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enjoy the lecture. Take care.
Without further ado, let's talk about fluids and electrolytes,
but not just fluids and electrolytes.
I want to show you that fluids and electrolytes are a big
portion of Med surg and Med surg is a huge portion of your exam.
Not even exam. Those of you that are students,
I see a lot of students in here as well too.
It's a part of your entire schooling.
So when you see that you've got Med surg and then a section of
fluids, fluids, and electrolytes, and now you're
moving forward with fluid and electrolytes and Med surg into
the board exams, I want to show you how medicine is medicine.
So get ready to take a lot of notes here and I'm going to go
at a decent pace. So if I make this a Part 1 and a
Part 2, don't worry about it. You'll catch Part 2 next week,
but make sure you're taking notes.
So the basic concept of fluid balance is what we need it for
cellular function. I mean every single cell, cell
has a transport, whether it be sodium, potassium, chloride,
magnesium, we've got some sort of an electrolyte going in and
out, in and out in each one of them serves a different purpose.
Also responsible for transport of nutrients, waste of
excretion. So you can imagine that fluid
balance is so important in every little minute detail working
forward, but what are the kidneys role?
The kidneys role is going to determine our fluid volume and
electrolytes through filtration. And if you were to go through
and look at the loop of Handley, the ascending loop, descending
loop, so on and so forth, what the glomeruli does, there's a
lot of different moving parts, things that get reabsorbed,
things that get excreted, things that get put back into the
blood. And then comes where we start
getting into the Med surge and where we get into the actual
boards and it comes into hormonal regulation.
This is where I start to teach you how important fluid balance
is the one concept, and I've taught this to my students left
and right and they'll know this is the renin angiotensin
aldosterone system are RAAS. Now I tell my students, the only
thing that I want you all to focus on is what part of this is
in fact aldosterone. Now everyone thinks renin
angiotensin aldosterone system I need to breathe a little bit,
but let's simplify things. Aldosterone is going to regulate
sodium. What follows sodium?
Well water. If I've got sodium and potassium
having an inverse relationship through that sodium, potassium
pump. If sodium goes up, well, what
happens to potassium? Potassium goes down.
Understand you. I saw it pointing down.
I love it. So yes, they go opposite.
So imagine how much we can control with fluid and
electrolytes just with aldosterone.
Think about it, just with aldosterone.
Now, now, now we're taking it a step further.
Aldosterone, where are we going to see aldosterone produced is
going to be where? In the adrenal glands, The
adrenal glands, they sit on top of the kidney.
Well, now, what system am I going into?
I'm talking Med surgeon fluid, electrolytes.
But I'm already taking you down what path?
Taking you down Endocrine. Yeah.
So now if I have, let's just say I have a tumor in the adrenals
in the portion that increases my aldosterone, what do I have?
If I have a tumor, I'm going to get excess, excess excess sodium
because that tumor is going to produce aldosterone, produce
aldosterone, produce aldosterone.
I just showed you primary hyper aldosteronism.
I just introduced you to Khan syndrome.
In that situation, in constant in Khan syndrome or in primary
hyperaldosteronism, I've now increased sodium.
Water is followed and my blood pressure is through the roof.
I'm hypokalemic. You think I got muscle cramps or
I'm at risk for dysrhythmia? I am.
Do you see how I'm tying in board questions, signs and
symptoms? What?
I'm freaking out about potassium asked Grab.
Then I take it a step further. What if in this situation I have
no aldosterone? What if I go the opposite way,
which means I've got adrenal insufficiency, adrenal
insufficiency, adrenal ADI, How about Addison's?
So now in this situation, I just knocked out sodium.
So if I knocked out sodium, water went with it.
So my blood pressure dropped and guess what just went up?
My potassium. I'm hyperkalemic.
So you see fluid balance or fluid and electrolytes and Med
surg and now endocrine. But that is all.
It's all the same. It all ties in.
