ELECTROLYTE EMERGENCIES: CASE #1 An 18 year old woman is brought to the ED by Urgences Sante (US). She was at a rave with her friends and was witnessed to suddenly lose consciousness and have a generalized tonic clonic convulsion. On arrival of US she was post-ictal, but en route she had two more seizures of about two minutes each. She received 5 mg of IM midazolam ten minutes ago. Her friends say she is not known for epilepsy and do not believe she takes any medication. They admit that she used “ecstasy” tonight. Presently she is postictal, moving all four extremities without obvious focal deficit. She is protecting her airway and has the following vital signs: BP 120/80 HR 110 (sinus) T 37.8 rectal RR 20 O2sat 100% on NRBM The remainder of the physical exam is normal.

1) What electrolyte abnormality do you suspect as the cause of this patient’s seizures?

2) Assuming you are correct, what is your immediate management?

3) What is the danger of correcting this electrolyte disorder too quickly?

4) What is the appropriate rate of correction of this electrolyte disorder?

ELECTROLYTE EMERGENCIES: CASE #2 You have just received signover on the monitored area of the ED at midnight. One of the patients signed over to you is a 78 year old unilingual Cantonese man with severe non-ketotic, non-acidotic hyperglycemia. He is a known type 2 diabetic who also has end-stage ischemic cardiomyopathy with an EF of 10 -15%, a pacemaker/defibrillator, and severe mitral regurgitation. No level of care sheet has been filled, and the family is no longer present at the bedside. Your colleague informs you that the patient is stable and awaiting consultation from internal medicine. He has been prescribed an insulin drip at 3 units/hr and his IV is running NS at 80 cc/hr. Presently his vital signs are: BP 90/60 HR 110 RR 24 O2sat 93% on 4L np T 38.1 rectally The patient is alert (you cannot assess orientation due to language barrier) and does not appear in distress. His exam is otherwise unremarkable save dry mucous membranes, a loud MR murmur, and some crackles at both lung bases. The jugular veins appear to be flat. His labs include the following abnormal values: Glucose 62 mmol/L Na 148 mmol/L Creat 189 (previously 135) Discuss the pitfalls of managing a case such as this one.

ELECTROLYTE EMERGENCIES: CASE #3 A 68 year old male is brought to your resuscitation area after a “code blue” was called at the entrance to the hospital. The code team tell you that he was witnessed to suddenly lose consciousness, and upon their arrival he was unresponsive and had no detectable pulse. CPR is ongoing and the patient is being ventilated by BVM with 100% O2. You ask the team to momentarily halt CPR in order to assess the rhythm and check for a pulse. This is the rhythm you see on the monitor:

He has no detectable pulse. The nurse asks you if she can start the IV into the patient’s fistula.

1) What is your differential diagnosis for pulseless electrical activity (in general) and what electrolyte disorder to you suspect as the cause of this particular patient’s cardiac arrest?

2) What immediate steps would you take to treat this patient’s electrolyte disorder?

3) What are the EKG findings associated with this electrolyte disorder in its earlier stages?

ELECTROLYTE EMERGENCIES: CASE #4 A 32-year-old pipefitter sustained an injury to 2.5% of the body surface area (hand) from exposure to 60% hydrofluoric acid while at work at an oil refinery. The patient is currently stable and is being treated appropriately for the local tissue injury. However, you are aware that this exposure to such a high concentration of HF could result in systemic toxicity. 1) What is the MAIN electrolyte disorder associated with mortality from HF

burns?

2) What symptoms/signs would suggest this electrolyte disorder?

3) What ECG findings could alert you to the onset of systemic toxicity in this patient?

4) How would you treat this electrolyte disorder?

ELECTROLYTE EMERGENCIES: CASE #5 You are called to the bedside of a patient being treated for pre-eclampsia, who is becoming increasingly lethargic.

1) What electrolyte disorder is the likely cause of this patient’s altered mental status?

2) What are some other symptoms/signs of this electrolyte disorder?

3) How would you treat this electrolyte disorder?

ELECTROLYTE DISORDERS: CASE #6 You have been asked to see in consultation a 23 year-old woman G1P0A0 (10 weeks pregnant by LMP) for hyperemesis gravidarum. She has been “vomiting all PO intake” for several days. On arrival in the ED she was found to be alert and well perfused, with the following vital signs: BP 100/58 HR 118 RR 20 O2SAT 99% on room air T 36.4 orally Her mucous membranes are moist and the rest of the exam is non-contributory. She was able to void and her urinalysis was strongly positive for ketones. The emergency physician has ordered an IV of D5 1/2NS at 125 cc/hr, IV dimenhydrinate, and 100 mg of IV thiamine. You note that the SMA-7 is normal except for the K+, which is 3.0.

1) Why do patients with hyperemesis become hypokalemic?

2) Estimate this patient’s potassium deficit.

3) What is the best way to correct this patient’s potassium deficit?

4) If the K+ level remains low despite what you had calculated to be adequate replacement, what would you do?