ER- fluids + electrolytes

normal values

-sodium

-potassium

-magnesium

-calcium

-bicarb

sodium- 135-145

potassium- 3.5-5

magnesium- 1.5-2.5

calcium- 8.5-10.5

bicarb- 22-32 (or 28 or 26 depending on what slide u look at)

order to correct disturbances (electrolytes, volume, and pH)

1- volume

2- pH

3- electrolytes

what fluid to rehydrate with?

LR or NS

risk of too much NS?

hyperchloremic metabolic acidosis

what fluid for maintenance?

D5 1/2 NS (+/- K)

which fluid can not be used with blood products?

LR

BP correlated with volume status (T/F)

false?

sodium does not contribute much to sodium osmolarity (T/F)

false- it is a major contributor

what 3 structures control sodium

-kidneys (excretion/reabsorption)

-posterior pituitary (via ADH)

-hypothalamus (thirst center)

pathophys of hyponatremia

water shifts across BBB into CNS

what if we correct hyponatremia too quickly?

osmotic demyelination syndrome (central pontine myelinolysis)

kids are (more/less) sensitive to osmotic demyelination syndrome

more

s/s of osmotic demyelination syndrome

bulbar dysfunction, quadriparesis, delirium, death

mc cause of hyponatremia?

hemodilution- water retention

what will cause pseudohyponatremia

-high lipids

-high proteins

-high blood sugar

-mannitol

normal serum osmo

275-295

causes of hyperosmolar hyponatremia

severe hyperglycemia

**us MD calc for corrected soidum value

an increase in glucose of 100mg decreases sodium by ___

1.6

pathophys of why high glucose causes low sodium

lots of glucose in ECF draws water out and causes dilution

causes of iso-osmolar hyponatremia

hyperproteinemia, hyperlipidemia

causes of hypovolemic hypoosmolar hyponatremia

-GI losses

-3rd spacing

-diuretic use

-adrenal insufficiency

causes of euvolemic hypoosmolar hyponatremia

SIADH

causes of hypervolemic hyposmolar hyponatremia

-CHF

-renal failure

-nephrotic syndrome

-cirrhosis

(think fluid overload)

which type of hyponatremia is true hyponatremia

hypoosmolar hyponatremia

s/s of hyponatremia

-seizures !!!!

-intractable vomitting

-coma

-confusion

-cardio arrest

Tx of severe hyponatremia

3% saline in 100ml bonus

goal of tx severe hyponatremia

raise by 5 in 1-2hr

tx of nonsevere hyponatrema

.9% NS

causes of hypovolemic hypernatremia

water loss-> vomitting/diarrhea/sweating/burns

causes of isovolemic hypernatremia

diabetes insipidus

causes of hypervolemic hypernatremia

too much salt-> via hypertonic saline/sodium bicarb

s/s of hypernatremia

-ataxia (cerebellar dysfunction)

-increased thirst

-seizure/coma

what pt population is at highest risk of hypernatremia?

lack of access to free water-> elderly, infants, debilitated

Tx of hypernatremia

isotonic saline switched to 1/2 NS or D5W

goal of tx of hypernatremia

-UOP >0.5/ml/kg/hr

-decrease sodium by .5/hr

when treating hypernatremia, avoid decreasing soidum by more than _____ in _______

10 in 24hr

Tx of diabetes insipidus

desmopressin

when potassium is messed up, always check which lab and why

-mg

-mg and K are co-transporters

causes of hypokalemia (excluding drugs)

-chronic alcoholics

-GI losses

-metabolic alkalosis

drugs that can cause hypokalemia

-K wasting diuretics (ex. furosemide)

-insulin

-albuterol

EKG changes in hypokalemia

-U waves !!!

-T wave flattening

-ST prolongation

tx of hypokalemia 2.5-3.5

20-40mg PO potassium

+mg

____mg of PO potassium increases serum potassium by _____

10, 0.1

Tx of hypokalemia <2.5 OR symptomatic

IV potassium, max 40mg/hr

+ mg

when giving IV potassium, a patient must be on what?

heart monitor if over 20mg/hr IV !!!!!!!

