電解

質不

平衡

的急

診處

理

羅東

博愛

醫院

急診

部主

任

張啟

宏

Cas

e 1

�7

0 y

/o f

emal

e p

’t i

s su

ffer

ed f

rom

gen

eral

wea

kn

ess

in r

ecen

t d

ays.

�P

E:

WN

L ,

Vit

al s

ign

: st

able

.

�W

hat

sh

ou

ld w

e d

o?

�H

ow

to

man

agem

ent?

Cas

e 1

�R

ou

tin

e ch

eck

up

fo

r C

BC

, E

lect

roly

tes,

sug

ar,

etc.

�H

yp

on

atre

mia

11

0 m

mo

l/L

�T

x.

N/S

IV

F o

r 3

% s

alin

e IV

F ?

�R

apid

or

slo

wly

res

po

nse

?

�W

hy

hy

po

nat

rem

ia?

�Is

hy

po

nat

rem

ia t

he

real

ch

ief

pro

ble

m?

Cas

e 2

�6

5 y

/o m

ale

p’t

w

ith

pre

sen

tati

on

of

con

s.

Dis

turb

ance

, b

rad

yca

rdia

, co

ld s

wea

tin

g.

�V

ital

sig

n:B

P 9

0/3

6,

HR

28

�P

ast

Hx

. C

hro

nic

ren

al f

ailu

re,

DM

�W

hat

sh

ou

ld w

e d

o?

�It

is

tru

e em

erg

ency

.

Cas

e 2

�A

BC

D

�A

BG

, su

gar

on

e to

uch

, E

lect

roly

tes,

EK

G

�M

on

ito

r

�H

yp

erk

alem

ia:

7.7

mm

ol/

L

�T

X.

Cas

e 3

�6

4y

/o m

ale

p’t

, su

dd

en c

oll

apse

.

�S

ent

by

11

9

DO

A

�C

PR

an

d A

ED

wer

e in

stru

cted

�A

t E

R a

syst

ole

was

fir

st n

ote

d

�C

PR

an

d V

T w

ith

car

dio

ver

tio

n b

y E

R d

oct

or

and

p

’t r

egai

ned

pu

lse

Cas

e 3

�W

hat

sh

ou

ld w

e d

o?

�C

om

ple

te E

KG

, A

BG

�R

ou

tin

e ch

eck

up

fo

r C

BC

, E

lect

roly

tes,

su

gar

, et

c.

�A

BG

:p

H 7

.03

1

PC

O2

59

.9

PO

28

5.9

N

a 1

36

K

9.2

7

�B

UN

:46

, C

r:2

.7,

Na:

13

6,

K:1

1.1

9

�P

ast

Hx

. :

DM

, C

hro

nic

ren

al i

nsu

ffic

ien

cy

Cas

e 4

�A

80

Y/O

mal

e p

’t s

uff

ered

fo

rm p

rog

ress

ive

BW

lo

ss a

nd

po

or

app

etit

e, g

ener

al w

eak

nes

s,

som

no

len

ce ,

gen

eral

ized

ach

e.

�P

ast

Hx

. H

ealt

hy

�N

o d

rug

Hx

.

�P

E:E

3V

3M

5,

Dry

sk

in ,

pal

e co

nju

nct

iva

�W

hat

kin

d o

f ex

amin

atio

ns

sho

uld

we

app

ly?

Cas

e 4

�R

ou

tin

e ch

eck

up

�L

ab.:

Hb

: 9

.2,

BU

N:8

0,C

r:3

.5,

Na:

15

5,

K:4

.5

�C

XR

, S

ku

ll,

pu

nch

ed o

ut

lesi

on

�H

yp

erca

lcem

ia:

13

mg

/dl

�H

ow

to

man

agem

ent?

Gen

eral

Ap

pro

ach

�O

ne

sho

uld

nev

er c

om

ple

tely

tru

st t

he

lab

ora

tory

.

�E

rro

rs m

ay o

ccu

r�

In o

bta

inin

g t

he

sam

ple

�L

abel

ing t

he

sam

ple

�P

erfo

rmin

g t

he

test

�R

eport

ing t

he

resu

lt

Gen

eral

Ap

pro

ach

�A

bn

orm

alit

ies

sho

uld

be

trea

ted

at

app

rox

imat

ely

th

e ra

te a

t w

hic

h t

hey

dev

elo

ped

sin

ce b

iolo

gic

sy

stem

s re

act

pri

mar

ily

to

rat

e o

f ch

ang

e an

d n

ot

to a

bso

lute

con

cen

trat

ion

s.

Gen

eral

Ap

pro

ach

�O

ne

sho

uld

no

t co

rrec

t th

e p

H w

ith

ou

t al

so

eval

uat

ing

po

tass

ium

, ca

lciu

m,

and

mag

nes

ium

lev

els.

