When Do I Order What?

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When Do I Order What?

• Bucky Boaz, ARNP-C

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Criteria for Detecting Electrolyte Abnormalities
in ED Patients

• Poor oral intake
• Vomiting
• Hypertension, diuretic use
• Age gt 65
• Recent Seizure
• Muscle Weakness
• Alcohol abuse
• Altered mental status
• Recent abnormal electrolytes

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Electrolyte Disorders

• Calcium
• Magnesium
• Potassium
• Sodium

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Calcium

• Normal range
• 8.5-10.5 mg/dL
• Panic!
• lt6.5 or gt13.5 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.

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Calcium
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Hypocalcemia

• Hypoparathyroidism
• Vitamin D deficiency
• Renal insufficiency
• Pseudohypo-parathyroidism
• Magnesium deficiency

• Hypophosphatemia
• Massive transfusion
• hypoalbuminemia

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Calcium
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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

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Calcium
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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

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Magnesium

• Normal range
• 1.8-3.0 mg/dL
• Panic!
• lt0.5 or 4.5 mg/dL
• Marbled top

• Concentration is determined by intestinal
  absorption, renal excretion, and exchange with
  bone and intracellular fluid

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Hypomagnesium

• Chronic diarrhea
• Enteric fistula
• Starvation
• Chronic alcholism
• Hypoparathyroidism
• Acute pancreatitis
• Chronic glomerulonephritis

• Diabetic ketoacidosis
• Drugs
• Albuterol
• Amphotericin B
• Calcium salts
• Cisplatin
• Cyclosporin
• Diuretics

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Hypomagnesemia

• (lt1.5 mEq/L)
• Due to diuretics, aminoglycosides, cyclosporine.
• Clinical features
• Irritable muscle,tetany,seizure,arrhythmia.
• Treat
• MgSO4 25-50 mg/kg IV over 20 min.

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Hypermagnesium

• Dehydration
• Tissue trauma
• Renal failure
• Hypothyroidism

• Drugs
• Aspirin (prolonged use)
• Lithium
• Magnesium salts
• Progesterone
• Triamterene

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Hypermagnesemia

• (gt2.2 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) 0.2-0.3 ml/kg (max 5 ml) IV.

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Potassium

• Normal range
• 3.5-5.0 mg/dL
• Panic!
• lt3.0 or gt6.0 mg/dL
• Marbled top

• Predominately an intracellular cation whose
  plasma level is regulated by renal excretion.
• Plasma concentration determines neuromuscular
  irritability

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Potassium
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Hypokalemia

• Clinical Features of Hypokalemia
• Lethargy, confusion, weakness
• Areflexia, difficult respirations
• Autonomic instability, Low BP
• ECG findings in Hypokalemia
• K lt 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

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Hyperkalemia

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

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Hyperkalemia

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

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Hyperkalemia

• K 5-6.0 peak T waves
• K 6-6.5 PR and QT intervals
• K 6.5-7 P, ST segments
• K 7-7.5 intraventricular conduction
• K 7.5-8 QRS widens, ST and T waves merge
• K gt 10 sine wave appearance

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Sodium

• Normal range
• 135-145 mg/dL
• Panic!
• lt125 or gt155 mg/dL
• Marbled top

• Predominately an extracellular cation.
• Serum sodium level is primarily determined by the
  volume status of the individual.

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Hyponatremia

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

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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

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Hyponatremia
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Hypernatremia

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

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Hypernatremia

• Dehydration (excessive sweating, vomiting,
  diarrhea)
• Polyuria (diabetes mellitus, diabetes insipidus)
• Hyperaldosteronism

• Inadequate water intake (coma, hypothalmic
  disease)
• Drugs
• Steroids
• Licorice
• Oral contraceptives

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Hypernatremia
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Endocrine Disorders

• Hyperthyroidism/
• Thyroid Storm
• Hypothyroidism/
• Myxedema Coma

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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, DC

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Clinical Features of Hyperthyroidism/Thyroid Storm

• Hyperkinesis
• Palpable goiter
• Proptosis, lid lag
• Exopthalmus, palsy
• Temp gt 101 F
• ?HR ?Pulse pressure
• Arrhythmia (new onset)
• Weight Loss

• Palpitations
• Dyspnea
• Psychosis
• Apathy
• Coma
• Tremor
• Hyperreflexia
• Diarrhea
• Jaundice

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Laboratory Findings Hyperthyroidism/Thyroid Storm

• ? free T4
• ? T3
• ? TSH
• ? T4RIA
• ? FT4I
• ? Glucose
• ? Ca2
• ? WBC
• ? Hb
• ? Cholesterol

• Lab test can diagnose hyperthyroid, but Thyroid
  Storm (Thyrotixicosis) is a clinical diagnosis

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Hypothyroidism/Myxedema Coma

• Precipitants
• Pneumonia
• GI bleed
• CHF
• Cold exposure
• Stroke
• Trauma
• ? pO2
• ? CO2
• ? Na

• Drugs
• Phenothiazides
• Narcotics
• Sedatives
• Phenytoin
• propanolol

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Clinical Features of Hypothyroidism/Myxedema Coma
Vitals Temp is ofter lt 90 F, 50 have BP lt 100/60
Cardiac ?HR, heart block, low voltage, ST-T changes, effusion
Pulmonary Hypoventilation, ?pCO2, ?O2, pleural effusions
Metabolic Hypoglycemia, hyponatremia
Neurologic coma, seizures, tremors, ataxia, nystagmus, psychiatric disturbances, depressed reflexes
GI/GU Ileus, ascites, fecal impaction, megacolon, urinary retention
Skin Alopecia, loss of lateral 1/3 of eyebrow, nonpitting puffiness around eyes, hands, and pretibial region
ENT Tongue enlarges, voice deepens and becomes hoarse
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Laboratory Findings of Hypothyroidism/Myxedema
Coma

