Presentation on theme: "When Do I Order What? Bucky Boaz, ARNP-C. Criteria for Detecting Electrolyte Abnormalities in ED Patients Poor oral intake Vomiting Hypertension, diuretic."— Presentation transcript:
Calcium Normal range: ٭8.5-10.5 mg/dL Panic! ٭ 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.
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
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
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.
Potassium Normal range: ٭3.5-5.0 mg/dL Panic! ٭ 6.0 mg/dL Marbled top Predominately an intracellular cation whose plasma level is regulated by renal excretion. Plasma concentration determines neuromuscular irritability
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
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
Laboratory Findings Hyperthyroidism/Thyroid Storm free T 4 T 3 TSH T 4 RIA FT 4 I Glucose Ca +2 WBC Hb Cholesterol Lab test can diagnose hyperthyroid, but Thyroid Storm (Thyrotixicosis) is a clinical diagnosis
Hypothyroidism/Myxedema Coma Precipitants ٭Pneumonia ٭GI bleed ٭CHF ٭Cold exposure ٭Stroke ٭Trauma ٭ pO 2 ٭ CO 2 ٭ Na + Drugs ٭Phenothiazides ٭Narcotics ٭Sedatives ٭Phenytoin ٭propanolol
Clinical Features of Hypothyroidism/Myxedema Coma VitalsTemp is ofter < 90 F, 50% have BP < 100/60 Cardiac HR, heart block, low voltage, ST-T changes, effusion Pulmonary Hypoventilation, pCO 2, O 2, pleural effusions MetabolicHypoglycemia, hyponatremia Neurologiccoma, seizures, tremors, ataxia, nystagmus, psychiatric disturbances, depressed reflexes GI/GUIleus, ascites, fecal impaction, megacolon, urinary retention SkinAlopecia, loss of lateral 1/3 of eyebrow, nonpitting puffiness around eyes, hands, and pretibial region ENTTongue enlarges, voice deepens and becomes hoarse
Laboratory Findings of Hypothyroidism/Myxedema Coma Serum TSH > 60 U/ml Total & free T 4 or total & free T 3
Liver Disease Laboratory Findings in Liver Disease DiseaseAST/SGOTALT/SGPTAlk PhosBilirubinAlbumin Abscess1-4 X 1-3 X1-4 XNormal Acetomenophren 50-100 X 1-2 X 1-5 X Normal Alcohol HepatitisAST>ALT 2:1 10 X 1-5 X Chronic Biliary Chirrosis 1-2 X 1-4 X 1-2 X Chronic Hepatitis 1-20 X 1-3 X Viral Hepatitis 5-50 X 1-3 X Normal
Stroke, TIA, and Subarachnoid Hemorrhage CT Scan abnormal > 95% if onset < 12h CT Scan abnormal 77% if onset > 12h CSF > 100,000 RBCs/mm 3 (mean) although any # can be seen Xanthochromia ECG = peaked, deep, or inverted T waves, QT, or large U wave
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
Clinically Significant CXR Abnormalities SSaturation < 90% OOlder than 59 years BBreath sounds diminished RRales or Respiratory rate > 24 bpm EEmbolic disease (prior DVT or PE) AAlcohol abuse TTuberculosis or Temp > 100.4 HHemoptysis 95% sensitive, 40% specificity SOBreath Criteria
Pulmonary Embolism DIAGNOSTIC STUDIESECG Findings CXR – abnormal in 60-84%Nonspecific ST-T changes50% Art blood gas – 92% A-a gradient T wave inversion42% Ventilation perfusion scan V/Q - below New right bundle branch15% D-Dimer – 95% sen, 50% specS in 1, Q in 3, T in 312% Angiography - > 98% sen/specRight axis deviation7% Echo – detects 90% causing BP Shift in transition to V57% CT – 90% sen for central PERight ventricle hypertrophy6% MRI - >90% sen for PEP pulmonale6%
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/mm 3 in most ٭Normal liver function tests in 98% ٭Absence of pancreatitis ٭US is 98% sensitive for gallstones
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
Pelvis Disoriented, Glasgow coma scale < 14Groin or suprapubic swelling Intoxication with drugs or alcoholPain, swelling, eccymosis of medial thigh, genitalia, or lumbosacral area Hypotension or gross hematuriaInstability of pelvis to anterior- posterior or lateral-medial presure Lower extremity neurologic deficitPain 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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