Fluids and Electrolytes

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Fluids and Electrolytes

• Staying Balanced
• Spring 2008

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Water H2O

• Universal solvent
• 60 of bodys weight
• Cells haf to have it.
• Arnold Schwarzenegger

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How much is that?

• 154 person x .60 (60)
• 92
• Water is approx 8 per gallon
• 11 ½ gallons water
• (Obese people/ less)
• (Thin people/ more)
• Infants
• Elders

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Basic Cellular Review

• The fundamental unit
• Requires
• Cell membrane
• Enzymes
• Internal membranes
• Genetic material

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Basic tissue types

• Epithelial
• Connective
• Muscle
• Nervous

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The cellular environment

• All metabolic reactions occur
• The precise regulation of volume and composition
  of body fluid is essential to health.

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Body fluid compartments

• Intracellular Fluid - ICF
• Extracellular Fluid ECF
• Intravascular Fluid- Plasma
• Interstitial Fluid

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Intracellular - ICF

• Fluid in all body cells
• 75 of the water (60)
• 31.50 L (70 kg adult)
• 40 of total body weight

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Extracellular - ECF

• 20 of water (60)
• 10.50 L (70 kg adult))
• Includes intravascular and interstitial
  compartments

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ECF

• Intravascular
• 4 of (60)
• 7.5 L

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ECF

• Interstitial
• 16 of (60)
• 17.5 L
• Fluid between cells and outside the vascular bed
• Connective tissue, cartilage, bone, CSF,
  intraocular fluid

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Hydration

• Water - Universal solvent
• Intake Output (IO)

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Hydration

• Homeostasis
• The bodys need for balance

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Aging and distribution of fluids

• Newborns TBW 80
• Children TBW 60-65
• Elders TBW lt 60

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Intake vs Output

• Food - 1200 ml
• Drink - 1000 ml
• Metabolic sources - 300 ml
• 2500 ml

• Lungs - 400 ml
• Kidneys - 1500 ml
• Skin - 400 ml
• Intestine (Feces) - 200 ml
• 2,500 ml

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Hydration

• Osmoreceptors - anterior hypothalamus
• Baroreceptors - carotid sinus, aortic arch,
  kidneys
• High and low blood pressure

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Hydration

• Anti-diuretic hormone (ADH)
• If tide goes out
• Pituitary Gland Excretes
• Tide comes in!!!
• Re-absorb from kidneys
• Decrease urine
• Thirst also regulates

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Dehydration

• Abnormal decrease in TBW
• Thus the weigh-in at fires
• Rarely involves only water loss
• Electrolyte loss

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Dehydration causes

• Signs and symptoms?
• Treatment?

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Causes of dehydration

• GI losses
• N/V/D
• Insensible losses
• Normal losses with fever
• Hyperventilation
• High Environmental Temps
• Increased sweating

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Causes of dehydration

• Internal losses
• Thirdspacing
• Peritonitis
• Pancreatitis
• Malnourished
• No protein to retain water

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Causes of Dehydration

• Plasma losses
• Burns
• Surgical Drains
• Open wounds

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Signs and symptoms

• Signs of shock
• Skin changes (turgor)
• Orthostatic hypotension
• Thirst
• Increased pulse rate
• Furrowed tongue

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S/S, cont.

• Decreased BP
• Dry mucosa
• Infants Anterior fontanelle sunken
• Dry diapers
• Absent tears
• Cap refill gt 2 seconds
• Dry mucosa

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Treatment

• ABCs
• O2
• Fluids
• Flavor?
• Consider PASG
• ECG

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Overhydration No thanks Im full.

• Edema
• Peripheral vs. central (more later)
• Aggressive treatment if Pulmonary Edema

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Overhydration

• ABCs
• O2
• Consider ETT
• Meds
• NTG.
• Lasix
• M.S.

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Fluid Electrolyte Disturbances

• Medical causes
• Diabetes
• Heat Emergencies
• Blood Loss

• Traumatic causes
• Blood loss

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Electrolytes

• In H2O dissociate into ions
• Cations positive
• Anions negative

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Principle CationsSodium-Potassium Pump

• Sodium (Na)
• Prevalent in ECF
• Water follows it
• Nerve impulses
• Hyper/
• Hyponatremia

• Potassium (K)
• Prevalent in ICF
• Nerve impulses
• Hypo/
• Hyperkalemia

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Other Cations

• Calcium (Ca)
• Prevalent in ICF
• Muscle contraction
• Nerve impulse
• Hypo/hypercalcemia

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Other Cations

• Magnesium (Mg)
• Present in ICF
• Necessary for many processes
• Found in some
• Antacids
• Laxatives
• Most associated with phosphate
• Renal Functions

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Principal Anions

• Chloride (Cl-)
• Present in ECF
• Balances cations
• Fluid balance
• Renal function
• Usually found hanging around sodium

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Principal Anions

• Bicarbonate (HCO3-)
• Found in ECF
• The Buffer
• Neutralizes Acidic (H)
• Tx for acidosis

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Anions

• Phosphate (HPO4--)
• Found in ICF - buffer
• Energy stores
• Mg in renal function

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• Electrolytes - mEq/L
• Non-Electrolytes -
• Glucose
• Urea
• Proteins

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How does it get there?