• Serum TSH gt 60 ?U/ml
• ? Total free T4
• ? or ?? total free T3

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Liver Disease

• Laboratory Findings in Liver Disease

Disease AST/SGOT ALT/SGPT Alk Phos Bilirubin Albumin
Abscess 1-4 X 1-4 X 1-3 X 1-4 X Normal
Acetomenophren 50-100 X ? 50-100 X ? 1-2 X ? 1-5 X ? Normal
Alcohol Hepatitis ASTgtALT 21? ASTgtALT 21? ? 10 X ? 1-5 X? Chronic ?
Biliary Chirrosis 1-2 X ? 1-2 X ? 1-4 X ? 1-2 X ? ?
Chronic Hepatitis 1-20 X ? 1-20 X ? 1-3 X ? 1-3 X ? ?
Viral Hepatitis 5-50 X ? 5-50 X ? 1-3 X ? 1-3 X ? Normal
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Stroke, TIA, and Subarachnoid Hemorrhage

• CT Scan abnormal gt 95 if onset lt 12h
• CT Scan abnormal 77 if onset gt 12h
• CSF gt 100,000 RBCs/mm3 (mean) although any can
  be seen
• Xanthochromia
• ECG peaked, deep, or inverted T waves, ? QT, or
  large U wave

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Imaging Low Back Pain

• Acute neuro deficit consistent
• Acute significant trauma
• Age gt 70, or minor trauma gt 50 years
• History of prolonged steroid use OR osteoperosis
• History of cancer OR unexplained wt loss
• History of recent infection OR fever gt 100 F OR
  parental drug abuse
• LBP worse at rest OR disability due to LBP gt 4
  weeks

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Fever in Children
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Clinically Significant CXR Abnormalities
SOBreath Criteria
S Saturation lt 90
O Older than 59 years
B Breath sounds diminished
R Rales or Respiratory rate gt 24 bpm
E Embolic disease (prior DVT or PE)
A Alcohol abuse
T Tuberculosis or Temp gt 100.4
H Hemoptysis
95 sensitive, 40 specificity
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Pulmonary Embolism
DIAGNOSTIC STUDIES ECG Findings
CXR abnormal in 60-84 Nonspecific ST-T changes 50
Art blood gas 92 ?A-a gradient T wave inversion 42
Ventilation perfusion scan V/Q - below New right bundle branch 15
D-Dimer 95 sen, 50 spec S in 1, Q in 3, T in 3 12
Angiography - gt 98 sen/spec Right axis deviation 7
Echo detects 90 causing ? BP Shift in transition to V5 7
CT 90 sen for central PE Right ventricle hypertrophy 6
MRI - gt90 sen for PE P pulmonale 6
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Abdominal Pain
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Abdominal Pain
Diagnostic Studies in Appendicitis
In first 24 hours, WBC count gt 11,000 20-40
After 24 hours, WBC gt 11,000 70-90
Urinalysis with gt 5 WBC or RBC/hpf 15-30
Ultrasound sensitivity 78-94
Ultrasound specificity 89-100
CT scan sensitivity 92-100
CT scan specificity gt95
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Abdominal Pain
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Abdominal Pain
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Abdominal Pain
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Biliary Tract Disease

• Clinical Features of Biliary Colic
• Pain usually begins 30-60 min after meal
• Pain duration lt 6-8 hrs
• Absence of fever
• WBC lt 11,000 cell/mm3 in most
• Normal liver function tests in 98
• Absence of pancreatitis
• US is 98 sensitive for gallstones

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Biliary Tract Disease

• Clinical Features Acute Cholecystitis

Pain duration gt 6-8 hrs gt 90
Temp gt 100.4 F 25
WBC gt 11,000 cell/mm3 in most gt95
Murphys sign 65
Elevated liver function tests 55
Pancreatitis 15
Ultrasound sensitivity 85
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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

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Painful Scrotum
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Trauma
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Accidental vs Non-accidental
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Head Trauma
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Head Trauma
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Head Trauma
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Cervical Spine
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Cervical Spine
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Thoracolumbar Spine
Indications for Thoracolumbar Spine Radiographs
in Blunt Trauma
Back pain or tenderness Ejection from motorcycle/vehicle
Neurologic deficit Motor vehicle crash gt 50 mph
Glasgow coma scale lt 14 Major distracting injury
Drug intoxication Pelvic fracture
Alcohol intoxication Long bone fracture
Blood alcohol gt 100 mg/dl Intrathoracic injury
Fall gt 10 feet Intraabdominal injury
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Shoulder
High-Yield Criteria for Shoulder Xrays in the
Emergency Department
Shoulder deformity History of fall (with age gt 43.5 years)
Shoulder swelling Abnormal range of motion
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Blunt Real Trauma
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Pelvis
Criteria for Pelvic Radiography Following Blunt
Trauma
Disoriented, Glasgow coma scale lt 14 Groin or suprapubic swelling
Intoxication with drugs or alcohol Pain, swelling, eccymosis of medial thigh, genitalia, or lumbosacral area
Hypotension or gross hematuria Instability of pelvis to anterior-posterior or lateral-medial presure
Lower extremity neurologic deficit Pain with abduction, adduction, rotation, or flexion of either hip
Femur pain
Pain or tenderness of pelvic girdle, symphysis pubis, or iliac spine
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Abdominal Trauma
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Abdominal Trauma
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Ottawa Knee
Age gt 55 Unable to flex 900
Unable to walk immediately after injury or 4 steps in the ED Isolated fibular head tenderness
Isolated patellar tenderness
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Pittsburgh Knee
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Foot and Ankle