Electrolyte Balance

electrolyte balance


total reflection

serum
Intra cellular mainly total

hyper kalemia hypo kalemia

excretion 
excretion 

excretion
aldosterone
aldosterone mechanism
excretion

Page | 1
Electrolyte Balance

Hypo kalemia

distal tubules Hypo

potassium losing mechanism diuretics

potassium sparing diuretic type

distal tubules
More excretion distal tubules

poly urea
poly urea hypo kalemia diabetic Poly urea

serum potassium level

excretion renal mechanism enhancement

distal tubules Negative charge of ions

excretion

extra cellular fluid Intra cellular regulate

extra cellular fluid Intra cellular shift

Hyperglycemia

hyperglycemia

Intra cellular utilization

Intra cellular
Hypo kalemia

keto acidosis endocrine

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Electrolyte Balance

hypo kalemia

Normal
empirically

glucagon
counter regulating hormone

sulbtamol Beta adrenergic stimuli

shift of intra cellular potassium << stimulation Beta agonist

Hyper kalemic
nebulizer

hyper kalemia Beta blocker

Hyper kalemia acidosis

hypo kalemia alkalosis

spelling Alkalosis
Loss K Alkalosis
Alkalosis hypo kalemia Loss

hemolysis muscle destruction crush injury

Intra vascular
extra cellular

clinical

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Electrolyte Balance

Hyper kalemia
Hyper kalemia
5.3

Hyper kalemia ‫أسباب ال‬

categories list
Intake 
potassium intake

kidney function

chronic kidney disease Kidney

Hyper kalemia
List

renal
IV fluids
Kidney ringer lactate
hyper kalemia

extra cellular Intra cellular potassium shift 

Hyperglycemic acidotic
Intra cellular
hyper kalemia

Hyper kalemia


extra cellular Intra cellular shift 

excretion 

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 Electrolyte Balance

excretion
Kidney
renal failure
Excretion

excretion adolesterone
aldosterone
aldosterone
Addison disease

Kidney excretion drugs 

ACE inhibitors


factica
Factica
Hyper kalemia
" pseudo hyper kalemia "


tourniquet

blood cells Pressure

tube wall
hemolysis of the RBCs
wrong

sever leucocytosis
thrombocytosis

blood
blood
Gently

Page | 5
 Electrolyte Balance

tube blood
hemolysis

tourniquet
tourniquet
Hyper kalemia hemolysis

Clinical manifestations of Hyper kalemia

clinical manifestations of hyper kalemia

asymptomatic 5.5
asymptomatic 6

Loss of tendon reflex muscle weakness

Hypo ventilation paralysis

severe arrhythmia Hyper kalemia

assessment
Investigations
pseudo hyper kalemia
ECG hyper kalemia wrong

Hyper kalemia
accidentally
ECG
sample repeat
pseudo hyper kalemia Precautions

History
history sheet

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Electrolyte Balance

chronic renal disease diabetic History

risk of rhabdomyolysis

risk of rhabdomyolysis
hyper kalemia
exercise
Hyper kalemia renal failure exercise
rhabdomylosis

tumor lysis syndrome

malignancy

drugs Hyper kalemia

Hyper kalemia drugs

Investigations

investigations
Investigations
serum potassium
5.3 potassium

renal creatine urea

kidney functions

Kidney Hyper kalemia

excretion kidney
urine excretion

kidney
Urine potassium excretion

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 Electrolyte Balance

urinary potassium
spot sample 24
renal 20 
renal kidney 40 
excretion
vague 40 20

kidney retention Kidney 

Kidney 

distal tubules potassium excretion

urine osmolality

Urine osmolality
equation
trans tubular potassium gradient TTKG

urine osmolality serum potassium serum osmolality Urine

renal cause 3 TTKG 

No renal cause 7 TTKG 

excretion Osmolality
60 excretion
renal cause
potassium excretion Osmolality

More accurate TTKG

urine osmolality excretion potassium

CBC

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 Electrolyte Balance

Pseudo hyper kalemia leucocytosis

thrombocytosis leucocytic count

blood film
fragmented RBCs
Hemolysis

metabolic profile
acidosis bicarbonate
hyper kalemia acidosis

hyperglycemia blood sugar

tumor lysis syndrome uric acid ADH

rhabdomyolysis creatinine kinase

renin activity serum cortisone Addison syndrome

Addison Addison

ECG

Hyper kalemia ECG

Lab Hyper kalemia
myocardium effect of potassium ECG
depressant effect on myocardium
Myocardium contractility
ECG changes

