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Lytes
Renal
| Question | Answer |
|---|---|
| hyponatremia = | Na <135 (symptoms seen at Na <125) |
| Etiology of hypervolemic hypotonic hyponatremia | CHF, nephrotic syndrome, ARF, hepatic cirrhosis |
| Etiology of euvolemic hypotonic hyponatremia | hypothyroid, glucocorticoid excess, SIADH, polydipsia, beer potomania |
| Etiology of hypovolemic hypotonic hyponatremia | dehydration, diarrhea, vomiting |
| Hyperkalemia (K >5) etiologies | ARF (most common), increased K load, metabolic acidosis, cell death, hyporeninemic hypoaldosteronism |
| Hypokalemia (K <3.5) nonrenal (urine K <20) etiologies | GI losses (N/V/D, Z-E syndrome), metabolic alkalosis (increases K secretion) |
| Hypercalcemia etiologies | HyperPTH (most common). Neoplasm (lung, head/neck, MM, NHL, cervical, RCC). Vit D intox. Paget. Adrenal insuff. Milk alkali syndrome. Sarcoid. ZE syndrome. Acromegaly. |
| Dry skin, brittle nails, mx cramps, paresthesias, laryngospasm/stridor, hyper DTRs, SOB, crackles, S3, syncope & angina = | hypocalcemia (Ca <8.5); usu 2/2 CKD or hypoPTH |
| Hyperphosphatemia (1.0-2.5); severe (<1.0) can lead to: | rhabdo, paresthesia, encephalopathy |
| Hypermagnesemia (2.5 mEq/L) sx/sx | 1st: reduced DTRs; mx weak, hypoTN, resp depression, cardiac arrest; N/V, flushing; high bleeding time/coag |
| Normal range: pH: | 7.40 (7.35-7.45) |
| Normal range: pO2: | 80-100 mmHg |
| Normal range: pCO2: | 35-45 mmHg |
| Normal range: HCO3: | 22-26 mmol/L |
| Anion gap = | cations (Na+) – anions (Cl- + HCO3-); Normal AG = 8-16 mmol/L |
| Respiratory compensation for metabolic acidosis | pCO2 should fall 1.2 for every 1.0 drop in HCO3 |
| Respiratory acidosis etiology | impairment in rate of alveolar ventilation; acute medullary resp ctr depression (narcotic OD), resp mx paralysis, airway obstruction; chronic (emphysema, pickwickian) |
| Resp acidosis Sx/Sx | metab encephalopathy: somnolence, confusion, narcosis, asterixis. Fundi: dilated, tortuous vessels, possible papilledema |
| Resp acidosis DDx/causes | COPD, airway obstruction, CNS depression (opioids, brainstem injury), neuromx (GBS, MG, botulism), myxedema |
| Resp alkalosis (hypocapnia) Patho | hyperventilation reduces PCO2, increases pH |
| Resp alkalosis Sx/Sx | lightheadedness, anxiety, perioral numbness, acroparesthesias (pain hands & feet) |
| Resp alkalosis DDx | PE, pulmo edema, PTX, ARDS, pulmo art HTN, asthma, interstitial pulmo fibrosis |
| NAGMA possible causes = | extrarenal bicarb loss (diarrhea, renal bicarb excretion); renal tubular acidosis; chronic renal failure, carbonic anhydrase inhibitors, diuretic, primary hyperPTHism, Addison dz |
| AGMA: MUDPILES | methanol, uremia, DKA, propylene glycol, isoniazid, lactic acidosis [shock, septicemia, hypoxemia], ethylene glycol, salicylates |
| AGMA: CUTE DIMPLES | C for Cyanide & T for Toluene plus MUDPILES |
| Metab acidosis Sx/Sx | CP, palpitations, HA, AMS, decreased visual acuity, N/V/abd pain, wt loss, mx weakness, bone pain; Kussmaul (profound DKA), lethargy, stupor, coma, seizures; V-tach, hypotension |
| Metabolic alkalosis: chloride-responsive (low urine Cl): due to: | diuretic tx (contraction alkalosis) or loss of gastric secretions (2/2 vomiting or NG tube) |
| Metabolic alkalosis: chloride-resistant (high urine Cl): etiology | Bartter or Gittelman syndrome; hyperaldosteronism; bicarb intake in CKD |
| Pathology of hypervolemic hypotonic hyponatremia | expansion of extracellular fluid relative to amount Na present |
| Pathology of hypovolemic hypotonic hyponatremia | 1) extrarenal. 2) renal salt/volume loss based on urine Na level |
