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Hey, what's up everyone, Doctor 
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enjoy the lecture. 
Take care. 

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Without further ado, let's talk 
about fluids and electrolytes, 

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but not just fluids and 
electrolytes. 

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I want to show you that fluids 
and electrolytes are a big 

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portion of Med surg and Med surg
is a huge portion of your exam. 

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Not even exam. 
Those of you that are students, 

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I see a lot of students in here 
as well too. 

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It's a part of your entire 
schooling. 

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So when you see that you've got 
Med surg and then a section of 

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fluids, fluids, and 
electrolytes, and now you're 

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moving forward with fluid and 
electrolytes and Med surg into 

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the board exams, I want to show 
you how medicine is medicine. 

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So get ready to take a lot of 
notes here and I'm going to go 

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at a decent pace. 
So if I make this a Part 1 and a

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Part 2, don't worry about it. 
You'll catch Part 2 next week, 

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but make sure you're taking 
notes. 

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So the basic concept of fluid 
balance is what we need it for 

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cellular function. 
I mean every single cell, cell 

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has a transport, whether it be 
sodium, potassium, chloride, 

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magnesium, we've got some sort 
of an electrolyte going in and 

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out, in and out in each one of 
them serves a different purpose.

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Also responsible for transport 
of nutrients, waste of 

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excretion. 
So you can imagine that fluid 

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balance is so important in every
little minute detail working 

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forward, but what are the 
kidneys role? 

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The kidneys role is going to 
determine our fluid volume and 

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electrolytes through filtration.
And if you were to go through 

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and look at the loop of Handley,
the ascending loop, descending 

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loop, so on and so forth, what 
the glomeruli does, there's a 

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lot of different moving parts, 
things that get reabsorbed, 

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things that get excreted, things
that get put back into the 

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blood. 
And then comes where we start 

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getting into the Med surge and 
where we get into the actual 

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boards and it comes into 
hormonal regulation. 

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This is where I start to teach 
you how important fluid balance 

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is the one concept, and I've 
taught this to my students left 

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and right and they'll know this 
is the renin angiotensin 

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aldosterone system are RAAS. 
Now I tell my students, the only

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thing that I want you all to 
focus on is what part of this is

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in fact aldosterone. 
Now everyone thinks renin 

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angiotensin aldosterone system I
need to breathe a little bit, 

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but let's simplify things. 
Aldosterone is going to regulate

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sodium. 
What follows sodium? 

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Well water. 
If I've got sodium and potassium

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having an inverse relationship 
through that sodium, potassium 

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pump. 
If sodium goes up, well, what 

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happens to potassium? 
Potassium goes down. 

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Understand you. 
I saw it pointing down. 

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I love it. 
So yes, they go opposite. 

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So imagine how much we can 
control with fluid and 

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electrolytes just with 
aldosterone. 

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Think about it, just with 
aldosterone. 

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Now, now, now we're taking it a 
step further. 

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Aldosterone, where are we going 
to see aldosterone produced is 

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going to be where? 
In the adrenal glands, The 

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adrenal glands, they sit on top 
of the kidney. 

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Well, now, what system am I 
going into? 

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I'm talking Med surgeon fluid, 
electrolytes. 

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But I'm already taking you down 
what path? 

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Taking you down Endocrine. 
Yeah. 

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So now if I have, let's just say
I have a tumor in the adrenals 

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in the portion that increases my
aldosterone, what do I have? 

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If I have a tumor, I'm going to 
get excess, excess excess sodium

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because that tumor is going to 
produce aldosterone, produce 

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aldosterone, produce 
aldosterone. 

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I just showed you primary hyper 
aldosteronism. 

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I just introduced you to Khan 
syndrome. 

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In that situation, in constant 
in Khan syndrome or in primary 

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hyperaldosteronism, I've now 
increased sodium. 

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Water is followed and my blood 
pressure is through the roof. 

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I'm hypokalemic. 
You think I got muscle cramps or

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I'm at risk for dysrhythmia? 
I am. 

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Do you see how I'm tying in 
board questions, signs and 

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symptoms? 
What? 