T wave 
T wave

Tall T wave
Hyper kalemia

Prolonged PR interval 
wide QRS 
 QRS

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Electrolyte Balance

P wave 
ECG changes

treatment rule ECG

Treatment

Hyper kalemia Hyper kalemia

severity evaluation
urgent treatment

Lines

to be shifted intra cellular 

Myocardium effect antagonism 
potassium excretion 
GIT potassium absorption 
dialysis Line 


Main cause

electrolyte
symptomatic
Hyper kalemia

severe Hyper kalemia

7
6.5 Moderate increase 6.9
severe 7

ECG changes
7 ECG changes
7 ECG changes

severe hyper kalemia ECG changes 6.5

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Electrolyte Balance

rapid increase situations

rhabdomyolysis 
Hemolysis 
tumor lysis syndrome 
rapid increase

intake

diuretic
potassium sparing diuretics
potassium losing diuretics

Uptake by cells
Intra vascular shifting
Intra cellular

Hypoglycemia

cells

salbetamol Beta two agonist

nebulizer
asthma
intra cellular shift

rule bicarbonate

severe acidosis

Page | 11
Electrolyte Balance

documented rule
benefits Hazards

severe metabolic acidosis

bicarbonates

severe metabolic acidosis

acidosis bicarbonate
dialysis renal failure
saline keto acidosis

ECG changes
Myocardium depressant
effect antagonize
calcium gluconate

potassium excretion
lasix frusemide diuretic edematous
diuresis

 
absorption
rectal enema Oral

dialysis chronic renal disease

6.5 5.5
dialysis

Hyper kalemia
absorption

dialysis
dialysis
renal failure indicating dialysis hyper kalemia

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Electrolyte Balance

Hyper kalemia

7.5
myocardium effect
Hyper kalemia dialysis

Underlying cause
hyper kalemia presented renal failure
Measures dialysis Main management
dialysis renal failure acute

hyper kalemia

hypo kalemia
Hypo kalemia
Hypo kalemia
3.5

Hypo kalemia
fluids

TPN
TPN
total parental nutrition

TPN gut

hypo kalemia

Loss Increase

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Electrolyte Balance

kidney 
 kidney 
Kidney

Mal absorption prolonged severe diarrhea

Whatever
prolonged vomiting diarrhea
ileus with massive intestinal dilatation
non renal

renal
hypo kalemia hypo kalemia
diuretic
hypo kalemia
prolonged use of glucocorticoids excess

congenital disorders

aldosterone

Peptic ulcer
salt and water retention
aldosterone
hyper tension salt and water retention

hypo kalemia
Muscles weakness

alkalosis

Page | 14
Electrolyte Balance

differential diagnosis
etiology guide line
hypo kalemic
With alkalosis 
with acidosis 

With acidosis
Hyper tension 
hypo tension 
diagnosis

recovery phase
diabetic keto acidosis
recovery
Hypo kalemia

IV fluids

recovery hypo kalemia

keto acidosis
hypo kalemia

acute tubular necrosis recovery

cells Intra cellular redistribution

hypo kalemia cells vascular

alkalosis acidosis

salbetamul asthma beta adrenergic agonist

beta two agonist
Hypo kalemia

Page | 15
Electrolyte Balance

hypo kalemia insulin therapy

Clinical presentation

generalized myalgia fatigue

Proximal muscle weakness

Intestinal movement Paralytic ileus

paralytic ileus

tubular damage Hypo kalemic

severe hypokalemia
Heart Hyper kalemia
Heart hypo kalemia

Investigations

hypo kalemia investigations

3.5

urine potassium
Kidney 
renal 

TTKG
renal renal 

Metabolic profile

Page | 16
Electrolyte Balance

hypo kalemia
Mg 100 Hypo kalemia

ventricular tachycardia
Mg
Hypo kalemia

resistant hypo kalemia

Profile hypo kalemia

special investigations
aldosterone renin

ECG changes

T wave
U wave wave
MCQ
U wave
hypo kalemia 
hyper kalemia 
hypo natremia 
hyper natremia 
hypo kalemia

