Electrolyte Disorders | The EM Boot Camp Course

all right don't cringe don't moan we're gonna talk about electrolytes and it's actually we get to do the fun part of electrolytes the nephrologists and the internists get to do all the hard part the kind of boring part we get to do the really fun part when it comes to electrolytes and just a little bit my background the reason I got into all of this is I started out in internal medicine and I did a full residency in internal medicine at UC San Francisco lo these many years ago and about halfway through that residency realized I'd made a gigantic mistake as far as what to do with my life like gigantic it was a quarter of a million dollars in debt and was doing the totally wrong thing like you can't get much lower than that actually in life it's like it was really bummed out but fortunately what I ended up doing was tripping I did my residency at UC San Francisco and I used to have a crying stairwell when I was totally stressed out I had a stairwell I'd go up there and cry so it was a crying stairwell in the residency program there and I was up in my it was it's a little dark stairwell and I was having a little pity party for myself and crying and crying crying and the door above me opened and I heard this coming down the stairs and before I had a chance to move from my perch sitting there on the stairs this person whipped around tripped over me and went all the way the bottom of that thing stairs I mean okay turn $50,000 in debt wrong specialty murderous just kill just killed somebody and so I've been rushing down to the bottom of the stairs and President got up and brushed himself off and it's like are you okay are you okay and he said no no I'm fine I'm fine maybe looked at me with my mascara stained face all teary and weepy and he said are you okay and I said no I'm not okay at all and see I said I you know I'm a I'm in dad did I do the right thing and he said come downstairs and he turns out it was the chair of emergency medicine at UC San Francisco and he took me in his office and he said you just rotated through the department you seemed to really like it did you ever think of switching so in 20 minutes I went from being a murderous and a ton of debt to going into a specialty that I absolutely passionately adore so I did a second residency in e/m and so what's happened with that dual residency training is I kind of end up niched into doing a lot of the teaching on sort of the flea or the internal medicine related stuff but I have to tell you that the stuff that's internal medicine related that we see in the ER is so much fun we get to do the fun part of it we'll talk about it with endocrine we get to do really the fun part of this internal medicine stuff and then punt it to people that take care of the law term stuff so let's talk about electrolytes because we get to take care of the fun part and a lot of what we do with electrolytes I just have to say before we start is do no harm we can do a lot of harm particularly with one of the electrolytes if we do things wrong so what I'm going to do is we're gonna walk through the major electrolyte disorders that we see in the ER and how to approach them but the main thing is remember do no harm so we know that our bodies are sort of a mishmash of chemicals cations and anions that basically all swim around together and make your membranes depolarize and basically make your muscles work and all of this stuff functions because you have this balance of sort of sodium and potassium chloride in there some bicarb it's pretty great it's a pretty wonderful soup that you happen to be made up of all of these different kinds of chemicals the electrolytes themselves but if they get out of whack they can cause some significant trouble so let's start with salt because salt is an extraordinarily part important part of your body when it comes to salt sodium we can do a ton of harm so what is crucially important is to first do no harm don't ever like I'm gonna like him back to what I said before never ever treat just a number always treat the clinical scenario for that individual patient never ever ever go crazy with just a number because there are certain areas we can really hurt people and this is one in particular so treat the patient not the number as far as this is concerned and it makes a difference with sodium fast versus slow so if somebody's sodium is really high or really low but it took a long time to get there that person's body's had time to kind of adjust and tweak things and let other electrolytes kind of balance out if it did it overnight or if it did it in a matter of hours so for instance of one of the local treatments for pediatric diarrhea in our local sort of community what sort of it's a cultural thing is to give basically dilute tea as the fluid replacement for these babies with lots and lots of sort of rotavirus kind of diarrhea well what you're doing is losing a lot of fluid that baby is getting just free water as what they're getting is first what they take in and that baby can get hyponatremic really fast that makes a difference fast versus slow matter so we'll talk about that in a second but remember fast versus slow especially when it comes to sodium and do no harm so let's start with sodium hypernatremia I'll tell you it is almost