Gen

eral

Ap

pro

ach

�T

he

pri

ori

ties

fo

r co

rrec

tin

g m

ult

iple

flu

id,

elec

tro

lyte

s, a

nd

aci

d-b

ase

abn

orm

alit

ies

are

as f

oll

ow

s:

1.

Flu

id v

olu

me

and

per

fusi

on

def

icit

2.

pH

3.

Po

tass

ium

, ca

lciu

m, an

d m

agn

esiu

m

abn

orm

alit

ies

4.

So

diu

m a

nd

ch

lori

de

abn

orm

alit

ies

Ele

ctro

lyte

s

�何時檢查

�例行檢查

�為何懷疑電質不平衡

�緊急處理否

�危及生命否

�處置錯誤之嚴重性

�報告之判斷

急診

常見

的電

解質

不平

衡

�S

od

ium

(N

a) (

13

3-1

45

mm

ol/

L)

�P

ota

ssiu

m (

K)

(3.3

0-5

.10

mm

ol/

L)

�C

alci

um

(C

a) (

8.5

– 1

0.7

mg

/dl)

�M

agn

esiu

m (

Mg

) (1

.60

- 2

.30

mm

ol/

L)

�P

ho

sph

oru

s (P

) (2

.5 –

4.8

mg

/dl)

�C

hlo

rid

e (C

l) (

96

-1

10

mm

ol/

L)

Th

e E

lect

roly

te C

on

entr

atio

n o

f B

od

y

Flu

ids

(mE

q/L

)

E

xtr

acel

lula

r

Inte

rsti

tial

Intr

acel

lula

r

Solu

tion

Sea

wat

er

Flu

id

F

luid

F

luid

Cat

ions

S

odiu

m

425

142

1

44

10

P

ota

ssiu

m

1

5

4.5

4.5

1

50

M

agnes

ium

105

2

1

.0

4

0

C

alci

um

35

4

.5

2.5

T

ota

l

580

153

152

200

Anio

ns

C

hlo

ride

500

102

113

----

P

hosp

hat

es

10

2

2

120

S

ulf

ates

45

1

1

30

B

icar

bonat

e

25

2

7

30

10

P

rote

in

---

16

1

40

O

rgan

ic a

cids

-

--

5

5

T

ota

l

580

153

152

200

Av

erag

e E

lect

roly

te C

on

ten

t o

f

Var

iou

s B

od

y F

luid

s

S

od

ium

P

ota

ssiu

m

Ch

lori

de

B

icar

bo

nat

e

Vo

lum

e/D

ay

Sal

iva

10

-60

10

-20

15

-40

30

-15

10

00

-20

00

Sto

mac

h

4

0-1

00

5-1

5

1

5-2

0

---

-

1

50

0-2

50

0

Bil

e

13

0-1

40

4-6

9

5-1

05

3

0-4

0

5

0-1

00

0

Pan

crea

s

1

30

-14

0

4

-6

40

-60

80

-10

0

10

00

-20

00

Sm

all in

tesi

ne

13

0-1

40

4-6

4

0-6

0

8

0-1

00

10

00

-20

00

Co

lon

8

0-1

40

2

5-4

5

8

0-1

00

3

0-5

0

1

00

-60

0

Sw

eat

40

-50

5

-10

45

-60

--

--

2

00

-15

00

Hy

per

nat

rem

ia

�C

lin

ical

fea

ture

s

�A

lter

ed m

enta

l st

atu

s

�W

eak

nes

s

�N

euro

mu

scu

lar

irri

tab

ilit

y

�F

oca

l n

euro

log

ical

def

icit

s

�S

eizu

re

�C

om

a

ⅠC

ause

s o

f H

yp

ern

atre

mia

()

Ⅰ.L

oss

of

wat

er

A.

Red

uce

d w

ater

in

tak

e

1

. D

efec

tiv

e th

irst

2

. U

nco

nsc

iousn

ess

3

. In

abil

ity t

o d

rin

k w

ater

4

. L

ack

of

acce

ss t

o w

ater

ⅡC

ause

s o

f H

yp

ern

atre

mia

()

B.

Incr

ease

d w

ater

lo

ss

1

. V

om

itin

g,

dia

rrh

ea

2

. S

wea

tin

g,

fev

er

3

. H

yp

erv

enti

lati

on

4

. D

iab

etes

in

sip

idu

s, o

smo

tic

diu

resi

s

5

. T

hy

roto

xic

osi

s

6

. S

ever

e b

urn

s

Cau

ses

of

Hy

per

nat

rem

ia(Ⅲ

)

Ⅱ.G

ain

of

sod

ium

A.

