hypokalaemia and hyponatraemia acute mx
TRANSCRIPT
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Managing My Salts
A guide to ED management of Hypo-K and Hypo-Na.
Dr Kyle KophamelCME 10 Dec 2015
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DisclaimerSimple ED specific approachIn light of NEATSome areas will be Charlies specificFeel free to challenge my conclusions
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AimHypo – K
Emergent treatmentDosing, Timing, Central vs Venous
Hypo - NaEmergent treatment of Severe, Symptomatic
Hyponatremia. An easy, evidence based ‘How to’ of super - salt
What to look out forHelpful Labs at presentation.What not to do.
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Hypo-K – Let’s define it. QuicklyMild: 3.0 – 3.5 mmol/LModerate: 2.5 – 3.0 mmol/LSevere < 2.5
Broadly speaking:ECG changes <2.7 mmols/L
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ECG ChangesFlat T’sU WavesProlonged Qt (QU)Broad QRSArrythmias (PAC’s, PVC’s, SVT, VT, TdP)
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SymptomsWeaknessFatigueMuscle crampsParalysis and RhabdomyolysisRespiratory DifficultyConstipation/Paralytic IleusLeg cramps
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LabsVBG
NaKClCreatinineGlucoseBicarb
Mg Level
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CorrectionMinimize LossesGive K.
Aim 4-4.5mmomls/L
Give Mg. Aim >1 mmol/L
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CorrectionIV vs OralPeripheral vs CentralCardiac Arrest
10 mmols IV over 5 mins peripherally
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CorrectionOral
Multiple marketed brands Controlled release formulations Oral electrolytes list on AMH Aim 40-100mmols/day In practice
Usually 2-3 tablets, 2-3 x daily for 2-3 days then review response.
If you’re interested 1mmol/L defecit is approximately 200mmol whole
body defecit
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CorrectionIV
Peripheral <40 mmols/L concentration <20mmols/hr Minibags (10mmols KCl in 100mls 0.29% NaCl) are
isotonic and can be administered peripherally.Central
>40mmols/L concentration >10mmols/Hr
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Hyponatremia - Let’s Define it. Quickly!
Sodium < 135 mmol/L Mild: 125 -134 Moderate: 120 – 124 Severe: < 120
True vs Factitious Hypotonic (Losing Sodium or Holding Water)
Hypovolaemic, Euvolaemic, Hypervolaemic Isotonic (Psuedohyponatremia) Hypertonic (Glucose, Mannitol)
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SymptomsAsymptomaticAltered Mental StateComaSiezureNeurological Defecit
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CausesLots.
Drugs, Drugs, Drugs Prescribed and Street
Water overloadSIADHBeerEndocrineOrgan FailuresThird space lossesFacticious
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The Simple ED Stepwise ApproachStep 1
VBG – DiagnosisU+ESerum OsmolalityUric Acid
• Urine• Electrolytes• Uric acid• Osmolality• Creatinine
• Endocrine Suspected• TSH/Cortisol
LABS
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Step 2Treat CNS Symptoms
Aim to raise Na by 2-6 mmol/L 100mls 3% NaCL over 10 mins
Simple way to make-up to follow Wait 10mins Repeat x 1ORRule of 3’s3mls/kg 3% NaCl over 30 mins and stop if mental state improves
If not worked after 3x, Recheck Na and look for alternate cause. CT Head
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Step 3Don’t do anything.Sit tight.Forget the formulas.
Or, just don’t look them up.
Be conservativeFluid RestrictWhy
Osmotic Demyelination AKA Cental Pontine Myelinolysis
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Step 4If you couldn’t follow step 3Na jump >10mmols
DDAvp 1-2 microgram dose IV Synthetic ADH, creates concentrate urine
Get help.Friendly NephrologistConsider 3-6mls/kg D5W over 1 hour (decreases Na
by 2mmols)
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A Just about 3% Salt solutionCharlies ED
Vials of 20% NaCl in 10mls availableAim to give approx 100mls over 10mins
My suggestion: Inject 10ml 20% NaCl into 100mls 0.9% Saline
Concentration of 2.63% Give over 10mins
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Case 1Would you make the diagnosis?32 Female
Walks into emergency Dept with familyComplaining of Nausea, Vomiting and headacheAt triage becomes edgy and agitatedAt Assessment is swimming in the bedAt Resus is lashing out, disorientated and not
coherantly respondingShe scored a tube.
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Case 1VBG
pH:7.47PCO2: 29Bicarb: 21BE: -3Na: 126K:3.7Lact:2.1
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Case 1Differential
EncephalitisPsych Intracranial Pathology
Bleed, Tumour Illicit DrugsHyponatremia
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Case 1Collateral
Playing touch rugby all morning (and previous day)40 degree dayDrank several liters of water
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Case 2Blue form anyone?89 year old, from home.Found by family in bed, unresponsiveTriage: ‘Neurological – Altered Mental State. Hit by
car low speed – now GCS 5Vitals normal, unremarkable physical examination
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Case 2Na 99K 2.0Not tubed.2 x 10ml 20% NaCl pushes.
GCS 9 in 1 hour
Admitted HDU5 days later, Na 127Discharged Day 10 zipping around on her zimmer frame.
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SummarySend the labs
Catheterise earlyTreat CNS Symptoms
100mls 3% NaCl (raises by 2mmols each time)
Sit tight. Fluid Restrict.Rescue remedies if you didn’t sit tight
dDAVPFriendly Nephrologist
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References Lifeinthefastlane
http://lifeinthefastlane.com/investigations/hyponatraemia/interpretation/
EMCrit http://emcrit.org/podcasts/hyponatremia/
Australian Medicines Handbook https
://amhonline-amh-net-au.qelibresources.health.wa.gov.au/chapters/chap-07/tables/electrolytes-oral.tb
Therapeutic Guidelines http://online.tg.org.au.qelibresources.health.wa.gov.au/ip/desktop/index.htm
• http://www.health.wa.gov.au/circularsnew/circular.cfm?Circ_ID=12986• Western Australian Policy for Use of Intravenous Potassium Chloride