MCQ
MCQ

TTKG
Hyper kalemic hypo kalemic
TTKG

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 Electrolyte Balance

Q wave 
wide QRS 

aldosterone hypo kalemia

Primary secondary
Conn's disease primary
renal artery stenosis renin Hypo kalemia secondary

Treatment

Hypo kalemia
severity hyper kalemia
Intake
Loss
shift
GIT absorption
Mechanism
simple

hyper kalemia
excretion
Intra cellular shift

Hypo kalemic
Loss
diarrhea diuretics

equivalent 1

equivalent

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Electrolyte Balance

+1

equivalent

equivalent
equivalent

2.5 3.5
1
400 200 total potassium
400 200

restore

IV potassium Oral potassium

Oral potassium

3.5 3 3.5
Oral potassium

IV potassium chloride

Precautions slow IV potassium chloride

Page | 19
Electrolyte Balance

precautions
central line potassium chloride 
central line
peripheral line rate

CVP central line 

central line

central line
femoral vein
femoral vein
CVP
femoral vein Central line
heart direct

CVP
right atrium

Peripheral line CVP

rate
10 rate
40

severe rate
20 10

ml mol / liter / hour

10
IV fluid
carrdic arrest
Over one hour IV fluids
rate
10
10

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Electrolyte Balance

250 100 fluid maximum

fluid
Saline

cells

diabetic

20 10
20 10
drip

IV fluids
central line
20

40 severe
20 10

400 200

over one hour typical

2.7
20

40

40

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Electrolyte Balance

10

2.6
30
Whatever

20 10 rate

400 400 rule

24 10

480 240

480 240
400 200

2.1 3.5

flow up rate

saline
20 10 rate
serum potassium good monitoring Patient good monitoring

carrdic monitoring
severe
40 carrdic problems hypo kalemic
40
20 10

cause electrolyte

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Electrolyte Balance

cells

cells

145 135 serum

Hypo natremia
severe hypo natremia

125 severe hypo natremia

120
115 severe text

severe

120 125

hypo natremia Pathophysiology

hyper tonic Hyper osmolar

hypo natremia
Osmolality
calculating osmolality


In general
serum sodium calculating osmolality

calculating osmolality

135 140

280
Normal osmolality
290 280

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Electrolyte Balance

Normal osmolality 290 275

equation
2 equation simple

Urea 2.8 2

X 2

X 2
4
140
144
2
calculating osmolality 288

Measured osmolality
measured osmolality
osmolometer

Osmolar gap Measured osmolality calculating

acidosis
Osmolar gap

hypo natremic
osmolality

osmolality

etiology
hyper osmolar hypo natremia

hypo natremia hyper osmolar

Pathophysiology
Simply
total body water relation

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Electrolyte Balance

body water relation

water
Osmolality water 
Hypo natremia water 

Hyper tonic hypo natremia

Hyper tonic hypo natremia
osmotic active substance blood
blood osmolality

Osmolality
vascular intra cellular water
Relatively

Hypo natremia

osmotic active substance

glucose
relation

200
1.6 100

simple diffusion

cells
dehydrated

Keto acidosis
Dehydrated dry
cells water
Intra vascular

hypo natremia relatively

400
2.4 400 100

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Electrolyte Balance

100
400 osmotic active substance

activity

more dilution

osmolality
Hyper osmolar hypo natremia

Iso osmolar hypo natremia

lipids

Hypo osmolar hypo natremia

Hypo osmolar

Hyper osmolar
Osmolality

Iso osmolar
Osmolality hypo osmolar

hypo osmolar
volume of fluid status osmolality

volume status
hyper volemic 
Iso volemic 
Hypo volemic 

etiology

Page | 26
Electrolyte Balance

Osmolality Osmolality
fluid status

differential diagnosis hyper volemic 

differential diagnosis iso volemic 
differential diagnosis Hypo volemic 
hypo natremia etiology