Incr

ease

d i

nta

ke

1

. H

yp

erto

nic

sal

ine

ing

esti

on

or

infu

sio

n

2

. S

od

ium

bic

arb

on

ate

adm

inis

trat

ion

B.

Ren

al s

alt

rete

nti

on

(u

sual

ly b

ecau

se o

f p

oo

r p

erfu

sio

n)

Cau

ses

of

Hyper

nat

rem

ia R

elat

ed

to B

lood V

olu

me

Ⅰ.H

ypo

vo

lem

ia

A

. N

on

ren

al H

2O

lo

sses

(U

Na

< 1

0 m

Eq

/L, U

Osm

> 4

00

mO

sm/L

)

fr

om

sk

in o

r G

I o

r re

spir

ato

ry t

ract

s

B

. R

enal

H2O

lo

sses

(U

Na

> 2

0 m

Eq

/L, U

Osm

< 3

00

mO

sm/L

)

fr

om

diu

reti

cs, re

nal

dis

ease

, re

lief

of

uri

nar

y

o

bst

ruct

ion

, ad

ren

al f

ailu

re, o

smo

rece

pto

r fa

ilu

re

Cau

ses

of

Hyper

nat

rem

ia R

elat

ed

to B

lood V

olu

me

Ⅱ.E

uv

ole

mia

A.

Imp

aire

d t

hir

st (

com

a)

B.

No

nre

nal

H2O

lo

sses

(G

I, s

kin

, re

spir

ato

ry)

C.

Ren

al H

2O

lo

sses

du

e to

DI,

res

et

osm

ost

at,

reli

ef o

f u

rin

ary

ob

stru

ctio

n,

ren

al d

isea

se,

osm

oti

c d

iure

tics

Cau

ses

of

Hyper

nat

rem

ia R

elat

ed

to B

lood V

olu

me

Ⅲ.H

yp

erv

ole

mia

A.

Iatr

og

enic

(h

yp

erto

nic

sal

ine

ther

apy

)

B.

Min

eral

oco

rtic

oid

ex

cess

(U

Na

> 2

0 m

E/L

,

UO

sm >

30

0 m

Osm

/L)

du

e to

hy

per

ald

ost

ero

nis

m, C

ush

ing

’s d

isea

se,

con

gen

ital

adre

nal

hyp

erpla

sia,

ex

og

eno

us

cort

ico

ster

oid

s

Hy

per

nat

rem

ia

�T

reat

men

t

�W

ater

def

icit

(in

lit

ers)

=T

BW

(1-

)

�N

orm

al s

alin

e o

r R

ing

er’s

so

luti

on

�H

alf

sali

ne

or

D5

W

Na

2

Na

1

Hy

po

nat

rem

ia�

Cli

nic

al f

eatu

res

�F

atig

ue

�W

eaknes

s

�M

usc

le c

ram

ps

�T

hir

st

�D

izzi

nes

s

�O

ligouri

a

�C

yan

osi

s

�C

hes

t pai

n

�A

bd. P

ain

�C

onfu

sion

�S

eizu

re

�C

om

a

Cau

ses

of

Hy

po

nat

rem

iaⅠ

.Hyponat

rem

ia w

ith d

ecre

ased

EC

F

A

. E

xtr

aren

al l

oss

es;

uri

nar

y N

a <

20 m

Eq/L

1.

Sw

eati

ng, vom

itin

g,

dia

rrhea

2.

Thir

d-s

pac

e se

ques

trat

ion

(

burn

s, p

erit

onit

is, pan

crea

titi

s)

B

. R

enal

loss

es;

uri

nar

y N

a >

20 m

Eq/L

1.

Loo

p o

r o

smoti

c diu

reti

cs

2.

Ald

ost

erone

def

icie

ncy

(A

ddis

on’s

dis

ease

)

3.

Ket

on

uri

a

4.

Sal

t-lo

sing n

ephro

pat

hie

s; r

enal

tu

bula

r ac

ido

sis

Cau

ses

of

Hy

po

nat

rem

ia

Ⅱ.H

yp

on

atre

mia

wit

h n

orm

al E

CF

; u

rin

ary

Na

> 2

0

mE

q/L

A

. In

app

rop

riat

e A

DH

sec

reti

on

B

. S

ick

-cel

l o

r “r

eset

osm

ost

at”

syn

dro

mes

C

. P

hy

sica

l an

d e

mo

tio

nal

str

ess

or

pai

n

D

. M

yx

edem

a, A

dd

iso

n’s

dis

ease

,

S

hee

han

’s s

yn

dro

me

Cau

ses

of

Hy

po

nat

rem

ia

Ⅲ.H

yp

on

atre

mia

wit

h i

ncr

ease

d E

CF

A

. U

rinar

y N

a >

20

mE

q/L

1

. R

enal

fai

lure

B

. U

rinar

y N

a <

20

mE

q/L

1

. C

irrh

osi

s

2

. C

ardia

c fa

ilu

re

3

. R

enal

fai

lure

Ⅳ.P

seu

do

hy

po

nat

rem

ia (

hy

per

pro

tein

emia

, h

yp

erli

pid

emia

, h

yp

erg

lyce

mia

)