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I'm freaking out about potassium
asked Grab. 

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Then I take it a step further. 
What if in this situation I have

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no aldosterone? 
What if I go the opposite way, 

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which means I've got adrenal 
insufficiency, adrenal 

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insufficiency, adrenal ADI, How 
about Addison's? 

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So now in this situation, I just
knocked out sodium. 

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So if I knocked out sodium, 
water went with it. 

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So my blood pressure dropped and
guess what just went up? 

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My potassium. 
I'm hyperkalemic. 

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So you see fluid balance or 
fluid and electrolytes and Med 

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surg and now endocrine. 
But that is all. 

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It's all the same. 
It all ties in. 

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It all ties in. 
And when you start to understand

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that if you sectionalize 
medicine, it's never going to 

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help pass the boards. 
If you sectionalize it, it's 

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going to make everything harder 
for you when you start tying in,

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oh, this subject is fluid 
electrolytes, but medicine is 

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medicine. 
Now we move on to because in 

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this situation, all we are 
regulating, what electrolyte 

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were we regulating? 
We're just focused on one 

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electrolyte and by default the 
other one followed or went the 

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opposite way. 
By default water follow or it 

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went with it. 
The next one is ADH, which is 

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anti diuretic hormone, anti 
diuretic hormone. 

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And not to get too much into 
this, but what is anti diuretic?

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Well, diuretic means I'm going 
to pee, diuretic means I'm going

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to pee. 
If it's anti diuretic, it's anti

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peeing. 
I'm not going to pee. 

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So for me, when I had to think 
about diabetes insipidus or I 

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had to think about SIADH, the 
way that I think about it, I had

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to dumb it down for myself. 
And I thought about it in terms 

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of peeing because it made sense 
to me. 

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Instead of worrying about a 
hormone I just thought about, 

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OK, well, a diuretic makes me 
pee. 

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This is anti diuretic, so I'm 
not going to pee, which means 

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I'm going to retain water if I 
have too much of it, which is 

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SIADH where we have 
inappropriate amounts of anti 

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diuretic hormone. 
So I'm not going to pee. 

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Now let's take this a step 
further. 

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Let's think boards, let's think 
school, let's go back. 

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Let's think real life in 
general, in general, not S i.e. 

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DH in general. 
If I don't pee, what is that 

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called? 
If I don't pee, I'm probably 

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what I'm probably dehydrated, 
right? 

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And I've said to everyone that 
dehydration is a concept that is

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presented in so many different 
ways. 

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So not peeing. 
Do you think this is something 

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that's going to happen in real 
life? 

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Now my students that have been 
in my course know the story. 

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I'm in Mai, Mean I'm in Mai was 
in MA before I went to medical 

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school. 
So I was a medical assistant and

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I would take the pee out of the 
little cabinet and sometimes it 

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was dark, it was concentrated 
and it was pungent and smelled 

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tea colored, cola colored. 
Signs and symptoms of 

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dehydration. 
Select all that applied. 

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I did a urine dipstick and guess
what? 

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It showed me that the specific 
gravity was elevated above 

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1.030. 
That the, that the urine 

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osmolality, the urine 
concentration was elevated. 

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That's not even talking about 
ADH, That's just talking about 

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dehydration in general. 
So you can see that fluids in 

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that situation or a lack of in 
dehydration throws off our fluid

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balance. 
But we must know our signs and 

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symptoms, our lab values, how 
the boards are going to ask it. 

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And that's what I'm trying to 
tie together. 

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So you understand, not only is 
this a fluid and electrolyte 

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message, look at how many other 
things I'm going to tie in 

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today. 
That's why I want you to take so

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many notes, really pay attention
today. 

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I that's why I was so excited 
about this lecture. 

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I was like, I'm super stoked 
about this. 

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This is just a little, a little 
definition, nothing to take away

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from this. 
Nothing, something that nothing 

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that's going to be tested. 
So it's just more definitions. 

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What intracellular fluid is, 
what extracellular fluid is, 

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interstitial and intravascular 
fluid as well too. 

