Objectives

Cover major electrolytes abnormalities and their respective treatments

Sodium

Potassium
Calcium

Mainly intracellular

Potassium
Reference range: 3.5-5.0 mmol/L

Acidosis drives K+ extracellularly Alkalosis drives K+ intracellularly Information from U+Es, ABGs

+ K

Hyperkalaemia

Hypokalaemia

Causes
Nephrotoxic medication! NSAIDs, ACEi
Rhabdomyolysis Acidosis (K+ brought extracellularly to bring H+ intracellularly)

Clinical Manifestations
ECG Changes
Peaked T waves Increased PR interval Flattened P waves Widened QRS Likely leads to VF and asystole

Skeletal Muscles/Nerves
Paraesthesia/Malaise

Hyperkalaemia
>5 but <6.5mmol/L or No symptoms No ECG changes >6.5mmol/L or Major symptoms ECG changes

MILD

SEVERE

Treatment
10ml of 10% Calcium Gluconate over 5 minutes (2ml/minute)
10 units soluble insulin (Actrapid) in 50ml of 50% glucose over 5-15 minutes Also Calcium Resonium 15mg TDS-QDS Salbutamol nebuliser 2.5-5mg QDS if severe May require haemodialysis

Causes
Drugs e.g. loop and thiazide diuretics
Gastrointestinal losses D + V Severe burns

Clinical Manifestations
ECG Changes Flattened T waves ST depression

Systemic
Muscle weakness Constipation

Prolonged QT interval
Atrial arrhythmias VT or VF

Abdominal discomfort
Depression Confusion

Hypokalaemia
2.5-3.4mmol/L and No symptoms No ECG changes <2.5mmol/L or Major symptoms ECG changes

MILD

SEVERE

Treatment
If mild
Oral Sando-K (12mmol/tab), 2 tds for 2-3days

If severe
IV 80-100mmol/day KCl May be diluted in 0.9% NS (preferred to 5% glucose) Max conc peripherally 40mmol/L, everything else should be given centrally

Calcium
Reference range: 2.2-2.6 mmol/L

Serum levels cannot be read in isolation must be adjusted for serum albumin levels
Adjusted calcium
Serum calcium + (40 Alb)/50

2+ Ca

Causes
Drugs e.g. thiazides, calcium supplements
Hyperparathyroidism (~50% patients) Multiple myeloma Malignancy with bony metastases Dehydration

Clinical Manifestations
Systemic
N+V Constipation Weight loss Tiredness Weakness

Abdominal pain
Confusion Depression

ECG Changes
Shortened QT

Hypercalcaemia
>3.0mmol/L >3.4mmol/L

MILD

SEVERE

Treatment
Rehydration
4-6L 0.9% NS over 24 hours 1L over 2hrs, 1L over 4, 1L over 6, 1L over 8

Forced diuresis with IV furosemide

Maintain adequate UO (2-300ml/hr)

Pamidronate
Indicated for hyperparathyroidism, not much evidence in bony mets Dilute in 0.9% NS
Adjusted Calcium 2.7-3.0 3.0-3.5 3.5-4.0 >4.0 Pamidronate (max conc 60mg/250ml)

15mg in 100ml 30mg in 250ml over 30mins 30mg in 250ml over 30mins 60mg in 250ml over 1hr 60mg in 250ml over 1hr 90mg in 500ml over 2hr 90mg in 500ml over 2hr

Causes
Hypoparathyroidism
Acute pancreatitis Vit D deficiency Septic shock

Clinical Manifestations
Systemic
Tetany Paraesthesia

Neuromuscular excitability
Carpopedal spasm Seizures

Hypocalcaemia
1.6-2.0 mmol/L and <1.6mmol/L or

Asymptomatic

Symptomatic

MILD

SEVERE

Treatment
Oral
SandoCal (10mmol and 25mmol tabs)

Intravenous
10ml of 10% Calcium Gluconate over 5-10 mins. Repeat as required.

Principal component of ECV

Sodium
Ref range: 135-145mmol/L

Kidneys excrete approx 2kg NaCl/day (main) Mainly affected by Kidney/Gut/Skin/Aldosterone

+ Na

Can be hypernatraemia or hyponatraemia

Clinical Manifestations
Anorexia
N+V Malaise, muscle cramps, weakness Lethargy, confusion, agitation, headache, seizures, coma, decreased reflexes, hypothermia

Hypervolaemic hyponatraemia
Na but H2O : apparent hyponatraemia
Causes: heart/liver/kidney failure Iatrogenic: thiazides/loop diuretics Treatment:
Strict fluid restriction! Reduce or stop diuretics

Euvolaemic hyponatraemia
SIADH (dx of exclusion)
Inappropriately conc urine with serum osmolality (2Na + Ur + Glu) Water retention. Na excreted via other mechs Causes of SIADH:
Head: Meningitis, encephalitis, trauma, neoplasm Chest: Pneumonia, bronchiecstasis, bronchogenic Ca, SC Lung Ca Other: Drugs (e.g. ecstasy, carbamezepine)

Hypovolaemic hyponatraemia
H2O and Na Causes
Endocrine: Addisons disease/hyperaldosteronism
Commence tx, then short synacthen test to confirm Especially in post op patients ?steroid withrawal

Renal
Salt-losing nephropathies, interstitial nephritis

Skin
Burns (massive fluid + electrolyte loss)

Enteral
Massive diarrhea/vomiting. High output ileostomy

Treatment
If Na replaced too quickly: gaze palsies/spasticity/hyperreflexia
Central Pontine Myelinosis Central area of white matter change

Do not raise Na by more than 10mmol/day

Approx 500ml-1L of 0.9% NS/day

Hypervolaemic hypernatraemia
Mainly iatrogenic
IV NaCl ++ Excess bicarbonate

Euvolaemic hypernatraemia
Diabetes insipidus
Dilute unconcentrated urine with high serum osmolality

Due to ADH deficiency/insufficiency

Central: Insufficient production (trauma/infection)
Nephrogenic: ADH receptor insensitivity, drugs (e.g. lithium, interstitial nephritis)

Treatment: Replace with desmopressin (DDaVP) oral or inhaled

Hypovolaemic hypernatraemia
Na but H2O : apparent hypernatraemia
Causes: Burns, GI losses, intense sweating, recovering ATN

Hard to tolerate. Conscious patients will drink a lot of water! Therefore usually only in unconscious patients
Reduce by 10-12mmol/day

Scenario 1
64 Female
Admitted with 2/7 hx of severe vomiting, 2/12 hx of weight loss

No other Sx
Background of T2DM, HTN, CKD Stage 3

What investigations would you do?

ECG : No new changes

PTH levels: 89pg/mL (Normal 10-55)

Serum Ca level: 2.7 Serum Alb: 15g/dL

AXR: Opacity in right ureter

Write up her drug chart!

Scenario 2
48 Male
Admitted initially with acute exacerbation of asthma, now become confused on the ward.

Background of brittle asthma

What investigations would you do?

ECG :

Serum K level: 2.6

Write up his drug chart!

Scenario 3
76 Male
Admitted overnight, found unresponsive in nursing home. Diagnosed with stroke.

Today, ATSP as he became acutely unwell. On ABG, he was found incidentally to have a potassium of 7.2

What would you like to do?

ECG :

Thank you!