impossible to get hypernatremia based on in taking too much salt I don't care how much soy sauce you add to your sushi you're just not going to take in enough salt most people are hypernatremia because they get dry they become a human salt lick they get really really dry so most hypernatremia takes a while to get there this the classic presentation is the nursing-home person they just didn't get watered enough they don't get out of bed they need to get brought water or water through their g-tube and they just don't get watered enough and that usually takes time to get hyper in a Tremec so it's almost always a lack of water it is rarely if ever a fluid last deal can be but it's usually just a lack of intake can't it's usually just a lack of intake a normal person when you get dry gets thirsty right so a normal person will go ahead and treat themselves they would drink water so the people that can't do that are the people at risk for hypernatremia makes total sense so it's the bed-bound person it's the child that can't walk or get themselves to water express themselves that they're thirsty it's the person that has a little bit of mental disorder where they just are wacky and they don't know to drink or they don't express the need for need for water so tensing people who they can't get to water or can't express this the idea of thirst the other thing to know is extreme symptoms things like seizures and coma don't happen at a sodium of 150 or 155 in fact they're seen usually sodium's of 160 or higher so so they have to be really really salty to get to the point where they actually have symptoms that would present to us as an emergent problem something we need to emergently do something about short of that your sodium is 152 or 155 you may feel lethargic you may feel weak you're irritable you some nausea the symptoms are pretty nonspecific but they also aren't urgent enough for you to go Berzerk fixing it right now fixing right now is seizures in coma that you basically need to fix right now otherwise no and how rapidly it got there no it's usually a long time it's really hard to get there fast so it's virtually always a chronic disorder when somebody's hyponatremic if a person can drink so if you can bring them water to drink let them so that you your but your physiology is brilliant the human body is an amazing thing and your physiology tells you your thirst Center says drink bar water and people will drink what they need to if they can't though so if they can't sort of treat themselves you're gonna need to treat them with some basically water of some sort now think about it if I kept and said the highest high sodium I've ever seen in a living human being is 178 if I give that person with a setting of 178 this just happened actually normal saline normal saline is a sodium of 154 it is hyponatremic to that person especially if they're dry giving them a 154 male equivalent sodium sort of bolus is hypovolemic to them and a volume replete er so it kind of gives both things so your basic you will need to repeat them at least up to a normal blood pressure if the hypotensive but you're gonna have to go nutty you know and you want to bring it down enough that they're not seizing or in a coma but once you're you've got them down some and they're symptoms symptoms are better you're gonna slow down your correction rate and you can core you can calculate this get out your your smartphone and you'll calculate the three water deficit and you'll basically teach you how to it'll show you how much you need to give and over what amount of time but you're the key is don't correct the number just the number the patient's easier comatose bring it down use normal saline that's actually dilute enough and then go ahead and replete them with not with free water over time no hurry on that I'll tell you we don't see that that often and honestly we don't have to treat that aggressively virtually ever it's really really uncommon to see hypernatremia to the point of needing urgent correction basically giving some water is fine hyponatremia is extraordinarily common and you can really do bad things to people if you address this thing wrong so let's say the lab calls you and says we have a critical value the sodium is 122 if the sodium is low the first step you will always always do low sodium the first thing you're gonna do is look for pseudo hyponatremia and the first thing you're going to look at when that sodium is low is you're gonna check the glucose instantly I want a synapse to be completely cemented in your brain that if a sodium is low immediately move your eyes down to the glucose column and see with that glucose column shows what you're gonna do is you're gonna correct the serum sodium there's a formula for that they're actually two if you have MD calc which I totally totally love which I dreamed of it you have MD calc go ahead and plug in the numbers there are two versions of the formula honestly it's not that humongously different the corrected correction factor but the key is what you're gonna find is a lot of those hyponatremic patients when you correct for their sodium or further a glucose aren't hyponatremic after all okay so they're not after all and there's a few other things that will also make them pseudo hyponatremic meaning they're not really