When Do I Order What?

1. When Do I Order What? Bucky Boaz, ARNP-C

2. Criteria for Detecting Electrolyte Abnormalities in ED Patients • Poor oral intake • Vomiting • Hypertension, diuretic use • Age > 65 • Recent Seizure • Muscle Weakness • Alcohol abuse • Altered mental status • Recent abnormal electrolytes

3. Electrolyte Disorders • Calcium • Magnesium • Potassium • Sodium

4. Normal range: 8.5-10.5 mg/dL Panic! <6.5 or >13.5 mg/dL Marbled top Serum calcium is the sum of ionized calcium plus complexed calcium and calcium bound to proteins (albumin) Level of ionized calcium is regulated by parathyroid hormone and vit D. Calcium

5. Calcium

6. Hypoparathyroidism Vitamin D deficiency Renal insufficiency Pseudohypo-parathyroidism Magnesium deficiency Hypophosphatemia Massive transfusion hypoalbuminemia Hypocalcemia

7. Calcium

8. Hyperparathyroidism Malignancies secreting parathyroid hormone-related protein (PTHrP) squamous cell of lung Renal cell carcinoma Leukemia Vitamin D excess Multiple myeloma Paget’s disease Sarcoidosis Vitamin A intoxication Thyrotoxicosis Addison’s disease Drugs Antacids, Calcium salts, Diuretic use, Lithium Hypercalcemia

9. Calcium

10. Calcium • Need to know serum albumin to know corrected calcium level. • For every decrease in albumin by 1 md.dl, calcium should be corrected upward by 0.8mg/dL. • Serum PTH level should be measured at initial presentation of all hypercalcemic patients

11. Normal range: 1.8-3.0 mg/dL Panic! <0.5 or 4.5 mg/dL Marbled top Concentration is determined by intestinal absorption, renal excretion, and exchange with bone and intracellular fluid Magnesium

12. Chronic diarrhea Enteric fistula Starvation Chronic alcholism Hypoparathyroidism Acute pancreatitis Chronic glomerulonephritis Diabetic ketoacidosis Drugs Albuterol Amphotericin B Calcium salts Cisplatin Cyclosporin Diuretics Hypomagnesium

13. Hypomagnesemia • (<1.5 mEq/L) • Due to diuretics, aminoglycosides, cyclosporine. • Clinical features: • Irritable muscle,tetany,seizure,arrhythmia. • Treat: • MgSO4 25-50 mg/kg IV over 20 min.

14. Dehydration Tissue trauma Renal failure Hypothyroidism Drugs Aspirin (prolonged use) Lithium Magnesium salts Progesterone Triamterene Hypermagnesium

15. Hypermagnesemia • (>2.2 mEq/L) • Due to renal failure, excess maternal Mg supplement, or overuse of Mg-containing medicine. • Clinical features: • weakness, hyporeflexia, paralysis, and ECG with AV block & QT prolongation. • Treat: • CaCl (10%) 0.2-0.3 ml/kg (max 5 ml) IV.

16. Normal range: 3.5-5.0 mg/dL Panic! <3.0 or >6.0 mg/dL Marbled top Predominately an intracellular cation whose plasma level is regulated by renal excretion. Plasma concentration determines neuromuscular irritability Potassium

17. Potassium

18. Hypokalemia • Clinical Features of Hypokalemia • Lethargy, confusion, weakness • Areflexia, difficult respirations • Autonomic instability, Low BP • ECG findings in Hypokalemia • K+ <3.0 mEq/L: low voltage QRS, • flat T waves, ST segment, • prominent P and U waves. • K+ = 2.5 mEq/L: prominent U wave • K+ = 2.0 mEq/L: widened QRS

19. Hyperkalemia • Causes of Hyperkalemia • Exogenous: • blood • Salt substitutes • K+ containing drugs (e.g. penicillinderivatives) • Acute digoxin toxicity • Beta blockers, ACE inhibitors • Succinylcholine • Non-steroidals

20. Hyperkalemia • Endogenous: • Acidemia • Trauma • Burns • Rhabdomyolysis • DIC • Sickle cell crisis • GI bleed • Chemotherapy (destroying tumor mass) • Mineralocorticoid deficiency • Congenital defects (21 hydroxylase deficiency)

21. Hyperkalemia • K+ 5-6.0: peak T waves • K+ 6-6.5:PR and QT intervals • K+ 6.5-7:P, ST segments • K+ 7-7.5:intraventricular conduction • K+ 7.5-8:QRS widens, ST and T waves merge • K+ > 10: sine wave appearance