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But we can take it a step 
further and get into our 

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electrolytes. 
The ones that I'm going to focus

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on are the ones that I feel, and
I'm going to focus on ones a 

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little bit more heavy than the 
other ones because I feel 

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there's more to it now. 
Sodium, our normal range, should

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we know it? 
Absolutely. 

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Why we're getting case studies 
now, and guess what case studies

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are throwing in? 
They're throwing in lab values 

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now. 
They're going to give you the 

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normal range. 
But guess what? 

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If you kind of know it off the 
top of your head, it makes life 

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easier. 
All I'm trying to do is make you

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prepared more for your exam and 
for real life. 

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But the extremes on each 
electrolyte is what we're 

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concerned about whether we're 
high or whether we're low and 

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what they entail. 
So if I'm low, I'm hyponatremic,

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hyponatremic below 135. 
When we get to below 120, we get

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a little, we get very scared and
we have to be careful how we 

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corrected. 
I'm going to talk about that 

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here in a little bit. 
But when we're hyponatremic, 

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what are we worried about? 
We're worried about one of ask 

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graph. 
Which one of ask graph are we 

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worried about altered mental 
status by way of seizures by way

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of seizures? 
So what are some ways that we 

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can develop that will 
hyponatremia if I'm retaining 

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fluid? 
Didn't we just talk about SIADH?

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Sure we did. 
What about in infants? 

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We talked about diluting what 
milk, water intoxication, right?

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Hypernatremia. 
If we're losing water, we're 

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losing water. 
We become hypernatremic, we 

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develop thirst, high sodium 
intake, so on and so forth. 

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Not really the one that I'm 
concerned about. 

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The one I'm freaking out about 
is seizures, because that is a 

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scrap. 
But potassium, do we have a lot 

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of room for air with potassium, 
3.5 to 5 milli equivalents? 

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No, we don't. 
And it is part of Asgraph. 

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And I don't say hypo or 
hyperkalemia, do I? 

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I say changes in potassium, 
changes in potassium. 

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And as we realize this, we're 
going to see that whether we're 

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hypo or hyperkalemic, hypo or 
hyperkalemic, we can develop 

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00:15:03,880 --> 00:15:07,240
arrhythmias. 
What part of the heart does 

227
00:15:07,240 --> 00:15:12,040
potassium predominantly control?
It is in fact the ventricle. 

228
00:15:13,240 --> 00:15:18,360
So now we just took it from 
fluid and electrolytes into 

229
00:15:18,400 --> 00:15:23,480
Ekgs. 
Do you see how we're we're not 

230
00:15:23,480 --> 00:15:26,560
jumping all over the place. 
We're making sense of things, 

231
00:15:27,280 --> 00:15:38,650
right? 
And in my in my EKG, I've got my

232
00:15:38,650 --> 00:15:44,720
QRST which is going to signify 
what's happening with the 

233
00:15:44,720 --> 00:15:51,360
ventricle. 
So can I get now, now look at 

234
00:15:51,360 --> 00:15:53,400
these terms and what they really
mean. 

235
00:15:53,680 --> 00:15:56,680
OK, so pay attention to these 
terms. 

236
00:15:57,560 --> 00:16:04,280
The term widened QRS complex. 
How many times you see a 

237
00:16:04,280 --> 00:16:09,840
medication and it says widened 
QRS complex or you you see that 

238
00:16:09,840 --> 00:16:11,600
term and you're like, wait a 
minute, what does that mean? 

239
00:16:13,160 --> 00:16:15,720
Well, ultimately, if it widens 
and widens and widens and 

240
00:16:15,720 --> 00:16:18,400
widens, can it not turn into a 
dysrhythmia like that? 

241
00:16:19,360 --> 00:16:22,160
Yeah. 
And what are we worried about 

242
00:16:22,160 --> 00:16:27,080
the most? 
Ventricular fibrillation with 

243
00:16:27,080 --> 00:16:30,680
hyperkalemia. 
You may see, and this is 

244
00:16:30,680 --> 00:16:35,920
exaggerated, a peaked T wave, 
but still affecting the 

245
00:16:35,920 --> 00:16:42,280
ventricle. 
So you see how potassium and 

246
00:16:42,280 --> 00:16:49,800
those dysrhythmias are so 
dangerous, so dangerous calcium.