And when you start to understand
that if you sectionalize medicine, it's never going to
help pass the boards. If you sectionalize it, it's
going to make everything harder for you when you start tying in,
oh, this subject is fluid electrolytes, but medicine is
medicine. Now we move on to because in
this situation, all we are regulating, what electrolyte
were we regulating? We're just focused on one
electrolyte and by default the other one followed or went the
opposite way. By default water follow or it
went with it. The next one is ADH, which is
anti diuretic hormone, anti diuretic hormone.
And not to get too much into this, but what is anti diuretic?
Well, diuretic means I'm going to pee, diuretic means I'm going
to pee. If it's anti diuretic, it's anti
peeing. I'm not going to pee.
So for me, when I had to think about diabetes insipidus or I
had to think about SIADH, the way that I think about it, I had
to dumb it down for myself. And I thought about it in terms
of peeing because it made sense to me.
Instead of worrying about a hormone I just thought about,
OK, well, a diuretic makes me pee.
This is anti diuretic, so I'm not going to pee, which means
I'm going to retain water if I have too much of it, which is
SIADH where we have inappropriate amounts of anti
diuretic hormone. So I'm not going to pee.
Now let's take this a step further.
Let's think boards, let's think school, let's go back.
Let's think real life in general, in general, not S i.e.
DH in general. If I don't pee, what is that
called? If I don't pee, I'm probably
what I'm probably dehydrated, right?
And I've said to everyone that dehydration is a concept that is
presented in so many different ways.
So not peeing. Do you think this is something
that's going to happen in real life?
Now my students that have been in my course know the story.
I'm in Mai, Mean I'm in Mai was in MA before I went to medical
school. So I was a medical assistant and
I would take the pee out of the little cabinet and sometimes it
was dark, it was concentrated and it was pungent and smelled
tea colored, cola colored. Signs and symptoms of
dehydration. Select all that applied.
I did a urine dipstick and guess what?
It showed me that the specific gravity was elevated above
1.030. That the, that the urine
osmolality, the urine concentration was elevated.
That's not even talking about ADH, That's just talking about
dehydration in general. So you can see that fluids in
that situation or a lack of in dehydration throws off our fluid
balance. But we must know our signs and
symptoms, our lab values, how the boards are going to ask it.
And that's what I'm trying to tie together.
So you understand, not only is this a fluid and electrolyte
message, look at how many other things I'm going to tie in
today. That's why I want you to take so
many notes, really pay attention today.
I that's why I was so excited about this lecture.
I was like, I'm super stoked about this.
This is just a little, a little definition, nothing to take away
from this. Nothing, something that nothing
that's going to be tested. So it's just more definitions.
What intracellular fluid is, what extracellular fluid is,
interstitial and intravascular fluid as well too.
But we can take it a step further and get into our
electrolytes. The ones that I'm going to focus
on are the ones that I feel, and I'm going to focus on ones a
little bit more heavy than the other ones because I feel
there's more to it now. Sodium, our normal range, should
we know it? Absolutely.
Why we're getting case studies now, and guess what case studies
are throwing in? They're throwing in lab values
now. They're going to give you the
normal range. But guess what?
If you kind of know it off the top of your head, it makes life
easier. All I'm trying to do is make you
prepared more for your exam and for real life.
But the extremes on each electrolyte is what we're
concerned about whether we're high or whether we're low and
what they entail. So if I'm low, I'm hyponatremic,
hyponatremic below 135. When we get to below 120, we get
a little, we get very scared and we have to be careful how we
corrected. I'm going to talk about that
here in a little bit. But when we're hyponatremic,
what are we worried about? We're worried about one of ask
graph. Which one of ask graph are we
worried about altered mental status by way of seizures by way
of seizures? So what are some ways that we
can develop that will hyponatremia if I'm retaining
fluid? Didn't we just talk about SIADH?
Sure we did. What about in infants?
We talked about diluting what milk, water intoxication, right?
Hypernatremia. If we're losing water, we're
losing water. We become hypernatremic, we
develop thirst, high sodium intake, so on and so forth.
Not really the one that I'm concerned about.
The one I'm freaking out about is seizures, because that is a
scrap. But potassium, do we have a lot
of room for air with potassium, 3.5 to 5 milli equivalents?