Cau

ses

of

SIA

DH

Cen

tral

ner

vo

us

syst

em d

iso

rder

s

H

ead

tra

um

a

B

rain

tu

mo

rs,

bra

in a

bsc

esse

s

M

enin

git

is,

ence

ph

alit

is

S

ub

arac

hn

oid

hem

orr

hag

e

D

elir

ium

tre

men

s

Tu

mo

rs

L

un

g c

ance

r (e

spec

iall

y s

mal

l ce

ll),

ca

nce

r o

f th

e p

ancr

eas,

ov

aria

n

can

cer

L

ym

ph

om

a

T

hym

om

a

Pu

lmo

nar

y d

iso

rder

s

T

ub

ercu

losi

s

P

neu

mo

nia

, em

pyem

a

L

un

g a

bsc

ess

C

yst

ic f

ibro

sis,

CO

PD

Dru

gs

N

arco

tics

C

hlo

rpro

pam

ide

N

SA

IDs

V

incr

isti

ne,

vin

bla

stin

e

C

ycl

op

ho

sph

amid

e, p

hen

oth

iazi

ne

M

on

oam

ine

ox

idas

e in

hib

ito

rs

T

ricy

clic

an

tid

epre

ssan

ts

T

hia

zid

e d

iure

tics

End

ocr

ine

dis

ord

ers

H

yp

oth

yro

idis

m

G

luco

cort

ico

id i

nsu

ffic

ien

cy

Mis

cell

aneo

us

P

orp

hyri

a

P

ain

, n

ause

a

Id

iop

ath

ic

Hy

po

nat

rem

ia

�T

reat

men

t

�W

ater

res

tric

tio

n

�H

yp

erto

nic

sal

ine

�C

alcu

lati

ng

so

diu

m d

efic

its:

TB

W(

x 6

0%

)(N

a 1-N

a 2)

�T

reat

men

t o

f p

seu

do

hy

po

nat

rem

ia

�O

smo

tic

dem

yel

inat

ion

sy

nd

rom

e

(cen

tral

po

nti

ne

my

elin

osi

s)

Hy

per

kal

emia

�C

lin

ical

fea

ture

s

�In

trac

ard

iac

blo

ck

�A

tria

l

�A

V n

od

e

�V

entr

icle

s

Co

mm

on

Cau

ses

of

Hy

per

kal

emia

Fac

titi

ous

L

abora

tory

err

or

P

seudohyper

kal

emia

: hem

oly

sis,

thro

mbocy

tosi

s,

leukocy

tosi

s

Met

aboli

c ac

idem

ia (

acute

)

Incr

ease

d i

nta

ke

into

the

pla

sma

E

xogen

ous:

die

t, s

alt

subst

itute

s, l

ow

-sodiu

m d

iet,

m

edic

atio

ns

E

ndogen

ous:

hem

oly

sis,

GI

ble

edin

g, ca

taboli

c st

ates

, cr

ush

in

jury

Inad

equat

e dis

tal

del

iver

y o

f so

diu

m a

nd d

ecre

ase

dis

tal

tublu

ar f

low

Co

mm

on

Cau

ses

of

Hy

per

kal

emia

Oli

gouri

c re

nal

fai

lure

Impai

red r

enin

-ald

ost

erone

axis

A

ddis

on’s

dis

ease

P

rim

ary h

ypoal

dost

eronis

m

O

ther

(hep

arin

, β

blo

cker

s, p

rost

agla

ndin

inhib

itors

, ca

pto

pri

l)

Pri

mar

y r

enal

tubula

r pota

ssiu

m s

ecre

tory

def

ect

s

ickle

cel

l dis

ease

s

yst

emic

lupus

eryth

emat

osu

s

P

ost

renal

tra

nsp

lanta

tion

O

bst

ruct

ive

uro

pat

hy

Co

mm

on

Cau

ses

of

Hy

per

kal

emia

Inh

ibit

ion

of

ren

al t

ub

ula

r se

cret

ion

of

po

tass

ium

S

pir

on

ola

cto

ne

D

igit

alis

Ab

no

rmal

po

tass

ium

dis

trib

uti

on

I

nsu

lin

def

icie

ncy

H

yp

erto

nic

ity

(h

yp

erg

lyce

mia

)

β

-Ad

ren

erg

ic b

lock

ers

E

xer

cise

S

ucc

iny

lch

oli

ne

D

igit

alis

Hy

per

kal

emia

�D

iag

no

sis

�W

hy

do

yo

u s

usp

ect?