247
00:16:52,920 --> 00:16:58,000
With calcium we may be 
hypocalcemic or hypercalcemic. 

248
00:16:59,680 --> 00:17:04,640
Now with hypocalcemia, what is 
the most popular way to develop 

249
00:17:04,960 --> 00:17:08,160
hypocalcemia on the boards? 
On the boards is a 

250
00:17:08,160 --> 00:17:11,359
thyroidectomy, where we get rid 
of the parathyroids, 

251
00:17:11,440 --> 00:17:12,839
incidentally. 
Yeah. 

252
00:17:13,520 --> 00:17:17,560
So we get rid of the 
parathyroids, which regulate 

253
00:17:17,800 --> 00:17:21,200
calcium, and now we've got 
hypocalcemia. 

254
00:17:21,480 --> 00:17:26,359
Now I ask the question, how will
it present and how will you more

255
00:17:26,359 --> 00:17:30,520
than likely see it? 
So we've got two different tests

256
00:17:30,800 --> 00:17:34,160
that you can see. 
You can see Trousseau's and you 

257
00:17:34,160 --> 00:17:37,520
can see Chalcedeck. 
So Trusolus is going to be the 

258
00:17:37,520 --> 00:17:39,440
most common one because you're 
probably going to go get a blood

259
00:17:39,440 --> 00:17:41,400
pressure on this patient and 
they're going to start to have 

260
00:17:41,400 --> 00:17:44,960
this carpal spasm and that 
tetany. 

261
00:17:46,680 --> 00:17:52,440
Whereas hypercalcemia, we're 
going to see lethargy with 

262
00:17:52,440 --> 00:17:56,040
magnesium. 
And I just talked about this 

263
00:17:56,440 --> 00:17:58,920
yesterday. 
As a matter of fact, with 

264
00:17:58,920 --> 00:18:02,600
magnesium, you're starting to 
see a lot of studies that talk 

265
00:18:02,600 --> 00:18:05,360
about nerve conduction, nerve 
nerve transmission, and how 

266
00:18:05,360 --> 00:18:11,120
magnesium is now helped with 
mood, with sleep to calm people 

267
00:18:11,120 --> 00:18:14,960
down so you can see that nerve 
transmission. 

268
00:18:14,960 --> 00:18:18,280
And I talked about this, those 
of you that have ever drank and 

269
00:18:18,440 --> 00:18:21,000
been hungover, the next day you 
deplete your magnesium and guess

270
00:18:21,000 --> 00:18:22,680
what happens? 
You get one of these. 

271
00:18:24,160 --> 00:18:27,480
You get tremors and you're like,
wait, what's going on? 

272
00:18:27,480 --> 00:18:30,640
That's nerve instability because
your loss of magnesium. 

273
00:18:31,680 --> 00:18:36,040
So hypomagnesium, 
hypomagnesemia, look at the 

274
00:18:36,040 --> 00:18:40,720
tremors, look at the anxiety. 
And then again, with too much 

275
00:18:40,720 --> 00:18:45,080
magnesium, they're going to get 
somnolent, they're going to get 

276
00:18:45,080 --> 00:18:50,320
lethargic. 
Chloride, not something I'm too 

277
00:18:50,560 --> 00:18:52,640
big on. 
The only thing I do want to show

278
00:18:52,640 --> 00:18:57,160
you is that chloride, it 
interacts with bicarb. 

279
00:18:57,160 --> 00:19:00,760
So chloride will kind of get in 
the way of bicarb. 

280
00:19:01,640 --> 00:19:03,920
So if you have too much 
chloride, it's going to 

281
00:19:03,920 --> 00:19:07,760
interfere with bicarb 
absorption, which means that I'm

282
00:19:07,760 --> 00:19:09,440
going to start to lose my 
bicarb. 

