SPECIAL RESUSCITATION SITUATIONS 特殊情況下的復甦術

致命的電解質異常 SPECIAL RESUSCITATION SITUATIONS特殊情況下的復甦術

40歲女性 Sudden collapse 經心臟電擊術後

40歲女性 12導程心電圖

40歲女性 血中鉀離子濃度過高 (K=7.0meq/L)

致命的電解質異常 • 造成心臟停止或降低急救成效 • 在檢驗數值出來前即採取急救措施 • 以高血鉀最易致命

高血鉀 • 血鉀> 5.0 mEq/L • pH  0.1 U  serum K+ 0.3 mEq/L

高血鉀原因 Drugs (K+-sparing diuretics, ACEI, NSAIDs, K supplements) ESRD Muscle breakdown (rhabdomyolysis) Metabolic acidosis Pseudohyperkalemia Hemolysis Tumor lysis syndrome Diet (rarely sole cause) Hypoaldosteronism (Addison disease, hyporeninemia) Type 4 renal tubular acidosis Other: hyperkalemic periodic paralysis

高血鉀 • 症狀:全身無力(由下肢往上漸進式發生) ，呼吸衰竭 • 心電圖變化 • T波變高 • P波變平 • PR延長 • QRS波變寬 • S波變深 • idioventricular rhythm • sine waves • VF、心跳停止

Hyperkalemia • Etiology – renal failure, transcellular shifts, cell death, drugs, pseudohyperkalemia • Manifestations – cardiac, neuromuscular

高血鉀症的症狀

Hyperkalemia • Treatment • Stop potassium! • Get an ECG • Hyperkalemia with ECG changes is a medical emergency

Hyperkalemia • Treatment • First phase is emergency treatment to counteract the effects of hyperkalemia • IV Calcium • Temporizing treatment to drive the potassium into the cells • glucose plus insulin • Beta2 agonist • NaHCO3 • Therapy directed at actual removal of potassium from the body • sodium polystyrene sulfonate (Kayexalate) • dialysis • Determine and correct the underlying cause

低血鉀 • 血鉀< 3.5 mEq/L • 原因 • 攝取減少 • 流失過多(腸胃道及腎臟為主) • 由細胞外移至細胞內

低血鉀 症狀: • 無力、疲累、麻痺 • 呼吸困難 • 便秘、麻痺性腸阻塞 • 小腿痙攣 • 肌肉崩解

低血鉀 心電圖變化 • U波 • T波變平 • ST改變 • 心律不整(服用digoxin者尤甚) • PEA or Asystole

低血鉀症的症狀 心率不整(Arrhythmia) • Atrial or ventricular tachyarrhythmia • Decreased amplitude of P wave • U wave. • Conjoined T-U wave: "camel's hump"

處置減少流失及補充鉀 • 心律不整或 K+ <2.5  IV K + • 最大量10-20 mEq/h + ECG • 心跳停止(VF/VT): • 2 mEq/min  10 mEq /5-10 min • 血鉀1mEq須補充150-400 mEq

高血鈉 • 血鈉 > 145 mEq/L • 症狀: 口渴、意識不清、無力、躁動、局部神經症狀、抽搐、昏迷

處置減少水份流失、補水 • 低血容:補生理食鹽水 • 缺水量 =體重 x 0.5 x (血鈉 - 140) /140 ♂體重 x 0.4 x (血鈉 - 140) /140 ♀ 70公斤男性，血鈉160，缺水量 ? L • 血鈉 0.5-1.0 mEq/h (< 12 / 24 hrs) • Daily supply: Water deficit x 10 / (血鈉 - 140) • Rate: Daily supply/24 + ongoing demand

低血鈉 • 血鈉 < 135 mEq/L • 症狀:急性或 <120 才有症狀噁心、嘔吐、頭痛、躁動、疲累、抽搐、昏迷或死亡

處置 • 補鈉排水 • SIADH: 限水 ( 50 - 66% ) • Na+ deficit= (desired [Na+] - current [Na+]) x 0.5x body wt (kg) (* 0.5 for men, 0.4 for women.) • 3% saline = 513 mEq Na+/L •  Na+ 0.5 -1/hr (max. 10-12/24h) • 補充太快 pontine myelinolysis

鎂 • Na, K, Ca之移動所必需低血鎂細胞內鉀無法補齊 • 穩定細胞膜作用: 可治療心律不整

高血鎂 • 血鎂 > 2.2 mEq/L • 最常見原因: 腎衰竭 • 其它原因: • 攝取過多 • 內臟破裂仍持續進食

高血鎂 • 神經症狀 : 肌無力、麻痺、運動失調、嗜睡、意識混亂 • 腸胃症狀:噁心、嘔吐 • 心血管症狀:血管擴張、緩脈、換氣不足、心肺停止

高血鎂 心電圖變化 • PR、 QT 延長 • QRS 變寬 • P波電位變小 • T波變高 • Complete AV block、Asystole

處置 • 補鈣離子 • CaCl2 ( 5 to 10 mEq IV ) 可避免致命性心律不整 • 移除血鎂 • 血液透析 • 腎及心血管功能正常 IV N /S + furosemide • 減少攝取

