Hypokalemia-causesHypokalemia-causes
Decreased K intakeDecreased K intake– Low calorie diets – rareLow calorie diets – rare
Increased K entry into cellsIncreased K entry into cells– AlkalosisAlkalosis– Increased insulinIncreased insulin– Increased CatecholaminesIncreased Catecholamines– ChannelopathiesChannelopathies– Increased RBC productionIncreased RBC production– HypothermiaHypothermia– Chlorquine intoxChlorquine intox
HypokalemiaHypokalemia Increased GI lossesIncreased GI losses
– Vomiting, Diarrhea, NG tube, laxatives Vomiting, Diarrhea, NG tube, laxatives Increased Urinary lossesIncreased Urinary losses
– DiureticsDiuretics– Mineralocorticoid excessMineralocorticoid excess– Nonreabsorbable ionsNonreabsorbable ions– Metabolic acidosisMetabolic acidosis– HypoMgHypoMg– NephropathiesNephropathies– Ampho BAmpho B– PolyuriaPolyuria– LicoriceLicorice
HypokalemiaHypokalemia
Increased Sweat LossesIncreased Sweat Losses DialysisDialysis PlasmaphoresisPlasmaphoresis
PresentationPresentation
Neuro muscular K 2-2.5Neuro muscular K 2-2.5– Weakness prox > distal, loss of reflexesWeakness prox > distal, loss of reflexes
CardiacCardiac– ArrhythmiasArrhythmias– EKGEKG
U waves, prolonged QT, small T waveU waves, prolonged QT, small T wave
Hyper HypoK+
K+K+
K+
K+
K+
K+
K+
K+K+
T wave
Familial Periodic Familial Periodic ParalysisParalysis TypesTypes
– Hyper Kalemic – HyperPPHyper Kalemic – HyperPP– Hypo Kalemic – HypoPPHypo Kalemic – HypoPP– Thyrotoxic- TPPThyrotoxic- TPP
Genetic mutationGenetic mutation– Autosomal dominant and sporadic Autosomal dominant and sporadic
ChannelopathiesChannelopathies
Inability to find a decent TV program Inability to find a decent TV program despite having cable and 150 despite having cable and 150 channels to chose from.channels to chose from.
Functional disturbances of ion Functional disturbances of ion channels in the cell membranechannels in the cell membrane
– ““Flaccid muscle weakness Flaccid muscle weakness due to under excitability of due to under excitability of sarcolemma.”sarcolemma.”
HypoPPHypoPP Rare, potentially fatal episodes of Rare, potentially fatal episodes of
muscle weaknessmuscle weakness– Asian populationAsian population
Acute attacks due to KAcute attacks due to K+ + moving into cellsmoving into cells Precipitated by exercise, carbs, stressPrecipitated by exercise, carbs, stress K levelK level
– LowLow– NormalNormal* (low K + Rhabdo)* (low K + Rhabdo)
Often self limitingOften self limiting
Treating K problemsTreating K problems
ABCsABCs IV – O2 – MonitorIV – O2 – Monitor Stat labsStat labs Check Mg, CPK, TFTsCheck Mg, CPK, TFTs Oral K is good for non life threatening Oral K is good for non life threatening
hypoKhypoK– Watch N/VWatch N/V– Use PO KCl if hypo K is due to loss of ClUse PO KCl if hypo K is due to loss of Cl
HypoPP - RxHypoPP - Rx
Administer KAdminister K+ +
– 10-20meq/hr IV (Higher via central line if 10-20meq/hr IV (Higher via central line if severe)severe)
– 40-60meq PO x240-60meq PO x2 Check the KCheck the K+ + q 15-30minq 15-30min Rx thyrotoxicosis w/ propanololRx thyrotoxicosis w/ propanolol
HypoPP - DischargeHypoPP - Discharge
Daily oral K does not prevent attacksDaily oral K does not prevent attacks Carbonic anhydrase inhibitors- Carbonic anhydrase inhibitors-
Acetozolamide Acetozolamide Low carb diet Low carb diet Consult/referralConsult/referral
Caveats – K problemsCaveats – K problems
1meq decrease in K represents 1meq decrease in K represents 300meq deficit300meq deficit**– If hypo K is due to lossIf hypo K is due to loss– Remember, 98% of K is in the ICFRemember, 98% of K is in the ICF
0.1 drop in pH raises K by 0.60.1 drop in pH raises K by 0.6– Think of acid/base problemsThink of acid/base problems
Is this primary or secondary problem?Is this primary or secondary problem?
Dangers in Rx PPDangers in Rx PP
Check the type before starting KCheck the type before starting K– Must confirm if hypo, hyper or nl Must confirm if hypo, hyper or nl
Remember this is a cellular shiftRemember this is a cellular shift– Rebound hyper K can occur if you are too Rebound hyper K can occur if you are too
aggressive w/ K replacementaggressive w/ K replacement Watch for respiratory insufficiencyWatch for respiratory insufficiency
!
