When Do I Order What? Bucky Boaz, ARNP-C

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

Electrolyte Disorders Calcium Magnesium Potassium Sodium

Calcium Normal range: ٭ 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.

Calcium

Hypocalcemia Hypoparathyroidism Vitamin D deficiency Renal insufficiency Pseudohypo- parathyroidism Magnesium deficiency Hypophosphatemia Massive transfusion hypoalbuminemia

Calcium

Hypercalcemia Hyperparathyroidism Malignancies secreting parathyroid hormone- related protein (PTHrP) ٭squamous cell of lung ٭Renal cell carcinoma ٭Leukemia Vitamin D excess Multiple myeloma Pagets disease Sarcoidosis Vitamin A intoxication Thyrotoxicosis Addisons disease Drugs ٭Antacids, Calcium salts, Diuretic use, Lithium

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

Magnesium Normal range: ٭ 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

Hypomagnesium Chronic diarrhea Enteric fistula Starvation Chronic alcholism Hypoparathyroidism Acute pancreatitis Chronic glomerulonephritis Diabetic ketoacidosis Drugs ٭Albuterol ٭Amphotericin B ٭Calcium salts ٭Cisplatin ٭Cyclosporin ٭Diuretics

Hypomagnesemia (<1.5 mEq/L) Due to diuretics, aminoglycosides, cyclosporine. Clinical features: ٭Irritable muscle,tetany,seizure,arrhythmia. Treat: ٭MgSO mg/kg IV over 20 min.

Hypermagnesium Dehydration Tissue trauma Renal failure Hypothyroidism Drugs ٭Aspirin (prolonged use) ٭Lithium ٭Magnesium salts ٭Progesterone ٭Triamterene

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%) ml/kg (max 5 ml) IV.

Potassium Normal range: ٭ 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

Potassium

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

Hyperkalemia Causes of Hyperkalemia ٭Exogenous: blood Salt substitutes K+ containing drugs (e.g. penicillinderivatives) Acute digoxin toxicity Beta blockers, ACE inhibitors Succinylcholine Non-steroidals

Hyperkalemia ٭Endogenous: Acidemia Trauma Burns Rhabdomyolysis DIC Sickle cell crisis GI bleed Chemotherapy (destroying tumor mass) Mineralocorticoid deficiency Congenital defects (21 hydroxylase deficiency)

Hyperkalemia K : peak T waves K : PR and QT intervals K : P, ST segments K : intraventricular conduction K : QRS widens, ST and T waves merge K+ > 10: sine wave appearance

Sodium Normal range: ٭ mg/dL Panic! ٭ 155 mg/dL Marbled top Predominately an extracellular cation. Serum sodium level is primarily determined by the volume status of the individual.

Hyponatremia Symptoms ٭Lethargy, apathy ٭Depressed reflexes ٭Muscle cramps ٭Pseudobulbar palsies ٭Cerebral edema ٭Seizures ٭Hypothermia

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

Hyponatremia

Hypernatremia Symptoms ٭Lethargy, irritability, coma ٭Seizures ٭Spasticity, hyperreflexia ٭Doughy skin ٭Late preservation of intravascular ٭volume (and vital signs)

Hypernatremia Dehydration (excessive sweating, vomiting, diarrhea) Polyuria (diabetes mellitus, diabetes insipidus) Hyperaldosteronism Inadequate water intake (coma, hypothalmic disease) Drugs ٭Steroids ٭Licorice ٭Oral contraceptives

Hypernatremia

Endocrine Disorders Hyperthyroidism/ Thyroid Storm Hypothyroidism/ Myxedema Coma

Hyperthyroidism/Thyroid Storm Underlying Thyroid Disease ٭Graves 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

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 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

Fever in Children

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 > 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%

Abdominal Pain

In first 24 hours, WBC count > 11, % After 24 hours, WBC > 11, % Urinalysis with > 5 WBC or RBC/hpf15-30% Ultrasound sensitivity78-94% Ultrasound specificity89-100% CT scan sensitivity92-100% CT scan specificity>95% Diagnostic Studies in Appendicitis

Abdominal Pain

Biliary Tract Disease Clinical Features of Biliary Colic ٭Pain usually begins 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

Biliary Tract Disease Clinical Features Acute Cholecystitis Pain duration > 6-8 hrs> 90% Temp > F25% WBC > 11,000 cell/mm 3 in most>95% Murphys sign65% Elevated liver function tests55% Pancreatitis15% Ultrasound sensitivity85%

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

Painful Scrotum

Trauma

Accidental vs Non-accidental

Head Trauma

Cervical Spine

Thoracolumbar Spine Back pain or tendernessEjection from motorcycle/vehicle Neurologic deficitMotor vehicle crash > 50 mph Glasgow coma scale < 14Major distracting injury Drug intoxicationPelvic fracture Alcohol intoxicationLong bone fracture Blood alcohol > 100 mg/dlIntrathoracic injury Fall > 10 feetIntraabdominal injury Indications for Thoracolumbar Spine Radiographs in Blunt Trauma

Shoulder Shoulder deformityHistory of fall (with age > 43.5 years) Shoulder swellingAbnormal range of motion High-Yield Criteria for Shoulder Xrays in the Emergency Department

Blunt Real 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

Abdominal Trauma

Ottawa Knee Age > 55Unable to flex 90 0 Unable to walk immediately after injury or 4 steps in the ED Isolated fibular head tenderness Isolated patellar tenderness

Pittsburgh Knee

Foot and Ankle