Transcript - Catalyst

Electrolyte And Acid
Base
Disorders
Dr. Douglas Paauw
A 79 yo man presents with fatigue, weakness and
a recent foot drop. On physical exam he has
lymphadenopathy and splenomegaly. Lab- Na 120, Cl82, WBC-5.8, HB - 9, HCT – 27 rouleux formation on
smear. SPEP shows M protein spike of 3.8 g/dl.
What is the most appropriate management of this
patients hyponatremia?
40
D)
N
o
@
sa
lin
e
0%
in
te
rv
en
ti o
n
0%
cc
/h
r
0%
10
0c
c/
hr
@
9N
S
B)
.
A)
Fl
ui
d
re
st
ri c
tio
n
0%
C)
3%
A) Fluid restriction
B) .9NS @100cc/hr
C) 3% saline @40 cc/hr
D) No intervention
Hyponatremia

Step 1
Determine if hyponatremia is real

Step 2
If hyponatremia is real, determine
water status of patient
Pseudohyponatremia
Hyperglycemia
Sodium is 1.6 meq less for every 100
glucose is over 100
 Hypertriglyceridemia, increased plasma
proteins (Waldenstroms)

Classification of hyponatremia by
volume status



Edematous- too much sodium, way too much
water
CHF, nephrotic syndrome, cirrhosis
Hypovolemic- too little sodium, too little water
these patients are hypotensive
with dry mucous membranes
“Euvolemic”- normal sodium ,a little too much
water
Hyponatremia- “Euvolemic”
Causes
Endocrine- hypothyroidism, adrenal
insufficiency
 Drugs- chlorpropamide, morphine, SSRI’s,
carbamezepine, hydrochlorothiazide
 SIADH
Carcinomas-small cell
Inflammatory lung disorders
CNS disorders

A 66 yo woman presents with fatigue. She has a history
of bipolar disorder and reflux disease. She has felt well
the past few months until the last few weeks.
Medications: Rabeprazole, lithium, paroxetine, calcium.
Physical exam is normal. As part of her workup she is
found to have the following labs: Na 120, K 3.6 Bun 3 Cr
.7 What is the most likely cause of her low sodium?
0%
D
0%
C
0%
B
0%
A
A) Hyperlipidemia
B) Nephrotic syndrome
C) Acute psychosis
D) Drug effect
What Is The Most Appropriate Immediate
Treatment?
at
ch
in
...
3%
e7
sa
5
lin
cc
e,
/h
r. .
m
3%
.
at
ch
sa
in
lin
g
e,
cc
50
f..
cc
/h
rw
ith
W
q.
at
.
er
re
st
ric
tio
n
al
sa
lin
e,
m
no
rm
E)
al
sa
lin
D)
0% 0% 0% 0% 0%
.9
C)
no
rm
B)
.9 normal saline, matching cc for
cc urine loss
.9 normal saline 75 cc/hr and
matching urine loss
3% saline, matching cc for cc
urine loss
3% saline, 50 cc/hr with q 2 hour
Na check
Water restriction
.9
A)
SSRI’s AND Hyponatremia
Older age
 Female
 Concomitant diuretic use
 Low body weight

A 19 yo woman is brought to the ED by friends after a seizure.
They report she was feeling well yesterday, and went to a party
last night. She stayed up all night and this morning was confused,
had trouble walking and then had a seizure. She had been
clenching her teeth for much of the early morning hours. BP
150/90 P 110 T 37. Patient is unable to converse.
Lab: WBC 11,000 Bun 4 Cr .4 HCO3 16 Na 118
What is the most likely cause of this patient’s
problems?
nu
s
0%
Te
ta
rin
Be
er
d
us
ke
rs
.
e
us
0%
e
0%
M
DM
A
0%
..
0%
ne
5.
Co
ca
i
4.
s
3.
ng
iti
2.
Meningitis
Cocaine use
Beer drinkers
potomania
MDMA use
Tetanus
M
en
i
1.
What Therapy do you
Recommend?
0%
e
3%
sa
lin
lin
sa
NS
½
D5
0%
e
0%
No
rm
al
0%
...
4.
ric
t
3.
re
st
2.
Fluid restriction
D5 ½ NS
Normal saline
3% saline
Flu
id
1.
Features of MDMA (Ecstasy) Intoxication

