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Metabolic Emergencies Flashcards

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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
how do you diagnose SIADH
1. Low Na+ with low Osmolality 2. Renal excretion of sodium 3. Euvolemic state 4. Absence of other causes low Na+
26
Important cause of euvolemic hyponatremia.
SIADH
27
EKG changes for Na abnormlaitiy
NO EKG CHANGES | *often has AMS
28
Signs and sx of hyperkalemia
1. Muscle weakness, 2. paralysis, 3. n/v/d, 4. abdominal cramping, 5. cardiac arrhythmias (palpitations), 6. cardiac arrest. *associated with metabolic acidosis
29
Causes of hyperkalemia
1. Iatrogenic overdose, 2. blood transfusion (rate dependent) 3 renal failure, 4. hemolysis or tissue injury, 5. diuretics (K+ sparing- spironolactone) 6. lab error*
30
EKG changes w/ hyperkalemia
1. peaky T waves 2. depressed ST segments 3. Prolonged PR interval 4. wide QRS 5. Bradycardia--> can progress to Vfib and aystole
31
What are critical values for hyperkalemia
Critical values: > 6.0 – emergency treatment warranted (esp if EKG changes)
32
Urgent treatment for hyperkalemia
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+
33
Non-urgent treatment of hyperkalemia
1. Kayelxalate- help stool out K+ 2. Furosemide- help urinate out K+ 3. admit to hosptial
34
Signs and sx of hypokalemia
1. Weakness, 2. tetany, 3. N/V, 4. ileus, 5. paraesthesias.
35
Causes of hypokalmeia
1. Diuretics, 2. certain Abx (anti-fungal, aminoglycosides), 3. albuterol, 4. diarrhea, 5. intestinal fistula, 6. vomiting, 7. insulin, 8. DKA.
36
EKG changes seen w/ hypokalemia
1. flatted T waves 2. U waves 3. ST segment depression 4. PACs 5. Torsades
37
tx of hypokalemia
1. correct hypomagneisum** 2. Replace orally whenever possible 3. KCl IV for severe cases.
38
What is the normal value for Ca
8.5-10.3mg/dL
39
Always correct for __ with Ca abnormality
albumin *can look falsely low
40
Signs and sx of hypercalcemia
1. Stones, 2. Bones, 3. Abdominal Groans, 4. Psychic Overtones/depression
41
Causes of hypercalcemia
1. Calcium IV, 2. hyperPTH*, 3. mets, 4. pagets disease, 5. addisons disease, 6. acromegaly, 7. neoplasm**, 8. sarcoid.
42
EKG changes w/ hypercalcemia
1. Short QT interval | 2. Prolonged PR interval
43
Tx of hypercalcemia
1. volume expansion with NS, 2. diuresis with furosemide. 3. hospitalize pts w/ ionized Ca >3.0
44
signs and sx of hypocalcemia
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
causes of hypocalcemia
1. Short bowel syndrome, 2. intestinal bypass, 3. sepsis, 4. acute pancreatitis, 5. diuretics, 6. renal failure, 7. hypoMg, 8. rhabdo
46
EKG findings w/ hypocalcemia
1. Prolonged QT
47
What is Chvostek's sign
facial spasm when taping facial nerve *associated w/ hypocalcemia
48
What is Trousseau sign
wrist curls w/ BP taking? *associated w/ hypocalcemia
49
Treatment of hypocalcemia
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
what are normal magnesium values
1.8-3.0 mg/dL
51
Signs and sx of hypermagnesium
1. Resp failure, 2. CNS depression, 3. decreased DTRs
52
Causes of hypermagnesium
1. TPN 2. renal failure 3. IV magnesium 4. taking too many antacids or laxatives?
53
Tx of hypermagnesium
1. Calcium gluconate IV, 2. NS + furosemide 3. dialysis. 4. admit if symptomatic
54
EKG changes w/ hypermagnesium
*similar to hyperK 1. prolonged QT 2. wide QRS 3. peaked T waves 4. bradycardia
55
Signs and sx of hypomagensium
1. Increased DTRs, 2. tetany, 3. asterixis--wrist flapping motion 4. tremor, 5. Chvostek, 6. ventricular ectopy
56
causes of hypomagnesium
1. TPN, 2. decreased Ca, 3. renal failure, 4. diarrhea, vomiting, 5. gastric suctioning, 6. aminoglycosides 7. CHRONIC ALCOHOL ABUSE!
57
treatment of hypomagnesium
1. MgSO4 IV (acute) 2. Mg oxide PO (chronic) 3. admit if symptomatic
58
glucose emergencies are most commonly found in who