低血鎂 • 血鎂 < 1.3 mEq/L • 比高血鎂症常見 • 吸收減少、流失增加所致 • PTH或某些藥物 (eg, pentamidine, diuretics, alcohol) • 補乳婦女:高危險

低血鎂- 原因 • GI loss: bowel resection, pancreatitis, diarrhea • Renal disease • Starvation • Drugs: diuretics, pentamidine, gentamicin, digoxin • Alcohol • Hypothermia • Hypercalcemia • Diabetic ketoacidosis • Hyperthyroidism/hypothyroidism • Phosphate deficiency • Burns • Sepsis • Lactation

低血鎂- 症狀 • 肌肉震顫、束顫或強直 • 眼球震顫 • 意識改變、運動失調、眩暈、抽搐、吞嚥困難 • 低血鈣、低血鉀

低血鎂- 心電圖變化 • QT延長 • 末段T波倒置 • Heart blocks • VF

處置 • Severe or symptomatic hypoMg • 1 to 2 g IV MgSO4 over 15’ • Torsades de pointes • 2 g of MgSO4 over 1 - 2’ • Seizures • 2 g IV MgSO4 over 10’ • Calcium gluconate (1 g) • 大部分有 hypoCa • 腎功能不全者小心補

鈣 • 1/2 Ca in the ECF: bound to alb • Alkalosis: Ca-alb binding  Ca2+ Acidosis  Ca2+ • serum alb  1 g/dL  total serum Ca  0.8 mg/dL (Ca = Serum Ca + 0.8 * (4 - Albumin)) • In hypoalb., Ca2+ may be normal • Ca antagonizes K and Mg at the cell mem. • Ca regulated by PTH and vit. D

高血鈣 • serum Ca > 10.5 mEq/L or Ca2+ > 4.8 mg/dL • Primary hyperparathyroidism and malignancy account for >90% cases.

高血鈣 -症狀 Total serum Ca ≧12 to 15 mg/dL • Neuro. S/S: • depression, weakness, fatigue, ,confusion (at lower levels) • hallucination, disorientation, hypotonicity, coma (at higher levels) • Renal concentration of urine

高血鈣 -症狀 • CV S/S: variable • < 15 to 20 : myocardial contractility  > 15 to 20 : myocardial depression • Automaticity and ventricular systole is shortened • Arrhythmias ( refractory period  ) • Digitalis toxicity is worsened • Hypertension • Many patients with hyperCa develop hypoK

高血鈣 -症狀 • GI S/S: • dysphagia • constipation • peptic ulcers • pancreatitis • Renal S/S: ability to concentrate urine  • dehydration • diuresis (loss of Na, K, Mg, and P vicious circle of Ca reabsorption)

高血鈣 -心電圖變化 • QT變短 • PR and QRS 延長 • QRS voltage 變大 • T-wave變平、變寬 • Notching of QRS • AV block

處置 Symptomatic or >15 mg/dL • NS at 300 to 500 mL/h --維持尿量200 to 300 mL/h • After adequate rehydration: NS at 100 to 200 mL/h • Closely monitor K & Mg • Heart F. or Renal I.: hemodialysis • Extreme conditions: chelating agents • PO4 50 mmol/8-12 h or • EDTA 10 to 50 mg/kg/4 h

處置(II) • Lasix (1 mg/kg IV) • controversial • heart failure: required •  reuptake of Ca from bone • Reduce bone resorption • calcitonin • Glucocorticoids (prednisolone 20~40 mg/day)

低血鈣 • serum Ca < 8.5 mEq/L or Ca2+ < 4.2 mg/dL • Causes: • toxic shock syndrome • abnormalities in Mg • tumor lysis syndrome • rapid cell turnover • hyperK, hyperP, and hypoCa

低血鈣 - 症狀 Occur when Ca2+ < 2.5 mg/dL • Paraesthesia • Muscle cramps, carpopedal spasm • Stridor • Tetany • Seizures • Hyperreflexia • Chvostek and Trousseau signs • Cardiac contractility, heart failure

處置急性，有症狀 • 10% Ca gluconate IV 10’ IV drip 0.5 to 2.0 mg/kg/hr in D5W • 檢測血鈣 Q4-6H • 維持血鈣7-9 mg/dL • 矯正Mg, K, and pH

SPECIAL RESUSCITATION SITUATIONS 特殊情況下的復甦術