Fluids / Electrolytes Principles of Homeostasis

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Fluids / ElectrolytesPrinciples of Homeostasis

• Silver Cross EMSS CME
• October 2012 3rd Trimester

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Our Agenda Today

• System news!
• Our main topic today Fluids and Electrolytes
• CHF vs. COPD a quick but important refresher
• (ALS) Strip O the Month PEA/Asystole

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System News!

• Please Press Take! For everything you remove
  from the Pyxis, you must press take. 5 IV
  catheters, 5 presses. 3 canulas, 3 presses.
  Etc. The supply people cant restock the machine
  properly otherwise and it leaves your fellow
  providers short of supplies.
• IDPH fees and online process for license apps and
  renewals went into effect September 1st.

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Body Systems Working Together

• Integumentary
• Skeletal
• Muscular
• Lymphatic
• Respiratory
• Digestive

• Nervous
• Endocrine
• Cardiovascular
• Renal / Urinary
• Reproductive

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Body Systems

• Parceling out vital functions to several
  different organ systems results in
  interdependence of all body cells.
• No individuals organ systems work in isolation.

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Necessary Life Functions

• Must be able to maintain their boundaries.
• Internal environment must remain distinct from
  the external environment
• Single cell organisms
• Human beings

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Necessary Life Functions

• Movement
• by muscles and the skeletal system
• walking, running, writing
• also other movement
• blood moved through cardiovascular system
• foodstuffs moved through digestive system
• urine moved through urinary system
• at the cellular level
• the ability of cells to move by shortening
  (contractility)

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Necessary Life Functions

• Responsiveness
• the ability to sense changes (stimulus) in the
  environment and respond to them
• reflex - like touching a hot stove
• carbon dioxide levels and respiratory rate

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Necessary Life Functions

• Digestion
• the process of breaking down ingested foodstuffs
  to simple molecules that can be absorbed into the
  blood.
• Nutrient rich blood is then distributed to all
  areas of the body
• Amoeba
• a single celled digestion factory

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Necessary Life Functions

• Metabolism
• a broad term that includes all chemical reactions
  which occur within body cells
• catabolism breaking down
• anabolism building up
• all catabolism all anabolism equals metabolism

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Necessary Life Functions

• Excretion
• the process of removing wastes from the organism
• get rid of non-useful substances
• toxins

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Necessary Life Functions

• Reproduction
• cellular
• cell division
• Mitosis and meiosis
• organism
• eggs and sperm

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Necessary Life Functions

• Growth
• increase in size of a body part or the organism
• usually the result of an increase in the number
  of cells
• may be due to increased size of existing cells
• in any case it is the result constructive
  activities occurring at a rate faster than
  destructive activities

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Survival/Physiological Needs

• nutrients
• oxygen
• water
• normal body temperature
• atmospheric pressure

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The body has a natural tendency to keep the
internal environment constant.
Temperature Water Sugar Blood
Volume Oxygen Carbon Dioxide Heart
Rate Respiratory rate Blood Pressure
HOMEOSTASIS
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Homeostasis

• Greek for like fixed conditions
• Walter Bradford Cannon (1871-1945) established
  our basic understanding about the global function
  of the adrenal gland/sympathetic nervous system
  axis

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Homeostatic Control Mechanisms

• Variable
• Receptor/affector
• Control center
• Brain
• Effector

• Negative feedback
• furnace thermostat
• Positive feedback
• bleeding
• delivery
• hormone balance

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Negative Feedback Loop

• A stimulus produces a response that opposes the
  original stimulus
• Thermostat controls heating/cooling
• When the room temperature rises/falls, the
  thermostat (control center) triggers an EFFECTOR
  response that restores normal temperature
• Can be either to warm up or to cool off

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Brains Negative Feedback Loop

• The brain is the control center for regulation of
  body temperature
• Receptor-sensors in skin/cells of
  thermoregulatory center (affector pathway) sense
  temperature outside the normal acceptable range

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Brains Negative Feedback Loop

• The brain sends a command, via EFFECTOR pathways
  for the skin and sweat glands to react and
  balance the heat in the body to regain
  homeostasis