No, we don't. And it is part of Asgraph.
And I don't say hypo or hyperkalemia, do I?
I say changes in potassium, changes in potassium.
And as we realize this, we're going to see that whether we're
hypo or hyperkalemic, hypo or hyperkalemic, we can develop
arrhythmias. What part of the heart does
potassium predominantly control? It is in fact the ventricle.
So now we just took it from fluid and electrolytes into
Ekgs. Do you see how we're we're not
jumping all over the place. We're making sense of things,
right? And in my in my EKG, I've got my
QRST which is going to signify what's happening with the
ventricle. So can I get now, now look at
these terms and what they really mean.
OK, so pay attention to these terms.
The term widened QRS complex. How many times you see a
medication and it says widened QRS complex or you you see that
term and you're like, wait a minute, what does that mean?
Well, ultimately, if it widens and widens and widens and
widens, can it not turn into a dysrhythmia like that?
Yeah. And what are we worried about
the most? Ventricular fibrillation with
hyperkalemia. You may see, and this is
exaggerated, a peaked T wave, but still affecting the
ventricle. So you see how potassium and
those dysrhythmias are so dangerous, so dangerous calcium.
With calcium we may be hypocalcemic or hypercalcemic.
Now with hypocalcemia, what is the most popular way to develop
hypocalcemia on the boards? On the boards is a
thyroidectomy, where we get rid of the parathyroids,
incidentally. Yeah.
So we get rid of the parathyroids, which regulate
calcium, and now we've got hypocalcemia.
Now I ask the question, how will it present and how will you more
than likely see it? So we've got two different tests
that you can see. You can see Trousseau's and you
can see Chalcedeck. So Trusolus is going to be the
most common one because you're probably going to go get a blood
pressure on this patient and they're going to start to have
this carpal spasm and that tetany.
Whereas hypercalcemia, we're going to see lethargy with
magnesium. And I just talked about this
yesterday. As a matter of fact, with
magnesium, you're starting to see a lot of studies that talk
about nerve conduction, nerve nerve transmission, and how
magnesium is now helped with mood, with sleep to calm people
down so you can see that nerve transmission.
And I talked about this, those of you that have ever drank and
been hungover, the next day you deplete your magnesium and guess
what happens? You get one of these.
You get tremors and you're like, wait, what's going on?
That's nerve instability because your loss of magnesium.
So hypomagnesium, hypomagnesemia, look at the
tremors, look at the anxiety. And then again, with too much
magnesium, they're going to get somnolent, they're going to get
lethargic. Chloride, not something I'm too
big on. The only thing I do want to show
you is that chloride, it interacts with bicarb.
So chloride will kind of get in the way of bicarb.
So if you have too much chloride, it's going to
interfere with bicarb absorption, which means that I'm
going to start to lose my bicarb.
Chloride goes up, which means if I get rid of bicarb, what do I
develop acidosis? If I'm dealing with chloride,
I'm getting rid of bicarb. What type of acidosis am I
talking about? I'm talking about metabolic
acidosis. So we just went into renal and
AB GS, we're in like 15 minutes, look at how much we've covered
and how much of medicine we've covered.
So we talked about this hyponatremia and hypernatremia.
And the take away that I want to do on this part is the
hyponatremia. And the one thing and as we get
into fluids, I want to show you is that at 120 milli equivalents
per liter and below we need to correct this.
And we're going to talk about the different types of solutions
here, different types of IV fluids.
We're going to give them 3% sodium chloride.
The thing about this solution is it is in fact hyper.
Tonic, meaning it is more dense than our normal blood.
It's packed with sodium chloride compared to our blood because
our objective is to bring that sodium up.
But what are we concerned about when we're when we're bringing
our sodium up? Are we trying to bring it up as
fast as we can because this patient's at risk for seizures?
Absolutely not. Absolutely not.
What we're going to do is we're going to increase this only by
four to six milli equivalents per liter in the 1st 24 hours.
That's it. So you're telling me if we're at
12119, we're only going to get to 120, three, 124, give or
take? Yeah, that's it.
