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EM·IM Conference

EM·IM Conference. Seth Trueger, MD EM1 June 24, 2009. Greet. 61M called in by Rad Onc Na 110 at clinic Nausea & vomiting Fall today. Triage Note. Urgency: Level 2 Bed: North. 129/86 82 20 36.6 95% on RA. HPI. 61y male Throat & mouth cancer Resected pituitary adenoma

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EM·IM Conference

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  1. EM·IM Conference Seth Trueger, MD EM1 June 24, 2009

  2. Greet 61M called in by Rad Onc Na 110 at clinic Nausea & vomiting Fall today

  3. Triage Note Urgency: Level 2 Bed: North 129/86 82 20 36.6 95% on RA

  4. HPI 61y male Throat & mouth cancer Resected pituitary adenoma Hypothyroidism Radiation therapy x8 days Vomiting x8 days Seen in Rad Onc today, blood drawn, sent home

  5. HPI In shower, became dizzy, fell, hit head, no LOC Rad Onc blood draw: Na 110 Sent to ED Thirsty

  6. Exam Well appearing, comfortable, A+O x3 Very slow to answer questions (not baseline) Abrasion to back of head GCS is 15. No focal motor or sensory deficits CN 2-12 intact, no nystagmus Slow speech Slow mentation Confusion

  7. 100 75 6 • 3.5 22 0.9 89 Labs 14 13.2 231 40 Calcium 0.7 Magnesium 1.1 Venous pH 7.37 Lactate 0.5 Troponin 0.0 CXR Normal Head CT asymmetric sella

  8. Vent Rate 79 bpm PR interval 240 ms QRS duration 112 ms QT/QTc 436/499 ms P-R-T axes 38 1 38 Sinus rhythm with 1st degree AV block Prolonged QT Abnormal ECG

  9. Course Normal saline Zofran Serial electrolytes Hypertonic saline MICU Urine electrolytes Urine creatinine Cortisol TFTs

  10. Pseudohyponatremia Fat Protein (Sugar) New assays = no problem Marx, JA “Hyponatremia,” Rosen's Emergency Medicine

  11. Redistributive Hyponatremia Add 1.6 to Na for every 100 glucose over 100 Glu 400 Na 130 (400-100)/100=3 3 x 1.6 = 4.8 130 + 5 = 135 Marx, JA “Hyponatremia,” Rosen's Emergency Medicine

  12. Hyponatremia Water problem Osmolarity problem Marx, JA “Hyponatremia,” Rosen's Emergency Medicine

  13. Hyponatremia Water problem Osmolarity problem Marx, JA “Hyponatremia,” Rosen's Emergency Medicine

  14. Brain Edema Vasculature Marx, JA “Hyponatremia,” Rosen's Emergency Medicine

  15. Sequelae none Nausea, malaise Headache, lethargy Seizure, coma Respiratory arrest Noncardiogenic pulmonary edema Sodium 130 125 115 110 Rose, BD “Manifestations of hyponatremia and hypernatremia,” UpToDate

  16. Hormones Renin-Angiotensin-Aldosterone sodium Antidiuretic Hormone water Catecholamines Opiates Caffeine Stress Hypoglycemia Hypoxia Marx, JA “Hyponatremia,” Rosen's Emergency Medicine

  17. Treatment (Desired [Na+] – measured [Na+]) x (0.6) (weight in kilograms) = mEq [Na+] administered Marx, JA “Hyponatremia,” Rosen's Emergency Medicine

  18. Treatment Seizure Coma Ativan Hypertonic Saline Marx, JA “Hyponatremia,” Rosen's Emergency Medicine

  19. Hypertonic Saline 3% Sodium Chloride 1-2 mEq/hr 1-2 mL/kg/hr 4 mL/kg/hr 1.5 x 70 = 100 100 mL total over 1 hr 4 x 70 = 280 wide open until no seizure Henderson, KE. The Washington Manual Endocrinology Subspecialty Consult Andrews, BT. Intensive Care in Neurosurgery

  20. Math 1 Liter NS (154 – pt’s Na) / (1 + (0.5 x wt in kg)) 1 Liter 3 % (513 – pt’s Na) / (1 + (0.5 x weight)) Weingart, S. Post Conference Letter. February 19, 2003

  21. Work Up Urine Electrolytes Urine Creatinine Urine Osmolarity Serum Osmolarity Thyroid & Adrenal Marx, JA “Hyponatremia,” Rosen's Emergency Medicine

  22. Treatment Volume or Lasix 10-20 mg as appropriate Fluid Restriction Marx, JA “Hyponatremia,” Rosen's Emergency Medicine

  23. Drugs Tolvaptan (PO) Conivaptan (IV) Vasopressin-receptor antagonist Vasopressin = Antidiuretic Hormone Not ready for ED Rose, BD “Treatment of hyponatremia,” UpToDate

  24. Complication Dysarthria Dysphagia Paraparesis Quadriparesis Behavioral disturbances Lethargy Coma Seizures Osmotic demyelination (central pontine myelinolysis) Rose, BD “Treatment of hyponatremia,” UpToDate

  25. References Andrews, BT (2003). Intensive Care in Neurosurgery. New York, NY: Thieme New York. Henderson, KE (2008). The Washington Manual Endocrinology Subspecialty Consult. Saint Louis, MO: Lippincott Williams & Wilkins. Marx, JA (Ed.). (2006). Hyponatremia. In Rosen's Emergency Medicine: Concepts and Clinical Practice (6th ed.), Philadelphia, PA: Mosby, Inc. Rose, BD (June 10, 2008). Manifestations of hyponatremia and hypernatremia. In UpToDate [Web]. Waltham, MA: UpToDate, Inc. Retrieved June 10, 2009, from <http://utdol.com/online/content/topic.do?topicKey=fldlytes/10601> Rose, BD (May 12, 2008). Treatment of hyponatremia. In UpToDate [Web]. Waltham, MA: UpToDate, Inc. Retrieved June 10, 2009, from <http://www.uptodate.com/online/content/topic.do?topicKey=fldlytes/29369> Rose, BD (February 12, 2008). Treatment of hyponatremia: SIADH and reset osmostat. In UpToDate [Web]. Waltham, MA: UpToDate, Inc. Retrieved June 10, 2009, from <http://www.uptodate.com/online/content/topic.do?topicKey=fldlytes/31514> Weingart, S. Personal Communication. Post Conference Letter. February 19, 2003 Special Thanks Reuben Strayer Scott Weingart Jasmine Koita Nick Genes

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