283
00:19:09,920 --> 00:19:14,840
Chloride goes up, which means if
I get rid of bicarb, what do I 

284
00:19:14,840 --> 00:19:18,960
develop acidosis? 
If I'm dealing with chloride, 

285
00:19:19,160 --> 00:19:22,600
I'm getting rid of bicarb. 
What type of acidosis am I 

286
00:19:22,600 --> 00:19:28,280
talking about? 
I'm talking about metabolic 

287
00:19:28,280 --> 00:19:31,280
acidosis. 
So we just went into renal and 

288
00:19:31,280 --> 00:19:39,320
AB GS, we're in like 15 minutes,
look at how much we've covered 

289
00:19:40,400 --> 00:19:42,600
and how much of medicine we've 
covered. 

290
00:19:44,120 --> 00:19:49,480
So we talked about this 
hyponatremia and hypernatremia. 

291
00:19:50,240 --> 00:19:55,720
And the take away that I want to
do on this part is the 

292
00:19:55,720 --> 00:20:01,920
hyponatremia. 
And the one thing and as we get 

293
00:20:01,920 --> 00:20:08,080
into fluids, I want to show you 
is that at 120 milli equivalents

294
00:20:08,120 --> 00:20:13,440
per liter and below we need to 
correct this. 

295
00:20:13,440 --> 00:20:15,640
And we're going to talk about 
the different types of solutions

296
00:20:15,640 --> 00:20:17,320
here, different types of IV 
fluids. 

297
00:20:17,800 --> 00:20:20,640
We're going to give them 3% 
sodium chloride. 

298
00:20:23,680 --> 00:20:28,480
The thing about this solution is
it is in fact hyper. 

299
00:20:29,520 --> 00:20:37,480
Tonic, meaning it is more dense 
than our normal blood. 

300
00:20:37,640 --> 00:20:41,640
It's packed with sodium chloride
compared to our blood because 

301
00:20:41,640 --> 00:20:43,880
our objective is to bring that 
sodium up. 

302
00:20:45,760 --> 00:20:49,800
But what are we concerned about 
when we're when we're bringing 

303
00:20:50,080 --> 00:20:54,120
our sodium up? 
Are we trying to bring it up as 

304
00:20:54,120 --> 00:20:56,960
fast as we can because this 
patient's at risk for seizures? 

305
00:20:58,640 --> 00:21:02,120
Absolutely not. 
Absolutely not. 

306
00:21:02,720 --> 00:21:12,040
What we're going to do is we're 
going to increase this only by 

307
00:21:12,040 --> 00:21:19,840
four to six milli equivalents 
per liter in the 1st 24 hours. 

308
00:21:20,720 --> 00:21:23,920
That's it. 
So you're telling me if we're at

309
00:21:23,920 --> 00:21:28,760
12119, we're only going to get 
to 120, three, 124, give or 

310
00:21:28,760 --> 00:21:31,240
take? 
Yeah, that's it. 

311
00:21:32,240 --> 00:21:36,720
That's it. 
And then moving forward, we're 

312
00:21:36,720 --> 00:21:41,240
only going to go up to 8 
milliequivalents per day. 

313
00:21:42,160 --> 00:21:46,200
Why? 
We can develop what's called. 

314
00:21:47,080 --> 00:21:50,560
There's multiple terms. 
I'm going to use a one, one of 

315
00:21:50,560 --> 00:21:56,920
them, osmotic demyelination 
syndrome or CPM. 

316
00:21:56,920 --> 00:22:00,640
I'll take that as well too, 
Central central pontine 

317
00:22:00,800 --> 00:22:08,320
myelinosis or I'll take another 
term, locked in syndrome, 

318
00:22:11,120 --> 00:22:16,800
osmotic demyelination syndrome, 
central pontine myelinosis or 

319
00:22:16,800 --> 00:22:20,760
locked in syndrome. 
I'll take any three of those as 

320
00:22:20,880 --> 00:22:25,960
a side effect of overcorrecting 
sodium too fast, because now 

321
00:22:25,960 --> 00:22:27,800
we're destroying their nervous 
system. 