diabetics
59
Signs and sx of hypoglycemia
1. Altered mental status, 2. neurologic deficits, 3. seizures, 4. coma. Milder symptoms: 5. shakiness, 6. nausea, 7. sweats / clammy, 8. lightheadedness.
60
causes of hypoglycemia
1. Generally related to diabetes medications and change in diet / missed meal. 2. Infection, 3. endocrine disorders, 4. malnutrition, 5. drugs / alcohol.
61
treatment of hypoglycemia
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
what is considered hyperglycemia
>200 w/ sx
63
Signs and sx of hyperglycemia
1. Classically: 3 P’s: polyuria, polydypsia, polyphagia 2. Fatigue / weakness, 3. blurry vision, 4. dehydration, 5. lightheadedness, 6. headache.
64
causes of hyperglycemia
1. Infections, 2. medication non-compliance, 3. new diagnosis DM 4. MI
65
treatment of hyperglycemia
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
complicatoins of hyperglycemia
1. DKA | 2. HHS
67
“Most common acute life-threatening complication of diabetes.”
DKA
68
Deficiency of insulin --> hyperglycemia with the formation of ketoacids.
DKA more common w/ Type 1 than type 2
69
Signs and sx of DKA
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
causes of DKA
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
Lab findings for DKA
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) 3. pH < 7.3 4. Serum bicarbonate < 15 mEq / L (LOW) 5. Serum osmolality > 340 mOsm/kg 6. Anion gap > 10. [Na] – ([Cl] + [HCO3]) = anion gap
72
Work up of DKA
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
Treatment of DKA
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
how do you fluid resusitate w/ DKA
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
how do you replace electrolytes w/ DKA
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
What is HHS
- 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
What are predisposing factors for HHS?
generally the same as DKA but pt population often > 65.
78
Signs and sx of HHS
1. 3 P's 2. generalized weakness 3. confusion (to coma) 4. VERY dehydration (9L deficit) **NO ABDOMINAL PAIN (AS SEEN W/ DKA)
79
Lab findings of HHS
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
treatment of HHS
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
Describe the fluid resuscitation of HHS
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
What is an anion gap
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
what is a normal anion gap
8-16
84
diseases that have normal anion gap
HARDUPS: 1. Hyperalimentation (TPN) 2. Acetazolamide 3. Renal Tubular Acidosis 4. Diarrhea 5. Uretero-enteric fistula 6. Pancreatoduodenal fistula 7. Spironolactone
85
Causes of Elevated anion gap
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
Causes of respiratory acidosis
1. Hypoventilation** (pnemuothorax, pleural effusion, airway obstruction, parenchymal lung disease) 2. Drug intox.* 3. cardiac arrest* 4. COPD*
87
causes of respiratory alkalosis
1. HYPERventilation (anxiety, fever, pain) 2. asthma exacerbation 3. PE 4. high altitude 5. ASA over dose *resp. problem
88
Causes of metabolic acidosis
**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
causes of metabolic alkalosis
1. vomiting 2. diarrhea 3. NG suctioning **volume loss with chloride depletion
90
how to interpret an ABG
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
-If pH low and pCO2 high: ___ -If pH high and pCO2 low: ___ If pH low and HCO3 low: ___ If pH high and HCO3 high: ___
respiratory acidosis respiratory alkalosis metabolic acidosis metabolic alkalosis
92
___ excess: excess or insufficient amount of bicarbonate in the system.
Base
93
A negative base excess indicates a ___ in the blood.
base deficit
94
how do you document ABGs
pH/pCO2/pO2/HCO3/O2 Sat/BE

Emergency Medicine (22 decks)

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