Transcript When Do I Order What?

When Do I Order What?
Bucky Boaz, ARNP-C
Criteria for Detecting Electrolyte
Abnormalities in ED Patients
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Poor oral intake
Vomiting
Hypertension, diuretic use
Age > 65
Recent Seizure
Muscle Weakness
Alcohol abuse
Altered mental status
Recent abnormal
electrolytes
Electrolyte Disorders
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Calcium
Magnesium
Potassium
Sodium
Calcium
• Normal range:
‫ ٭‬8.5-10.5 mg/dL
• Panic!
‫< ٭‬6.5 or >13.5 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.
Calcium
Hypocalcemia
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Hypoparathyroidism
Vitamin D deficiency
Renal insufficiency
Pseudohypoparathyroidism
• Magnesium deficiency
• Hypophosphatemia
• Massive transfusion
• hypoalbuminemia
Calcium
Hypercalcemia
• Hyperparathyroidism
• Malignancies secreting
parathyroid hormonerelated protein (PTHrP)
‫ ٭‬squamous cell of lung
‫ ٭‬Renal cell carcinoma
‫ ٭‬Leukemia
• Vitamin D excess
• Multiple myeloma
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Paget’s disease
Sarcoidosis
Vitamin A intoxication
Thyrotoxicosis
Addison’s disease
Drugs
‫ ٭‬Antacids, Calcium salts,
Diuretic use, Lithium
Calcium
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
Magnesium
• Normal range:
‫ ٭‬1.8-3.0 mg/dL
• Panic!
‫< ٭‬0.5 or 4.5 mg/dL
• Marbled top
• Concentration is
determined by
intestinal absorption,
renal excretion, and
exchange with bone
and intracellular fluid
Hypomagnesium
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Chronic diarrhea
Enteric fistula
Starvation
Chronic alcholism
Hypoparathyroidism
Acute pancreatitis
Chronic
glomerulonephritis
• Diabetic ketoacidosis
• Drugs
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Albuterol
Amphotericin B
Calcium salts
Cisplatin
Cyclosporin
Diuretics
Hypomagnesemia
• (<1.5 mEq/L)
• Due to diuretics, aminoglycosides,
cyclosporine.
• Clinical features:
‫ ٭‬Irritable muscle,tetany,seizure,arrhythmia.
• Treat:
‫ ٭‬MgSO4 25-50 mg/kg IV over 20 min.
Hypermagnesium
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Dehydration
Tissue trauma
Renal failure
Hypothyroidism
Drugs
‫ ٭‬Aspirin (prolonged
use)
‫ ٭‬Lithium
‫ ٭‬Magnesium salts
‫ ٭‬Progesterone
‫ ٭‬Triamterene
Hypermagnesemia
• (>2.2 mEq/L)
• Due to renal failure, excess maternal
Mg supplement, or overuse of Mgcontaining 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.
Potassium
• Normal range:
‫ ٭‬3.5-5.0 mg/dL
• Panic!
‫< ٭‬3.0 or >6.0 mg/dL
• Marbled top
• Predominately an
intracellular cation
whose plasma level is
regulated by renal
excretion.
• Plasma concentration
determines
neuromuscular
irritability
Potassium
Hypokalemia
• Clinical Features of Hypokalemia
‫ ٭‬Lethargy, confusion, weakness
‫ ٭‬Areflexia, difficult respirations
‫ ٭‬Autonomic instability, Low BP
• ECG findings in Hypokalemia
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K+ < 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
Hyperkalemia
• Causes of Hyperkalemia
‫ ٭‬Exogenous:
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blood
Salt substitutes
K+ containing drugs (e.g. penicillinderivatives)
Acute digoxin toxicity
Beta blockers, ACE inhibitors
Succinylcholine
Non-steroidals
Hyperkalemia
‫ ٭‬Endogenous:
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Acidemia
Trauma
Burns
Rhabdomyolysis
DIC
Sickle cell crisis
GI bleed
Chemotherapy (destroying tumor mass)
Mineralocorticoid deficiency
Congenital defects (21 hydroxylase deficiency)
Hyperkalemia
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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+ > 10: sine wave appearance
Sodium
• Normal range:
‫ ٭‬135-145 mg/dL
• Panic!
‫< ٭‬125 or >155 mg/dL
• Marbled top
• Predominately an
extracellular cation.
• Serum sodium level is
primarily determined
by the volume status
of the individual.
