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When Do I Order What?
Bucky Boaz, ARNP-C
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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
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Electrolyte Disorders
• Calcium
• Magnesium
• Potassium
• Sodium
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Calcium
• 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.
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Calcium
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Hypocalcemia
• Hypoparathyroidism• Vitamin D deficiency• Renal insufficiency• Pseudohypo-
parathyroidism• Magnesium deficiency
• Hypophosphatemia• Massive transfusion• hypoalbuminemia
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Calcium
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Hypercalcemia
• 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
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Calcium
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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
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Magnesium
• 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
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Hypomagnesium
• Chronic diarrhea• Enteric fistula• Starvation• Chronic alcholism• Hypoparathyroidism• Acute pancreatitis• Chronic
glomerulonephritis
• Diabetic ketoacidosis• Drugs
٭ Albuterol
٭ Amphotericin B
٭ Calcium salts
٭ Cisplatin
٭ Cyclosporin
٭ Diuretics
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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.
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Hypermagnesium
• Dehydration• Tissue trauma• Renal failure• Hypothyroidism
Drugs٭ Aspirin (prolonged
use)
٭ Lithium
٭ Magnesium salts
٭ Progesterone
٭ Triamterene
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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.
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Potassium
• 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
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Potassium
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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
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Hyperkalemia
• Causes of Hyperkalemia٭ Exogenous:
• blood • Salt substitutes• K+ containing drugs (e.g. penicillinderivatives)• Acute digoxin toxicity• Beta blockers, ACE inhibitors• Succinylcholine• Non-steroidals
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Hyperkalemia
٭ Endogenous:• Acidemia• Trauma• Burns• Rhabdomyolysis• DIC• Sickle cell crisis • GI bleed • Chemotherapy (destroying tumor mass) • Mineralocorticoid deficiency • Congenital defects (21 hydroxylase deficiency)
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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
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Sodium
• 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.
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Hyponatremia
• Symptoms٭ Lethargy, apathy٭ Depressed reflexes ٭ Muscle cramps٭ Pseudobulbar palsies٭ Cerebral edema٭ Seizures٭ Hypothermia
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Hyponatremia
• 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
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Hyponatremia
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Hypernatremia
• Symptoms٭ Lethargy, irritability, coma٭ Seizures٭ Spasticity, hyperreflexia٭ Doughy skin٭ Late preservation of intravascular٭ volume (and vital signs)
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Hypernatremia
• Dehydration (excessive sweating, vomiting, diarrhea)
• Polyuria (diabetes mellitus, diabetes insipidus)
• Hyperaldosteronism
• Inadequate water intake (coma, hypothalmic disease)
• Drugs٭ Steroids
٭ Licorice
٭ Oral contraceptives
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Hypernatremia
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Endocrine Disorders
• Hyperthyroidism/
Thyroid Storm
• Hypothyroidism/
Myxedema Coma
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Hyperthyroidism/Thyroid Storm
• 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
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Clinical Features of Hyperthyroidism/Thyroid Storm
• 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
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Laboratory Findings Hyperthyroidism/Thyroid Storm
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
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Hypothyroidism/Myxedema Coma
• Precipitants٭ Pneumonia٭ GI bleed٭ CHF٭ Cold exposure٭ Stroke٭ Trauma pO2
CO2
Na+
• Drugs٭ Phenothiazides
٭ Narcotics
٭ Sedatives
٭ Phenytoin
٭ propanolol
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Clinical Features of Hypothyroidism/Myxedema Coma
Vitals Temp is ofter < 90 F, 50% have BP < 100/60
Cardiac HR, heart block, low voltage, ST-T changes, effusion
Pulmonary Hypoventilation, pCO2, O2, pleural effusions
Metabolic Hypoglycemia, hyponatremia
Neurologic coma, seizures, tremors, ataxia, nystagmus, psychiatric disturbances, depressed reflexes
GI/GU Ileus, ascites, fecal impaction, megacolon, urinary retention
Skin Alopecia, loss of lateral 1/3 of eyebrow, nonpitting puffiness around eyes, hands, and pretibial region