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Positive Feedback Loop

• Initial stimulus produces a response that
  reinforces a stimulus
• EX thermostat wired so when temperature is low,
  the heater turns on rather than the air
  conditioning
• Initial stimulus (decreased heat/temp) causes
  response (heater on) and heat stimulus
  strengthened instead of cooled

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Thermoregulation

• If the thermoregulation center in the brain is
  unable to function, the body would die from
  either hyperthermia or hypothermia

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Homeostatic Control Mechanisms

• Antagonist
• blocks a physiological response
• reverses or opposes
• -olytic

• Agonist
• causes a physiological response
• -mimetic

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FLUIDS
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Water

• Water is an essential medium which forms the
  chief environment in which cells live and
  function
• Transport medium for nutrients, hormones, blood
  cells and waste products
• Regulates body temperature

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Some additional quick terminology...
intra
cellular
within
pertaining to cells
extra
vascular
outside of
pertains to vessels
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Hyper-
Hypo-
high / increased
low / decreased
heme, hema, hemo
blood
-carbia
carbon dioxide
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WATER

• Most abundant substance in the human body
• 60 of total body weight
• Fluid Compartments
• Intracellular
• Extracellular
• intravascular
• interstitial

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7.5
17.5
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Fluid compartments of the body.
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Intracellular Fluid (ICF)

• Basic unit of organ structure
• Contains nucleus, mitochondria, endoplasmic
  reticulum and lysosomes

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Extracellular Fluid (ECF)

• Water that surrounds the cell/outside the cell
• Interstitial fluid bathes cells
• Intravascular fluid plasma portion of blood
  found in circulatory system/in the vessel.
• Plasma carries RBC, WBC, platelets, electrolytes,
  hormones, waste, etc.

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Water Intake

• How do we get it into our bodies?
• Well of course drinking water and other fluids.
• From eating fruits and vegetables
• Oxidative metabolism

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Water Intake

• But also by eating foods not typically thought of
  as containing a great deal of water
• Actual fluids 1640cc/day
• Food 750 cc/day
• Oxidative metab. 350 cc/day
• TOTAL 2,740 cc/day

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Water Output

• All the water excreted from the body as urine but
  also
• Water excreted including the lungs, skin and
  intestines

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Sources of OUTPUT
How much intake fluid is required?

• Urine 1700 cc
• GI tract 150 cc
• Sweat 150 cc
• Vapor in resp. 400 cc 2400 cc

Insensible losses
HOMEOSTASIS
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Monitoring Water Balance

• Daily weight
• 1 kg (2.2lbs) means a fluid loss or gain of 1
  liter of fluid
• Takes 3,000 ml of ECF deficit to produce signs of
  dehydration (4 of total body wt.)

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Abnormal decrease in total body water

• Insensible losses (saliva, sweating,
  respirations)
• such as from fever states
• Sweating
• Internal losses (Third Spacing)
• Plasma losses (Burns, surgical drains, fistulae)
• Gastrointestinal losses (diarrhea, vomit)
• Implies loss of electrolytes (increased metabolic
  rate)

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Signs and Symptoms

• Dry mucus membranes
• Thirst
• Poor skin turgor
• Tachycardia
• Hypotension
• In infants, sunken fontanel, lack of tears, fewer
  diaper changes
• Dark urine

• Orthostatic hypotension
• Absence of normal sweating
• Hematocrit elevated in pure
• dehydration, may be decreased if
• actively bleeding
• Increased respiratory rate
• Confusion, Coma, Death
• Decreased urinary output

DEHYDRATION
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Treatment

• ALS/ILS
• Get fluid in
• IV isotonic solution
• Well get to this part later!

DEHYDRATION
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An excess of total body water

• May aggravate Congestive Heart Failure
• Chronic overhydration can cause renal failure

The major sign of over-hydration is EDEMA.
OVERHYDRATION
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Signs and Symptoms

• Hypertension may indicate overload
• Jugular Vein Distention (JVD)
• Tachycardia
• Dependent edema / crackles
• Hematocrit decreased
• Shortness of Breath
• Headaches, confusion, coma, seizures

OVERHYDRATION
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Treatment

• GET THE WATER OFF!
• How would you do this as a paramedic?
• How does the body do this on its own?

