Transcript UPMC Interesting Cases

Hypokalemia-causes
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Decreased K intake
– Low calorie diets – rare
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Increased K entry into cells
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Alkalosis
Increased insulin
Increased Catecholamines
Channelopathies
Increased RBC production
Hypothermia
Chlorquine intox
Hypokalemia
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Increased GI losses
– Vomiting, Diarrhea, NG tube, laxatives
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Increased Urinary losses
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Diuretics
Mineralocorticoid excess
Nonreabsorbable ions
Metabolic acidosis
HypoMg
Nephropathies
Ampho B
Polyuria
Licorice
Hypokalemia
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Increased Sweat Losses
Dialysis
Plasmaphoresis
Presentation
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Neuro muscular K 2-2.5
– Weakness prox > distal, loss of reflexes
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Cardiac
– Arrhythmias
– EKG
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Hyper
U waves, prolonged QT, small T wave
K+
K+ + K+
K +
K+
K K+
K+ K+
T wave
Hypo
K+
Familial Periodic Paralysis
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Types
– Hyper Kalemic – HyperPP
– Hypo Kalemic – HypoPP
– Thyrotoxic- TPP
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Genetic mutation
– Autosomal dominant and sporadic
Channelopathies
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Inability to find a decent TV program
despite having cable and 150
channels to chose from.
Functional disturbances of ion
channels in the cell membrane
– “Flaccid muscle weakness
due to under excitability of
sarcolemma.”
HypoPP
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Rare, potentially fatal episodes of
muscle weakness
– Asian population
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Acute attacks due to K+ moving into
cells
Precipitated by exercise, carbs, stress
K level
– Low
– Normal* (low K + Rhabdo)
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Often self limiting
Treating K problems
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ABCs
IV – O2 – Monitor
Stat labs
Check Mg, CPK, TFTs
Oral K is good for non life threatening
hypoK
– Watch N/V
– Use PO KCl if hypo K is due to loss of Cl
HypoPP - Rx
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Administer K+
– 10-20meq/hr IV (Higher via central line if
severe)
– 40-60meq PO x2
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Check the K+ q 15-30min
Rx thyrotoxicosis w/ propanolol
HypoPP - Discharge
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Daily oral K does not prevent attacks
Carbonic anhydrase inhibitorsAcetozolamide
Low carb diet
Consult/referral
Caveats – K problems
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1meq decrease in K represents
300meq deficit*
– If hypo K is due to loss
– Remember, 98% of K is in the ICF
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0.1 drop in pH raises K by 0.6
– Think of acid/base problems
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Is this primary or secondary problem?
Dangers in Rx PP
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Check the type before starting K
– Must confirm if hypo, hyper or nl
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Remember this is a cellular shift
– Rebound hyper K can occur if you are too
aggressive w/ K replacement
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Watch for respiratory insufficiency
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MUDPILES
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Methanol/Ethylene glycol
– Certainly possible
– Pt denied
– No visual sx
– No Ca oxalate xtals
– Woods lamp
– Osm gap
MUDPILES
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Uremia
– BUN/Creat OK
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DKA
– Not a diabetic, Glucose OK
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Paraldahyde
– No pungent odor
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Isoniazid
– No hx TB Rx
MUDPILES
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Lactic Acidosis
– Abd pain -> dead gut
– Decreased perfusion
– Liver failure
– Alcohols
– Meds
– Inborn errors
– Lactate -> 27
MUDPILES
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Ethanol - Alcohol Ketoacidosis
– Binge drinker, Not eating
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Salicylates
– No Hx of ASA use
Hospital Course
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Developed DTs
+ C. Dif culture
Feeding tube placed
acute alcoholic hepatitis and severe
dehydration and metabolic disarray
with severe hypokalemia,
hypophosphatemia, hypomagnesemia,
acute renal failure, lactic acidosis,
Alcohol ketoacidosis
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Uncommon, often missed
Binge drinkers
AKA - 3 factors
1. Alcohol intake
2. Decreased caloric intake
3. Volume depletion
Results in starvation physiology
AKA
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Decreased caloric intake
– Counter regulatory hormone release
– Epinephrine, cortisol, growth hormone
– Elevated glucagon, decreased insulin
– Promotes lipolysis and fatty acid
mobilization
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Volume depletion
– Elevated glucagon, decreased insulin
AKA
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Alcohol intake
– Oxidation of ETOH-> ->acetate
– NAD->NADH which raises glucagon,
decreases insulin
– Promotes betahydoxybutyrate vs
acetoacetate
– Decreased gluconeogenisis
AKA
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Symptoms
– N, V, abd pain
– Dyspnea, tremulousness
– Muscle pain, fever, diarrhea, syncope, Sz
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Physical
– Tacycardia, tachypnea, abdominal pain,
– Hepatomegaly, hypotension
AKA
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Differential Dx
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Cholecystitis
Peptic ulcer, gastritis
Mesenteric ischemia
Pacreatitis
Withdrawal syndromes
Metabolic acidosis
DKA
Methanol, Ethylene glycol
AKA - labs
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pH –low, high or nl
– Metabolic acidosis -> ketones
– Metabolic alkalosis -> vomiting
– Respiratory alkalosis -> hyperventilation
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Serum ketones low, high or nl
– Betahydoxybutyrate
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Lytes –abnormal
Lactate – mildly elevated
AKA-treatment
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Volume replace
Carbohydrate replacement
– D5NS
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Fix electrolyte abnormalities
– K, Mg, acidosis
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Address associated problems
– Withdrawal, Wernikes, GI bleed, hepatitis,
pancreatitis, pneumonia, rhabdo, etc.
I have never been lost, but I
will admit to being confused
for several weeks.