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Hyponatremia and Other Critical Electrolyte Abnormalities Phillip D. Levy, MD, MPH, FACEP Associate Professor and Associate Director of Clinical Research.

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Presentation on theme: "Hyponatremia and Other Critical Electrolyte Abnormalities Phillip D. Levy, MD, MPH, FACEP Associate Professor and Associate Director of Clinical Research."— Presentation transcript:

1 Hyponatremia and Other Critical Electrolyte Abnormalities Phillip D. Levy, MD, MPH, FACEP Associate Professor and Associate Director of Clinical Research Department of Emergency Medicine Assistant Director of Clinical Research Cardiovascular Research Institute Wayne State University School of Medicine

2 Disclosures None relevant to this presentation

3 Objectives To provide a brief review of common electrolyte abnormalities encountered in the ED and discuss basic treatment To take a closer look at hyponatremia and evolving approaches to management

4 Potassium Hyperkalemia -Most common life-threatening electrolyte abnormality -Three stage approach to treatment Membrane stabilization Shift potassium into cells Remove potassium from the body

5 Common Causes Pfenning et al. Critical Decisions in Emergency Medicine 2011;10;2-11.

6 Potassium Hyperkalemia -Most common life-threatening electrolyte abnormality -Three stage approach to treatment Membrane stabilization Shift potassium into cells Remove potassium from the body

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8 Typical ECG Changes Pfenning et al. Critical Decisions in Emergency Medicine 2011;10;2-11.

9 Potassium Hyperkalemia -Most common life-threatening electrolyte abnormality -Three stage approach to treatment Membrane stabilization Shift potassium into cells Remove potassium from the body

10 Potassium Hyperkalemia -Most common life-threatening electrolyte abnormality -Three stage approach to treatment Membrane stabilization Shift potassium into cells Remove potassium from the body

11 Potassium Hypokalemia -Often coupled with hypomagnesemia -Frequently asymptomatic Cramps, weakness -Classic ECG findings

12 Common Causes Pfenning et al. Critical Decisions in Emergency Medicine 2011;10;2-11.

13 Potassium Hypokalemia -Often coupled with hypomagnesemia -Frequently asymptomatic Cramps, weakness -Classic ECG findings

14 Potassium Hypokalemia -Often coupled with hypomagnesemia -Frequently asymptomatic Cramps, weakness -Classic ECG findings

15 Potassium Hypokalemia -Replete orally for mild to moderate decreases Each 0.3 mEq < normal = 100 mEq deficit -Prolonged therapy may be needed for severe cases -Requires concurrent magnesium to move intracellularly

16 Potassium Hypokalemia -Replete orally for mild to moderate decreases Each 0.3 mEq < normal = 100 mEq deficit -Prolonged therapy may be needed for severe cases -Requires concurrent magnesium to move intracellularly

17 Potassium Hypokalemia -Replete orally for mild to moderate decreases Each 0.3 mEq < normal = 100 mEq deficit -Prolonged therapy may be needed for severe cases -Requires concurrent magnesium to move intracellularly

18 Calcium Hypercalcemia –Most often caused by parathyroid disease and malignancy –“Bones, moans, groans and stones” Arrhythmias with concomitant electrolyte abnormalities –Primary treatment is normal saline Furosemide can help with associated diuresis but no longer routinely recommended Bisphosphonates = definitive therapy

19 Common Causes Pfenning et al. Critical Decisions in Emergency Medicine 2011;10;2-11.

20 Calcium Hypercalcemia –Most often caused by parathyroid disease and malignancy –“Bones, moans, groans and stones” Arrhythmias with concomitant electrolyte abnormalities –Primary treatment is normal saline Furosemide can help with associated diuresis but no longer routinely recommended Bisphosphonates = definitive therapy

21 Calcium Hypercalcemia –Most often caused by parathyroid disease and malignancy –“Bones, moans, groans and stones” Arrhythmias with concomitant electrolyte abnormalities –Primary treatment is normal saline Furosemide can help with associated diuresis but no longer routinely recommended Bisphosphonates = definitive therapy

22 Calcium Hypocalcemia –Typically caused by hypoalbuminemia –Muscle cramping, paresthesias Chvostek sign Trousseau sign –Oral repletion for mild cases, IV for more significant deficits Ionized calcium level more accurate than total

