Wednesday Lectures: 05/06/2015

TTHM 12.1  Electrolytes Day  (5/6/15) Tintinalli 19,20,21,137,142,225.

 

10a ~ Acid/Base (Prasad)

1) Primary Disturbance? Acidosis? Alkalosis? pH? 7.35 to 7.45?

2) Resp or Metabolic? pCO2<40? Bicarb<24?

3) Secondary Disturbance? AG? DeltaAG? (in acidosis, difference from 10…)

AGMA? MUDPILES…

4) Corrected Bicarb should be is Measured Bicarb plus DeltaAG…

Winters Formula for Metabolic Acidosis expected pCO2 should be 1.5x Bicarb plus 8!

*Mixed disorders such as ASA OD (Sepsis & LiverDsx) can cause Met Acid c Resp Alk…

 

1030 ~ Nutritional Disorders (Nicholas)

*Case 1) EtOH, lazy eye, well known…

Wernicke’s Encephalopathy, Thiamine (Folate, B12…) Thiamine is rapidly metabolized quickly as a water soluble vitamin, need regular intake!  Wernicke’s develops rapidly.  Genetic predisposition & absorption problems play a role even despite supplementation.  Magnesium is also an important cofactor.  If in doubt, hang a banana bag.  Ophthalmoplegia & nystagmus often resolve within days, Ataxia & AMS may take longer & have sequelae.  ICU stays may be indicated!

*Case 2) 3 wks N/V in 24F ~ Hyperemesis gravidarum is formal diagnosis c ketone formation.  Ketone clearance (urine check) needs dextrose metabolism in addition to IVF!

*Case 3) Skin discoloration from chronic exlax use (phenolphthaline), fixed drug eruption… Developed “Cathartic Colon” causing persistence of electrolyte disturbance.  Anorexia should be screened for concomitant psych or metabolic disorders… screen for SI risk, bulemia…

 

11a ~ Small Groups (Rodriguez, Lavoie)

*VA, old guy, weakness… EKG!!! HyperKalemia… Calcium Albuterol InsulinGlucose, Kayexalate

Theoretically be aware of Digoxin toxicity, “stone heart”, CaCl sclerosing (avoid in Peds & IO), CaGluc generally favored.  10U Insulin Regular & D50 x50cc Amp, may shift K up to ~1mEq… Albuterol can neb continuously, numerous treatments (10 to 20mg!!!), can use IV terbutaline?! …but may be ineffective if beta blocked or idiopathic inefficacy.

…Dialysis.

 

12p ~ Kai Academic Project ~ Snow on ED volumes… NEG correlation between visits/day & avg inches snowfall. ~5% effect strength.

 

1230 ~ Jr/Sr Session (Paolo, Lavoie)

Procedures… More blocks, splinting, suturing…  Ortho nomenclature: “displaced”, “angulated”, “rotated”… NYTimes ~ Maureen Dowd? “Stroke of Fate”… Dave Newman response in HuffPost… Finger angulation allowed 10, 20, 30, 40 degrees respectively until reduction needed… Fix rotational deformity for preservation of function of hand… Boxer’s Frx c Ulnar Gutter splints, 20* & 90* intrinsic plus positioning, or radial gutter splint c thumb hole.  Carpals: remember 3 curves: radius, lunoscaphoid, capitate. Scaphoid Frx ~ thumb spica splint.

*Weber ankle frxs: from A to C: higher fibula, lower tibial tuberosity frx…

Posterior Leg splint & stirrup splints

Lacerations: lidocaine allergy… what to use? Lidocaine (amide) vs Esters (cocaine, procaine, benzocaine, tetracaine, chlorprocaine) …(2 “i”s in amides).

Irrigation pressure matters!

Absorbable v Nonabsorbable sutures similar efficacy

Dental Blocks, benzocaine topical followed by inferior alveolar, mental nerve, infraorbital(maxillary)

Peritonsillar Abscesses DO NOT NEED ENT!  It’s an abscess, needs I&D, maybe Abx…

Lateral Canthotomy, know how to do it!

Wrist blocks! ~ Ulnar nerve (lateral to flexor carpi ulnaris, not in artery).  Median Nerve between flexor radialis & flexor longus… Radial nerve (snuffbox under pollicis longus)

 

130p ~ Calcium (Kloss)

Parathyroid gland parafollicular Ccells make calcitonin which “tones” the Calcium “in”to the bones, & lowers serum Ca…  PTH does the opposite, dissolves bone to increase serum Ca!

Dietary calcium increases Ca which increases calcitonin to keep serum level down…

*HYPERCALCEMIA can be primary hyperparathyroidism (high PTH) or paraneoplastic syndrome (high PTHlh), HypervitaminosisD (absorbs more Ca), granulomatous disease…

HYPERCa ~ “Moans, Groans, Stones, Psych Overtones”… short QT.

