Objectives

Review causes and clinical manifestations of

severe electrolyte disturbances

Outline emergent management of electrolyte

disturbances

Recognize acute adrenal insufficiency and

appropriate treatment

Describe management of severe hyperglycemic

syndromes

Principles of Electrolyte Disturbances

Implies an underlying disease process

Treat the electrolyte change, but seek the cause

Clinical manifestations usually not specific to a

particular electrolyte change, e.g., seizures,
arrhythmias

Principles of Electrolyte Disturbances

Clinical manifestations determine urgency of

treatment, not laboratory values

Speed and magnitude of correction

dependent
on clinical circumstances

Frequent reassessment of electrolytes

required

Hypokalemia
Neuromuscular manifestations (weakness,
fatigue, paralysis, respiratory dysfunction)
GI (constipation, ileus)
Nephrogenic DI
ECG changes (U waves, flattened T waves)
Arrhythmias

Hypokalemia

Spurious hypokalemia
Marked

leukocytosis
A dose of insulin right before the blood draw

Redistribution hypokalemia
Alkalosis

(K decreases .3 for every .1 increase in pH)

Increased Beta2 adrenergic activity
Theophylline
Familial

toxicity

Hypokalemia

Extrarenal depletion
diarrhea
laxative

abuse
sweat losses
fasting or inadequate intake

Hypokalemia

Renal potassium depletion

urine

potassium > 20 mEq/24 hrs

spot urine with > 20 mEq K/gram creatinine
classified whether they occur with a metabolic
alkalosis
vomiting/NG suction
diuretic tx
Mineralocorticoid excess syndromes

Hypokalemia

Renal losses
metabolic

acidosis

RTA Type I and II

DKA
Carbonic anhydrase inhibitor therapy
Ureterosigmoidostomy

No

acid-base disorder

Mg deficiency
Drugs

Hyperkalemia
Severe hyperkalemia is a medical emergency
Neuromuscular signs (weakness, ascending
paralysis, respiratory failure)
Progressive ECG changes (peaked T waves,
flattened P waves, prolonged PR interval,
idioventricular rhythm and widened QRS
complex, sine wave pattern, V fib)

Hyperkalemia

Etiology renal failure,

transcellular shifts, cell
death, drugs,
pseudohyperkalemia

Manifestations
cardiac, neuromuscular

Hyperkalemia

Impaired potassium secretion

Aldosterone

deficiency

adrenal failure
Syndrome of hyporeninemic hypoaldosteronism (SHH)
tubular unresponsiveness

Renal

failure

GFR < 10 -20% of normal

Hyperkalemia

Treatment
Stop

potassium!
Get and 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

Hyperkalemia

Treatment
Therapy

directed at actual removal of potassium

from the body
sodium polystyrene sulfonate (Kayexalate)
dialysis

Determine

and correct the underlying cause

Body Fluid Distribution

Water
[Na]
(L)
(mmol/L)
ECF
Vascular
3
Interstitial
16
ICF
Intracellular
23
TOTAL

42

[K]
(mmol/L)
140
140

5
5

10

150