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When Do I Order What?. Bucky Boaz, ARNP-C. Criteria for Detecting Electrolyte Abnormalities in ED Patients. Poor oral intake Vomiting Hypertension, diuretic use Age > 65 Recent Seizure Muscle Weakness Alcohol abuse Altered mental status Recent abnormal electrolytes.
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When Do I Order What? Bucky Boaz, ARNP-C
Criteria for Detecting Electrolyte Abnormalities in ED Patients • Poor oral intake • Vomiting • Hypertension, diuretic use • Age > 65 • Recent Seizure • Muscle Weakness • Alcohol abuse • Altered mental status • Recent abnormal electrolytes
Electrolyte Disorders • Calcium • Magnesium • Potassium • Sodium
Normal range: 8.5-10.5 mg/dL Panic! <6.5 or >13.5 mg/dL Marbled top Serum calcium is the sum of ionized calcium plus complexed calcium and calcium bound to proteins (albumin) Level of ionized calcium is regulated by parathyroid hormone and vit D. Calcium
Hypoparathyroidism Vitamin D deficiency Renal insufficiency Pseudohypo-parathyroidism Magnesium deficiency Hypophosphatemia Massive transfusion hypoalbuminemia Hypocalcemia
Hyperparathyroidism Malignancies secreting parathyroid hormone-related protein (PTHrP) squamous cell of lung Renal cell carcinoma Leukemia Vitamin D excess Multiple myeloma Paget’s disease Sarcoidosis Vitamin A intoxication Thyrotoxicosis Addison’s disease Drugs Antacids, Calcium salts, Diuretic use, Lithium Hypercalcemia
Calcium • Need to know serum albumin to know corrected calcium level. • For every decrease in albumin by 1 md.dl, calcium should be corrected upward by 0.8mg/dL. • Serum PTH level should be measured at initial presentation of all hypercalcemic patients
Normal range: 1.8-3.0 mg/dL Panic! <0.5 or 4.5 mg/dL Marbled top Concentration is determined by intestinal absorption, renal excretion, and exchange with bone and intracellular fluid Magnesium
Chronic diarrhea Enteric fistula Starvation Chronic alcholism Hypoparathyroidism Acute pancreatitis Chronic glomerulonephritis Diabetic ketoacidosis Drugs Albuterol Amphotericin B Calcium salts Cisplatin Cyclosporin Diuretics Hypomagnesium
Hypomagnesemia • (<1.5 mEq/L) • Due to diuretics, aminoglycosides, cyclosporine. • Clinical features: • Irritable muscle,tetany,seizure,arrhythmia. • Treat: • MgSO4 25-50 mg/kg IV over 20 min.
Dehydration Tissue trauma Renal failure Hypothyroidism Drugs Aspirin (prolonged use) Lithium Magnesium salts Progesterone Triamterene Hypermagnesium
Hypermagnesemia • (>2.2 mEq/L) • Due to renal failure, excess maternal Mg supplement, or overuse of Mg-containing medicine. • Clinical features: • weakness, hyporeflexia, paralysis, and ECG with AV block & QT prolongation. • Treat: • CaCl (10%) 0.2-0.3 ml/kg (max 5 ml) IV.