�W

hat

to

do

?

�A

BG

�E

KG

�Q

uic

kly

ass

essm

ent.

EK

G c

han

ge

of

Hy

per

kal

emia

Hy

per

kal

emia

Em

erg

ency

Th

erap

y o

f H

yp

erk

alem

ia

D

ura

tio

n o

f H

yp

ok

ale

mic

Th

era

py

M

ech

an

ism

D

ose

O

nse

t o

f A

cti

on

E

ffec

t

Ca

chlo

rid

e (1

0%

) A

nta

go

nis

m 5

- 1

0m

L I

V 1

-3 m

in 3

0-5

0 m

in

Na

bic

arb

on

ate

A

nta

go

nis

m a

nd

5

0 m

Eq

IV

5

-10

min

1

-2 h

re

dis

trib

uti

on

Insu

lin

plu

s g

luco

se R

edis

trib

uti

on

1

0 U

reg

ula

r in

suli

n 3

0 m

in 4

-6 h

w

ith

25

g g

luco

se I

V

Diu

reti

cs E

xcr

etio

n 4

0 t

o 8

0 m

g I

V W

ith

diu

resi

s W

ith

diu

resi

s

F

uro

sem

ide

5

0 m

g I

V

E

thac

ryn

ic a

cid

Cat

ion

-ex

chan

ge

resi

n E

xcr

etio

n 1

5-5

0 g

PO

or

rect

ally

1

-2 h

4

-6 h

(K

ayex

alat

e)

w

ith

so

rbit

ol

Per

ito

nea

l d

ialy

sis

or

E

xcr

etio

n W

ith

in m

inu

tes

D

uri

ng

dia

lysi

s

hem

od

ialy

sis

Hy

po

kal

emia

�C

lin

ical

fea

ture

s

�M

usc

le w

eak

nes

s

�In

test

inal

ile

us

�R

esp

irat

ory

par

aly

sis

�R

elat

ed t

o d

igit

alis

Cau

ses

of

Hy

po

kal

emia

Ⅰ.

Sh

ift

into

th

e ce

ll

A.

Rai

sin

g t

he

pH

of

blo

od

B.

Ad

min

istr

atio

n o

f in

suli

n a

nd

glu

cose

Ⅱ.

Red

uce

d i

nta

ke

Cau

ses

of

Hy

po

kal

emia

Ⅲ. In

crea

sed l

oss

A. R

enal

loss

1

. P

rim

ary h

yper

aldost

ero

nis

m

2

. S

econdar

y h

yper

aldost

eron

ism

aso

ciat

ed w

ith d

iure

tics

, m

alig

nan

t hyper

tensi

on, B

artt

er’s

syndro

me,

ren

al a

rter

y

sten

osi

s

3

. M

isce

llan

eous

a

. H

yper

calc

emia

b

. L

iddle

’s s

yndro

me(

pse

udohyper

aldost

eronis

m)

c

. M

agnes

ium

def

icie

ncy

d

. R

enal

tubula

r ac

idosi

s

e

. A

cute

myel

ocy

tic

and m

onocy

tic

leukem

ias

B.

Gas

troin

test

inal

loss

(vo

mit

ing, d

iarr

hea

, fi

stu

las)

Hy

po

kal

emia

�T

reat

men

t

�1

0-1

5 m

Eq

KC

l IV

in

fusi

on

per

hr

�N

ever

ex

ceed

20 m

Eq K

Cl/

500

ml

�4

0-5

0 m

Eq

KC

l to

rai

se 1

.0m

Eq

/L

�O

ral

po

tass

ium

Sy

mp

tom

s an

d s

ign

s o

f H

yp

erca

lcem

iaG

ener

al

M

ala

ise,

weak

nes

s

P

oly

dip

sia,

deh

ydra

tio

n

Neu

rolo

gic

C

onfu

sion

A

pat

hy

, d

epre

ssio

n,

stu

po

r

D

ecr

eas

ed m

em

ory

I

rrit

abil

ity

H

all

ucin

ati

ons

H

ead

ach

e

A

taxia

H

yp

ore

flexia

, h

ypo

ton

ia

M

enta

l re

tard

ati

on (

infa

nts

)