322
00:22:28,680 --> 00:22:31,440
We're getting the cellular 
swelling because sodium is going

323
00:22:31,440 --> 00:22:34,360
intracellularly and guess what's
following it? 

324
00:22:34,720 --> 00:22:36,720
Water. 
You think those cells are going 

325
00:22:36,720 --> 00:22:38,440
to expand, expand, expand and 
burst. 

326
00:22:39,680 --> 00:22:41,280
That's exactly what's going to 
happen. 

327
00:22:44,600 --> 00:22:48,720
So we're going to get this 
locked in syndrome. 

328
00:22:48,720 --> 00:22:51,400
And why is that scary? 
Why are we so concerned? 

329
00:22:51,520 --> 00:22:55,520
Why do we do this in the ICU, 
monitoring them every two to 

330
00:22:55,520 --> 00:23:03,800
four hours minimum to a 2 
minimum two hours because locked

331
00:23:03,800 --> 00:23:06,560
in syndrome, they can see, they 
can hear and they can't move, 

332
00:23:07,280 --> 00:23:09,000
period. 
And it's permanent. 

333
00:23:09,760 --> 00:23:14,200
There is no reversing it. 
So again, very important to 

334
00:23:14,200 --> 00:23:16,640
understand that we're going to 
give them that hypertonic 

335
00:23:16,640 --> 00:23:21,760
solution in severe hyponatremia,
severe hyponatremia below that 

336
00:23:21,760 --> 00:23:23,960
120. 
Otherwise we can use normal 

337
00:23:23,960 --> 00:23:27,320
saline to try to correct it. 
And we'll talk about this a 

338
00:23:27,320 --> 00:23:31,400
little bit more. 
Hypernatremia, again, we just 

339
00:23:31,400 --> 00:23:35,760
talked about that. 
Again, I want to talk about the 

340
00:23:35,760 --> 00:23:37,760
ones that I feel are going to be
more tested. 

341
00:23:38,240 --> 00:23:40,800
Hypernatremia, if we're talking 
about dehydration, I just wanted

342
00:23:40,800 --> 00:23:43,520
to say with dehydration, 
diabetes insipidus, give them 

343
00:23:43,520 --> 00:23:46,160
what they don't have, right? 
That's my common saying. 

344
00:23:46,480 --> 00:23:52,000
If diabetes insipidus they don't
have ADH, then give it to them 

345
00:23:52,680 --> 00:23:58,040
and what is and what is ADH, How
do we give it to them? 

346
00:23:59,240 --> 00:24:01,680
That's what precedent, right? 
Give them what they don't have 

347
00:24:02,080 --> 00:24:09,040
dehydration, give them normal 
saline, hydrate them, cool. 

348
00:24:09,720 --> 00:24:16,000
The next one is hypokalemia and 
hyperkalemia. 

349
00:24:17,680 --> 00:24:21,560
And the reason why I wanted to 
talk about this one is, again, 

350
00:24:21,600 --> 00:24:25,920
we're worried about Ask Graph. 
So what do we give them in a 

351
00:24:25,920 --> 00:24:28,880
situation where the hypokalemic 
give them what they don't have? 

352
00:24:29,440 --> 00:24:31,160
So give them potassium 
supplements. 

353
00:24:31,440 --> 00:24:34,160
What do we know about IV 
supplements for potassium? 

354
00:24:34,160 --> 00:24:35,600
How does it feel? 
Anybody know? 

355
00:24:35,600 --> 00:24:37,560
Anybody ever gotten one? 
Anybody ever given one? 

356
00:24:38,640 --> 00:24:42,640
Is it pleasant for the patient? 
It burns. 

357
00:24:42,680 --> 00:24:44,920
Yeah, it burns. 
It's not pleasant at all. 

358
00:24:44,920 --> 00:24:47,520
So educate them. 
Just they sting a little bit. 

359
00:24:48,240 --> 00:24:50,360
A little bit burning sensation 
is expected. 

360
00:24:51,880 --> 00:24:56,840
But the next one I wanted to 
talk about because you will see 

361
00:24:56,960 --> 00:25:00,720
potentially on the boards, 
you'll see this. 

