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Flashcards in fluids Deck (83)
1

ii. The normal osmolarity of serum is about

290

2

iii. At any temperature above absolute zero, electrolytes will

diffuse throughout a solution to achieve uniform osmolarity.

3

iv. In biological systems, fluid compartments

(e.g., the extracellular and intracellular compartments) are separated from each other by semi-permeable membranes

4

If you have two solutions of different concentrations that are separated by a semi-permeable membrane, the tendency of those solutions to equalize their concentration by moving water across the membrane is called the _________

osmotic pressure gradient.

5

vi. The movement of water is called

osmosis

6

vii. The effect osmolarity has on this process is called

tonicity

7

_________are fluids that are close to the normal serum osmolarity of 290 mOsm/L.

a. Isotonic fluids are

8

_______fluids are fluids that have a lower osmolarity than serum.

b. Hypotonic fluids

9

_______are fluids that have a higher osmolarity than serum.

Hypertonic fluids are fluids that have a higher osmolarity than serum.

10

small solutes; can move a little freely with this type of fluid

crystalloid

11

big solutes; like blood wit this type of fluid

colloid
protein
plasma

12

nml Na

a. Normal value: between 135-145 mEq/L.

Critical for fluid balance, nerve function, muscle function.

13

c. The #1 extracellular electrolyte.

Na

14

hypotonic crystalloid

D5W

of 1/2 NS (.45%)

15

Because sodium is so closely linked to serum osmolarity, sodium derangement leads to changes of the body’s osmotic pressure gradient.

This causes cells to ______ in hyponatremia

or ______ in hypernatermia


this phenomena is worse here

cells to swell (in hyponatremia), or to shrink (in hypernatremia).


g. While this phenomenon affects all cells, it has an outsized effect on brain cells.

16

hyponatremia is defined as

this is usually due to

Hyponatremia (Na <135)

May not see clinical signs until Na+ is <125.

17

sxs of hyponatermia

Symptoms include lethargy disorientation, muscle cramps, anorexia, hiccups, nausea/vomiting, seizures.

Patient may have weakness, agitation, stupor, hyperreflexia, orthostatic hypotension, delirium, coma, death

18

Extrarenal losses

losing fluids faster than they can replenish it

19

Treatment of hyponatermia is to

correct the water overload (or deficit) and/or raise the sodium. (hypertonic sollution 3%)

vii. Find the underlying cause.
viii. Fluid restriction and monitoring.
ix. May give hypertonic saline for severe symptoms

20

Careful of rapid correction of hyponatremia because

Careful of rapid correction—can cause central pontine myelinolysis (i.e., brain damage).

21

list the colloids

blood
albumin
dextran
FFP
PRBCs

22

dextran

glucose polysaccharide

23

hypernatremia is defined as and caused by

i. Hypernatremia (Na >145)

(1) inadequate fluid intake;
(2) excess water loss;
(3) iatrogenic (in the hospitalized patient).

24

FFP needed for

pts that would be bleeding a lot
(coagulants)

25

PRBC

trauma -usually whole blood but not always

26

how to make decisions about fluids

do you need to make a decision right away

27

unstable pt start with

2 L NS

responder or non responder

28

10% of body weight loss in an adult is what stage of dehydration

severe

29

mild and moderate dehydration looks like

6%
8%

30

replenishing fluids in a pt with CHF or renal failure

really need to be slow with fluids

31

maintenance fluids

what's normal

unlike resuscitation you're not trying to make up for significant loss
usually NPO

