Transcript orientation(1)

SPECIAL RESUSCITATION SITUATIONS
特殊情況下的復甦術
致命的電解質異常
1
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
5
高血鉀
 血鉀 > 5.0 mEq/L
 pH  0.1 U
 serum K+  0.3 mEq/L
6
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
7
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
8
Hyperkalemia
 Etiology – renal failure,
transcellular shifts, cell
death, drugs,
pseudohyperkalemia
 Manifestations –
cardiac, neuromuscular
9
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
13
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
14
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
15
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
17
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
18
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
19
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
20
處置
 補鈉排水
 SIADH: 限水 ( 50 - 66% )
 Na+ deficit= (desired [Na+] - current [Na+])
x 0.5 x 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
21
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
22
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
23
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
24
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
25
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
26
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
27
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
28
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
29
低血鎂 - 心電圖變化
 QT延長
 末段T波倒置
 Heart blocks
 VF
30
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
31
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
32
高血鈣
 serum Ca > 10.5 mEq/L or
Ca2+ > 4.8 mg/dL
 Primary hyperparathyroidism and
malignancy account for >90% cases.
33
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
34
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
35
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)
36
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
37
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
38
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)
39
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
40
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
41
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
42
43