362
00:25:01,400 --> 00:25:06,600
So on the boards you may see 
sodium polystyrene sulfonate, 

363
00:25:06,920 --> 00:25:09,200
which is K isolate, but again 
we're going to go generic. 

364
00:25:09,560 --> 00:25:13,800
You may see an option as IV 
calcium or you may see insulin 

365
00:25:13,800 --> 00:25:16,640
with glucose or you may say 
dialysis. 

366
00:25:18,480 --> 00:25:23,200
When we talk about hyperkalemia,
when we talk about hyperkalemia,

367
00:25:23,960 --> 00:25:29,760
if we're hovering around that 
5.5 milliequivalents, we're OK 

368
00:25:29,760 --> 00:25:33,240
to give the sodium polystyrene 
sulfonate because it's not an 

369
00:25:33,240 --> 00:25:35,120
emergency. 
If they don't have any other 

370
00:25:35,120 --> 00:25:38,080
symptoms, if they don't have any
type of palpitations or anything

371
00:25:38,080 --> 00:25:44,160
that we can see on an EKG strip 
or an ECG strip, I'm not too 

372
00:25:44,160 --> 00:25:49,640
concerned about it. 
So I can take my time and I can 

373
00:25:49,640 --> 00:25:51,760
give them sodium polystyrene 
sulfonate. 

374
00:25:52,600 --> 00:26:00,240
But what do we see in this? 
We see sulfa, so we have to be 

375
00:26:00,240 --> 00:26:09,040
careful, we must monitor. 
But what if we start to get up 

376
00:26:09,200 --> 00:26:12,960
at that 6.5 million equivalents 
per litre? 

377
00:26:14,200 --> 00:26:21,120
What if we start to see those 
peaked T waves or widened QRS? 

378
00:26:24,480 --> 00:26:27,240
Now we've got to do something 
more aggressive. 

379
00:26:27,640 --> 00:26:33,160
This becomes life threatening 
hyperkalemia. 

380
00:26:33,680 --> 00:26:36,600
It becomes life threatening 
hyperkalemia. 

381
00:26:37,200 --> 00:26:41,520
So now we must do an immediate 
intervention and your options 

382
00:26:41,520 --> 00:26:49,000
could be IV calcium, insulin 
with glucose, or dialysis. 

383
00:26:50,560 --> 00:26:55,320
Sometimes you can use 
combination and throw in maybe 

384
00:26:55,920 --> 00:27:02,640
KR sodium polystyrene sulfonate 
in conjunction with these, but 

385
00:27:03,040 --> 00:27:10,720
in severe hyperkalemia select 
all that apply or a patient 

386
00:27:10,720 --> 00:27:15,200
presents with a sodium level of 
6.5 with peak T waves. 

387
00:27:15,440 --> 00:27:16,680
That's the one you're going to 
see first. 

388
00:27:16,680 --> 00:27:18,840
Initial priority, urgent, most 
concerning immediate report to 

389
00:27:18,840 --> 00:27:24,920
HCP. 
So when we see this and I'm sure

390
00:27:24,920 --> 00:27:27,120
we've seen these on Q banks, I 
know I've written questions 

391
00:27:27,120 --> 00:27:31,120
about this and a lot of people 
tend to trend towards going with

392
00:27:31,120 --> 00:27:36,360
sodium polystyrene sulfonate and
they disregard IV calcium, 

393
00:27:36,360 --> 00:27:38,720
insulin, glucose dialysis or you
get confused. 

394
00:27:39,760 --> 00:27:42,760
But there is a fine line of 
where we are able to do 

395
00:27:42,760 --> 00:27:46,680
something a little bit slower 
where we're not in trouble 

396
00:27:47,080 --> 00:27:51,160
versus where we are in trouble 
and we're seeing EKG changes or 

397
00:27:51,160 --> 00:27:57,800
we have an elevated 6.5 and 
above potassium level and we are

398
00:27:57,960 --> 00:28:00,600
freaking out about it. 
We are freaking out about it. 

399
00:28:02,760 --> 00:28:02,960
Cool.