hyponatremic it's just that they have a lot of lipids in their system so when that blood gets drawn and it looks all kind of looks like fat in their serum that's somebody who would they may have pseudo hyponatremia or they have a super elevated Billy or they have a history of blood just Courageous those can do it as well but the biggest actor in this is sugar so low sodium first thing you do look at the sugar and correct the serum sodium now if it's still low when you've corrected it now you have to address that but you address it based on symptoms you don't address it based on the number per se so if somebody comes in seizing our comatose what you're gonna do is take you're not gonna know their sodium is low to start you're gonna do your usual seizing comatose addressing the patient if you find another cause they're seizing your comatose because they have a big brain bleed what you're gonna do is fix that brain bleed you're gonna take care of whatever is the underlying other cause however if there's not another reason that they're seizing in comatose and their sodium is low now you need to fix that seizing or fix that coma now and it is where you are on purpose going to pull out 3% saline yeah we use it now and head trauma all the time we're gonna pull this out on purpose to start to fix that low sodium that's causing them to seize the dosing is basically the hundred CCS and you do it three times in a row except you're smart people so go ahead and hang that three percent and go ahead and let a hundred cc's of that run in the patient okay if we want what they want them to our goal here is to stop seizing or wake up become less comatose that's our goal so a hundred cc's is going in and now I'm gonna go back and I'm gonna figure out was this something that is quick if it was a fast onset so this is so this is that baby who was given dilute tea for their fluid replacement who's gotten a really low sodium over a matter of just several hours to a day that kid I'm gonna go ahead and give all three doses boom I'm gonna basically replete them right away however if that person came on overtime this is somebody who's been on a diuretic for a long time was just given a now an additional medicine of lasix and got their sodium really really low by losing it all through their urine and now they're seizing her comatose that took a little longer to get there okay that actually took a little longer to get there I'm gonna be a little more careful and again your goal all your goal period in this is you try not to correct more than 1/2 to 1 milli equivalents per liter per hour so they started say 118 and you 10 hours later you're gonna want them to be the maximum of that 10 higher than that 1:28 you don't want to go much higher than that and your goal honestly isn't a number your goal is symptom improvement so if I give that first hundred CCS a three percent saline and my seizing patient stops seizing or my comatose patient starts to wake up I'm gonna back off and slow down I'm gonna not go so wildly crazy and I'll tell you this once you get to a sodium of 125 so say they start at 118 or 112 or 110 you get them up to 125 they should wake up or stop seizing and if they don't rethink your diagnosis go back and rethink it it's like whoa at 125 no one should be seizing your comatose is there something else causing this person to be seizing in comatose that's not related to this low sodium in and of itself so don't correct too fast and correct really only till the symptoms go away and then you can back off and do it more slowly okay that's what you're really aiming for now if I word my head my internal medicine hat on what I would do at the point of having somebody was hyponatremia because I would go all kind of crazy with calculating things like Finas and getting urine awesomes and all this kind of jazz if you do that as this internal emergency medicine person I will slap you I will slap you silly because what you're gonna do is be smarter okay you're gonna be more immediately sort of agile in your thoughts because you're gonna base it on the patient's clinical history which and what you're looking for here is hyponatremic and hyponatremia comes in three flavors it comes in I'm too little volume I have just enough volume I have too much volume so if I am hyponatremic and I have too much volume on board like let's say cirrhosis or congestive heart failure that person is one kind of way to treat if I'm somebody who's super hypovolemic I don't have enough volume and I'm hyponatremic say a diuretic or lots and lots of GI sort of losses that's another so GI adrenals that's this category and there's the know my volume is fine it's just my sodium is low that's a third category and you're gonna based you know this you you're examining the patient you're talking to them so somebody who basically is hypovolemic that's somebody basically has renal losses or kidney or extra meat like GI losses that's the diuretic person and you see that's the one we see the most out to be frank you see the person whose sodium comes back at 124 they've been on hydrochlorothiazide forever in a day it's kind of a random finding it's like wow I wasn't expecting that they're not symptomatic got to fix it over time don't have to hurry if they're euvolemic so I have actually my bow my volume is