OVERHYDRATION
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Kidney Function

• Regulates blood volume/blood pressure
• Adjusts volume of H2O lost in urine
• Regulates hormones erythropoietin renin release
• Regulates concentration of plasma ions of Na,
  K, Cl- by controlling amount lost in urine
• Controls blood pH by controlling loss of H ions
  and HCO3- ions concentrated in urine

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Production of Urine

• Blood flows through the glomerulus
• Glomerular pressure pushes fluid out of the
  glomerular capillaries and into the Bowmans
  capsule at the rate of 180 L / day
• Peritubular capillaries reabsorb water, glucose,
  sodium and other nutrients and put it back in the
  general circulation
• Peritubular capillaries also secrete hydrogen
  ions, potassium ions and ammonia

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Urine Regulation

• Aldosterone
• ADH
• Atrial natiuretic factor hormone
• Prostaglandins and kinins

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Aldosterone

• hormone secreted by the adrenal gland
• stimulates tubules to reabsorb sodium salts to
  attract and hold water

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ANTIDIURETIC HORMONE (ADH)

• Secreted in the posterior pituitary gland
• osomoreceptors are stimulated by an increase in
  the osmolality of body fluids
• atrial receptors are stimulated by a fall in
  venous blood volume
• makes distal and collecting tubules permeable to
  water, thus increasing water reabsorption
• water is therefore retained in the presence of ADH

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Increased ADH production

• high plasma osmolality compared to interstitial
  fluid
• low circulating volume sensed by baroreceptors
• stimulation of sympathetic nervous system
• Drugs-- morphine, oxytocin, diabinase
• head injuries, meningitis - syndrome of
  inappropriate ADH Secretion

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Decreased ADH production

• Decreased production of ADH results from--
• Decreased plasma osmolatity
• Increased circulating volume
• Alcohol consumption
• Caffeine
• Cold

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Atrial Natiuretic Factor/PeptideANP

• Secreted from cells in the right atrium of the
  heart when pressure in the right atrium increases
• ANF inhibits ADH secretion and reduces the
  ability of the kidney to concentrate urine

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Prostaglandins Kinins

• Formed in the kidneys
• Promote vasoconstriction and increased capillary
  permeability
• Part of the inflammatory process
• Influence the rate of filtrate formation and
  sodium ion reabsorption

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Cant you make it any easier?

• Kidneys have two options--
• Retain water, put it back in the intravascular
  space.
• -or-
• Dump (water) urine into the urinary bladder

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Administration of Diuretic Therapy

• Furosemide (Lasix)
• inhibits sodium and chloride reabsorption by the
  loop of Henle
• also causes venous dilation
• used primarily for acute pulmonary edema CHF

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Furosemide (Lasix)

• Contraindicated in pregnancy
• Precautions
• dehydration
• electrolyte depletion (hypo-kalemia)
• contributing to digitalis toxicity
• Side effects
• hypotension
• ECG changes
• chest pain
• electrolyte deficiencies
• Dosage
• 20-40 mg IVP (at medical control discretion)

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ELECTROLYTES

• Related to 5 physiologic processes
• Water distribution
• Osmotic pressure
• Neuromuscular activity
• Acid/Base Balance
• Support of cellular metabolism

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Electrolytes

• Chemical substances (ions) that dissociate
  charged particles when placed in water and are
  usually measured in milliequivalents (mEq/L).

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ELECTROLYTES

• The Endocrine system and the kidneys are the
  primary way of regulating fluids and
  electrolytes.
• Osmoreceptors in the hypothalamus monitor fluid
  concentrations.
• Hypothalamus secretes ADH
• ADH stored in the Posterior pituitary gland
• Kidneys release Renin which in turn controls
  release of Aldosterone
• Aldosterone helps controls pH, electrolyte and
  fluid balance

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ELECTROLYTES
Anions have a negative charge
Cations have a positive charge
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ESSENTIAL CATIONS

• SODIUM (Na)
• Prevalent in the extracellular fluid
• Normal range is 135-145 mEq/L
• Helps regulate distribution of water
• Helps transmit nerve impulses

Na
Na
Na
Na
Na
Na
Na
Na
Na
Na
Na
Na
Cell
Na
Na
Na
Na
Na
Na
Na
Na
Na
Na
Na
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Sodium (Na)

