primary:
- Insulin / Glucose
- Sodium Bicarbonate (Avoid in renal disease)
- Beta-2 Adrenergic Agonists (Avoid in coronary ischemia)
Secondary:
- Diuretics
- Cation-resin Exchange
- Dialysis
- Kayexalate
What are common causes of hypomagnesemia (< 1.7)?
- Impaired Absorption (UC, Diarrhea)
- Alcoholism
- Hypokalemia
- Diuretics
What are signs and symptoms of hypomagnesemia?
Tetany, Twitching
Arrhythmia
HTN
Sudden Death
What is a common cause of hypermagnesemia (>2.3)?
Renal Insufficiency
What are signs and symptoms of hypermagnesemia?
- Nausea, Emesis
- Bradycardia, Heart Block, Asystole
- Respiratory Failure
- Death
How is hypermagnesemia treated?
- Discontinue Mg2+ containing medications
- IVF and Diuretics is Asymptomatic
- IV Ca2++ if cardiac symptoms
- HD in the setting of kidney disease
What are common causes of hypophosphatemia (<2.5)?
- Increased Renal Elimination (Diuretics)
- Re-feeding Syndrome
- Respiratory Alkalosis
- DKA Treatment
What are common signs and symptoms of hypophosphatemia?
- Tissue Hypoxia
- Neurologic (Confusion, Sz, Coma)
- Cardiopulmonary (Respiratory Failure, CHF)
What are common causes of hypomagnesemia (< 1.7)?
- Impaired Absorption (UC, Diarrhea)
- Alcoholism
- Hypokalemia
- Diuretics
What are signs and symptoms of hypomagnesemia?
Tetany, Twitching
Arrhythmia
HTN
Sudden Death
What is a common cause of hypermagnesemia (>2.3)?
Renal Insufficiency
What are signs and symptoms of hypermagnesemia?
- Nausea, Emesis
- Bradycardia, Heart Block, Asystole
- Respiratory Failure
- Death
How is hypermagnesemia treated?
- Discontinue Mg2+ containing medications
- IVF and Diuretics is Asymptomatic
- IV Ca2++ if cardiac symptoms
- HD in the setting of kidney disease
What are common causes of hypophosphatemia (<2.5)?
- Increased Renal Elimination (Diuretics)
- Re-feeding Syndrome
- Respiratory Alkalosis
- DKA Treatment
What are common signs and symptoms of hypophosphatemia?
- Tissue Hypoxia
- Neurologic (Confusion, Sz, Coma)
- Cardiopulmonary (Respiratory Failure, CHF)
What TWO diseases are commonly seen with hyperphosphatemia?
- CKD
2. Hypoparathyroidsm
T/F: Patient with hyperphosphatemia are typically asymptomatic
True
How is Hyperphosphatemia treated?
- Dietary restrictions
- Saline Infusion
- Dialysis
- Phosphate Binders (Calcium Carbonate, Calcium Acetate)
What are common causes of hypocalcemia?
- CKD
- Hypoparathyroidism
- Vitamin D Deficiency
- Alcoholism
What are some of the many treatment options for hypercalcemia?
- Isotonic Saline Hydration
- Calcitonin
- Bisphosphonates
- Loop Diuretics
- Glucocorticoids
- Dialysis
What are the acute hypocalcemia Sx?
Acute:
Syncope
CHF
Angina
What are the neuromuscular hypocalcemia Sx?
Numbness Tingling Cramping Tetany Wheezing Hoarseness
What are the neurologic hypocalcemia Sx?
Irritability
Fatigue
Sz
What are the chronic dermatological hypocalcemia Sx?
Coarse Hair Brittle Nails Psoriasis Dry Skin Poor Dentition
What are the TWO most common causes of hypercalcemia?
- Malignancy
2. Hyperparathyroidism
What are the CNS Sx of hypercalcemia?
GI Sx?
Renal?
Cardiac?
CHS:
Lethargy, Weakness, Confusion
GI:
Constipation, Nausea
Renal:
Polyuria, Nocturia, Stones
Cardiac:
Syncope, Arrhythmia
What are some of the many treatment options for hypercalcemia?
- Isotonic Saline Hydration
- Calcitonin
- Bisphosphonates
- Loop Diuretics
- Glucocorticoids