Met

asta

tic

calc

ific

atio

n

B

and k

erat

opath

y

C

onju

ncti

vit

is

P

ruri

tus

Skel

etal

F

ract

ure

s

B

one

pai

n

D

efo

rmit

ies

Car

dio

vas

cula

r

H

yper

tensi

on

A

rrhy

thm

ias

V

ascu

lar

calc

ific

atio

ns

E

CG

abnorm

alit

ies

Q

T s

hort

enin

g

C

ovin

g o

f S

T-T

wav

e

W

iden

ing o

f T

wav

e

D

igit

alis

sen

siti

vit

y

Gas

troin

test

inal

A

nore

xia

, w

eight

loss

N

ause

a, v

om

itin

g

C

onst

ipat

ion

A

bdom

inal

pai

n

P

epti

c ulc

er d

isea

se

P

ancr

eati

tis

Uro

logic

P

oly

uri

a, n

oct

uri

a

R

enal

insu

ffic

iency

N

ephro

lith

iasi

s

Cau

ses

of

Hy

per

calc

emia

Ma

lig

na

ncy

L

un

g (

squ

am

ou

s ce

ll c

an

cer)

B

rea

st

K

idn

ey

M

yel

om

a

L

euk

emia

En

do

crin

op

ath

ies

P

rim

ary

hy

per

pa

rath

yro

idis

m

H

yp

erth

yro

idis

m

P

heo

chro

mo

cyto

ma

A

dre

na

l In

suff

icie

ncy

A

cro

meg

aly

Dru

gs

H

yp

erv

ita

min

osi

s D

an

d A

T

hia

zid

es

L

ith

ium

H

orm

on

al

ther

ap

y f

or

bre

ast

Gra

nu

lom

ato

us

dis

ease

S

arc

oid

T

ub

ercu

losi

s

H

isto

pla

smo

sis

C

occ

idio

my

cosi

s

Imm

ob

iliz

ati

on

Mis

cell

an

eou

s

P

ag

et’s

dis

ease

of

bo

ne

P

ost

ren

al

tra

nsp

lan

tati

on

R

eco

ver

y f

rom

acu

te r

ena

l fa

ilu

re

P

ho

sph

ate

dep

leti

on

sy

nd

rom

e

Tre

atm

ent

of

Hy

per

calc

emia

Dru

g

Do

se

Cau

tio

ns

Sal

ine

U

nti

l E

CF

is

rest

ore

d

W

atch

fo

r

h

yp

ok

alem

ia

Fu

rose

mid

e

40

-10

0 m

g I

V q

2-4

h

D

igit

alis

, re

nal

fai

lure

Dec

reas

e b

on

e ab

sorp

tio

n

C

alci

ton

in

0.5

-4 M

RC

un

its/

kg

IV

o

ver

24

h (

or

IM q

6 h

in

div

ided

do

ses)