Normal range: 3.5-5.0 mg/dL Panic! <3.0 or >6.0 mg/dL Marbled top Predominately an intracellular cation whose plasma level is regulated by renal excretion. Plasma concentration determines neuromuscular irritability Potassium
Hypokalemia • Clinical Features of Hypokalemia • Lethargy, confusion, weakness • Areflexia, difficult respirations • Autonomic instability, Low BP • ECG findings in Hypokalemia • K+ <3.0 mEq/L: low voltage QRS, • flat T waves, ST segment, • prominent P and U waves. • K+ = 2.5 mEq/L: prominent U wave • K+ = 2.0 mEq/L: widened QRS
Hyperkalemia • Causes of Hyperkalemia • Exogenous: • blood • Salt substitutes • K+ containing drugs (e.g. penicillinderivatives) • Acute digoxin toxicity • Beta blockers, ACE inhibitors • Succinylcholine • Non-steroidals
Hyperkalemia • Endogenous: • Acidemia • Trauma • Burns • Rhabdomyolysis • DIC • Sickle cell crisis • GI bleed • Chemotherapy (destroying tumor mass) • Mineralocorticoid deficiency • Congenital defects (21 hydroxylase deficiency)
Hyperkalemia • K+ 5-6.0: peak T waves • K+ 6-6.5:PR and QT intervals • K+ 6.5-7:P, ST segments • K+ 7-7.5:intraventricular conduction • K+ 7.5-8:QRS widens, ST and T waves merge • K+ > 10: sine wave appearance
Normal range: 135-145 mg/dL Panic! <125 or >155 mg/dL Marbled top Predominately an extracellular cation. Serum sodium level is primarily determined by the volume status of the individual. Sodium
Hyponatremia • Symptoms • Lethargy, apathy • Depressed reflexes • Muscle cramps • Pseudobulbar palsies • Cerebral edema • Seizures • Hypothermia
CHF Cirrhosis Vomiting Diarrhea Excessive sweating (replacing water, but not salt) Salt-loss nephropathy Adrenal insufficiency Water intoxication SIADH Drugs Thiazides Diuretics ACE Inhibitors Chlorpropamide Carbamazepine Hyponatremia
Hypernatremia • Symptoms • Lethargy, irritability, coma • Seizures • Spasticity, hyperreflexia • Doughy skin • Late preservation of intravascular • volume (and vital signs)
Dehydration (excessive sweating, vomiting, diarrhea) Polyuria (diabetes mellitus, diabetes insipidus) Hyperaldosteronism Inadequate water intake (coma, hypothalmic disease) Drugs Steroids Licorice Oral contraceptives Hypernatremia
Endocrine Disorders • Hyperthyroidism/ Thyroid Storm • Hypothyroidism/ Myxedema Coma
Underlying Thyroid Disease Grave’s Disease (#1) Toxic nodular goiter Toxic adenoma Factitious thyrotoxicosis Excess TSH Precipitants Infection (#1) Pulmonary embolus DKA or HHNC Thyroid hormone excess Iodine therapy/dye Stroke, surgery Childbirth, D&C Hyperthyroidism/Thyroid Storm
Hyperkinesis Palpable goiter Proptosis, lid lag Exopthalmus, palsy Temp > 101 F HR + Pulse pressure Arrhythmia (new onset) Weight Loss Palpitations Dyspnea Psychosis Apathy Coma Tremor Hyperreflexia Diarrhea Jaundice Clinical Features of Hyperthyroidism/Thyroid Storm
free T4 T3 TSH T4RIA FT4I Glucose Ca+2 WBC Hb Cholesterol Lab test can diagnose hyperthyroid, but Thyroid Storm (Thyrotixicosis) is a clinical diagnosis Laboratory Findings Hyperthyroidism/Thyroid Storm
Precipitants Pneumonia GI bleed CHF Cold exposure Stroke Trauma pO2 CO2 Na+ Drugs Phenothiazides Narcotics Sedatives Phenytoin propanolol Hypothyroidism/Myxedema Coma
Serum TSH > 60 U/ml Total & free T4 or total & free T3 Laboratory Findings of Hypothyroidism/Myxedema Coma
Liver Disease Laboratory Findings in Liver Disease
Stroke, TIA, and Subarachnoid Hemorrhage • CT Scan abnormal > 95% if onset < 12h • CT Scan abnormal 77% if onset > 12h • CSF > 100,000 RBCs/mm3 (mean) although any # can be seen • Xanthochromia • ECG = peaked, deep, or inverted T waves, QT, or large U wave
Imaging Low Back Pain • Acute neuro deficit consistent • Acute significant trauma • Age > 70, or minor trauma > 50 years • History of prolonged steroid use OR osteoperosis • History of cancer OR unexplained wt loss • History of recent infection OR fever > 100 F OR parental drug abuse • LBP worse at rest OR disability due to LBP > 4 weeks
Clinically Significant CXR Abnormalities SOBreath Criteria 95% sensitive, 40% specificity
Abdominal Pain Diagnostic Studies in Appendicitis
Biliary Tract Disease • Clinical Features of Biliary Colic • Pain usually begins 30-60 min after meal • Pain duration < 6-8 hrs • Absence of fever • WBC < 11,000 cell/mm3 in most • Normal liver function tests in 98% • Absence of pancreatitis • US is 98% sensitive for gallstones
Biliary Tract Disease Clinical Features Acute Cholecystitis
Pancreatitis • Suspect abscess, hemorrhage, or pseudocyst if fever, persistent amylase, bilirubin, WBC. • US – 60-80% sensitive, 95% specific • CT – 90% sensitive, 100% specific • Obtain CT or US if suspected pseudocyst, abscess, gallstones, or trauma