just fine but my sodium today is 122 I need to figure that out the biggest area that is SIADH that's an inappropriate so but it basically sida syndrome of inappropriate antidiuretic hormone and that's related to certain kinds of conditions like cancers so it tends to be brain problems lung problems and cancers tend to cause that and then the final one over here is I have too much volume I'm I'm volume overloaded hyponatremic that person you know that person is the cirrhotic that's the person with with renal failure who has lots of fluid overload the congestive heart failure patient so you can clinically figure out what to do with these people because the treatments are based on what their volume status is so once they've stopped seizing and they're not comatose or if they never get there you're not gonna go crazy you're gonna basically on purpose make a decision on what you do so if they're not not seizing not comatose they're just basically the sodium comes back low they're a little lethargic they just don't feel so great what you're gonna do is if there's too much fluid on board cirrhotic congestive heart failure you're just not going to give him any more fluid restriction for that person usually is and you may need to give a little bit diuretic just to get some of the fluid out you still run a risk of getting more sodium out with that but you get the fluid out usually loop diuretics lasix or euro so my it's the one for that but in general you fluid restrict those people if they're not comatose there's no hurry here there's no hurry to get that thing up to normal if they're you bulimic that's that SIADH kind of person if they need fluid or seems to be if there's a hypovolemic that person needs fluid and again remember you can go ahead and give a little a little bit to tank them up but you don't have to go nutty with this okay you don't have to correct the sodium you're just basically filling their tank you have to go nutty with this and then if their fluid is just right you're gonna fluid restrict those until we figure out why why they have sath why is it that this person is actually a normal volume but has a low sodium the key to this is not to do harm so your disposition is you're gonna admit people who are sick when they come in so comatose altered etc whose sodium is less than 120 when they come in because to safely get that thing up to a normal range is gonna take 20 or more than 24 hours okay or there's no the reason to admit they're sick they're sick for whatever reason that is when you're going to take your mouse and you're good over to urine awesomes you're gonna go over to you're in sodium and you're in electrolytes not before then because that's how they'll use those upstairs just fine you don't need to do have those numbers to make your decision on what to do in the emergency setting for somebody's a low sodium and you're gonna observe people if they have a sodium about 125 or so until you can just get them up to a normal range now I'll tell you why it's important it may know why it's important not to raise their sodium too fast too hot too quickly not to normalize the number there's a condition called central pontine myelinolysis it has a new name recently but that's basically what happens is say I decide I'm going to be a hero and I take my person who had a sodium - start of 118 but they're fine they're talking to me they're fine and I'm gonna send them upstairs in the normal normal sodium level so I go crazy giving them three percent saline or give me the normal scene and I get those numbers buffed to normal before they go upstairs I feel really good about myself the problem is that person central nervous system doesn't like getting that much that much sort of sodium back that fast it's gotten used to having a lower sodium level and what will happen is the myelin sheath usually of your paw in your brain gets destroyed and not today well you sent the patient upstairs but tomorrow or the next day that person ends up locked in they're awake they're alert and they can't move forever so you don't want to cause harm so don't go crazy fixing a number treat the patient as is appropriate if you want sort of a summary in words or two slides here with words you can go ahead and sort of take a look at that okay that's sodium or no potassium it's the other big one that we see and it's the other sort of electrolyte abnormalities that we see and hyperkalemia is really really common we had - I mean this happens all the time right you get a person who's sent to the I love this gets sent to the ER from there they got a call from their primary care office saying you've got to go to the ER right away you have an elevated potassium you've got to go there right away we checked your labs on Tuesday yes it's Friday but go ahead and go to the ER it happens all the time they get random labs checked and their sodium is or their potassium is five point eight or six and they get sent to the ER we see this all the time your job as an emergency person if somebody's potassium is elevated first of all if it's elated on Tuesday and it's now Friday first check again and see if it's still even up there but if it's elevated the first thing you're gonna do is take out your lovely little mouse and you're gonna click on EKG cuz you want to see if that elevated