That's it. And then moving forward, we're
only going to go up to 8 milliequivalents per day.
Why? We can develop what's called.
There's multiple terms. I'm going to use a one, one of
them, osmotic demyelination syndrome or CPM.
I'll take that as well too, Central central pontine
myelinosis or I'll take another term, locked in syndrome,
osmotic demyelination syndrome, central pontine myelinosis or
locked in syndrome. I'll take any three of those as
a side effect of overcorrecting sodium too fast, because now
we're destroying their nervous system.
We're getting the cellular swelling because sodium is going
intracellularly and guess what's following it?
Water. You think those cells are going
to expand, expand, expand and burst.
That's exactly what's going to happen.
So we're going to get this locked in syndrome.
And why is that scary? Why are we so concerned?
Why do we do this in the ICU, monitoring them every two to
four hours minimum to a 2 minimum two hours because locked
in syndrome, they can see, they can hear and they can't move,
period. And it's permanent.
There is no reversing it. So again, very important to
understand that we're going to give them that hypertonic
solution in severe hyponatremia, severe hyponatremia below that
120. Otherwise we can use normal
saline to try to correct it. And we'll talk about this a
little bit more. Hypernatremia, again, we just
talked about that. Again, I want to talk about the
ones that I feel are going to be more tested.
Hypernatremia, if we're talking about dehydration, I just wanted
to say with dehydration, diabetes insipidus, give them
what they don't have, right? That's my common saying.
If diabetes insipidus they don't have ADH, then give it to them
and what is and what is ADH, How do we give it to them?
That's what precedent, right? Give them what they don't have
dehydration, give them normal saline, hydrate them, cool.
The next one is hypokalemia and hyperkalemia.
And the reason why I wanted to talk about this one is, again,
we're worried about Ask Graph. So what do we give them in a
situation where the hypokalemic give them what they don't have?
So give them potassium supplements.
What do we know about IV supplements for potassium?
How does it feel? Anybody know?
Anybody ever gotten one? Anybody ever given one?
Is it pleasant for the patient? It burns.
Yeah, it burns. It's not pleasant at all.
So educate them. Just they sting a little bit.
A little bit burning sensation is expected.
But the next one I wanted to talk about because you will see
potentially on the boards, you'll see this.
So on the boards you may see sodium polystyrene sulfonate,
which is K isolate, but again we're going to go generic.
You may see an option as IV calcium or you may see insulin
with glucose or you may say dialysis.
When we talk about hyperkalemia, when we talk about hyperkalemia,
if we're hovering around that 5.5 milliequivalents, we're OK
to give the sodium polystyrene sulfonate because it's not an
emergency. If they don't have any other
symptoms, if they don't have any type of palpitations or anything
that we can see on an EKG strip or an ECG strip, I'm not too
concerned about it. So I can take my time and I can
give them sodium polystyrene sulfonate.
But what do we see in this? We see sulfa, so we have to be
careful, we must monitor. But what if we start to get up
at that 6.5 million equivalents per litre?
What if we start to see those peaked T waves or widened QRS?
Now we've got to do something more aggressive.
This becomes life threatening hyperkalemia.
It becomes life threatening hyperkalemia.
So now we must do an immediate intervention and your options
could be IV calcium, insulin with glucose, or dialysis.
Sometimes you can use combination and throw in maybe
KR sodium polystyrene sulfonate in conjunction with these, but
in severe hyperkalemia select all that apply or a patient
presents with a sodium level of 6.5 with peak T waves.
That's the one you're going to see first.
Initial priority, urgent, most concerning immediate report to
HCP. So when we see this and I'm sure
we've seen these on Q banks, I know I've written questions
about this and a lot of people tend to trend towards going with
sodium polystyrene sulfonate and they disregard IV calcium,
insulin, glucose dialysis or you get confused.
But there is a fine line of where we are able to do
something a little bit slower where we're not in trouble
versus where we are in trouble and we're seeing EKG changes or
we have an elevated 6.5 and above potassium level and we are
freaking out about it. We are freaking out about it.
Cool.