SE of IV potassium

tissue burning/phlebitis

a patient can get a one time dose of potassium for hypokalemia tx (T/F)

false- need multiple doses to replace

when can you discharge a hypokalemic pt?

K >2.9 and asymptomatic or only mildly symptomatic, can discharge after repletion

mcc of hyperkalemia

hemolysis

other causes of hyperkalemia

-renal failure/missed dialysis

-rhabdo

-aldoseryome deficiency

drugs that can cause hyeprkalemia

-spironolactone

-ACE/ARB

s/s of hyperkalemia

-muscle weakness

-paresthesias / paralysis

-metabolic acidosis

EKG changes of hyperkelmia

-peaks T waves

-wide QRS

-prolonged PR

when treating hyperkalemia, always give ______ first. why?

calcum- stabilize cardiac membrane

how to remove potassium from body

dialysis or kayexelate/lokelma

tx of hyperkalemia 5.5-6.5

-bolus lasix with NS

-kayexelate/lokelma

Tx of hyperkalemia 6.5-7.5

1) 1 amp D50

2) 5-10u insulin

-albuterol/bicarb

-lokelma/kayexalate

tx of hyperkalema >7.5

everything. calcium, albuterol, insulin/D50, bicarb, nephro, admit

when you get a lab back and it shows hyperkalemia, always what?

recheck level!!

Mg is in chem panel (T/F)

false

causes of hypomagnesemia

-alcoholism

-pancreatitis

-refeeding syndrome

-PPI/loops

s/s of hypomagnesemia

-increased DTR/tetany (stiff)

-seizures

-muscle weakness/confusion

tx of hypomagenesmia 1.2-1.5

PO mg 400mg, multiple doses

SE of mg tx

makes you poop

tx of hypomagenesmia <1.2

2g IV mg

causes of hypermagnesemia

-lithium

-renal failure

-rhabdo

-tumor lysis

-Tx of preeclampsia

s/s of hypermagnesemia

-somnolence

-decreased DTRs (floppy)

-respiratory depression !!!!

Tx of hypermagnesemia

NS + lasix

tx of severe hypermagnesmia

NS + lasix + IV calcum chloride

how does PTH impact calcium

increases

how does calcitonin impact calcium

decreases

what defines true hypocalcemia

<2 ionized

causes of hypocalcemia

-sepsis/shock

-rhabdo

-pancreatitis/alcoholism

-hypoparathyroidism

-high phosphate

-vit D deficiency

-malignancy

s/s of hypocalcemia

-increased DTRs (stiff)

-chovstek's/trosseaus signs

-paresthesias (circumoral/fingers)

-cramps/seizures

EKG changes of hypocalecmia

QT prolongation

tx of asymptomatic hypocalcemia

PO calcium 1-4g PO Q6hr

+mg

Tx of symptomatic hypocalcemia

IV calcium

+mg

causes of hypercalcemia

malignancy or hyperparathyroidism!!! call their oncologist

s/s of hypercalcemia

bone pain, stones, abd pain, psychic moans

if _________ lab is low, hypercalcemia level needs to be corrected via MD calc

albumin

hypercalcemia EKG changes

short QT

Tx of hypercalcemia

-fluids

-lasix 40mg IV

-steroids

-calcitonin/bisphosphonates

when to admit hypercalcemia

-12-14 with sx

->14

what is Co2 on a venous blood draw?

bicarb

normal values on ABG

pH- 7.35-7.45

CO2- 35-45

HCO3- 22-28

MUDPILES for anion gap metabolic acidosis

-Methanol

-Uremia

-Diabetic ketoacidosis

-Propylene glyco

- Isoniazid

- Lactic acidosis

-Ethylene glycol

-Salicylates

3 up 3 down metabolic acidosis

up-> anion gap, RR, potassium

down-> pH, CO2, Bicarb

Tx of dka

-insulin

-fluids

-glucose