potassium is doing anything to the organ we really care about which is the heart right we this is what's used in lethal injection capital punishment cases is they use potassium for to stop the heart we don't want to do that in the emergency department so what you're gonna want to do is order an immediate EKG and somebody that has an elevated potassium what you're gonna look for are the changes that you see related to that and I think of these as taking a string so I think of my EKG with all of its little squiggles I take a string if I take that string and I push the ends together first what will happen is my t wave will go nice and peaked it's gonna look and it looks peaked it's a lot of T wave it's just kind of a little bit taller a little bit it's tends to be a pretty peaked and compared to an old one to see if it looks kind of weird to you but that's it's like a teeny wave you don't want to sit on it's just too peaky and then as my potassium gets higher and my heart gets not so happy about this you pull that EKG out so the first thing that happens is that P R gets longer and then my little bump of a P wave just flattens out and then my QRS complex gets wider and eventually I developed the sine wave which is the lethal sort of end result or having your potassium be too high I want to tell you something else though anywhere in there meaning that the EKG can be stone-cold normal you can get bradycardic as as a cardiac toxicity of hyperkalemia so I will tell you a really good practitioner will take somebody who's called in as a bradycardic you know somebody's a symptomatic bradycardia case coming in on a run and what they're gonna do is they're gonna go right to the bedside and they're gonna take this patient's leaves and they're gonna look at the patient's arms and they're gonna be looking for hemodialysis fistula or shunts if you have symptomatic bradycardia and somebody has a shunt on board if you can do a point-of-care potassium do it right then and there if you don't just give them some calcium so they have no other reason to have bradycardia and you have somebody who is a dialysis patient odds are their potassium is high treat it okay it can cause bradycardia in and of itself with none of the other peak teas cute none of that other jazz you can just do that alone oh by the way the causes of this the most common cause of hyperkalemia is renal failure but the other night you mungus group is ace inhibitors so you're also not just check the shunts you're gonna ask for the meds list and you're gonna look for a sand hitlers look for someone with a pearl on the end of it and that's gonna be a suggestion lisinopril seems to be the biggest actor in this but any pril so look for the pearls as far as causing this here those EKG changes i told you about but remember bradycardia can be just in there in and of itself just bradycardia can be all they have the treatment for us you guys know this right so our first line if that heart looks irritable so that their changes on the EKG or bradycardia I can't explain I'm gonna give calcium okay my goal listing of calcium that protects the heart and there you have a choice of gluconate or calcium chloride honestly either one is fine the key is to get calcium to the heart so Joe it grab it off the crash cart grab your calcium chloride and give them a push of that what you'll see if this is somebody who's symptomatic bradycardia from their missing dialysis a couple of times is that bradycardia suddenly just goes away or if they're QRS is wide and they've lost their P waves watch that EKG shrink back down to normal it's like magic it's like magic what this will do so calcium is really really important if the heart is having problems then what you need to do is get that potassium somewhere else get it somewhere else so what we do is we shift it for a while and we shift it with that glucose insulin combo insulin shoves potassium into cells we'll talk about that again when we talk about DKA bicarbonate especially somebody's acidotic bicarbonate will shove potassium into cells so you can get bicarb and inhaled andrew nergic so you give somebody inhaled you know beta agonists give them and haled albuterol that will also drive it into cells so all that's doing though is shifting it it's not getting rid of it it's just moving it into cells for a while so it's a tight buys you time eventually we need to eliminate them but I will tell you for most patients who are in the ER the Eliminator that we really need is dialysis if it's a dialysis patient who missed dialysis what they need is dialysis so you will need to get the renal people in or transport the patient to where they get where they get died at their dialysis because the things on this slide are yes they will eventually get rid of the potassium but I'll tell you they don't work very fast they don't work very fast at all so we KX lates what we've used forever today it's gotten a lot of bad press deservedly so it's not particularly effective it can cause conic necrosis so it has some pretty significant downsides so kayexalate although a lot of us still think about it or order it or told to order it it turns out it's not really a great agent for this there are two new agents out ones drug name is local ma I'll let you read that if it's a zirconium binder as well