• Osmosis
• Diffusion
• Active Transport
• Facilitated Diffusion

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• Isotonic
• Hypertonic
• Hypotonic
• Osomotic gradient - difference in concentration

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Osmosis

• Movement of water (solvent)
• Semi-permeable membrane
• Towards higher solute concentration

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Diffusion

• Movement of solutes
• Across membrane

• Towards lesser solute concentration

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Active transport

• Movement of solutes
• Across membrane
• Against osmotic gradient
• Requires energy (ATP)
• Sodium-potassium pump

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Active transport
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Facilitated diffusion

• Helper proteins
• Insulin
• Open gate
• Glucose

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Facilitated diffusion
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Osmotic Pressure

• Governs movement of water and solutes across cell
  membrane
• Pressure exerted by concentration of solutes
• Pulls from other side of membrane

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Lysis Crenation
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Blood Plasma

• Colloid osmotic pressure
• Plasma
• Hydrostatic pressure
• Blood pressure
• Filtration

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Edema

• Localized
• Site of injury
• Organ systems - brain, lungs, heart, abdomen
• Generalized
• Dependent edema
• Pitting edema

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RELATIVE HYDRATION

• Body water in interstitial spaces not available
  for metabolism
• Relative dehydration

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Edema

• Decrease in production of plasma proteins
• Liver disorder
• Burns
• Open wounds

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More about Edema

• Increase in hydrostatic pressure
• Venous obstruction
• Salt and water retention
• Thrombophlebitis
• Liver obstruction
• Tight clothing
• Prolonged standing

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And more about edema

• Increased capillary permeability - plasma
  proteins escape
• Inflammation and immune response
• Allergic reactions
• Burns
• Trauma
• Cancer

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And still more edema

• Lymphatic channel obstruction
• Infection
• Surgery

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Blood transfusions
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Blood Components

• Plasma
• Formed Elements
• Leukocytes (WBCs)
• Erythrocytes (RBCs) gt99
• Thrombocytes

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Plasma

• Mostly Water (92)

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Leukocytes

• Monocytes (Big eaters, chronic)
• Neutrophils (bacteria)
• Basophils (inflamation)
• Eosinophils (allergies, parasites)
• Lymphocytes (intracellular)

• Indicate Combat Readiness

• State of the union

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Erythrocytes Hemoglobin

• Transports oxygen
• 40-45 Hematocrit
• After specimen is spun
• Hemoglobin -
• Iron-based compound binds with oxygen

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Thrombocytes

• Major role in blood clotting

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Viscosity of blood

• Determined by ratio of plasma to formed elements

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Blood types

• Antigens
• Blood type proteins
• Antibodies
• Resistance (in serum)

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ABO system

• A
• A Antigen
• B Antibody
• B
• B Antigen
• A Antibody

• AB
• A B Antigen
• No Antibodies
• Universal Recipient

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• O
• No Antigens
• A B Antibodies (serum)
• Universal Donor

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RH factor

• Measured in or
• Anti-Rh antibodies present
• - Ok.
• - No Anti-Rh antibodies pres.
• - Ok
• Sensitization
• Severe reaction / death

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Blood products
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Blood products, cont.
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Blood Transfusion

• Physicians order
• Check type and cross-match verify with partner
• Check blood bag for bubbles, cloudiness, dark
  color, sediment
• Check patients vital signs
• Temperature
• BP
• Pulse
• Respirations

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• Rotate blood bag gently
• Pull back tabs on blood unit bag, expose port.
• Spike blood bag port carefully and hang unit. (Be
  sure clamp is closed).
• Open clamp and fill drip chamber. Make sure
  filter is submerged in blood.
• Open clamp on tubing, carefully run blood through
  tubing, and place needle on end of tubing.

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• Check primary IV solution Never use dextrose
  solutions!
• Attach blood tubing into IV port and tape into
  place.
• Shut off primary IV and begin transfusion.
• Administer blood slowly for first 15 minutes,
  20 gtts/min.
• ALLOWS TIME TO OBSERVE FOR ADVERSE REACTION

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• When blood bag is empty, clamp off tubing to bag,
  open clamp to normal saline bag, and flush line.
• Close all clamps and remove blood tubing from
  injection port.
• Monitor patient for s/s of transfusion reaction.

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Transfusion ReactionUsually occurs in first 15
minutes

• S/S
• Sudden increase in temperature (may be 105o)
• Hypotension
• Dry, flushed skin
• Abdominal pain
• Headache
• Lumbar pain
• Sudden chill
• Urticaria
• Respiratory wheezing, laryngeal edema

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Treatment

• Stop transfusion immediately
• Change tubing
• Observe for shock
• Monitor vitals every 15 minutes until stable
• Keep blood tubing and bag for ED staff.
• Control hyperthermia
• Consider antihistamine if allergic reaction

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First Patient

• A 40 y/o male driver involved in a head-on
  collision at 40 mph. Pt is seat belted with a
  lap belt only. Pt is CAO PPTE on arrival, c/o
  acute abd. Pain and SOB.
• P rapid, thready
• BP unable to auscultate
• RR rapid

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• DDX?
• Why?
• TX?
• Why?

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Second Pt

• This patient is 82 y/o, and calls you at 0030,
  c/o feeling ill.
• Pt is CAO PPTE, but slow to respond
• B/P 120/76
• P 94, irreg.
• RR 24
• Skin cool, dry, pale
• Mucous membranes dry with furrowed tongue and
  sunken eyes

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• DDX?
• Why?
• Tx?
• Why?

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Third Patient

• You are called to a 60 year old male c/o SOB,
  chest pain. His sx started 2 hrs ago while
  painting the garage. He says the chest pain went
  away almost immediately, but hes increasingly
  short of breath.
• PMH Pulmonary edema, Angina, HTN, recent URI

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• Pt is CAO PPTE, anxious, in tripod position.
• BBS decreased with coarse crackles in the bases
• BP 130/60
• HR 126, sl irreg.
• RR 36, shallow
• Skin pale, cool, dry with poor turger, dry mucous
  membranes, furrowed tongue

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• DDX?
• Why?
• Tx?
• Why?

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