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Common Electrolyte Abnormalities in Emergency Medicine

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Common Electrolyte Abnormalities in Emergency Medicine

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Common Electrolyte Abnormalities in Emergency Medicine

  1. 1. COMMON ELECTROLYTE ABNORMALITIES IN EMERGENCY MEDICINE Tim Martin Dec 2016
  2. 2. AIMS AND OBJECTIVES To discuss the investigation and diagnosis of common electrolyte abnormalities Specifically focusing on hyponatraemia and a way to subdivide causes To become familiar with emergency management of these conditions
  3. 3. SODIUM Main extracellular electrolyte Distributed in the extracellular fluid which accounts for 20% total body weight and 33% total body water Sodium concentrations mEq/L: • Plasma 142 • Normal saline 154 • Hartmann’s 130
  4. 4. HYPONATRAEMIA Serum sodium below 130mEq/L Moderate symptoms < 130 : Headache, confusion, agitation Severe symptoms < 120 : Intractable seizures, vomiting, coma Mortality due to cerebral oedema and brainstem herniation
  5. 5. ASSESSMENT Clinical fluid status Urine and plasma osmolality Calculated osmolality = 2 x (Na + K) + Glucose + Urea Urine sodium
  6. 6. 61 year old male referred in from GP with Sodium 121 on routine blood tests Repeat blood checked - sample as shown What specific management does this patient require?
  7. 7. PSEUDOHYPONATRAEMIA Occurs with severe hyperproteinaemia or hyperlipidaemia Analytical error due to water displacement in sample Some laboratories may be able to correct value No treatment required for sodium, GP to review lipid profile please!
  8. 8. HYPEROSMOLAR HYPONATRAEMIA - >295 Similar phenomenon with hyperglycaemia Corrected Sodium = Sodium + (Glucose - 5)/4 Hyponatraemia occurs due to osmotic diuresis including mannitol use Correct with saline
  9. 9. HYPO-OSMOLAR HYPONATRAEMIA < 275 Hypovolaemic Normovolaemic Hypervolaemic
  10. 10. Hypovolaemic hyponatraemia - Loosing sodium in excess to wate PRE RENAL RENAL LOSS Third space loss Sweating/vomiting/diarrhoea Addison’s Diuretic phase of renal failure Renal tubular acidosis Thiazide diuretics
  11. 11. Normovolaemic hyponatraemia URINE OSMOLALITY < SERUM OSMOLALITY URINE OSMOLALITY > SERUM OSMOLALITY Tea and toast diet Psychogenic polydipsia Iatrogenic Amphetamine use Exercise induced - hypotonic fluid ingestion SIADH
  12. 12. SYNDROME OF INAPPROPRIATE ADH SECRETION Precipitated by malignancy (ectopic ADH in small cell lung cancer), head injury/intracerebral infection, medications (cyclophosphamide, carbamazepine, SSRIs, amiodarone) Hypotonic hyponatraemia Urine osmolality > serum osmolality Urine Sodium > 20mmol Euvolaemia clinically Normal adrenal, renal, cardiac, hepatic and thyroid function
  13. 13. Treatment includes: Fluid restriction Vasopressin antagonists eg tolvaptan Demeclocycline and lithium
  14. 14. Hypervolaemic - Oedematous state Congestive cardiac failure, liver cirrhosis, nephrotic syndrome Treated with fluid restriction In CCF consideration loop diuresis and or vasopressin antagonist eg tolvaptan
  15. 15. EMERGENCY MANAGEMENT HYPONATRAEMIA - SEIZURES Target a sodium of 125 3ml/kg of 3% sodium chloride will raise sodium by 3 OR 100ml 3% sodium chloride over 10-15 minutes repeated unto a total of 300ml based on clinical symptoms Limit sodium increase to 8mEq/L in first 24 hours
  16. 16. 3 days post admission for hyponatraemia, corrected with hypertonic saline in intensive care patient stepped down to ward Over next day develops dysarthria, dysphagia and a bulbar palsy What complication has occurred?
  17. 17. 2 weeks post total thyroidectomy a 60 year old man presents with cramping in hands and feet Surgical note state 2 parathyroid glands spared When blood pressure checked his left wrist painfully contracts What is the most likely underlying problem? Miller-Keane Encyclopedia and Dictionary of Medicine, Nursing, and Allied Health, Seventh Edition. © 2003 by Saunders, an imprint of Elsevier, Inc
  18. 18. HYPOCALCAEMIA Ionised calcium less than < 2 Most body calcium bound in bone Ionised calcium (50%) is the active form compared with protein bound (40%) and complex calcium (10%) PTH secreted in response to hypoclacaemia and is influenced by vitamin D and magnesium PTH increases osteoclast activity as well as inducing calcium reabsorption in the kidney and vitamin D synthesis
  19. 19. CLINICAL SIGNS AND COMPLICATIONS Chvostek sign and Trousseau sign https://www.youtube.com/watch?v=6jFwxawwcbg https://www.youtube.com/watch?v=2quH8gvtEAw Spasms and cramps Arrhythmias and Torsade de Pointes Hallucinations and seizures
  20. 20. INVESTIGATIONS Total and ionised calcium, PTH level, Vitamin D, Magnesium, Albumin level, Renal function and electrolytes ECG - prolonged QTc, T wave changes resembling ischaemia
  21. 21. TREATMENT Oral replacement 500 - 3000mg elemental calcium/day IV calcium chloride (10ml of 10%) vs calcium gluconate (10- 30ml of 10%) Caution if concurrent digoxin use
  22. 22. 75 year old lady presents short of breath ?COPD, crackles all over chest ? Ischaemic ECG
  23. 23. VBG shows a new creatinine of 750 and a potassium of 7.9
  24. 24. MANAGEMENT OF HYPERKALAEMIA Cessation of nephrotoxic agents and potassium sparing diuretics Enhanced elimination - fluids, diuretics, binding agents, dialysis Membrane stabilisation with constant ECG monitoring - Calcium (gluconate vs chloride again) Moving potassium intracellularly - Salbutamol nebulisers, 10 units ActRapid insulin in 50mls 50% dextrose, Sodium bicarbonate (if patient acidotic)
  25. 25. Tintinalli’s Emergency Medicine 8th edition. Tintinalli et al Oxford Handbook Emergency Medicine 7th edition. Longmore et al Textbook of Adult Emergency Medicine 4th edition. Cameron et al Life in the Fast Lane

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