it's a powder that mixes up and they drink that but that doesn't work quickly and in fact the product insert itself says limit is basically should be should not be used as an emergency treatment of life-threatening hyperkalemia cuz it doesn't work fast it takes hours to work it's basically meant to keep people who stay high even despite dialysis to bring their potassium is down there's also another one called Val testa which is the drug name this is Petit patear Amir this is another one that basically is the same same concept it takes a little while to work so you may be asked to order these things just know it's not going to be magic and it's going to take a while to work and your shifters that you gave earlier eventually gonna basically it metabolized and that potassium is gonna come back out so just keep an eye on those folks hypokalemia is the other thing we see a ton because there's so many people on diuretics most of our diuretics are our potassium wasting drugs the only one that isn't is spironolactone all the rest of them you basically pee out its prolactin to try and free but you basically pee out potassium so it's part of what you lose sodium and potassium in the urine so you can also lose this with GI shift so somebody who has GI and renal losses they could lose this as well and the symptoms that people get this is the main thing honestly is weakness they feel kind of weak and just which is a very nonspecific finding they can end up with ectopy they can end up with constant and PVCs or not are pretty common actually with low potassium is people get PVCs nausea they may have some polyuria but mainly it's just I feel lethargic and I feel a little nauseated if they get really bad though if they get really really low you cannot contract a muscle unless you have potassium it's actually required for muscle contraction your sodium ATP channel works to shift things back and forth and it allows you to make a commercial contraction so if you're if your potassium gets really really low you can end up paralyzed the cases of this that are awesome are the cases of so my favorite case of this it's not it was a hypokalemia case where a family brought in their son like 20-something son and the chief complaint was he's a lazy son of a that they literally like deposited him in a chair and said he's lazy and the dad said every night he sits in front of television set any channel surf so he eats ice cream every night and he just sits there and channel surfs and he won't move and he just sits there he sits there knee won't get a job and he's just a lazy son of a and tonight not only was he sitting in the chair and eating his ice cream he slid out of the chair and laid on the floor I told him to get out of that chair and he wouldn't get up so they dragged him and the guy is sitting in the chair like this looks like whoa dude couldn't lift an arm couldn't lift a leg had a potassium of 1:1 what he had was periodic paralysis he got a soda or a sugar load every day by eating ice cream his insulin released in his own body it shoved his own potassium over excessively into his own cells and he basically drove his own potassium down everyday by eating icecream awesome you don't have to treat that by the way tends to come back on its own unless they're really really bad like they're not breathing kind of bad and they can give a little but most the time they'll shift right back out again so remember that if somebody comes in kind of weak and lethargic check their potassium that may be the problem also know the potassium has a friend an electrolyte friend that they are always together and that's magnesium sodium it's a potassium and magnesium are best friends to fix one you have to treat the other so even if the magnesium level is normal when you measure it to fix a low potassium you've got to give magnesium so I give a little bit of magnesium and give a gram or two and then give them two tasking because it won't stay so treating people you can do it orally is fine you don't have to do it IV if they're really there can't move fine IV but if they if they're otherwise fine go ahead and treat him orally but no if somebody comes in with a potassium level of 2.5 and they've been on a diuretic for a while they are literally hundreds of millions down it's gonna take you a while to really replete that completely a single dose is gonna do it so what you're gonna need to do often is put those kinds of people in ops and just let them get orally replete and tell their potassium is up to be a safe level and again remember mag you've got to give mag four potassium to stay absorb appropriately here's an EKG changes just for interest sake I'm gonna switch to the last two electrolytes and then we're gonna do our Q&A session hypercalcemia so the time so this is basically their two reasons people get hypercalcemia if you're lucky it's because you're hyper parathyroid your parathyroid glands go crazy you basically release calcium into your bloodstream and you end up hypercalcemia if you're unlucky it's because you have a parathyroid hormone like chemical in your body from a cancer so we tend to see hypercalcemia primarily in cancer patients that's the group we see this in the most it's a little bit complicated because calcium likes to be bound to protein some of it floats