• Changes in concentration stimulate pituitary
  gland to secrete or withhold ADH
• Electrolyte of ventricular depolarization

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Sodium (Na)

• Kidneys are the chief regulator of Na
• Moves rapidly between vascular and interstitial
  spaces
• Rapid movement of water (in and out of cell)
  causes concentration of Na to change quickly,
  even though Na does not cross cell wall
  membranes easily

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Hyponatremia

• Water retention
• ECF becomes hypotonic to the cell and water
  shifts into ICF. This causes ? blood volume and a
  large portion of the body fluid in the cell
  pitting edema
• Osmolality ? r/t ? Na resulting in fluid
  (osmosis) movement from ECF to ICF

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Hyponatremia

• vomiting and diarrhea
• 3rd space losses of ECF from peritonitis,
  ascites, ileus
• CHF, peripheral edema
• Excessive use of oral water intake
• When crackles/rales are present volume is ? at
  least 1500 ml from normal

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Hyponatremia

• Signs and symptoms
• Mental confusion, delusions
• ? blood volume, ? BP, tachycardia
• Muscle weakness, abdominal cramping
• Flat neck veins
• Flushed skin, increased body temperature
• Headache
• Dry mucous membranes

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Hyponatremia

• Treatment
• IV normal saline (isotonic) for dehydration
• Diuretics for CHF with Na deficit
• What are some of the common diuretics patients
  take?

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Hypernatremia

• Sodium excess, water loss without salt loss
• What happens?
• ECF becomes hypertonic and water shifts from ICF
  to ECF until equal

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Hypernatremia

• Decreased intake of fluids, especially in hot
  weather
• Febrile states, increased sweating
• Copious watery diarrhea
• Salt H2O retention related to inability to
  excrete Na r/t starvation, severe illness,
  dehydration

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Hypernatremia

• Sodium reabsorption from steroid use
• ? capillary permeability during inflammation or
  allergic process
• ? plasma proteins in nephrosis or cirrhosis or
  from renal failure

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Hypernatremia

• Results from burns, excessive sweating and DKA
  (diabetic ketoacidosis/hyperglycemia
• Hypothyroidism, Cushings Syndrome and toxemia
  during pregnancy

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Hypernatremia

• Drugs that ? Na levels
• Diuretics
• Heparin
• NSAIDS
• antidepressants

• Drugs that ? Na levels
• Steroids
• Antibiotics
• Cough meds
• Laxatives
• Oral contraceptives

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Hypernatremia

• Treatment
• Sodium restriction
• diuretics

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ESSENTIAL CATIONS

• Potassium (K)
• Prevalent in the intracellular fluid (ICF)
• Key role in the transmission of electrical
  impulses/cell excitability

Extracellular
Intracellular
K
K
Na
Na
K
K
K
K
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Potassium (K)

• Normal range 3.5 5.2 mEq/L
• Renal failure causes K to not be flushed out
  normally causing toxicity
• K continually moves in and out of cells
• Entrance into cell depends on normal metabolism
  and utilization of glucose

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Hyperkalemia

• Renal failure, burns
• Tissue trauma, massive crush injuries
• Excessive K intake
• Respiratory/metabolic acidosis
• When tubules excrete H ions to ? pH levels, K
  accumulates in the blood

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Hyperkalemia

• Signs/symptoms
• Muscle weakness, irritability
• Nausea, diarrhea
• Intestinal colic, muscle cramp pain
• EKG changes
• Wide QRS, peaked T wave, depressed S-T segments,
  no P wave, cardiac arrest/asystole

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Hyperkalemia

• Treatment
• Elimination of K intake
• IV infusion of normal saline in large volume
• CaCl- IV to antagonize K affects on myocardium
• Glucose and insulin to drive K into cells

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Hypokalemia

• K deficit caused by excessive loss of K
• Metabolic alkalosis
• Diuretic therapy
• Acute alcoholism
• Uncontrolled diabetes
• Excessive perspiration

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Hypokalemia

• Signs/symptoms
• Apathy, lethargy, muscle weakness
• Tachycardia
• Abdominal distention/gas
• Weak pulse
• DIB, shallow respirations
• Metal depression
• EKG flat T wave, depressed ST segment, VF