Common Features
Euphoria
Bruxism
Tachycardia

Serious Side Effects
Severe Hypertension
Hyperthermia
Hyponatremia

Distinguishing Features
Bruxism
Hyponatremia
Meth-mouth
Management of Hyponatremia



Edematous- Diuretics ( usually loop diuretics like
furosemide)
Hypovolemic- Normal saline infusion
“Euvolemic”- Water restrict
If severe symptoms (seizure, coma) give hypertonic
saline chronic- can treat with demeclocycline or lithium
A 69 yo man presents with weight loss and fevers. He
has been sick for the past 6 weeks. He has a past history
of CHF and CVA. On exam he is a cachetic man who
appears weak and tired. He has rales bilaterally in the
upper lung fields. He has no organomegaly and no
peripheral edema. Chest xray- bilateral upper lobe
infiltrates. Lab- Na-126, Cl-93, Bun-4, Cr- .6, Ca- 11.3
What is the most likely cause for his hyponatremia?
0%
D
0%
C
0%
B
0%
A
A) Adrenal insufficiency
B) CHF
C) Hypothyroidism
D) Tuberculosis
A 77 yo woman with dementia presents
with obtundation and decreased urine
output. The patient has been less
responsive the past two days and is not
eating. No fevers, chills or signs of
infection.
Lab- Na-163, CL-110, K-3.0, Bun-90
Cr-3.0, WBC-11,000, HCT-44
What is Your Next Step in
Management?
0%
G
iv
e
M
an
ni
to
l
0%
Li
th
iu
m
G
iv
e
al
S
G
iv
e
VP
0%
D5
W
0%
al
in
e
0%
No
rm
5.
IV
4.
DD
A
3.
G
iv
e
2.
Give DDAVP
Give IV Normal Saline
Give D5W
Give Lithium
Give Mannitol
G
iv
e
1.
Causes of a high Bun/Cr ratio

Volume depletion

Gastointestinal bleeding

High dose corticosteriod use

Pre renal state due to poor CO or ACE
inhibitor/NSAID
Hypernatremia Calculation of
free water deficit
(Actual plasma Na X TBW) – TBW
Desired plasma Na
TBW= Body weight(Kg) x .6
Hypernatremia
Most common cause- inability to get to
water
usually patient bed bound, stroke or
unconscious
 Less common
Central diabetes insipidus
Nephrogenic diabetes insipidus

Central Diabetes insipidus
Causes
Head Trauma
 A whole bunch of zebra’s
Sarcoidosis
Histiocytosis X
Craniopharyngioma
Vasculitis

Nephrogenic DI
Toxic most common- THINK LITHIUM
 Vascular- Sickle cell
 Inflammatory- Sarcoid, Sjogren’s
 Structural- Polycystic kidney disease

A 52 yo man presents with fatigue and dizziness.
As part of his workup he is found to have a
magnesium level of .8 (normal 1.6-2.2)
What other lab is very likely to be abnormal?
B)
C)
D)
E)
Sodium
Potassium
Bicarbonate
phosphate
Creatinine
0%
0%
0%
0%
0%
S
o
d
iu
P
m
o
ta
ss
B
i
ic um
ar
b
o
n
at
p
h
e
o
sp
h
C ate
re
at
in
in
e
A)
A 33 yo man with chronic alcoholism comes into the ED
with a head injury. He has been drinking 16-20 beers a
day as well as a fifth of gin every other day. What
electrolyte abnormalities would you expect to see?
0%
bi
c.
..
..
,l
ow
po
t.
Lo
w
m
sp
ha
t
ag
ne
si
um
e,
l
,l
ph
o
Lo
w
0%
ow
ow
m
po
t..
po
ta
ss
iu
m
lo
w
0%
a.
..
.
0%
at
e,
4.
Lo
w
3.
ph
os
ph
2.
High phosphate, low potassium, high bicarb, high
sodium
Low potassium, low magnesium, low calcium, low
bicarb
Low phosphate, low potassium, low magnesium,
high calcium
Low magnesium, low bicarb, high phosphate, high
calcium, low potassium
H
ig
h
1.
What should I Know about A Low
Magnesium?
Most common causes: Heavy alcohol
intake, diuretics, Cis Platinum
 If magnesium is low, potassium is
almost always low
 Potassium can’t be replaced adequately
until magnesium is replaced

