Electrolyte Emergencies

Hyponatremia

Decreased serum sodiumDecreased serum sodium

Na+ <135 mEq/LNa+ <135 mEq/L

Hyponatremia CausesCauses

Loss of salt and waterLoss of salt and water DiureticsDiuretics Addison’s diseaseAddison’s disease Osmotic diuresis (DKA)Osmotic diuresis (DKA) VomitingVomiting DiarrheaDiarrhea DiaphoresisDiaphoresis

Hyponatremia CausesCauses

Increase in body water (dilutional Increase in body water (dilutional hyponatremia)hyponatremia) Excess water intake (water intoxication)Excess water intake (water intoxication) CHFCHF Renal failureRenal failure CirrhosisCirrhosis

Hyponatremia

Signs/SymptomsSigns/SymptomsLethargy, apathy secondary to Lethargy, apathy secondary to

cerebral edemacerebral edemaHeadacheHeadacheMuscle twitching, crampsMuscle twitching, crampsSeizures Seizures

NaNa++ < 110 mEq/L < 110 mEq/L

Hyponatremia

TreatmentTreatmentNS infused at a rate to restore normal NS infused at a rate to restore normal

sodium over 48 hourssodium over 48 hours

Hypernatremia

Elevated serum sodiumElevated serum sodium

NaNa+ + >150 mEq/L>150 mEq/L

Hypernatremia

CausesCausesPure water lossPure water loss

Diabetes insipidusDiabetes insipidusPure solute gainPure solute gain

NaHCONaHCO33 administration administration

Hypernatremia

CausesCausesWater loss > Solute lossWater loss > Solute loss

DiarrheaDiarrhea VomitingVomiting SweatingSweating Osmotic diuresisOsmotic diuresis

Hypernatremia Signs/SymptomsSigns/Symptoms

Irritability, restlessnessIrritability, restlessnessComaComaIntracranial hemorrhageIntracranial hemorrhageBlood sludging - thrombosisBlood sludging - thrombosisSeizuresSeizuresThirst, dry mucus membranes, poor skin Thirst, dry mucus membranes, poor skin

turgorturgor

Hypernatremia

TreatmentTreatmentInfusion of D5W (free water) to correct Infusion of D5W (free water) to correct

water deficit over 48 hourswater deficit over 48 hours

Hypokalemia

Decreased serum potassiumDecreased serum potassium

KK++ < 3.5 mEq/L < 3.5 mEq/L

Hypokalemia CausesCauses

Gastrointestinal lossesGastrointestinal losses DiarrheaDiarrhea VomitingVomiting NG suctionNG suction

Urinary lossesUrinary losses DiureticsDiuretics Osmotic diuresisOsmotic diuresis

Hypokalemia

CausesCausesIntracellular shiftsIntracellular shifts

AlkalosisAlkalosis agentsagents TheophyllineTheophylline

Inadequate intakeInadequate intake

Hypokalemia

Signs/SymptomsSigns/SymptomsWeakness, hyporeflexia, paresthesiasWeakness, hyporeflexia, paresthesiasDecreased GI motility Decreased GI motility Nausea, vomitingNausea, vomitingIncreased sensitivity to digitalisIncreased sensitivity to digitalis

Hypokalemia Signs/SymptomsSigns/Symptoms

EKG changesEKG changes Flat to inverted T wavesFlat to inverted T waves U wavesU waves ST segment depressionST segment depression

Cardiac arrhythmiasCardiac arrhythmias Ventricular ectopyVentricular ectopy V-FibV-Fib

Hypokalemia

TreatmentTreatmentCorrect underlying causeCorrect underlying cause10 mEq KCL IV over 1 hour, repeated 10 mEq KCL IV over 1 hour, repeated

until serum Kuntil serum K++ > 3.5 mEq/L > 3.5 mEq/L

Hyperkalemia

Elevated serum potassiumElevated serum potassium

KK++ > 5.5 mEq/L > 5.5 mEq/L

KK++ > 6 mEq/L - > 6 mEq/L - EmergencyEmergency

KK++ > 7 mEq/L - > 7 mEq/L - Life ThreatLife Threat

Hyperkalemia

CausesCausesDecreased excretionDecreased excretion

Renal failureRenal failure Addison’s diseaseAddison’s disease - blockers- blockers HyperglycemiaHyperglycemia AcidosisAcidosis

