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Fluid and electrolytes

Fluid and electrolytes. Daily fluid requirements is 2-3 liters Insensible losses: respiratory tract (500 to 700 mL/d) the skin (250 to 350 mL/d), feces (100 mL/d). Fever increases requirements to 500 mL/d per 1°C (1.8°F) . hyponatremia. Na < 135 Due to water gain or Na loss

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Fluid and electrolytes

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  1. Fluid and electrolytes

  2. Daily fluid requirements is 2-3 liters • Insensible losses: • respiratory tract (500 to 700 mL/d) • the skin (250 to 350 mL/d), • feces (100 mL/d). • Fever increases requirements to 500 mL/d per 1°C (1.8°F)

  3. hyponatremia • Na < 135 • Due to water gain or Na loss • nausea, vomiting, anorexia, muscle cramps, confusion, and lethargy, and culminate ultimately in seizures and coma

  4. Hypertonic hyponatremia (Posm >295) Hyperglycemia • Mannitol excess • Glycerol therapy

  5. Isotonic (pseudo) hyponatremia (Posm 275–295)Hyperlipidemia • Hyperproteinemia (e.g., multiple myeloma, Waldenström macroglobulinemia)

  6. treatment • If hyponatremia is: • severe (<120 mEq/L) • develops rapidly (>0.5-mEq/L decrease in serum [Na+] per hour) • associated with coma or seizures • 3% hypertonic saline (25-100 cc) should be given • The rise in [Na+] should be no greater than 0.5 to 1.0 mEq/L per hour. • In the face of seizures, this can be increased to 1 to 2 mEq/L per hour

  7. Complications of therapy • central pontine myelinolysis • Worse in chronic hyponatremia • Occurs if hyponatremia is corrected too fast

  8. hypernatremia • Serum sodium of 150 mEq/L • Usually caused by decreased water intake but sometimes increased sodium intake

  9. Diabetes insipidus • Failure of central or peripheral ADH • Distinguish with vasopressin administration • Central responds well • Nephrogenic does not

  10. treatment • Cornerstone is volume replacement • The reduction in [Na+] should not exceed 10 to 15 mEq/L per day. • There is usually a total water deficiency in hypernatremia

  11. potassium • 70-75% found in muscle tissue • Foods high in potassium are baked potatoes, spinach, lima beans, dried prunes, tomatoes, and bananas. • 90% excreted by the kidneys

  12. hypokalemia • Serum K < 3.5 • A rise in the pH of 0.10 generally causes a 0.5 mEq/L decrease in serum [K+] • Most common causes • intracellular shifts • increased losses (GI) • Diuretic therapy

  13. Signs and symptoms

  14. treatment • Oral is ideal • Iv for severe hypokalemia • 10 mEq/hr in peripheral IV • No more than 40 mEq should be added to each liter of IV fluid, and infusion rates should be no greater than 40 mEq/h.

  15. hyperkalemia • Serum K > 5.5 • Main causes • Hemolysis • Acidosis • Renal failure • Potassium sparing diuretics • Rhabdo/crush injury

  16. EKG changes

  17. treatment • CaCl 5-10 mL IV • Ca gluconate 10-20 mL IV • Sodium bicarb 50-100 mEq IV • Insulin 10 units iv • One amp D50 iv • Albuterol breathing treatment • Kayexalate 25-50 g PO or PR • hemodialysis

  18. calcium • Most abundant mineral in body • PTH secreted by parathyroid gland in response to low Ca • Works via • Stimulates osteoclasts to increase bone absorption • Kidney (increases absorption) • Intestine (increases abdorption)

  19. calcium • Ionized calcium is active • 50 % is bound to plasma proteins (albumin) • A 1-gram decrease in albumin results in a 0.8 milligram/dL decrease in total calcium, with no change in ionized fraction

  20. hypocalcemia • Ionized calcium < 2.0 mEq/L • Common causes include shock, sepsis, renal failure, and pancreatitis • Also hypoparathyroidism and drugs (loops)

  21. Signs and symptoms

  22. Signs and symptoms

  23. Classic ekg finding is prolonged QT interval • Treatment • None or oral replacement if mild • Iv for severe hypocalcemia • Replace magnesium as well

  24. hypercalcemia • Serum calcium > 10.5 mg/dL • Causes • Malignancy and hyperparathyroidism (90%) • Drugs (lithium) • Paget’s disease of bone

  25. Signs and symptoms • stones (renal calculi) • bones (osteolysis) • moans (psychiatric disorders) • groans (peptic ulcer disease, pancreatitis, and constipation).

  26. Ekg findings • depressed ST segments • widened T waves • shortened ST segments and QT intervals • Treatment • Fluid replacement • Iv bisphosphonates • Pamindronate 90 mg IV over 24 hours • Calcitonin 4 units/kg SC

  27. hypomagnesiumemia • Causes: alcoholism, malnutrition, and those with cirrhosis, pancreatitis, or excessive GI fluid losses • Symptoms: Tetany, Muscle weakness, Cerebellar (ataxia, nystagmus, vertigo), Confusion, obtundation, coma, Seizures, Apathy,depression, Irritability, Paresthesias, Dysphagia, Anorexia, nausea, Heart Failure, Dysrhythmias, Hypotension, Hypokalemia, Hypocalcemia, Anemia

  28. Treatment • 50 mEq oral • Alcoholics and severe hypomagnesium may require 8-12 mg iv per day

  29. Hypermagnesiumemia • Rare in ED • Causes • Renal failure • lithium ingestion • volume depletion • familial hypocalciuric hypercalcemia

  30. references • Ch. 21 Tintinalli

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