23 Calcium Hypocalcemia –Typically caused by hypoalbuminemia –Muscle cramping, paresthesias Chvostek sign Trousseau sign –Oral repletion for mild cases, IV for more significant deficits Ionized calcium level more accurate than total

24 Calcium Hypocalcemia –Typically caused by hypoalbuminemia –Muscle cramping, paresthesias Chvostek sign Trousseau sign –Oral repletion for mild cases, IV for more significant deficits Ionized calcium level more accurate than total

25 Magenesium Hypomagnesemia –Typically caused by insufficient dietary intake, GI disorders, and medication effects –Symptoms relatively non-specific –Treatment generally IV gm/h Watch for loss of deep tendon reflexes and development of respiratory depression

26 Magenesium Hypomagnesemia –Typically caused by insufficient dietary intake, GI disorders, and medication effects –Symptoms relatively non-specific –Treatment generally IV gm/h Watch for loss of deep tendon reflexes and development of respiratory depression

27 Magenesium Hypomagnesemia –Typically caused by insufficient dietary intake, GI disorders, and medication effects –Symptoms relatively non-specific –Treatment generally IV gm/h Watch for loss of deep tendon reflexes and development of respiratory depression

28 Sodium Hypernatremia -Hypovolemia most common cause -Also consider diabetes insipidus Central (deficient production of AVP) Nephrogenic (diminished response to AVP)

29 Sodium Hypernatremia -Hypovolemia most common cause -Also consider diabetes insipidus Central (deficient production of AVP) Nephrogenic (diminished response to AVP)

30 Sodium Hypernatremia -Hypovolemic: replace free water deficit TBW = 0.6 x current weight (kg) Desired TBW = measured Na x current TBW / normal Na Body water deficit = desired TBW – current TBW -Diabetes insipidus Central: DDAVP Nephrogenic: thiazide diuretic

31 Sodium Hypernatremia -Hypovolemic: replace free water deficit TBW = 0.6 x current weight (kg) Desired TBW = measured Na x current TBW / normal Na Body water deficit = desired TBW – current TBW -Diabetes insipidus Central: DDAVP Nephrogenic: thiazide diuretic

32 Hyponatremia Most common electrolyte abonormality Classified by volume status –Hypovolemic hyponatremia Decrease in total body water with greater decrease in total body sodium –Euvolemic hyponatremia Normal body sodium with increase in total body water –Hypervolemic hyponatremia Increase in total body sodium with greater increase in total body water

33 Hyponatremia Most common electrolyte abonormality Classified by volume status –Hypovolemic hyponatremia Decrease in total body water with greater decrease in total body sodium –Euvolemic hyponatremia Normal body sodium with increase in total body water –Hypervolemic hyponatremia Increase in total body sodium with greater increase in total body water

34 Hyponatremia Most common electrolyte abonormality Classified by volume status –Hypovolemic hyponatremia Decrease in total body water with greater decrease in total body sodium –Euvolemic hyponatremia Normal body sodium with increase in total body water –Hypervolemic hyponatremia Increase in total body sodium with greater increase in total body water

35 Hyponatremia Most common electrolyte abonormality Classified by volume status –Hypovolemic hyponatremia Decrease in total body water with greater decrease in total body sodium –Euvolemic hyponatremia Normal body sodium with increase in total body water –Hypervolemic hyponatremia Increase in total body sodium with greater increase in total body water

36 Hyponatremia Most common electrolyte abonormality Classified by volume status –Hypovolemic hyponatremia Decrease in total body water with greater decrease in total body sodium –Euvolemic hyponatremia Normal body sodium with increase in total body water –Hypervolemic hyponatremia Increase in total body sodium with greater increase in total body water

37 Hyponatremia Critical diagnostic tests –Urine osmolality –Serum osmolality –Urine sodium concentration

38 Hyponatremia Subclassified by effective serum osmolality –Hypertonic Pseudohypernatremia –Isotonic High protein or lipid concentration –Hypotonic < 280 mOsm/kg

39 Hyponatremia Subclassified by effective serum osmolality –Hypertonic Pseudohypernatremia –Isotonic High protein or lipid concentration –Hypotonic < 280 mOsm/kg

40 Hyponatremia Subclassified by effective serum osmolality –Hypertonic Pseudohypernatremia –Isotonic High protein or lipid concentration –Hypotonic < 280 mOsm/kg