MM U D P I L E S U D P I L E S
Methanol/Ethylene glycolMethanol/Ethylene glycol– Certainly possibleCertainly possible– Pt deniedPt denied– No visual sxNo visual sx– No Ca oxalate xtalsNo Ca oxalate xtals– Woods lampWoods lamp– Osm gapOsm gap
M M U D PU D P II L E S L E S
UremiaUremia– BUN/Creat OKBUN/Creat OK
DKADKA– Not a diabetic, Glucose OKNot a diabetic, Glucose OK
ParaldahydeParaldahyde– No pungent odorNo pungent odor
IsoniazidIsoniazid– No hx TB RxNo hx TB Rx
M M U D PU D P II LL E S E S
Lactic AcidosisLactic Acidosis– Abd pain -> dead gutAbd pain -> dead gut– Decreased perfusionDecreased perfusion– Liver failureLiver failure– AlcoholsAlcohols– MedsMeds– Inborn errorsInborn errors– Lactate -> 27Lactate -> 27
M M U D PU D P II LL EE S S
Ethanol - Alcohol KetoacidosisEthanol - Alcohol Ketoacidosis– Binge drinker, Not eatingBinge drinker, Not eating
SalicylatesSalicylates– No Hx of ASA useNo Hx of ASA use
Hospital CourseHospital Course
Developed DTsDeveloped DTs + C. Dif culture+ C. Dif culture Feeding tube placedFeeding tube placed acute alcoholic hepatitis and severe acute alcoholic hepatitis and severe
dehydration and metabolic disarray dehydration and metabolic disarray with severe hypokalemia, with severe hypokalemia, hypophosphatemia, hypomagnesemia, hypophosphatemia, hypomagnesemia, acute renal failure, lactic acidosis, acute renal failure, lactic acidosis,
Alcohol ketoacidosisAlcohol ketoacidosis
Uncommon, often missedUncommon, often missed Binge drinkersBinge drinkers
AKA - 3 factorsAKA - 3 factors
1.1. Alcohol intakeAlcohol intake
2.2. Decreased caloric intakeDecreased caloric intake
3.3. Volume depletionVolume depletion
Results in starvation physiology
AKAAKA
Decreased caloric intakeDecreased caloric intake– Counter regulatory hormone releaseCounter regulatory hormone release– Epinephrine, cortisol, growth hormoneEpinephrine, cortisol, growth hormone– Elevated glucagon, decreased insulinElevated glucagon, decreased insulin– Promotes lipolysis and fatty acid Promotes lipolysis and fatty acid
mobilizationmobilization Volume depletionVolume depletion
– Elevated glucagon, decreased insulinElevated glucagon, decreased insulin
AKAAKA
Alcohol intakeAlcohol intake– Oxidation of ETOH-> ->acetateOxidation of ETOH-> ->acetate– NAD->NADH which raises glucagon, NAD->NADH which raises glucagon,
decreases insulindecreases insulin– Promotes betahydoxybutyrate vs Promotes betahydoxybutyrate vs
acetoacetateacetoacetate– Decreased gluconeogenisisDecreased gluconeogenisis
AKAAKA
SymptomsSymptoms– N, V, abd painN, V, abd pain– Dyspnea, tremulousnessDyspnea, tremulousness– Muscle pain, fever, diarrhea, syncope, SzMuscle pain, fever, diarrhea, syncope, Sz
PhysicalPhysical– Tacycardia, tachypnea, abdominal pain,Tacycardia, tachypnea, abdominal pain,– Hepatomegaly, hypotensionHepatomegaly, hypotension
AKAAKA
Differential DxDifferential Dx– CholecystitisCholecystitis– Peptic ulcer, gastritisPeptic ulcer, gastritis– Mesenteric ischemiaMesenteric ischemia– PacreatitisPacreatitis– Withdrawal syndromesWithdrawal syndromes– Metabolic acidosisMetabolic acidosis– DKADKA– Methanol, Ethylene glycolMethanol, Ethylene glycol
AKA - labsAKA - labs
pH –low, high or nlpH –low, high or nl– Metabolic acidosis -> ketonesMetabolic acidosis -> ketones– Metabolic alkalosis -> vomitingMetabolic alkalosis -> vomiting– Respiratory alkalosis -> hyperventilationRespiratory alkalosis -> hyperventilation
Serum ketones low, high or nlSerum ketones low, high or nl– BetahydoxybutyrateBetahydoxybutyrate
Lytes –abnormalLytes –abnormal Lactate – mildly elevatedLactate – mildly elevated
AKA-treatmentAKA-treatment
Volume replaceVolume replace Carbohydrate replacementCarbohydrate replacement
– D5NSD5NS Fix electrolyte abnormalitiesFix electrolyte abnormalities
– K, Mg, acidosisK, Mg, acidosis Address associated problemsAddress associated problems
– Withdrawal, Wernikes, GI bleed, hepatitis, Withdrawal, Wernikes, GI bleed, hepatitis, pancreatitis, pneumonia, rhabdo, etc.pancreatitis, pneumonia, rhabdo, etc.
I have never been lost, I have never been lost, but I will admit to being but I will admit to being confused for several confused for several weeks. weeks.
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