around in your body free and some of its bound to protein so to measure it completely you need to know an albumin level as well but when people get hypercalcemia what tends to happen is they get lethargic they get constipated they get nauseated they get dry they just feel gross they feel gross and this is sort of the thing I was taught it was boasting the bones the bones the Toxic all this so to get painful bones basically because leaching calcium out of their bones they get kidney stones they can over time they get constipation so a lot of belly pain some nausea nausea that goes with that and it can make them lethargic and I've actually can make put them into a coma I think it's too high so this is and think about it you're a cancer patient you're getting chemo that makes you nauseated and feel gross you're getting opioids to treat your cancer pain which gives you constipation so you're gonna feel lethargic and nausea didn't constipated unless you're an astute clinician and you glanced at those labs and notice wow that calcium is 12.8 that's too high that's too high and actually corrected it's a little higher than that because I looked at the album and I corrected it a little higher than that maybe this person symptoms aren't from their chemo and their cancer and their opiates maybe they're symptomatic because their hypercalcemia it makes you dry it just makes you miserable absolutely miserable there's a heartbreaking study that looked at hyper calcium at cancer patients in the hospital and half of them never had the calcium addressed even though their symptoms were related to being hypercalcemia so what you'll also see is an EKG that shows a shortened QT so the QT may be maybe short not a big clinical sign to you that oh maybe what's going on here maybe clinical sign your job if you diagnose hypercalcemia is to water the patient hydrate them so you can give them normal saline that's all you need to worry about all the other jazz honestly can get done later the calcitonin can be done later the bisphosphonates can be done later your job is to get that patient rehydrated often they'll pee out enough of that calcium that they feel much much better before anything more aggressive is done now hypocalcemia the most common cause of this is renal failure labs my favorite case of this was a guy that was brought into triage because he said I keep getting hand cramps what's up with that I keep getting hand cramps I'm having seizures at my hands what's up with that young guy totally young guy you know in mid-20s early teens really young guy and he was out there like this it's like what is happening it's like doing this whole car papito spasm thing the critical value called from the lab was a calcium of for four he also had a phosphate of like 9 and AB you and creatinine of like a hundred and something over nineteen he was in raging renal failure from untreated hypertension which was really sad so hyper hypocalcemia is when things you see in renal failure they can get tetiny and this is the tetany you can see when they put the blood pressure cuff up you they may you may see that so they may get tetany with this and again it's just car papito spasm it's not super bad to ten ik and this you basically can treat either either orally or you can treat IV nope you don't go crazy with this okay treating hypocalcemia you have to go nutty and in fact if it's from renal failure and their phosphate is high treating it to aggressively can cause them to deposit calcium in their body so you're gonna basically just get on the horn and that kind of person that renal failure patient and get them dialyzed alright last two things hypomagnesemia really really common not that commonly treated for us and the group we see this in mainly is the people that don't eat well so people that are poorly nourished and alcoholics alcoholics tend to be hypomagnesemia so the symptoms here are also very vague you can measure it on your lab if it's if it's definitely low on lab go ahead and treat it and remember anybody who's k is low you're also gonna treat even if they're mag is normal oral therapy is absolutely fine okay don't have to go crazy give me an IV oral therapy is fine and then hyper mag we only see in renal failure it's hardly ever seen anywhere other than renal failure so it is really really rare so that's not something you need to worry about so remember when it comes to sodium only treat the patient not the number do no harm okay and when it comes to low sodium you'll figure out what their volume status is and you're an expert hyperkalemia it's the heart you worry about the most hypokalemia you don't have to go crazy treating to orally just as a matter they're got a lot of volume deplete the hypercalcemia think about is amis lethargic and constipated especially their cancer patient treat that with IV fluids all the rest of it's pretty straightforward and don't forget when you're repeating potassium always replete magnesium to there's a key geez if you're interested and it's gonna be Q&A time thank you

Channel: The Center for Medical Education

Views: 24,914

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Keywords: emergency medicine, em boot camp, nurse practitioner, physician assistant

Id: fvl1pyEY_RA

Length: 32min 59sec (1979 seconds)

Published: Thu Mar 12 2020