100-150mL an hour

small lil lady 90

32

70Kg adult looses

2500-3000 mL/day

33

4-2-1 for children

4mL up to 10Kg
2Ml for next 10Kg
1mL per Kg after that

or broselow tape with weight and height

34

27 yo women in 1st trimester has been vomiting for 3 days

BP 90/60 HR 120 skin turgur decreased

what do we start with

need to know stable of unstable
this woman is severely dehydrated but unstable

10-15 mL/kg bolus
around 1 L
given antiemetics

after a second L of NS--> peeing

too much NS can lead to acidosis

35

Parkland Formula

burn formula
exposed tissue come with incredible amounts of bluid loss

4ml x % body surface area burned x weight for the first 8 hrs

give 1/2 fluid at 8 hrs and then 1/2 that at 16

36

non focal LOC

infection-meningitis, encephalitis

trauma

seizure

CVA

overdose

metabolic- hypoglycemia or hyponatremia

alcohol

37

when you have someone with hyponatremia you need to

this is the neuro electrolyte
will shrink or swell brain cells

check a glucose

38

ADH effects of osmolarity

CONSERVES WATER
hormonal control of Na

too much ADH can lead to water intoxication

39

aldosterone effects on osmolarity

conserves SODIUM and too much leads to K loss and Na retention

40

pseudohyponatremia is due to

high concentrations of glucose lipids or proteins in the plasma

makes the water want to leave the cells and rush into extracellular space making it look lik ehyponatremia

water is drawn out and into plasma

41

each 100 mg/dL glucose elevation decreases the Na by

1.6- 1.8 mEq/L

42

treatment of pseudohyponatremia

manage the underlying cause

consider volume status and serum osmoles

43

sxs of hypervolemic hyponatremia

confusion HA vomiting seizures coma and death

44

hypervolemic hyponatremia Rx

if stable need to restrict water and weight

is seizing or coma would consider using hypertonic saline

45

hypovolemic and hyponatermia tx

seen with decreased extracellular fluid

rx volume replacement with NS

46

central pontine myelinolysis

what is the general rule to help avoid this

looks like pig on CT

too rapid correction of hypovolemic hyponatremia

Na that causes shrinkage fo the brain cells and leads to damage

in general better to correct no faster than it occured

(in chronic pts no more than .5 mEq/hour)

47

older woman LOC
Na=164
BUN=55
Cr=2.5

dehydration and hypernatremia

too little water or no ADH can lead to this as does sweating hyperventilation

48

hypernatremia sxs

when >155 -160 OR osm>350

Irritability restlessness
seizures
coma
permanent neuro damage

tx with NS or D5 1/2 NS

49

44 yo man that missed 2 dialysis treatments

NEED EKG first

seen with peaked T waves

the kidneys aren't filtering so the body is retaining potassium

50

5.5 mEq/L: EKG changes

Peaked T-waves (repolarization abnormalities).

51

>6.5 mEq/L ekg changes

: P wave flattens, PR prolongation (paralysis of atria).

52

>7.0 mEq/L EKG

QRS prolongation, ventricular arrhythmias.

53

> 9.0 mEq/L EKG

Cardiac arrest due to asystole, ventricular fibrillation, or PEA.

54

three goals of treating hyperkalemia

➤ Protect the cardiac conduction system;

➤ Shift potassium from the extracellular fluid compartment back into the cells;

➤ Remove excess potassium from the body.

55

what type of Ca do you give

calcium Chloride for Coding
needs to be given through a central line
need to avoid unless you're in a situation that really calls for it
very caustic to the tissues

calcium Gluconate for any other time

56

why do you give insulin

to move K into the cell

if their sugars are high

if they are normal given glucose and insulin

57

other than insulin what else moves Ca into the cell

ALBUTEROL

58

Intravenous calcium is given in hyperkalemia in order to

Intravenous calcium to antagonize the membrane actions of hyperkalemia (see 'Calcium' below)

59

hypokalemia looks like what on a EKG (4)

i. Flattened T waves
ii. Prolonged QT interval
iii. U waves
iv. Ventricular arrhythmias

muscle WEAKNESS

60

Tx of hypokalemia

Not an emergency unless cardiac manifestations are present.

Replete potassium (50 mEq will raise serum K+ by 1.0)

Can give orally, which is safer but slower.

When giving IV, need to use a large vein (potassium is is very irritating)
v. Give up to 20 mEq/hr.