A 36 yo women presents with fever, chills and flank pain.
On exam BP 80/60, p-145, T-39.8. She has right flank
tenderness and an enlarged spleen. Lab- Na 136, K-7.4,
Cl-102, Cr- 1.2, WBC-344,000, HCT-22, Plt-34,000, UAPacked field WBC’s and GNR on
gram stain. What is the most
appropriate initial order?
A) ECG
B) Calcium gluconate
C) IV glucose and insulin
D) Kayexalate
0%
0%
A
B
0%
C
0%
D
Hyperkalemia
 Is



it real?
Causes of pseudohyperkalemia
Hemolysis
Very high WBC (leukemia)
Very high platelet count
Hyperkalemia
Hyperkalemia- Causes
Too much intake
- Iatrogenic or too much salt substitute
 Too little excretion
- Renal failure
- Drugs that block renal K excretion
 Shift
- Acidosis
- Muscle injury (rhabdomyolysis)

A 45 yo IDU is brought into the ER
comatose. His friend last saw him 2 days ago.
He is quickly intubated and labs come back- Na
150, K-7.8 ,Bun-77, Cr-8.0, HCO3-14. Review of
his chart shows he had a Bun of 15 and Cr of
1.0 two weeks ago.

What are the likely causes for his hyperkalemia?
What Immediate Treatment Do
You Recommend?
0%
0%
Al
bu
te
ro
l
0%
Ca
lc
iu
m
0%
IV
0%
Ka
ye
xy
la
te
NG
K
ay
ex
yl
at
e
5.
IV
4.
id
e
3.
fu
ro
se
m
2.
IV furosemide
IV Kayexylate
NG Kayexylate
IV Calcium
Albuterol
IV
1.
Treatment of Hyperkalemia
Emergent- IV calcium gluconate
 Urgent- IV HCO3
IV glucose and insulin
 Timely
Kayexalate
Furosemide
Dialysis

Acid Base Disorders
A 41 yo woman is brought into the ER comatose. No
history is available other than she was found by a friend
at home unconscious. Labs- Na-137,Cl 96, Bun-27, Cr1.6, HCO3- 4, Glu- 80, WBC-14,500, Ca- 8.9, serum
osmolality 312, AST-115
What is the most likely diagnosis?
0%
0%
E
0%
C
0%
B
A
0%
D
A) Ethylene glycol poisoning
B) Alcoholic ketoacidosis
C) Sepsis (lactic acidosis)
D) Diarrhea due to GI bleed
E) Renal tubular acidosis
Differential of Anion Gap
acidosis
Methanol
 Uremia
 Lactic acidosis
 Ethylene glycol
 Paraldehyde
 Aspirin
 Ketoacidosis (diabetic, alcoholic, starve)

How to calculate a serum
osmolality
2 X Na + Bun + Glu
2.8 18
Differential diagnosis for anion
gap acidosis and osmolol gap

Methanol

Ethylene glycol
Pearls about Ethylene Glycol
Poisoning

Oxalate crystals in urine

Renal insufficiency

Urine may fluoresce with Woods lamp

Fomepizole is an appropriate therapy
n
sp
iri
E)
A
A
)D
B
)L
K
A
ac
C
t
)R
ic
ac
en
id
al
os
tu
is
bu
la
r
ac
id
os
is
D
)D
ia
rr
he
a
A 57 yo man with type 2 DM presents with 1 week hx of
nausea, vomiting and diarrhea. Current MedsOmeprazole, Glyburide, Metformin, Atenolol, and
Lisinopril. Labs obtained 3 mo ago: Na-140, Cl-100,
HCO3-27, Bun-23, Cr-1.5. Todays labs- Na-137, Cl-95,
HCO3- 6, Bun-69, Cr-3.8.
What is the most likely cause
for his acidosis?
A) DKA
B) Lactic acidosis
0% 0% 0% 0% 0%
C) Renal tubular acidosis
D) Diarrhea
E) Aspirin
A 56 yo man with a history of alcoholism and cirrhosis
presents with fever and abdominal pain. On exam he has
BP-80/50, p- 130.Abd exam-fluid wave and tenderness.
Lab- WBC-14,000, Na-134, Cl- 112, HCO3 13. Labs 1
mo ago – Na-135, Cl-111, HCO3 -23 , ALT-12, Alb-1.4.
What is the most likely explanation
for this patient’s acidosis?
A) Nonanion gap acidosis due to diarrhea
B) Nonanion gap acidosis due to RTA
C) Nonanion gap acidosis due to hyperchloremia
D) Anion gap acidosis due to lactate from sepsis
E) Anion gap acidosis due to Uremia
0%
E
0%
D
0%
C
0%
B
A
0%
Decreased Anion Gap