M

ith

ram

yci

n

2

5 µ

g/k

g I

V

B

on

e m

arro

w a

nd

ren

al t

ox

icit

y

H

yd

roco

rtis

on

e

3 m

g/k

g p

er d

ay I

V i

n

M

ay t

ake

3 w

eek

s to

d

ivid

ed d

ose

s q

6 h

lo

wer

Ca2

+

I

nd

om

eth

acin

2

5 m

g P

O q

6 h

P

epti

c u

lcer

dis

ease

,

GI

ble

edin

g

Tre

atm

ent

of

Hy

per

calc

emia

�C

alci

um

>1

2 m

g/d

l

�S

ym

pto

ms

�In

abil

ity

to

mai

n a

go

od

flu

id i

nta

ke

�A

bn

orm

al r

enal

fu

nct

ion

Sy

mp

tom

s an

d s

ign

s o

f H

yp

oca

lcem

ia�

Gen

eral

Wea

kn

ess,

fat

igu

e�

Neu

rolo

gic

Tet

any

Ch

ov

stek

’s s

ign

, T

rou

ssea

u’s

si

gn

Cir

cum

ora

l an

d d

igit

al

par

esth

esis

Imp

aire

d m

emo

ry,

con

fusi

on

Hal

luci

nat

ion

s ,d

emen

tia,

se

izu

res

Ex

trap

yra

mid

al d

iso

rder

s�

Der

mat

olo

gic

Hyp

erp

igm

enta

tio

n

Co

urs

e, b

ritt

le h

air

Dry

, sc

aly s

kin

�C

ard

iov

ascu

lar

Hea

rt f

ailu

re

vas

oco

nst

rict

ion

�M

usc

ula

r

Sp

asm

s, c

ram

ps

Wea

kn

ess

�S

kel

etal

Ost

eod

yst

rop

hy

Ric

ket

s

Ost

eom

alac

ia�

Mis

cell

aneo

us

d

enta

l h

yp

op

lasi

a

Cat

arac

ts

Dec

reas

ed i

nsu

lin

sec

reti

on

Cau

ses

of

Hy

po

calc

emia

Sh

ock

or

sep

sis

Imp

aire

d p

rod

uct

ion

of

1α

, 2

5-

dih

yd

rox

yv

itam

in D

3

M

alab

sorp

tio

n

S

ever

e h

epat

ic f

ailu

re

R

enal

fai

lure

A

nti

con

vu

lsan

t th

erap

y

Pan

crea

titi

s

Cau

ses

of

Hy

po

calc

emia

Hy

po

mag

nes

emia

Alk

alo

sis

Dec

reas

ed s

eru

m a

lbu

min

lev

els

Hy

po

par

ath

yro

idis

m

I

dio

pat

hic

P

ost

surg

ical

P

seud

ohy

po

par

ath

yro

idis

m

Ost

eob

last

ic m

etas

tase

s

Fat

em

bo

lism

sy

nd

rom

e

Dru

gs

Th

at C

an C

ause

Hy

po

calc

emia

Cim

etid

ine

Ph

osp

hat

es (

e.g

., e

nem

as,

lax

ativ

es)

Dil

anti

n,

ph

eno

bar

bit

al

Gen

tam

icin

, to

bra

my

cin

Cis

pla

tin

Hep

arin

Th

eop

hy

llin

e

Dru

gs

Th

at C

an C

ause

Hy

po

calc

emia

Pro

tam

ine

Glu

cago

n

Nore

pin

eph

rine

Cit

rate

(blo

od)

Loo

p d

iure

tics

Glu

coco

rtic

oid

s

Mag

nes

ium

su

lfat

e

So

diu

m n

itro

pru

ssid

e

Tre

atm

ent

of

Hy

po

calc

emia

Par

ente

ral

Ca2

+ g

luco

nat

e

(10

%)

Ca2

+ c

hlo

rid

e

(10

%)

Ora

l

Ca2

+ g

lub

ion

ate

Tab

lets

Ca2

+ g

lub

ion

ate

(Neo

-cal

glu

con

)

Ca2

+ l

acta

te

Tab

lets

Ca2

+ c

arb

on

ate

Tit

rala

c

Os-

Cal

10

-mL

am

pu

les

10

-mL

am

pu

les

10

00

mg

(al

so 3

25

-,

5

00

-, a

nd

60

0-m

g

tab

lets

)

5 m

L s

yru

p

65

0 m

g

5-m

L s

olu

tio

n, o

r 6

50

-mg

ta

ble

t

Tab

let

93

mg

Ca2

+

(4.6

mE

q)

27

2 m

g C

a2+

(13

.6 m

Eq

)

92

mg

Ca2

+

(4.5

mE

q)

23

mg

Ca2

+ /

mL

79

mg

Ca2

+

17

0,

400

mg C

a2+

25

0 m

g C

a2+

(12

5 U

vit

amin

D)

10

-30

mL

in

10

0m

L

D

5W

ov

er

1

0-1

5 m

in

2.5

-10

mL

in 1

00

mL

D

5W

ov

er 1

0-1

5

m

in

1-4

g/d

ay i

n d

ivid

ed d

ose

s q

6 h

1-4

g/d

ay i

n d

ivid

ed d

ose

s q

6 h

1-4

g/d

ay i

n d

ivid

ed d

ose

s q

6 h

1-4

g/d

ay i

n d

ivid

ed d

ose

s q

6 h

Cau

ses

of

Hy

po

mag

nes

emia

Gas

troin

test

inal

P

rote

in-c

alori

e m

alnutr

itio

n

H

yper

alim

enta

tion a

fter

mal

nutr

itio

n

M

alab

sorp

tion (

dia

rrhea

), f

istu

las

A

lcoholi

c ci

rrhosi

s

P

ancr

eati

tis

Ren

al

G

lom

erulo

nep

hri

tis,

py

elonep

hri

tis

D

iure

tic

phas

e of

acute

tubula

r nec

rosi

s

H

yper

calc

emia

Endocr

ine

A

ldost

eronis

m

H

yper

par

athy

roid

ism

, hy

per

thy

roid

ism

Dru

g-i

ndu

ced

D

iure

tics

A

min

ogly

cosi

des

C

ispla

tin

V

itam

in D

into

xic

atio

n

D

igoxin

A

lcohol

I

nsu

lin

C

itra

te (

blo

od)

Mis

cell

aneo

us

L

act

atio

n

S

wea

tin

g

H

ungry

bone

syndro

me

B

urn

s

S

epsi

s

Sym

pto

ms

and S

igns

of

Hypom

agnes

emia

Neu

rom

usc

ula

r

T

etan

y

M

usc

le w

eaknes

s

C

ereb

ella

r (a

taxia

, nyst

agm

us,

ver

tigo)