Hyponatremia
• Symptoms
‫ ٭‬Lethargy, apathy
‫ ٭‬Depressed reflexes
‫ ٭‬Muscle cramps
‫ ٭‬Pseudobulbar palsies
‫ ٭‬Cerebral edema
‫ ٭‬Seizures
‫ ٭‬Hypothermia
Hyponatremia
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CHF
Cirrhosis
Vomiting
Diarrhea
Excessive sweating
(replacing water, but
not salt)
• Salt-loss nephropathy
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Adrenal insufficiency
Water intoxication
SIADH
Drugs
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Thiazides
Diuretics
ACE Inhibitors
Chlorpropamide
Carbamazepine
Hyponatremia
Hypernatremia
• Symptoms
‫ ٭‬Lethargy, irritability, coma
‫ ٭‬Seizures
‫ ٭‬Spasticity, hyperreflexia
‫ ٭‬Doughy skin
‫ ٭‬Late preservation of intravascular
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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
Hypernatremia
Endocrine Disorders
• Hyperthyroidism/
Thyroid Storm
• Hypothyroidism/
Myxedema Coma
Hyperthyroidism/Thyroid Storm
• Underlying Thyroid
Disease
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Grave’s Disease (#1)
Toxic nodular goiter
Toxic adenoma
Factitious
thyrotoxicosis
‫ ٭‬Excess TSH
• Precipitants
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Infection (#1)
Pulmonary embolus
DKA or HHNC
Thyroid hormone
excess
‫ ٭‬Iodine therapy/dye
‫ ٭‬Stroke, surgery
‫ ٭‬Childbirth, D&C
Clinical Features of
Hyperthyroidism/Thyroid Storm
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Hyperkinesis
Palpable goiter
Proptosis, lid lag
Exopthalmus, palsy
Temp > 101 F
HR + Pulse pressure
Arrhythmia (new onset)
Weight Loss
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Palpitations
Dyspnea
Psychosis
Apathy
Coma
Tremor
Hyperreflexia
Diarrhea
Jaundice
Laboratory Findings
Hyperthyroidism/Thyroid Storm
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 free T4
 T3
 TSH
 T4RIA
 FT4I
 Glucose
 Ca+2
 WBC
 Hb
 Cholesterol
• Lab test can diagnose
hyperthyroid, but
Thyroid Storm
(Thyrotixicosis) is a
clinical diagnosis
Hypothyroidism/Myxedema
Coma
• Precipitants
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Pneumonia
GI bleed
CHF
Cold exposure
Stroke
Trauma
 pO2
 CO2
 Na+
• Drugs
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Phenothiazides
Narcotics
Sedatives
Phenytoin
propanolol
Clinical Features of
Hypothyroidism/Myxedema Coma
Vitals
Temp is ofter < 90 F, 50% have BP < 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
Laboratory Findings of
Hypothyroidism/Myxedema Coma
• Serum TSH > 60
U/ml
•  Total & free T4
•  or  total & free
T3
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
AST>ALT
2:1
AST>ALT
2:1 
10 X 
1-5 X
Chronic 
Biliary Chirrosis
1-2 X 
1-2 X 
1-4 X 
1-2 X 
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Chronic Hepatitis
1-20 X 
1-20 X 
1-3 X 
1-3 X 
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Viral Hepatitis
5-50 X 
5-50 X 
1-3 X 
1-3 X 
Normal
Stroke, TIA, and Subarachnoid
Hemorrhage
• CT Scan abnormal > 95% if onset < 12h
• CT Scan abnormal 77% if onset > 12h
• CSF > 100,000 RBCs/mm3 (mean) although
any # can be seen
• Xanthochromia
• ECG = peaked, deep, or inverted T waves, 
QT, or large U wave
Imaging Low Back Pain
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Acute neuro deficit consistent
Acute significant trauma
Age > 70, or minor trauma > 50 years
History of prolonged steroid use OR osteoperosis
History of cancer OR unexplained wt loss
History of recent infection OR fever > 100 F OR
parental drug abuse
• LBP worse at rest OR disability due to LBP > 4
weeks
Fever in Children
Clinically Significant CXR
Abnormalities
SOBreath Criteria
S
Saturation < 90%
O
Older than 59 years
B
Breath sounds diminished
R
Rales or Respiratory rate > 24 bpm
E
Embolic disease (prior DVT or PE)
A
Alcohol abuse
T
Tuberculosis or Temp > 100.4
H
Hemoptysis
95% sensitive, 40% specificity
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 - > 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 - >90% sen for PE
P pulmonale
6%
Abdominal Pain
Abdominal Pain
Diagnostic Studies in Appendicitis
In first 24 hours, WBC count > 11,000
20-40%
After 24 hours, WBC > 11,000
70-90%
Urinalysis with > 5 WBC or RBC/hpf
15-30%
Ultrasound sensitivity
78-94%
Ultrasound specificity
89-100%
CT scan sensitivity
92-100%
CT scan specificity
>95%
Abdominal Pain
Abdominal Pain
Abdominal Pain
Biliary Tract Disease
• Clinical Features of Biliary Colic
‫ ٭‬Pain usually begins 30-60 min after meal
‫ ٭‬Pain duration < 6-8 hrs
‫ ٭‬Absence of fever
‫ ٭‬WBC < 11,000 cell/mm3 in most
‫ ٭‬Normal liver function tests in 98%
‫ ٭‬Absence of pancreatitis
‫ ٭‬US is 98% sensitive for gallstones
Biliary Tract Disease
Clinical Features Acute Cholecystitis
Pain duration > 6-8 hrs
> 90%
Temp > 100.4 F
25%
WBC > 11,000 cell/mm3 in most
>95%
Murphy’s sign
65%
Elevated liver function tests
55%
Pancreatitis
15%
Ultrasound sensitivity
85%
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
Painful Scrotum
Trauma
Accidental vs Non-accidental
Head Trauma
Head Trauma
Head Trauma
Cervical Spine
Cervical Spine
Thoracolumbar Spine
Indications for Thoracolumbar Spine
Radiographs in Blunt Trauma
Back pain or tenderness
Ejection from motorcycle/vehicle
Neurologic deficit
Motor vehicle crash > 50 mph
Glasgow coma scale < 14
Major distracting injury
Drug intoxication
•Pelvic fracture
Alcohol intoxication
•Long bone fracture
•Blood alcohol > 100 mg/dl
Intrathoracic injury
Fall > 10 feet
Intraabdominal injury
Shoulder
High-Yield Criteria for Shoulder Xrays in the
Emergency Department
Shoulder deformity
Shoulder swelling
History of fall (with
age > 43.5 years)
Abnormal range of
motion
Blunt Real Trauma
Pelvis
Criteria for Pelvic Radiography Following
Blunt Trauma
Disoriented, Glasgow coma scale < 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 anteriorposterior 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
Abdominal Trauma
Abdominal Trauma
Ottawa Knee
Age > 55
Unable to flex 900
Unable to walk
immediately after injury or
4 steps in the ED
Isolated fibular head
tenderness
Isolated patellar tenderness
Pittsburgh Knee
Foot and Ankle