61

what causes hypokalemia

i. Diuretics
ii. Vomiting
iii. Diarrhea


also
alkalosis
insulin
albuterol and beta adrenergic

62

hypokalemia defined as

Defined as potassium less than 3.5 mEq/L

63

other than excessive excretion what else can cause hypokalemia

b. Can be caused by potassium being shifted into the cells
i. Alkalosis
1. Insulin and glucose use

2. Use of beta-2 agonists (e.g., albuterol).

64

27yo woman presents to the ED with tingling around her mouth for two days. She also has some facial twitching.
ii. PMH: had thyroid surgery two weeks ago.

PE: Normal vitals.


LABS you want


Chem 7

TSH

CBC

But her calcium is 6.4 (normal is 8.5-10.5).

65

normal Ca levels

8.5-10.5 CC looks like an 8

66

Hypocalcemia Ca++ defined as

<8.5

67

what's more common hypo or hyper Ca

hypo more common than hypercalcemia.

68

causes of hypo Ca

Most commonly results from a chronic disease, with chronic kidney disease being the most frequent cause.


1. Hypoparathyroidism
2. Acute pancreatitis
--> fatty sludge chelates to the Ca
3. Alkalosis
4. Massive blood transfusions

69

EKG with hypoCa

prolonged QT interval that may progress to Torsades de Pointe.

70

sxs of hypoCa

1. Dry skin and brittle nails
2. Muscle cramping
3. Pruritus
4. Shortness of breath
5. Numbness and tingling
6. Syncope, angina, heart failure
7. Hyperreflexia, tetany, clonus

71

Chvostek’s sign

Tap the patient’s face just in front of the ear. A positive Chvostek’s sign is when the patient’s lip twitches on the same side where you’re tapping.

72

Trousseau’s sign

hyperca evaluation

Apply a blood pressure cuff, inflate it above the patient’s systolic blood pressure, and leave it on for 3-5 minutes.

A positive Trousseau’s sign is when the patient’s hand and forearm muscles go into spasm.

73

TX of hypoCa

1. ABCs
2. Treat severe hypocalcemia with IV calcium gluconate or calcium chloride.
3. Mild hypocalcemia can be treated outpatient with oral calcium replacement and Vitamin D supplements.

74

Ca plays essential role in

Important in transmission of nerve impulses, muscle contraction, cardiac electrical conduction, and other things

75

There are multiple complex interrelated mechanisms that contribute to serum calcium homeostasis. These involve

Vitamin D levels
the small intestine
renal tubules
parathyroid hormone (PTH)
and bone.

The most direct of these mechanisms, is PTH. If PTH is high, then calcium is high and phosphorus is low. If PTH is low, then calcium is low and phosphorus is high.

76

causes of hyperCa

1. Elevated PTH
2. Cancer with bony metastases
3. Elevated Vitamin D
4. Thiazides
5. Sarcoidosis
6. Many other possible causes….

77

sxs of hyperCa

Stones, Bones, Groans, Moans, Thrones, and Psychiatric Overtones.”

1. Nephrolithiasis
2. Bone pain
3. Lethargy and fatigue
4. Abdominal pain
5. Polyuria and polydipsia
6. Confusion, depression, irritability, anxiety, hallucinations…

78

tx of hyper Ca

1. IV fluids

a. Large amounts of isotonic crystalloid to restore volume.

2. Increase calcium excretion with a loop diuretic (NOT a thiazide).

3. Drugs that decrease the release of calcium from bone
a.Calcitonin, mithramycin, corticosteroids,
bisphosphonates

79

not typically on a chem panel but need to order these if you suspect any electrolyte abnormalities

magnesium and phosphorus

80

hypo phophorus sxs

muscle dysfunction
weakness
decreased cardiac output
confusion delirium

sxs usually occur with levels less than 2mg/dL

81

treat hypophos

underlyinG
DKA/diarrhea anatacid
vit d

TX with oral repletion until level <1mg/dL then give IV

82

hyperphosphorus

usually asymptomatic

secondary to laxatives/enemas renal failure
prolonged exercise

diet/phosphate binders if indicated

83

what is a blous

however big the IV is will determine how fast the pt gets it when the line is wide open

ALWAYS think about this

the bolus is as fast as it will go in

you can say this but if you want to go slower you have to specify 150cc an hour is crazy slow (7 hours per liter)