C

onfu

sion, obtu

ndat

ion, co

ma

S

eizu

res

A

pah

ty, dep

ress

ion

I

rrit

abil

ity

P

ares

thes

ias

Gas

troin

test

inal

D

ysp

hag

ia

A

nore

xia

, nau

sea

Car

dio

vas

cula

r

H

eart

fai

lure

A

rrhyth

mia

s

H

ypote

nsi

on

Mis

cell

aneo

us

H

ypokal

emia

H

ypoca

lcem

ia

A

nem

ia

Tre

atm

ent

of

Hy

po

mag

nes

emia

Dru

g

Par

ente

ral

MgS

O4(1

g =

98 m

g o

f ele

men

tal

Mg

2+)

MgC

l 2(1

g =

118 m

g

ele

men

tal

Mg

2+)

Ora

l

MgO

Mg(O

H) 2

(m

ilk o

f m

agnes

ia)

Siz

e an

d C

on

ten

ts

10%

(20-m

L a

mpule

s, 0

.81

mE

q/m

L)o

r

50%

(2-m

l am

pule

s,

4 m

Eq/m

L)

20%

(30-m

L b

ott

le,

1.9

7

mE

q/m

L)

400-m

g t

able

ts

(20 m

Eq)

7.5

% (

2.9

mE

q/5

mL

)

Dose

1-2

g M

gS

O4 o

r

MgC

l 2 b

y c

onti

nuous

IV

ever

y 4

-6 p

rn

1-4

per

day

5-1

5 m

L t

id

Co

mm

on

Cau

ses

of

Hy

per

kal

emia

�E

nd

og

eno

us

Cau

ses

�C

hro

nic

ren

al f

ailu

re

�M

etab

oli

c ac

idosi

s

�P

seudohypoal

dost

eronis

m t

ype

II

�C

hem

oth

erap

y c

ausi

ng t

um

or

lysi

s

�R

hab

dom

yoly

sis

�R

enal

tubula

r ac

idosi

s

�H

emoly

sis

�H

ypoal

dost

eronis

m

�H

yper

kal

emic

per

iodic

par

alysi

s

Co

mm

on

Cau

ses

of

Hy

per

kal

emia

�E

xo

gen

ou

s ca

use

s

�M

edic

atio

ns:

K+

-sp

arin

g d

iure

tics

, A

CE

inh

ibit

ors

, N

SA

IDS

, p

ota

ssiu

m s

up

ple

men

ts,

pen

icil

lin

der

ivat

ives

, su

ccin

ylc

ho

lin

e, h

epar

in

ther

apy

, β

- b

lock

ers

�B

loo

d a

dm

inis

trat

ion

�D

iet,

sal

t su

bst

itu

tes

�P

seu

do

hy

per

kal

emia

Tre

atm

ent

of

Hy

per

kal

emia

�F

or

mil

d e

lev

atio

n (

5 t

o

6 m

Eq

/L)

�1

. D

iure

tics

: fu

rose

mid

e 4

0 t

o 8

0 m

g I

V

�2

. R

esin

s: K

ayex

alat

e 1

5 t

o 3

0 g

in

50

to

10

0 m

l

of

20

% s

orb

ito

l ei

ther

ora

lly

or

by

ret

enti

on

enem

a

Tre

atm

ent

of

Hy

per

kal

emia

�F

or

mo

der

ate

elev

atio

n (

6 t

o 7

mE

q/L

)

�1

. G

luco

se p

lus

insu

lin

: m

ix 2

5g

(5

0m

l o

f

D5

0)g

luco

se a

nd

10

U r

egu

lar

insu

lin

an

d g

ive

IV

ov

er 1

5 t

o 3

0 m

ins.

�2

. S

od

ium

bic

arb

on

ate:

50

mE

q I

V o

ver

5 m

ins

�3

. N

ebu

lize

d a

lbu

tero

l: 1

0 t

o 2

0 m

g n

ebu

lize

d

ov

er 1

5m

ins.

Tre

atm

ent

of

Hy

per

kal

emia

�F

or

sev

er e

lev

atio

n (

>7

mE

q/L

)�

1. C

alci

um

chlo

ride

(10%

): 5

00 t

o1000 m

g I

V o

ver

2 t

o 5

m

ins.

�2. S

odiu

m b

icar

bonat

e: 5

0 m

Eq I

V o

ver

5 m

ins

�3. G

luco

se p

lus

insu

lin:

mix

25g (

50m

l of

D50)g

luco

se

and 1

0 U

reg

ula

r in

suli

n a

nd g

ive

IV o

ver

15 t

o 3

0 m

ins.

�4. N

ebuli

zed a

lbute

rol:

10 t

o 2

0 m

g n

ebuli

zed o

ver

15m

ins

�5. D

iure

tics

: fu

rose

mid

e 40 t

o 8

0 m

g I

V�

6. R

esin

s: K

ayex

alat

e 15 t

o 3

0 g

in 5

0 t

o 1

00 m

l of

20%

so

rbit

ol

eith

er o

rall

y o

r by r

eten

tion e

nem

a�

7. D

ialy

sis