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Hypokalemia

• Treatment
• KCl- (potassium chloride)
• IV lactated ringers

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Potassium (K)

• Drugs that ? levels
• Diuretics
• Laxatives
• ASA

• Drugs that ? levels
• Heparin
• Epinephrine
• Mannitol
• Histamines

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ESSENTIAL CATIONS

• Calcium (Ca)
• Plays major role in muscle contraction
• Plays major role in nerve impulse transmission
• Assists with Na and K crossing cell membrane

Extracellular
K
Na
Ca
Intracellular
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Calcium Ca

• Normal range 9.0-10.5 mg/dl
• Helps to coagulate blood
• Maintains normal heart depolarization of the SA
  and AV nodes
• Maintains plasma membrane permeability

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Calcium (Ca)

• Gate to allow Na to enter into cell for
  depolarization (contraction) to occur. Increased
  levels of Ca block this gate, leading to
  decreased cell permeability and depressed
  peripheral nervous system

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Calcium (Ca)

• Regulated in the bone, intestine and kidney
• Parathyroid hormone (PTH) and vitamin D maintains
  levels of Ca. PTH is released in response to
  low Ca and renal tubules and intestine reabsorb
  Ca through Vitamin D

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Hypercalcemia

• Increased Ca absorption
• Prevention of renal excretion
• Hypercalcemia which decreases cell membrane
  permeability resulting in decreased
  neuro-muscular excitability

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Hypercalcemia

• Renal disease
• Excessive ingestion of milk or Vit. D
• Prolonged immobilization bed rest
• Bone cancer (Ca is released from the bone in
  large amounts)
• hyperthyroidism

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Hypercalcemia

• Signs and symptoms
• Fatigue, depression

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Hypocalcemia

• Massive infections, peritonitis, pancreatitis
• Chronic renal failure
• Burns
• Hypothyroidism

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Hypocalcemia

• Signs/symptoms
• Muscle cramps
• Muscular excitability, twitching, tetany
• Signs of malnutrition, chronic alcoholism
• Anxiety
• Increased GI motility (N,V,D)
• Laryngeal spasms, hypoxia
• EKG prolonged QT interval
• Decreased BP
• Hyperventilation, increased respirations

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Testing for Hypocalcemia

• Just for fun, dont try this!!
• Trousseaus Sign Place BP cuff on arm and
  inflate to exceed systolic pressure for 3
  minutes. Note carpal spasm with contraction of
  thumb and fingers. Note inability to open the
  hand.
• Hyperexcitaility is due to decreased Ca that is
  enhanced by the ischemia
• THIS IS ONLY A POTENTIAL TEST.DO NOT DO THIS IN
  THE FIELD

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Hypocalcemia

• Treatment
• IV fluids, normal saline
• Calcium gluconate, CaCl- or Vitamin D
• To reverse hyperventilation (alkalosis), have
  patient rebreathe CO2

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ESSENTIAL CATIONS

• Magnesium (Mg)
• Necessary for
• several biochemical processes, neuromuscular
  transmission/excitability, metabolism of carbs
  and proteins

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Magnesium (Mg)

• Normal range 1.2 2.0 mEq/L
• Intracellular cation that is bound to ATP energy
  and found mostly in bone (67) and muscle (20)
• Modifies enzyme activity
• Found in legumes, grains, green veggies, meat
  seafood

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Magnesium (Mg)

• Essential for glycolysis which is necessary for
  ATP production
• Activates the Na/K ATPase pump
• More on this in cardiology!!