ENT Tongue enlarges, voice deepens and becomes hoarse
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Laboratory Findings of Hypothyroidism/Myxedema Coma• Serum TSH > 60
U/ml Total & free T4
or total & free T3
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Liver Disease
Laboratory Findings in Liver DiseaseDisease AST/SGOT ALT/SGPT Alk Phos Bilirubin Albumin
Abscess 1-4 X 1-4 X 1-3 X 1-4 X Normal
Acetomenophren 50-100 X 50-100 X 1-2 X 1-5 X Normal
Alcohol Hepatitis AST>ALT 2:1
AST>ALT 2:1
10 X 1-5 X Chronic
Biliary Chirrosis 1-2 X 1-2 X 1-4 X 1-2 X
Chronic Hepatitis 1-20 X 1-20 X 1-3 X 1-3 X
Viral Hepatitis 5-50 X 5-50 X 1-3 X 1-3 X Normal
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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
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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
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Fever in Children
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Clinically Significant CXR Abnormalities
S Saturation < 90%
O Older than 59 years
B Breath sounds diminished
R Rales or Respiratory rate > 24 bpm
E Embolic disease (prior DVT or PE)
A Alcohol abuse
T Tuberculosis or Temp > 100.4
H Hemoptysis
95% sensitive, 40% specificity
SOBreath Criteria
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Pulmonary EmbolismDIAGNOSTIC STUDIES ECG Findings
CXR – abnormal in 60-84% Nonspecific ST-T changes 50%
Art blood gas – 92% A-a gradient T wave inversion 42%
Ventilation perfusion scan V/Q - below
New right bundle branch 15%
D-Dimer – 95% sen, 50% spec S in 1, Q in 3, T in 3 12%
Angiography - > 98% sen/spec Right axis deviation 7%
Echo – detects 90% causing BP Shift in transition to V5 7%
CT – 90% sen for central PE Right ventricle hypertrophy 6%
MRI - >90% sen for PE P pulmonale 6%
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Abdominal Pain
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Abdominal Pain
In first 24 hours, WBC count > 11,000 20-40%
After 24 hours, WBC > 11,000 70-90%
Urinalysis with > 5 WBC or RBC/hpf 15-30%
Ultrasound sensitivity 78-94%
Ultrasound specificity 89-100%
CT scan sensitivity 92-100%
CT scan specificity >95%
Diagnostic Studies in Appendicitis
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Abdominal Pain
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Abdominal Pain
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Abdominal Pain
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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
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Biliary Tract Disease
Clinical Features Acute Cholecystitis
Pain duration > 6-8 hrs > 90%
Temp > 100.4 F 25%
WBC > 11,000 cell/mm3 in most >95%
Murphy’s sign 65%
Elevated liver function tests 55%
Pancreatitis 15%
Ultrasound sensitivity 85%
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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
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Painful Scrotum
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Trauma
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Accidental vs Non-accidental
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Head Trauma
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Head Trauma
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Head Trauma
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Cervical Spine
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Cervical Spine
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Thoracolumbar Spine
Back pain or tenderness Ejection from motorcycle/vehicle
Neurologic deficit Motor vehicle crash > 50 mph
Glasgow coma scale < 14 Major distracting injury
Drug intoxication •Pelvic fracture
Alcohol intoxication •Long bone fracture
•Blood alcohol > 100 mg/dl Intrathoracic injury
Fall > 10 feet Intraabdominal injury
Indications for Thoracolumbar Spine Radiographs in Blunt Trauma
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Shoulder
Shoulder deformity History of fall (with age > 43.5 years)
Shoulder swelling Abnormal range of motion
High-Yield Criteria for Shoulder Xrays in the Emergency Department
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Blunt Real Trauma
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Pelvis
Disoriented, Glasgow coma scale < 14 Groin or suprapubic swelling
Intoxication with drugs or alcohol Pain, swelling, eccymosis of medial thigh, genitalia, or lumbosacral area
Hypotension or gross hematuria Instability of pelvis to anterior-posterior or lateral-medial presure
Lower extremity neurologic deficit Pain with abduction, adduction, rotation, or flexion of either hip
Femur pain
Pain or tenderness of pelvic girdle, symphysis pubis, or iliac spine
Criteria for Pelvic Radiography Following Blunt Trauma
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Abdominal Trauma
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Abdominal Trauma
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Ottawa Knee
Age > 55 Unable to flex 900
Unable to walk immediately after injury or 4 steps in the ED
Isolated fibular head tenderness
Isolated patellar tenderness
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Pittsburgh Knee
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Foot and Ankle