| Conditions associated with isotonic hyponatremia | Hyperlipidemia (familial HLD or nephrotic syndrome), hyperproteinemia (multiple myeloma, macroglobulinemia) |
| Isotonic hyponatremia patho | Na amount in plasma stays same, but more of other solutes -> decrease in relative Na conc |
| Hypertonic hyponatremia etiology | Hyperglycemia (100mg/dL rise -> 1.5mEq/L Na drop); hypertonic tx (eg, mannitol) -> water leaves cells, Na leaves vascular space to extracellular space |
| Hypernatremia defn = | serum Na >145mEq/L (osmo >290) |
| Hypernatremia correction | Free water deficit = Wt x [(Na - 140)/140]. Correct over 48h; drop Na by 1mEq/L/hr. |
| Hypokalemia (K <3.5) renal (urine K > 40) etiologies | diuretics, renal tubular acidosis, adrenal hormones, hyperaldosteronism, Cushing/steroids, digoxin, low Mg |
| Hypokalemia clinical features | Muscle cramps, ileus, dysrhythmia |
| Hypokalemia with acidosis & without HTN: suspect: | RTA |
| Hypokalemia with high urine Cl without HTN / acidosis: suspect: | Diuretics or Bartter syndrome (low urine Cl = N/V) |
| High dose K repletion for severe hypokalemia (<2.5 mEq/L) | Max 20 mEq/L/h and max 60 mEq/L. Should be via central venous access |
| Dysrhythmias associated with severe hyperkalemia (>6.5) | Brady, prolonged PR, peaked T waves progressing to long QRS; V-fib |
| Most potassium in body is found in: | Intracellular |
| Hyperkalemia from K shift from intracellular to extracellular space may be 2/2: | Burns, rhabdo, hemolysis, severe infxn, internal bleeding, extreme exercise |
| Hyperkalemia clinical findings | Initial hyperreflexia, then flaccid paralysis; vasodilation |
| Hyperkalemia mgmt | IV beta-agonists (salbutamol), Na bicarb, IV insulin (w/D5NS); Ca gluconate (stabilizes cardiac membrane); SPS; loop diuretics; ?HD |
| Ca distribution in body | 99% in bone. 0.01% in body fluids. 50% of Ca bound to albumin, 10% to other, 40% free. |
| Hypocalcemia etiologies | CKD (most common: 2/2 decreased vit D production). Low albumin. Sepsis. Acute pancreatitis. Post-thyroid surgery. hypoPTH. Blood transfusion. Medullary ca of thyroid (calcitonin secretion). |
| Hypocalcemia patho | Low Ca (2/2 low intake/absorption or low PTH or increased Ca into bone) -> lower NM excitation threshold -> reduced contractile force in vascular smooth & cardiac mm |
| Symptomatic hypocalcemia mgmt. | IV Ca gluconate 10% infusion, ?IV CaCl |
| Hypercalcemia clinical findings | Weakness, polydipsia, hyporeflexia, confusion, renal calculi, N/V, constipation, ileus, nephrogenic DI, bone pain/fx |
| Hypercalcemia mgmt. | IVF forces urinary excretion of Ca. +/- furosemide (thiazide may worsen high Ca). +/-HD. |
| Hypercalcemia mgmt.: underlying causes | Metastatic bone dz: calcitonin +/- pamidronate (inhibit bone resorption). Sarcoid/MM/leukeumia/BrCa/vit D intox: glucocorticoids |
| PO4 distribution in body | 70% intracellular, 29% intraskeletal, <1% serum |
| Hypophosphatemia etiology | Decreased GI absorption, vit D def, refeeding syndrome, hyper PTH, hyperthyroid, DKA, sepsis, ASA toxicity |
| Severe hypophosphatemia results in: | Decreased affinity of Hgb for O2 |
| Hypophosphatemia workup | Serum PO4 <2.5. Urine PO4 >20 = renal loss. PTH. Bone bx: ?osteomalacia. CK (rhabdo) |
| Hyperphosphatemia etiology | CKD, AKI, hypoPTH, acromegaly. Increased intake, vit D, rhabdo, cell lysis, AGMA |
| Phosphate binders | Sevelamer, lanthanum, Aluminum hydroxide |
| Resp alkalosis (hypocapnia) etiology | Hyperventilation syndrome (?anxiety). GNR sepsis, cirrhosis, PE, CHF, ILD, PNA, pulmo edema, HAPE, CVA, anemia, PG (2/2 progesterone stim of resp ctr), acute ASA tox |
| Low anion gap seen in: | NAGMA, myeloma, hypoalbuminemia, lithium Rx |
Created by:
Abarnard
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