Electrolyte disturbance

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Synonyms and Keywords: abnormal electrolytes, abnormal lytes, lytes

Overview

Electrolytes play a vital role in maintaining homeostasis within the body. They help to regulate myocardial and neurological function, fluid balance, oxygen delivery, acid-base balance and much more. Electrolyte imbalances can develop by the following mechanisms: excessive ingestion; diminished elimination of an electrolyte; diminished ingestion or excessive elimination of an electrolyte. The most common cause of electrolyte disturbances is renal failure.

The most serious electrolyte disturbances involve abnormalities in the levels of sodium, potassium, and/or calcium. Other electrolyte imbalances are less common, and often occur in conjunction with major electrolyte changes. Chronic laxative abuse or severe diarrhea or vomiting can lead to electrolyte disturbances along with dehydration. People suffering from bulimia or anorexia are at especially high risk for an electrolyte imbalance.

Nomenclature

There is a standard nomenclature for electrolyte disorders:

  1. The name starts with a prefix denoting whether the electrolyte is abnormally elevated ("hyper-") or depleted ("hypo-").
  2. The word stem then gives the name of the electrolyte in Latin. If no Latin equivalent exists, then the corresponding term in English is used.
  3. The name ends with the suffix "-emia," meaning "in the blood." (Note, this doesn't mean that the disturbance is only in the blood; usually, electrolyte disturbance is systemic. However, since the disturbance is usually detected from blood testing, the convention has developed.)

For instance, elevated potassium in the blood is called "hyperkalemia" from the Latin term for potassium, "kalium".

Causes

Table of common electrolyte disturbances

Electrolyte Ionic formula Elevation disorder Depletion disorder
Sodium Na+ hypernatremia hyponatremia
Potassium K+ hyperkalemia hypokalemia
Calcium Ca2+ hypercalcemia hypocalcemia
Magnesium Mg2+ hypermagnesemia hypomagnesemia
Chloride Cl- hyperchloremia hypochloremia
Phosphate PO43- hyperphosphatemia hypophosphatemia
Bicarbonate HCO3- hyperbicarbonatemia hypobicarbonatemia

General Function

Electrolytes are important because they are what your cells (especially nerve, heart, muscle) use to maintain voltages across their cell membranes and to carry electrical impulses (nerve impulses, muscle contractions) across themselves and to other cells. Your kidneys work to keep the electrolyte concentrations in your blood constant despite changes in your body. For example, when you exercise heavily, you lose electrolytes in your sweat, particularly sodium and potassium. These electrolytes must be replaced to keep the electrolyte concentrations of your body fluids constant.

Electrolyte Abnormalities and ECG Changes

The most notable feature of hyperkalemia is the "tent shaped" or "peaked" T wave. Delayed ventricular depolarization leads to a widened QRS complex and the P wave becomes wider and flatter. When hyperkalemia becomes severe, the ECG resembles a sine wave as the P wave disappears from view. In contrast, hypokalemia is associated with flattenting of the T wave and the appearance of a U wave. When untreated, hypokalemia may lead to severe arrhythmias.

The fast ventricular depolarization and repolarization associated with hypercalcemia lead to a characteristic shortening of the QT interval. Hypocalcemia has the opposite effect, lengthening the QT interval.

Differentiating electrolyte disturbances from other diseases

Electrolyte disturbance must be differentiated from other causes of headache, altered mental status and seizures such as brain tumors and delirium trmemns.

Diseases Diagnostic tests Physical Examination Symptoms Past medical history Other Findings
Na+, K+, Ca2+ CT /MRI CSF Findings Gold standard test Neck stiffness Motor or Sensory deficit Papilledema Bulging fontanelle Cranial nerves Headache Fever Altered mental status
Brain tumour[1][2] ? Cancer cells[3] MRI ? ? ?  ? ? ? Cachexia, gradual progression of symptoms
Delerium Tremens ? Clinical diagnosis ? ?  ?  ? ? ? Alcohal intake, sudden witdrawl or reduction in consumption Tachycardia, diaphoresis, hypertension, tremors, mydriasis, positional nystagmus, tachypnea
Subarachnoid hemorrhage[4] ? Xanthochromia[5] CT scan without contrast[6][7] ? ? ? ?  ? ? ? ? Trauma/fall Confusion, dizziness, nausea, vomiting
Stroke ? Normal CT scan without contrast ? ? ? ? ? TIAs, hypertension, diabetes mellitus Speech difficulty, gait abnormality
Neurosyphilis[8][9] ? ? Leukocytes and protein CSF VDRL-specifc

CSF FTA-Ab -sensitive[10]

? ? ? ? ? ? Unprotected sexual intercourse, STIs Blindness, confusion, depression,