Low Albumin (decreased unmeasured anions)

Myeloma (increased unmeasured cation)

Hypermag, hypercalcemia, lithium, bromide
A 46-year-old man with type 1 diabetes presents for
evaluation of fatigue. As part of his evaluation an
electrolyte/renal function panel is drawn with the following
results: Na-137, K-5.9, Cl-112, HC03-16, Bun-22, Cr-1.4.
What is the most likely cause of his acid base/electrolyte
abnormalities?
A. Diabetic ketoacidosis
B. Type IV renal tubular acidosis
C. Chronic diarrhea
D. Lactic acidosis
E. Ethylene glycol ingestion
0%
A
0%
B
0%
C
0%
0%
D
E
Differential diagnosis of
Nonanion Gap Acidosis
GI
Diarrhea
Small bowel loss
Ureterosigmoidostomy
 Carbonic anhydrase inhibitors
 Renal tubular acidosis

A 33 yo woman with type 1 DM for 10 years
comes to the ER with a 3 day history of abdominal
pain, nausea and vomiting. She has taken some
regular insulin (Lispro) but has not taken any long
acting insulin because she can’t keep any food down.
She has no symptoms of infection. Exam is remarkable
for BP 100/60 lying down, 80/40 standing up, and pulse
increase from 110 to 150.
Lab- Na-134, Cl-82 , K-3.0, HCO3 –20
Bun- 30, Cr-3.8, Glu-490
What abnormalities does this patient have?
2.
3.
4.
5.
6.
7.
Anion gap metabolic acidosis
Non anion gap metabolic acidosis
Anion gap metabolic acidosis and nonanion gap
metabolic acidosis
Anion gap metabolic acidosis and respiratory alkalosis
Anion gap metabolic acidosis and metabolic alkalosis
Metabolic alkalosis
0% 0% 0% 0% 0% 0% 0%
Respiratory Alkalosis
An
io
n
ga
No
p
m
n
et
an
ab
io
ol
n
An
ic
ga
io
ac
p
n
m
i..
ga
.
et
An
p
a
m
bo
io
et
n
lic
ab
ga
...
An
ol
p
ic
io
m
ac
n
et
ab
ga
i..
.
p
ol
ic
m
et
ac
ab
i..
ol
.
M
i
c
et
ac
ab
id
ol
Re
...
ic
sp
a
i ra
lk
al
to
os
ry
is
A
lk
al
os
is
1.

Why did these occur?

Outline your treatment plan

What is a Delta/Delta?

What are the causes of metabolic acidosis?
Delta/Delta concept
Change anion gap
Change in bicarb
If ratio is > 2 then concurrent metabolic
alkalosis is present
 If ratio is < 1 then combined anion gap
and non anion gap acidosis are present

23 yo actress presents with fatigue, and dizzy spells.
Exam: BP 108/60 sitting P 90
Labs: Urine PH 8.0 Urine Na 20 Urine Cl 3
Na- 138 K- 2.8 Cl- 90 HCO3 31 BUN-14 Cr .9
What is the most likely diagnosis?
0%
0%
0%
iti
Hy
ng
po
m
ag
ne
se
m
ia
0%
Vo
m
5.
0%
Sy
nd
ro
m
Ex
e
ce
ss
Li
co
ri c
La
e
xa
tiv
e
ab
us
e
4.
an
3.
lm
2.
Gitelman Syndrome
Excess Licorice
Laxative abuse
Vomiting
Hypomagnesemia
G
ite
1.
What to Think of With Hypokalemia
and Low Vascular Volume
Low Urine Chloride
Vomiting
Remote Diuretic Use
CF
 High Urine Chloride
 Diuretics
 Bartter’s and Gitelman’s syndromes
 Decreased Magnesium

Causes of metabolic alkalosis
Na CL responsive
Vomiting
Diuretics
Urine Cl<15
Na Cl resistant
Hyperaldosteronism
Cushings syndrome
Licorice
Urine Cl >15