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Magnesium (Mg)

• Therapeutic effects
• Bronchodilating properties for acute asthma
• Stops seizure activity in eclampsia
• Treat alcoholism withdrawal
• Treats tachycardia in digoxin toxicity
• Acute MI for increased resuscitation outcome
  (pts generally have low levels)

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Hypermagnesemia

• Very rare
• Chronic renal failure
• Laxative/cathartic abuse
• Antacids, maalox, pepto, milk of magnesia

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Hypermagnesemia

• Signs/symptoms
• Respiratory depression
• Lethargy, confusion,
• GI r/t nausea and vomiting
• Uncontrolled diabetes
• EKG short QT interval, prolonged PR and QRS
  intervals, bradycardia and heart blocks

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Hypermagnesemia

• Treatment
• Control diabetes and GI loss
• Treat cardiac dysrhythmias
• Administer Ca
• dialysis

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Hypomagnesemia

• Decreased dietary intake, alcoholism
• Fistulas
• GI disorders
• AMI, post CABG
• DKA due to diuresis
• Decreased K

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Hypomagnesemia

• Signs/symptoms
• Weakness, irritability
• Tremors, tetany
• Vertigo, seizures
• HTN, hx of AMI
• Increased systemic vascular resistance
  (tachycardia)
• Insulin resistance

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Hypomagnesemia

• Treatment
• Administer Magnesium Sulfate (MgSO4)

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Magnesium

• Drugs that ? levels
• Antacids
• Thyroid meds
• Antibiotics
• diuretics

• Drugs that ? levels
• Insulin
• antibiotics

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ESSENTIAL ANIONS

• Chloride (Cl-)
• Balances the positive charge associated with the
  cations
• Plays major role in fluid balance and renal
  function by maintaining osmotic pressure
• Close association with sodium

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Chloride (Cl-)

• Normal range 90-110 mEq/L
• Extracellular anion
• Combines with H ions to produce hydrochloric
  acid to aid in acid/base balance

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Hyperchloremia

• Dehydration
• Eclampsia
• Metabolic acidosis, respiratory alkalosis
• hyperthyroidism

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Hyperchloremia

• Signs/symptoms
• Lethargy, weakness
• Deep respirations
• Kussmauls respirations
• Decreased cognition

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Hypochloremia

• Overdhydration
• CHF
• Burns
• Metabolic alkalosis, respiratory acidosis
• burns

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Hypochloremia

• Signs/symptoms
• Shallow respirations
• Decreased BP
• Tetany, hyperexcitability

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Chloride

• Drugs that ? levels
• Cortisone
• Estrogen
• Anti-inflammatory

• Drugs that ? levels
• Bicarbonate
• diuretics

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ESSENTIAL ANIONS

• Bicarbonate (HCO3- )
• Principle Ion of the Buffering System
• Controlling pH levels of the body
• ECF

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Bicarbonate (HCO-3)

• Normal range 135-145 mEq/L
• Intracellular
• Renal component of acid/base balance
• Binds H ions to form carbonic acid in the
  process of buffering metabolic acidosis caused by
  anaerobic metabolism and lactic acid production

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Bicarbonate

• Carbonic acid rapidly crosses into cells causing
  a worsening of intracellular hypercarbia (too
  much carbon) and acidosis which depresses
  myocardial and cerebral function
• Bicarbonate crosses into cells more slowly

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Sodium Bicarbonate

• Medical indications for NaHCO3
• Late in cardiac arrest after defib, CPR, ET,
  oxygenation/ventilation and at least 2
  administrations of epinephrine
• Overdose with tricyclic antidepressants (binds
  Na channels)
• Alkalinize urine in drug overdoses

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Sodium Bicarbonate

• Effects of administration
• Fluid retention (cardiovascular)
• Tissue necrosis at IV site (skin)
• Can cause metabolic alkalosis (electrolyte)

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Sodium Bicarbonate

• IMPORTANT NOTE
• Do not mix NaHCO3- with calcium agents as it will
  precipitate
• Monitor for fluid overload
• Crackles
• Pink, frothy sputum
• Peripheral edema

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Fluid and Electrolyte Imbalance

• There comes a point where the body (especially
  the kidney) can no longer maintain
  interrelationships of fluids and electrolytes
  essential to normal function resulting in
  imbalance
• Your job is to prevent further imbalance by
  recognizing the s/s AND knowing what therapy to
  administer

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Problems with Fluids and Electrolytes

• Result from
• Volume disturbance (too much/too little)
• Irregularities in transportation of fluid (CHF,
  shock)
• Ratio of fluid and electrolytes imbalanced
  (acidosis, alkalosis)
• Shifts of fluid to the wrong places
  (edema/ascites)