Abnormal gait

Viral encephalitis ? Increased RBCS or xanthochromia, mononuclear lymphocytosis, high protein content, normal glucose Clinical assesment ? ? ?  ? ? ? ? Tick bite/mosquito bite/ viral prodome for several days Extreme lethargy, rash hepatosplenomegaly, lymphadenopathy, behavioural changes
Herpes simplex encephalitis ? Clinical assesment ? ? ? ? ? History of hypertension Delirium, cortical blindness, cerebral edema, seizure
Wernicke’s encephalopathy Normal ? ? ? History of alcohal abuse Ophthalmoplegia, confusion
CNS abscess ? ? leukocytes >100,000/ul, ? glucose and ? protien, ? red blood cells, lactic acid >500mg Contrast enhanced MRI is more sensitive and specific,

Histopathological examination of brain tissue

? ? ? ? ? ? ? History of drug abuse, endocarditis, ? immune status High grade fever, fatigue,nausea, vomiting
Drug toxicity ? ? Lithium, Sedatives, phenytoin, carbamazepine
Conversion disorder Diagnosis of exclusion ? ?  ? ? ? Tremors, blindness, difficulty swallowing
Electrolyte disturbance ? or ? Depends on the cause ? ? Confusion, seizures
Febrile seizures Not performed in first simple febrile seizures Clinical diagnosis and EEG  ? ? ? ? Family history of febrile seizures, viral illness or gastroenteritis Age > 1 month,
Subdural empyema ? Clinical assesment and MRI ? ? ? ? ? ? History of relapses and remissions Blurry vision, urinary incontinence, fatigue
Hypoglycemia ? or ? Serum blood glucose

HbA1c

?  ? ? History of diabetes Palpitations, sweating, dizziness, low serum, glucose

ACC/AHA/ESC 2006 Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death (DO NOT EDIT) [11]

Recommendations for Electrolyte Disturbances

Class I
"1. Potassium (and magnesium) salts are useful in treating ventricular arrhythmias secondary to hypokalemia (or hypomagnesmia) resulting from diuretic use in patients with structurally normal hearts. (Level of Evidence: B)"
Class IIa
"1. It is reasonable to maintain serum potassium levels above 4.0 mM/L in any patient with documented life-threatening ventricular arrhythmias and a structurally normal heart. (Level of Evidence: C)"
"2. It is reasonable to maintain serum potassium levels above 4.0 mM/L in patients with acute MI. (Level of Evidence: B)"
"3. Magnesium salts can be beneficial in the management of VT secondary to digoxin toxicity in patients with structurally normal hearts. (Level of Evidence: B)"

References

  1. Soffer D (1976) Brain tumors simulating purulent meningitis. Eur Neurol 14 (3):192-7. PMID: 1278192
  2. Weston CL, Glantz MJ, Connor JR (2011). "Detection of cancer cells in the cerebrospinal fluid: current methods and future directions.". Fluids Barriers CNS. 8 (1): 14. PMC 3059292Freely accessible. PMID 21371327. doi:10.1186/2045-8118-8-14. 
  3. Yeh ST, Lee WJ, Lin HJ, Chen CY, Te AL, Lin HJ (2003) Nonaneurysmal subarachnoid hemorrhage secondary to tuberculous meningitis: report of two cases. J Emerg Med 25 (3):265-70. PMID: 14585453
  4. Lee MC, Heaney LM, Jacobson RL, Klassen AC (1975). "Cerebrospinal fluid in cerebral hemorrhage and infarction.". Stroke. 6 (6): 638–41. PMID 1198628. 
  5. Birenbaum D, Bancroft LW, Felsberg GJ (2011). "Imaging in acute stroke.". West J Emerg Med. 12 (1): 67–76. PMC 3088377Freely accessible. PMID 21694755. 
  6. DeLaPaz RL, Wippold FJ, Cornelius RS, Amin-Hanjani S, Angtuaco EJ, Broderick DF; et al. (2011). "ACR Appropriateness Criteria® on cerebrovascular disease.". J Am Coll Radiol. 8 (8): 532–8. PMID 21807345. doi:10.1016/j.jacr.2011.05.010. 
  7. Liu LL, Zheng WH, Tong ML, Liu GL, Zhang HL, Fu ZG; et al. (2012). "Ischemic stroke as a primary symptom of neurosyphilis among HIV-negative emergency patients.". J Neurol Sci. 317 (1-2): 35–9. PMID 22482824. doi:10.1016/j.jns.2012.03.003. 
  8. Berger JR, Dean D (2014). "Neurosyphilis". Handb Clin Neurol. 121: 1461–72. PMID 24365430. doi:10.1016/B978-0-7020-4088-7.00098-5. 
  9. Ho EL, Marra CM (2012). "Treponemal tests for neurosyphilis--less accurate than what we thought?". Sex Transm Dis. 39 (4): 298–9. PMC 3746559Freely accessible. PMID 22421697. doi:10.1097/OLQ.0b013e31824ee574. 
  10. Zipes DP, Camm AJ, Borggrefe M, Buxton AE, Chaitman B, Fromer M; et al. (2006). "ACC/AHA/ESC 2006 Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death: a report of the American College of Cardiology/American Heart Association Task Force and the European Society of Cardiology Committee for Practice Guidelines (writing committee to develop Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death): developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society.". Circulation. 114 (10): e385–484. PMID 16935995. doi:10.1161/CIRCULATIONAHA.106.178233. 

Related Chapters

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