41 Hyponatremia Subclassified by effective serum osmolality –Hypertonic Pseudohypernatremia –Isotonic High protein or lipid concentration –Hypotonic < 280 mOsm/kg

42 Hypotonic Hyponatremia Hypovolemic –Caused by GI loss, renal loss, or 3 rd spacing Non-renal: urine sodium < 20 mEq/L Renal: urine sodium > 20 mEq/L –Treat with IV normal saline

43 Hypotonic Hyponatremia Hypovolemic –Caused by GI loss, renal loss, or 3 rd spacing Non-renal: urine sodium < 20 mEq/L Renal: urine sodium > 20 mEq/L –Treat with IV normal saline

44 Hypotonic Hyponatremia Isovolemic –Glucocorticoid insufficiency –Hypothyroidism –Psychogenic polydipsia –Medications Amitriptyline, carbamazepine –Diuretic use with potassium depletion –SIADH Urine sodium > 20 mEq/L Urine osmolality > 200 mOsm/kg

45 Hypotonic Hyponatremia Hypervolemic –Heart failure –Liver disease –CKD –Nephrotic syndrome

46 Hypotonic Hyponatremia Treatment considerations –Acute vs. chronic –Degree of sodium depletion Mild: mEq/L Moderate: mEq/L Severe: < 120 mEq/L –Symptoms Neurologic –Underlying cause

47 Hypotonic Hyponatremia Treatment considerations –Acute vs. chronic –Degree of sodium depletion Mild: mEq/L Moderate: mEq/L Severe: < 120 mEq/L –Symptoms Neurologic –Underlying cause

48 Hypotonic Hyponatremia Treatment considerations –Acute vs. chronic –Degree of sodium depletion Mild: mEq/L Moderate: mEq/L Severe: < 120 mEq/L –Symptoms Neurologic –Underlying cause

49 Hypotonic Hyponatremia Treatment considerations –Acute vs. chronic –Degree of sodium depletion Mild: mEq/L Moderate: mEq/L Severe: < 120 mEq/L –Symptoms Neurologic –Underlying cause

50 Hyponatremia and HF Gheorghiade et al. Eur Heart J 2007;28: (Days) or (%) P <.0001 Na < 135 mEq/L Na ≥ 135 mEq/L Length of In-hospital Post-discharge Death or stay (days) mortality (%) mortality (%)rehospitalization since discharge (%)

51  V asopressin Non-osmotic stimulation of AVP secretion  H 2 0 retention  Intravascular volume Dilutional hyponatremia  Sympathetic activity  Vasoconstriction  Fibrosis  Myocardial & vascular hypertrophy Aortic/ carotid sinus baroreceptors stimulation Goldsmith and Gheorghiade JACC 2005;46: Vasopressin Mediated

52 Maisel et al. Circ Heart Fail. 2011;4:

53 Hypotonic Hyponatremia Treatment options –Hypertonic saline (3% soln) Reserved for acute, severe cases Bolus 100 mL over 10 min q 1 hr x 2 doses Infusion of 1-2 mL/kg/hr Target correction: 0.5 mEq/L/hr –Fluid restriction –Medication withdrawal –Diuresis –Democlocycline

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55 Central Pontine Myelinolysis

56 Hypotonic Hyponatremia Treatment options –Hypertonic saline (3% soln) Reserved for acute, severe cases Bolus 100 mL over 10 min q 1 hr x 2 doses Infusion of 1-2 mL/kg/hr Target correction: 0.5 mEq/L/hr –Fluid restriction –Medication withdrawal –Diuresis –Democlocycline

57 Vasopressin Antagonists Conivaptan –Dual V1/V2 receptor antagonist Tolvaptan –V2 receptor antagonist >>V1 Lixivaptan –V2 receptor antagonist >>>V1

58 Cassagnol et al. J Pharm Practice 2011;24:391-9.

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63 Improves Sodium But… Konstam et al. JAMA 2007; 297:

64 No Effect On “Outcomes” Konstam et al. JAMA 2007; 297:

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67 Elhassan and Schrier. Expert Opin. Investig. Drugs 2011;20:

68 Final Thoughts Obtain ECGs early with suspected or confirmed electrolyte abnormalities –Irritable cardiomyocytes need attention Little has changed in therapeutic approach for most –Think normal saline for hyper-anything –Deficiencies tend to comingle Don’t ignore those low sodiums! –Especially in HF…


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