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SEMIPERMEABLE MEMBRANES

• Cell membrane which allows passage of certain
  substances and restricts the passage of others.
• Allows
• Oxygen, Carbon Dioxide, Water
• Restricts
• Proteins, Glucose

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Only capillaries have walls thin enough to let
solutes pass through.
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Colloids vs. Crystalloids

• Colloids
• Contains proteins or high molecular weight
  (large) molecules
• salt-poor albumin, dextran
• Crystalloids
• Primary compounds used in pre-hospital
• Lactated Ringers, Normal Saline, D5W

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COLLOID SOLUTIONS

• Advantages
• Requires less solution to replace vascular volume
• Maintains colloid oncotic pressures
• Effective as volume expanders

• Disadvantages
• More expensive
• Pulmonary complications
• Allergic reactions
• Interference with platelet function
• Renal complications

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CRYSTALLOIDS

• Advantages
• Inexpensive
• Readily available
• Causes no allergic reactions
• No infectious disease transmission
• Effective volume expanders
• Cleared by lymphatics

• Disadvantages
• Need large amounts of solution to replace
  vascular volume
• 3 to 1 ratio -adult
• 20 cc/kg peds

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Were going to be especially interested in three
spaces.
Where do we put fluid?
Intracellular space
Interstitial space
Intravascular space
Via intravenous catheters
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TONICITY
(Concentration of molecules)

• ISO Same
• Hyper More
• Hypo Less

tonic
Number of molecules
tonic
tonic
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Tonicity

• The degree of concentration (osmolarity) of a
  solution depends on the amount of solutes
  (particles) dissolved in water
• Tonicity controls movement of water across the
  membrane

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Tonicity
Cell
Interstitial
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Isotonic (Iso means same right?)
Cell
Interstitial
129
TONICITY

• HYPERTONIC -- A state where a solution has a
  higher solute concentration on one side of a
  semipermeable membrane compared to the other side.

Cell
Interstitial
Intravascular
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Cell
Interstitial
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TONICITY

• HYPOTONIC -- A state where a solution has a lower
  solute concentration on one side of a
  semipermeable membrane compared to the other side.

Cell
Interstitial
Intravascular
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Cell
Interstitial
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Hypotonic Hypertonic
Cell
Interstitial
134
What is the tonicity of these?
Cell
Interstitial
135
?
?
Cell
Interstitial
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Water and Electrolyte Distribution

• One of the forces that govern the movement of
  water/electrolytes is passive transport
• Passive transport moves substances down their
  concentration gradient through the appropriate
  transport proteins

137
Passive Transport

• Osmosis
• Diffusion
• Facilitated Diffusion
• PASSIVE TRANSPORT MEANS NO ATP ENERGY IS
  REQUIRED FOR MOVEMENT
• Ex fish that swim with the current

138
OSMOSIS The movement of water across a
semipermeable membrane from an area of relatively
lower solute concentration to an area of
relatively higher solute concentration.
Cell
Interstitial
139
Osmosis

• Water moves along the concentration gradient from
  an area of low solute concentration to an area of
  high solute concentration to achieve equilibrium
• The force that makes the water move is called the
  osmotic pressure

140
Osmosis
141
Osmotic Pressure

• The amount of pressure required to stop osmosis
  and water moving across the semipermeable membrane

142
Osmosis

• How are patients affected by osmosis?
• Increased ICP due to cerebral edema
• Give manitol as a hypertonic solution as the
  particles will pull water
• Diabetic ketoacidosis (DKA)
• Increased glucose make plasma hypertonic to
  interstitial fluid
• Fluid moves from interstitial space to vascular
  space

143
Osmosis

• How are patients affected by osmosis?
• Can experience dehydration acidosis
• Give infusions of normal saline (isotonic) to
  dilute the plasma and rehydrate interstitial
  compartment

144
DIFFUSION The movement of solutes across a
semipermeable membrane from an area of relatively
greater solute concentration to an area of
relatively lower solute concentration.
Cell
Interstitial
145
Diffusion

• Spontaneous process that distributes molecules
• Molecules continually are in motion and collide.
  The collisions cause molecules to change
  direction and spread out until they are uniformly
  distributed

146
Diffusion

• Move down the concentration gradient because they
  diffuse from regions of higher concentration to
  lower concentration
• Solutes move more slowly than water
• Ex O2 and CO2 in the lungs

147
And now for something Completely Different!

• Lets take a few minute break, then come back.

