0071643192.pdf

ENDOCRINE, METABOLIC, FLUID, AND

ELECTROLYTE DISORDERS

Do not use succinylcholine for

RSI on patients who have

known or suspected

hyperkalemia or in patients

with neurologic conditions

(Guillaine-Barré, muscular

dystrophy, old CVA, old burn,

crush, or spinal cord injury)

that may predispose them to

a large increase in serum K+

with succinylcholine.

TREATMENT

■ Three categories of treatment (see Table 7.3)

■ Without ECG findings, treatment can be limited to decreased intake and

potassium excreting drugs.

■ ECG findings prompt use of protective agents such as insulin and calcium

until definitive excretory methods can take effect. Generally, give calcium

if there is QRS widening.

■ Sodium bicarbonate has no effect on nonacidotic patients.

COMPLICATIONS

■ Inadequate treatment of hyperkalemia can lead to life-threatening cardiac

arrhythmias.

■ Only kayexalate, dialysis, and diuretics remove potassium. The other meas-

ures are temporizing measures that protect against high potassium levels

without changing total body potassium.

A 54-year-old female undergoing treatment for breast CA presents to your

ED with abdominal pain, nausea, and vomiting. Her electrolytes show a

creatinine of 3.1 mg/dL and a Ca^2 +of 13.6 mg/dL. What treatmentsshould

you initiate?

Treat this patient with fluid, furosemide, hydrocortisone, and either calci-

tonin, mithramycin, or a bisphosphonate.

CALCIUM

■ Almost all calcium (99%) is in bone. The rest is in the plasma with half

bound to proteins and half as free (ionized or active) ions.

■ Normal plasma calcium levels are maintained by Vitamin D and parathy-

roid hormone with normal concentrations of about 8.8–10.3 mg/dL.

TABLE 7.3. Treatments for Hyperkalemia

DURATION OF

INTERVENTION MECHANISMCATEGORY USUALDOSE ONSET OFACTION EFFECT ONK+

Kayexalate Excretory 15 g PO or 30 g PR 1–2 hrs 4–6 hrs

Furosemide Excretory 40 mg IV <1 hr 6 hrs

Dialysis Excretory – Immediate Continuous

Insulin and glucose Redistribution 10–15 U regular insulin 30 min 4–6 hrs

and 50 g of D50

Sodium bicarbonate Redistribution 1 mEq/kg IV 5 min 2 hrs

Albuterol Redistribution 10–20 mg inhaled 30 min 2–4 hrs

Calcium gluconate/ Membrane stabilization 10–20 mL IV of 10% 1–3 min 30–60 min

chloride