Hyperparathyroid gets Surgery! (elevated PTH serum, solitary adenoma).   Treat c Massive IVF & then Lasix! (consider bisphosphonate, calcitonin, steroid).  ED levels: >10 to 12 HCTZ… 12 to 14 hyperparathyroid, >14 likely malignancy… consider HemeOnc & ADM.  Bisphosphonates inhibit osteoclast bone dissolution activity.

*HYPOCALCEMIA <9 Chvostek Sign, Trousseau Sign (Carpopedal spasm)… Pseudohypocalcemia can occur in hypoalbuminemia.  HypoMag can also be related to hypoCa… Hyperphosphatemia can lower Ca.   Pancreatitis ~ Saponifacation c Calcium & Lipid…

Rhabdomyolysis releases intracellular phosphate, which binds Ca.  Cows milk has high phos!!! Citrate from blood TFs binds Ca!!  hydroFluoric Acid burns deplete Ca!!  Treat c repletion of CaGluc or CaCl

 

2p ~ Potassium (Kloss)

Normal 3.5 to 5.5, intracellular cation…

*HYPERKALEMIA >6.5, muscle aches, arrhythmias, EKG changes… Hemolysis FalsePOS… get EKG if high.  Pseudohyperkalemia c leukemia & mononucleosis, acidosis, but MOSTLY Renal Failure.  Apoptosis/Rhabdo/Hemolysis causes release of intracellular K!  ACEi & NSAIDs, esp in elderly is bad… Spironolactone/Triamterene K sparing… peaked T, longPR, loss of P, long QRS, Sine wave of death…

Calcium, Glucose, Insulin, IVF, Albuterol, Bicarb, Kayexalate, Dialysis! & EKG…

Intracellular shift by Insulin, Albuterol (glucose transport channel, cAMP~Na/K/ATPase)

Calcium given for EKG changes, especially wide QRS.

Hyperkalemia can cause isolated bradycardia! ~ treat c Calcium.

*HYPOKALEMIA <3.5… weakness, cramps, paralysis… Emesis/Diarrhea, thiazides or loop diuretics, Bartter’s/Gitelman’s syndrome, Albuterol OD, theophylline/caffeine, hyperthyroid, familial hereditary periodic paralysis (intracellular dramatic shift), thyrotoxic periodic paralysis?!

Uwave, flat or inverted T… “Twave is made of potassium”… Low K may also have lowMg!

 

230p ~ Sodium (Joslin)

Dr. Joslin likes Egrets.  Fluid compartments in 70 kg pt… 28L H20 Intracellular, 10.5L Interstitial, 3.5L Intravascular? Regulated by Renin Angiotensin (I &II) Aldosterone Axis, Renal Tubules c Aquaporin channels, ADH/AVP from posterior pituitary…

Angiotensin II is vasoconstrictive, incl afferent renal vasculature & decreases H20 loss…

*HYPONATREMIA <135 low home, <130 low ADM?, <125 very low ADM/MICU, <120 very very low MICU!!!  hypovolemia dt diuretics or GI losses… esp Thiazides! (HCTZ)… beware K loss as well.  SIADH dt CNS Dsx, malignancy, drugs, recent SG… dilutional vs “salt~wasting” disorder…

Treat SIADH c fluid restriction & possible hypertonic saline.  SSRIs can cause SIADH… Cortisol usually suppresses ADH, so Addison’s can result in SIADH.  Pregnancy also dilutes & resets “osmostat”.  Exercise Associated Hyponatremia (half to full marathons, 4 to 6hrs)… No evidence yet of protection c salt pills… Quick Low can be quickly corrected, can give 100cc 3% saline for AMS… up to 800cc bolus has been given with benefit.  Bicarb can be given as 8% substitute.

MDMA can cause significant hyponatremia (~14% of users, independent of ED visit status).  Hyponatremia in Hyperglycemia approximate correction ~ 1.6 mEqNa correction per 100mg/dL elevation >100 of glucose!!!  Although correction factor actually higher c glucose >400!

Rapid Correction ~ beware Central Pontine Myelinolysis!!! ~ Sx in 2 to 6 days! Correction no more than 9 mEq in 24 hr recommended.  100cc of 3% will raise ~1 to 2 mEq.

*HYPERNATREMIA correct c D5W… “Don’t just do something, stand there” ~ mostly nonactionable.

 

3p ~ Pituitary Disease (Farber)

Physiology Anterior & Posterior… Treatment & Imaging…

Anterior: ACTH, GH, TSH, Gonadotropins

Posterior: Prolactin, Oxytocin, ADH, Gonadotropins

Mostly Hypopituitarism… Tumor cause bilateral hemianopsia dt sella turcica impingement…

Pituitary Apoplexy ~ bleeding of adenoma… can become adrenal insufficient & hypothyroid…

*Case: recurrent Sz… Hx Sheehan’s postpartum hemorrhage, lack of breastfeeding… Empty Sella Sign on MRI, may not show on CT?!?! Refractory hypotension c adrenal insufficiency!

Russel’s Viper Venom ~ PanHypoPit?!

Don’t forget steroids in Adrenal Insufficiency!

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