148
CHF vs. COPD

• We are seeing a lot of this in narratives lately
• Patient exhibiting difficulty breathing with
  wheezes. Patient given Albuterol via nebulizer,
  no change in condition.

149
CHF vs. COPD

• Then as we read further, we see information like
  this
• Patients BP 160/100. Patient hx CHF/pulmonary
  edema/left-side heart failure. Patient EKG
  atrial fibrillation. Patient meds lasix,
  Cardizem, coumadin.

150
RED FLAGS!!!

• History of CHF/pulmonary edema and/or afib
• High blood pressure
• Trouble breathing
• Noisy lungs

151
Consider CHF!

• Red flags indicate high suspicion for CHF, NOT
  COPD
• Nebulized albuterol is not going to help.
• Will just raise heart rate and work heart further
• Might help a tiny bit if the patient has
  co-morbid COPD or asthma, but not much
• You can always throw an in-line neb on the CPAP
  if you suspect a bit of COPD too.

152
But remember CHF is not a respiratory issue

• Congestive heart failure and pulmonary edema are
  cardiac issues.
• Need a cardiac solution
• Your go-tos
• CPAP
• Nitro
• Lasix and Morphine with medical control approval
• CPAP and nitro are miracle-workers in CHF!

153
Then why do we hear wheezing?

• In the field, occasionally hard to differentiate
  between wheezes and crackles/rales.
• Wheezes are musical
• More common during expiratory phase
• Crackles, well, crackle (and pop and click and
  bubble)
• More common during inspiratory phase

154
Online!

• If you have a moment, Google lung sounds. Its a
  great way to learn the difference!
• An example of a good lung sound site
• http//www.stethographics.com/main/physiology_ls_i
  ntroduction.html

155
Strip O the Month

• Asystole/PEA

156
Asystole (Cardiac Standstill)

• Asystole is a total absence of ventricular
  electrical activity
• There is no ventricular rate or rhythm, no pulse,
  and no cardiac output
• Some atrial electrical activity may be evident
• P-wave asystole

157
Asystole ECG Characteristics
158
Asystole Causes

• Pulmonary embolism
• Acidosis
• Tension pneumothorax
• Cardiac tamponade
• Hypovolemia
• Hypoxia
• Heat/cold (hypothermia/hyperthermia)
• Hypokalemia/hyperkalemia (and other electrolytes)
• Myocardial infarction
• Drug overdose/accidents (cyclic antidepressants,
  calcium channel blockers, beta-blockers, digoxin)

PATCH-4-MD
PATCH-4 MD
159
Asystole Intervention

• Confirm the absence of a pulse
• Perform immediate CPR
• Confirm the rhythm in two leads
• Consider possible causes of the rhythm
• Pharm Epinephrine 110,000 1mg IV/IO
• No More Atropine!!!

160
Pulseless Electrical Activity (PEA)

• Pulseless electrical activity is a clinical
  situation, not a specific dysrhythmia
• Formerly called electromechanical dissociation
  (EMD)

161
Pulseless Electrical Activity

• PEA exists when organized electrical activity
  (other than VT) is present on the cardiac
  monitor, but the patient is pulseless

162
PEA Causes

• Pulmonary embolism
• Acidosis
• Tension pneumothorax
• Cardiac tamponade
• Hypovolemia (most common cause)
• Hypoxia
• Heat/cold (hypothermia/hyperthermia)
• Hypokalemia/hyperkalemia (and other electrolytes)
• Myocardial infarction
• Drug overdose/accidents (cyclic antidepressants,
  calcium channel blockers, beta-blockers, digoxin)

PATCH-4-MD
163
PEA Intervention

• Begin CPR
• Search aggressively for possible cause(s) of the
  situation
• Often finding the right H or T can solve PEA
  quickly
• Most common cause hypovolemia
• Pharm Epinephrine 110,000 IV/IO
• No More Atropine!!!

164

• Questions?
• If you are watching live, type into text box.
• Otherwise, feel free to email afinkel_at_silvercross.
  org or call 815-300-7425