Electrolytes

Imbalance

Hypercalcemia

• Calcium Level: Greater than 10.5 mg/dL.

Signs and Symptoms

• Lethargy and fatigue.
• Altered mental status (AMS).
• Decreased deep tendon reflexes (DTRs) and muscle weakness.

Potential Causes

• Kidney disease.
• Hyperparathyroidism.
• Malignancies.

Treatment

• Administer isotonic fluids (0.9% normal saline) for hydration.
• Promote calcium excretion with diuretics (e.g., furosemide).
• Utilize calcitonin to reduce calcium levels.

Imbalance

Hypocalcemia

• Calcium Level: Below 8.5 mg/dL.

Signs and Symptoms

• Increased irritability and anxiety.
• Seizure activity.
• Cardiac arrhythmia: Torsades de Pointes.
• Positive Chvostek’s sign (facial muscle twitching with facial nerve tap).
• Positive Trousseau’s sign (carpal spasm induced by BP cuff inflation).

Potential Causes

• Chronic kidney disease.
• Acute inflammation of the pancreas.
• Insufficient parathyroid hormone production (hypoparathyroidism).

Treatment

• Hydration with isotonic fluids (0.9% normal saline).
• Administer calcium gluconate or calcium chloride to restore calcium levels.

Imbalance:

Hyperphosphatemia

• Phosphate Level: Exceeds 4.5 mEq/L.

Signs and Symptoms

• Heightened irritability and restlessness.
• Anxiety or agitation.
• Seizure activity in severe cases.

Potential Causes

• Impaired kidney function reducing phosphate excretion.
• Chronic renal failure.

Treatment

• Use phosphate-binding agents.
• Administer calcium carbonate to help reduce phosphate levels.

Imbalance:

Hypophosphatemia

• Phosphate Level: Below 3.0 mEq/L.

Signs and Symptoms

• General fatigue and reduced energy levels.
• Altered mental status (confusion or disorientation).
• Decreased deep tendon reflexes (DTR).
• Muscular weakness.
• Gastrointestinal complaints such as constipation and abdominal discomfort.

Potential Causes

• Chronic alcohol use or dependency.
• Increased phosphate uptake into cells, often associated with total parenteral nutrition (TPN).

Treatment

• Administer phosphate supplements to replenish levels.

Imbalance

Hyperkalemia

• Potassium Level: Above 5.1 mEq/L.

Signs and Symptoms

• Heightened irritability and discomfort.
• Muscle weakness or cramping.
• EKG Changes:
  • Widened QRS complexes.
  • Peaked T-waves.
  • Bradycardia.
  • Pulseless Electrical Activity (PEA).

Potential Causes

• Renal failure impairing potassium excretion.
• Early stages of severe burns.
• Extensive crush injuries.

Treatment

• Administer Kayexalate to remove potassium.
• Use insulin with glucose to drive potassium intracellularly.
• Promote excretion with furosemide or dialysis.

Imbalance:

Hypokalemia

• Potassium Level: Less than 3.5 mEq/L.

Signs and Symptoms

• Depressed mood or mental status changes.
• Shallow breathing patterns.
• Decreased deep tendon reflexes (DTR).
• Muscular weakness.
• EKG Changes:
  • Ventricular tachycardia (VT).
  • Ventricular fibrillation (VF).

Potential Causes

• Acute alcohol consumption.
• Liver cirrhosis.
• Use of diuretics.

Treatment

• Administer lactated Ringer’s (LR) solution.
• Replenish potassium with potassium chloride.

Imbalance:

Hypermagnesemia

• Magnesium Level: Greater than 2.5 mEq/L.

Signs and Symptoms

• Lethargy or unresponsiveness (coma).
• Respiratory depression or arrest.
• Decreased deep tendon reflexes (DTR).
• EKG Changes: Bradyarrhythmias.

Potential Causes

• Renal dysfunction or failure.
• Overuse of laxatives or antacids containing magnesium.

Treatment

• Promote excretion with furosemide or dialysis.
• Administer calcium to counteract magnesium effects.
• Discontinue magnesium-containing substances.

Imbalance:

Hypomagnesemia

• Magnesium Level: Below 1.6 mEq/L.

Signs and Symptoms

• Agitation or confusion.
• Hyperactive reflexes.
• Positive Chvostek and Trousseau signs.
• EKG Changes: Ventricular arrhythmias.

Potential Causes

• Chronic alcohol use or dependency.
• Use of digoxin, cisplatin, or during diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS).
• Nausea, vomiting, diarrhea, or malnutrition.

Treatment

• Replenish with magnesium sulfate.

Imbalance:

Hypernatremia

• Sodium Level: Above 145 mEq/L.

Signs and Symptoms

• Altered mental state: stupor or coma.
• Restlessness or irritability.
• Increased heart rate (tachycardia) and low blood pressure (hypotension).
• Excessive thirst and dry mucous membranes.

Potential Causes

• Diabetic ketoacidosis (DKA) or hyperosmolar hyperglycemic state (HHS).
• Diabetes insipidus (DI).
• Osmotic diuresis.
• Dehydration or excessive insensible fluid loss.

Treatment

• Limit dietary sodium intake.
• Administer IV fluids such as D5W or 0.45% normal saline to correct imbalance.
• Use vasopressin for cases related to diabetes insipidus.

Imbalance:

Hyponatremia

• Sodium Level: Below 135 mEq/L.

Signs and Symptoms

• Depressed mental state or confusion.
• Shallow breathing.
• Reduced deep tendon reflexes (DTR).
• Muscle weakness.
• EKG Changes: Potential for ventricular tachycardia (VT) or ventricular fibrillation (VF).

Potential Causes

• Traumatic brain injury or syndrome of inappropriate antidiuretic hormone (SIADH).
• Heart failure (HF).
• Fluid overload or excessive retention.

Treatment

• Restrict fluid intake.
• Administer loop diuretics to promote fluid elimination.

Key Points to Keep in Mind

• Chvostek Sign: Facial muscle twitching or contraction triggered by tapping the facial nerve.
• Trousseau Sign: Wrist and hand spasms occurring after blood pressure cuff inflation for over 3 minutes.
• Calcium-Phosphorus Relationship: These electrolytes have an inverse correlation:
  • Increased calcium results in decreased phosphorus.
  • Decreased calcium results in increased phosphorus.
• Alcoholism: A common underlying cause of:
  • Low phosphorus levels (hypophosphatemia).
  • Low potassium levels (hypokalemia).
  • Low magnesium levels (hypomagnesemia).