22. Normal range: 135-145 mg/dL Panic! <125 or >155 mg/dL Marbled top Predominately an extracellular cation. Serum sodium level is primarily determined by the volume status of the individual. Sodium

23. Hyponatremia • Symptoms • Lethargy, apathy • Depressed reflexes • Muscle cramps • Pseudobulbar palsies • Cerebral edema • Seizures • Hypothermia

24. CHF Cirrhosis Vomiting Diarrhea Excessive sweating (replacing water, but not salt) Salt-loss nephropathy Adrenal insufficiency Water intoxication SIADH Drugs Thiazides Diuretics ACE Inhibitors Chlorpropamide Carbamazepine Hyponatremia

25. Hyponatremia

26. Hypernatremia • Symptoms • Lethargy, irritability, coma • Seizures • Spasticity, hyperreflexia • Doughy skin • Late preservation of intravascular • volume (and vital signs)

27. Dehydration (excessive sweating, vomiting, diarrhea) Polyuria (diabetes mellitus, diabetes insipidus) Hyperaldosteronism Inadequate water intake (coma, hypothalmic disease) Drugs Steroids Licorice Oral contraceptives Hypernatremia

28. Hypernatremia

29. Endocrine Disorders • Hyperthyroidism/ Thyroid Storm • Hypothyroidism/ Myxedema Coma

30. Underlying Thyroid Disease Grave’s Disease (#1) Toxic nodular goiter Toxic adenoma Factitious thyrotoxicosis Excess TSH Precipitants Infection (#1) Pulmonary embolus DKA or HHNC Thyroid hormone excess Iodine therapy/dye Stroke, surgery Childbirth, D&C Hyperthyroidism/Thyroid Storm

31. Hyperkinesis Palpable goiter Proptosis, lid lag Exopthalmus, palsy Temp > 101 F HR + Pulse pressure Arrhythmia (new onset) Weight Loss Palpitations Dyspnea Psychosis Apathy Coma Tremor Hyperreflexia Diarrhea Jaundice Clinical Features of Hyperthyroidism/Thyroid Storm

32.  free T4  T3  TSH  T4RIA  FT4I  Glucose  Ca+2  WBC  Hb  Cholesterol Lab test can diagnose hyperthyroid, but Thyroid Storm (Thyrotixicosis) is a clinical diagnosis Laboratory Findings Hyperthyroidism/Thyroid Storm

33. Precipitants Pneumonia GI bleed CHF Cold exposure Stroke Trauma  pO2  CO2  Na+ Drugs Phenothiazides Narcotics Sedatives Phenytoin propanolol Hypothyroidism/Myxedema Coma

34. Clinical Features of Hypothyroidism/Myxedema Coma

35. Serum TSH > 60 U/ml  Total & free T4  or  total & free T3 Laboratory Findings of Hypothyroidism/Myxedema Coma

36. Liver Disease Laboratory Findings in Liver Disease

37. Stroke, TIA, and Subarachnoid Hemorrhage • CT Scan abnormal > 95% if onset < 12h • CT Scan abnormal 77% if onset > 12h • CSF > 100,000 RBCs/mm3 (mean) although any # can be seen • Xanthochromia • ECG = peaked, deep, or inverted T waves,  QT, or large U wave

38. Imaging Low Back Pain • Acute neuro deficit consistent • Acute significant trauma • Age > 70, or minor trauma > 50 years • History of prolonged steroid use OR osteoperosis • History of cancer OR unexplained wt loss • History of recent infection OR fever > 100 F OR parental drug abuse • LBP worse at rest OR disability due to LBP > 4 weeks

39. Fever in Children

40. Clinically Significant CXR Abnormalities SOBreath Criteria 95% sensitive, 40% specificity

41. Pulmonary Embolism

42. Abdominal Pain

43. Abdominal Pain Diagnostic Studies in Appendicitis

44. Abdominal Pain

45. Abdominal Pain

46. Abdominal Pain

47. Biliary Tract Disease • Clinical Features of Biliary Colic • Pain usually begins 30-60 min after meal • Pain duration < 6-8 hrs • Absence of fever • WBC < 11,000 cell/mm3 in most • Normal liver function tests in 98% • Absence of pancreatitis • US is 98% sensitive for gallstones

48. Biliary Tract Disease Clinical Features Acute Cholecystitis

49. Pancreatitis • Suspect abscess, hemorrhage, or pseudocyst if fever, persistent  amylase,  bilirubin,  WBC. • US – 60-80% sensitive, 95% specific • CT – 90% sensitive, 100% specific • Obtain CT or US if suspected pseudocyst, abscess, gallstones, or trauma

50. Painful Scrotum