Part 9

Treatment of? 

Use of hypotonic fluid (5% dextrose) 

Lower levels by max 10mmol/L per day 

Acute therapy = hypotonic fluid, lower 1-2mmol/L per hour 

Acute increase in plasma levels can lead to irreversible neurologic injury 

<3.5mmol/L 

Caused by: decreased intake, increased entry into cells, increased losses (GI,  Urine) 

Manifestations = muscle weakness (<2.5mmol/L), ECG changes into arrhythmias. If chronic = renal impairement, impaired concentration and raised BP 

ECG: 

Flat T wave 

U waves

ST depression 

PR interval and QT interval prolonged 

Treatment for? 

Correct Mg

Replace lost levels (oral or IV) 

Cardiac monitoring 

>5.5mmol/L 

Caused by: increased release from cells and decreased urinary excretion 

Symptoms = paraesthesia, muscle weakness, paralysis, arrhythmias 

ECG

Tall T waves 

Shortened QT 

PR and QRS lengthening 

P waves disappear 

Sine wave 

ECG changes are life threatening 

Treatment for ?

Antagonise membrane action - IV calcium gluconate 

Drive into cells - Insulin (with glucose), NaHCO3, beta agonists 

Remove from the body - loop diuretics, consider haemodialysis 

Low arterial body pH in conjuction with reduced serum HCO3- conc. 

Normal anion gap ranges 

Increased anion gap = 

(due to bicarb buffering and therefore levels falling)

Glycols (ethylene / propylene) 

Oxyproline (biproduct of paracetamol)

L-lactate

D-lactate 

Methanol (acidic by product is formic acid / formaldehyde) 

Aspirin 

Renal failure 

Ketoacidosis 

Hypovolemic 

Cardiogenic 

Anaphylactic 

Septic 

Leads to reduced perfusion to tissues and lack of O2 therefore anaerobic respiration and a build up of lactate 

Base excess low or high = metabolic acidosis 

pH = 7.35-7.45

PaCO2 = 4.5-6 kPa 

PaO2 = 10-13kPa 

HCO3 = 24-28mmol/L 

O2 sat = 96-100% 

Base excess = +/- 2 mEq/L 

12 y/o presents with laboured breathing 

pH = 7.15

pCO2 = 2kPa 

pO2 = 16kPa 

HCO3- = 11mmol/L 

Anion gap = 15 

Blood Glc = 33 

68 y/o 

Hx of COPD 

pH = 7.22

pO2 = 7.2

pCO2 = 5.5 

HCO3- = 23

Base excess = -9 

Anion gap = 18 

62y/o

3 day Hx fever, unwell, SOB and cough of discoloured sputum 

BP = 66/32

HR = 132 

T = 38.9 

CRP = 232 

High flow O2 

Blood cultures 

IV Abx

Fluid challenge

Measure lactate

Measure UO 

Five day Hx of cough / fever 

Mild decreased O2 sats 

Left basal crackles 

Stony dully percussion note 

Increased CRP 

Expansion = decreased 

Mediastinum / trachea = deviated away if large 

Percussion = stoney / dull / muffled 

Ausculation = decreased, bronchial breath sounds at level of effusion 

Resonance = reduced 

CXR = no hemi-diaphragm, dense white shadowing creeping up side of chest 

Transudate = 

Exudate = 

77 y/o F 

Unwell, febrile 

Cough with green sputum, mildly confused 

Dull right base 

CRP = 349 

CXR = creeping up shadow 

pH = 7.12 

Thoracocentesis results =

High protein and LDH

Glucose nearly 0 

Fluid clearly showed pus 

MCS = strep milleri 

(mortality of 20%)

56 F 

PC = Cough, haemoptysis, weight loss 

40 pack smoking Hx

Cachexia, clubbing 

Reduced BS left base

CRP = 40 

Tests = high protein 

Cytology = metastatic adenocarcinoma - lung origin 

Lung, breast, ovarian, lymphoma 

Stage IV if you find cancer cells in pleural fluid 

Incurable at this point, median survival = 4-6mo

Pleurodesis (make pleural levels stick together to prevent future build up)

Tunnelled drain (remains in, drained 3 times a week) 

67 F 

MHx = IHD, CKD, HTN, T2DM, high cholesterol 

Increased SOB, orthopnoea 

O2 sats = 88% on 4L 

JVP increased at jaw 

Dull at midzones, crackles on top 

Sacral and ankle pitting oedema 

Tests = low protein therefore exudate and low LDH 

29 M 

Smoker 

PC = sudden pain in left chest - stabbing sensation 

Minor SOB 

Tall and skinny 

Left side = decreased breath sounds, < expansion, >percussion