Hyperkalemia

CausesCausesIncreased intakeIncreased intake

Crush injury, burns, sepsisCrush injury, burns, sepsis Massive hemolysisMassive hemolysis Blood transfusionBlood transfusion High-dose penicillinHigh-dose penicillin Increased oral intakeIncreased oral intake

Hyperkalemia Signs/SymptomsSigns/Symptoms

Muscle weaknessMuscle weaknessNumbness, tinglingNumbness, tinglingEKG changesEKG changes

Tall, peaked T wavesTall, peaked T waves Broadening of QRS; decreased P wave sizeBroadening of QRS; decreased P wave size ““Sine wave” leading to V-Fib then asystoleSine wave” leading to V-Fib then asystole

Hyperkalemia

TreatmentTreatmentCalcium - 0.5 - 1.0g Calcium - 0.5 - 1.0g

Antagonizes cardiac toxicityAntagonizes cardiac toxicityNaHCONaHCO33 - 50 mEq - 50 mEq

Drives KDrives K++ into cells into cellsDD5050W (25g)/insulin (10 units regular)W (25g)/insulin (10 units regular)

Drives KDrives K++ into cells into cells

Hypocalcemia

Decreased serum calciumDecreased serum calcium

CaCa2+2+ < 8.5 mg/100ml < 8.5 mg/100ml

Hypocalcemia

CausesCausesHypoparathyroidismHypoparathyroidismVitamin D deficiencyVitamin D deficiencyDecreased dietary intakeDecreased dietary intakeAlkalosisAlkalosisMassive blood transfusionMassive blood transfusion

Citrate toxicityCitrate toxicity

Hypocalcemia Signs/SymptomsSigns/Symptoms

ParesthesiasParesthesiasHyperreflexia, carpopedal spasm, tetanyHyperreflexia, carpopedal spasm, tetanySeizuresSeizuresTrousseau’s sign:Trousseau’s sign:

Carpopedal spasm following BP cuff Carpopedal spasm following BP cuff compression of armcompression of arm

Hypocalcemia

Signs/SymptomsSigns/SymptomsChvostek’s signChvostek’s sign

Contraction of facial muscles when Contraction of facial muscles when face is tapped at angle of jawface is tapped at angle of jaw

LaryngospasmsLaryngospasmsProlonged QT intervalProlonged QT intervalIncreased ventricular irritabilityIncreased ventricular irritability

Hypocalcemia

ManagementManagementCalcium chlorideCalcium chloride

1g over 10 - 20 minutes1g over 10 - 20 minutesOverly rapid administration of calcium Overly rapid administration of calcium

can cause bradycardia, hypotension, can cause bradycardia, hypotension, and cardiac arrestand cardiac arrest

Hypercalcemia

Increased serum calciumIncreased serum calcium

CaCa2+2+ > 10.5 mg/100ml > 10.5 mg/100ml

Hypercalcemia

CausesCausesMalignanciesMalignancies

Skeletal, breast, lungsSkeletal, breast, lungsHyperparathyroidismHyperparathyroidismVitamin D toxicityVitamin D toxicityAddison’s diseaseAddison’s diseaseMilk/alkali syndromeMilk/alkali syndrome

Hypercalcemia

Signs/SymptomsSigns/SymptomsApathy, fatigue, depression, comaApathy, fatigue, depression, comaMuscle weaknessMuscle weaknessHypertensionHypertensionAnorexia, nausea, abdominal painAnorexia, nausea, abdominal pain

Hypercalcemia

Signs/SymptomsSigns/SymptomsKidney stonesKidney stonesShort QT interval, heart block, cardiac Short QT interval, heart block, cardiac

arrestarrest““Bones, Stones, Hypertones, Bones, Stones, Hypertones,

Abdominal moans”Abdominal moans”

Hypercalcemia

TreatmentTreatment1 - 2 liters NS over 1 hour1 - 2 liters NS over 1 hour

Decrease CaDecrease Ca2+2+ reabsorption reabsorptionFurosemide 40 mg IVFurosemide 40 mg IV

Inhibits CaInhibits Ca2+2+ reabsorption reabsorptionCalcitoninCalcitonin

Directly lowers CaDirectly lowers Ca2+2+