Mechanism Hypo volemic hypo osmolar

hypo volemia

Increase sympathetic activity 

Proximal tubules water and sodium re absorption 

sympathetic activity
renin angiotensin aldosterone system

water
distal tubules

distal tubules
anti diuretic hormone
volume
anti diuretic hormone volume

collecting duct anti diuretic hormone

water absoprtion 
anti diuretic hormone 

angiotensin sympathetic activity

stimulation

Page | 27
Electrolyte Balance

total
relatively
still hypo volemic

Underlying mechanism

renal perfusion
distal tubules
thirst mechanism increase anti diuretic hormone
hypo natremia

diuretic
diuretics diuretics diuretic

sodium loss mechanism diuretic

hypo volemia
Hypo volemia mechanism stimulation

Addison

salt wasting nephropathy

tubular disorders Interstitial disease
tubules
Fanconi syndromes
reabsorption

Loss of sodium

cerebral salt wasting

salt wasting nephropathy
cerebral salt wasting
tumor Intra cranial hemorrhage
sympathetic
wasting 

Page | 28
 Electrolyte Balance

renal loss
Hypo volemic hypo osmolar hypo natremia

fluid loss vomiting diarrhea

Iso volemic
hypo volemia volume over load

SIADA

syndrome of in appropriate anti diuretic hormone

endocrine

SIADA endocrine
SIADA syndrome drugs

psychogenic poly depsia

SIADA syndrome
psychogenic
SIADA syndrome differential diagnosis

Hypo tonic excess IV fluids

glucose glucose

saline Hypo tonic

More dilution

Hypo thyroidism

hyper volemia euo volemic SIADA

hyper volemia
Iso volemic

hypo volemic euo volemic

hyper volemia
SIADA syndrome

Page | 29
Electrolyte Balance

Hyper volemia
Lower limb edema
ascites

situations
situations
edematous conditions

cirrhotic 
nephrotic 
congested right side heart failure 
lower limb edema

situations
Mechanism
Overloaded clinically
electrolyte fluid distribution actually

Interstitial fluid
lower limb edema
Intra vascular intra cellular Interstitium

spaces
ascites pleural effusion

Intra vascular

hypo albuminic cirrhotic liver

Osmotic pressure
ascites edema Mechanisms

Intra vascular
Interstitium Intra vascular

Totally
Overloaded

Page | 30
Electrolyte Balance

Over loaded 
deficient Intra vascular volume 
renal hypo perfusion Mechanism
anti diuretic hormone

hypo volemia anti diuretic hormone

Over loaded
anti diuretic hormone
intra vascular

mechanism
intra vascular

what ever cardic cirrhotic patient Line of treatment

Salt and water restriction

Hypo volemia Mechanism

line
Salt and water restriction
totally over loaded

nephrotic heart failure liver disease

steroid Nephrotic

Liver disease
hypo natremia
very bad Hepato renal syndrome
mechanism Hypo natremia
deficient intra vascular

very bad In general

Page | 31
Electrolyte Balance

acidic cirrhotic advanced chronic liver disease

electrolyte
very bad Prognosis

Hypo natremia

Hyper osmolar 
Iso osmolar 
Hypo osmolar 

hypo osmolar

severe hypo natremia Hypo natremia glucose

severe
Prostate dissection
glyceine

active substance diffusion glyceine

Hypo natremia

hypo osmolar

Hypo volemic 
iso volemic 
hyper volemic 
chornic liver disease

clinical
early symptoms
asymptomatic hypo natremia
apathy vomiting Nasuea anorexia

Page | 32
Electrolyte Balance

Late symptoms
coma disoriented rapid onset
neurological fits
convulsion fits

assessment
drugs History assessment
diabetic
Patient History

volume status
volume status assessment
ascites Edema

‫ اللي هنعملها للعيان ده بسرعة ؟؟؟‬Investigations ‫إيه ال‬


Osmolality 
Urine sodium urine osmolality 
15 10 Urine sodium
15

Kidney

tubular defect kidney 20 excretion

whatever wasting nephropathy

volume

diuretic 
salt wasting nephropathy 

Overloaded volume

Page | 33
Electrolyte Balance

SIADA syndrome normal

diagnosis
imaging
hypo natremia

CT abdominal ultra sound

chest infection SIADA syndrome

malignancy granuloma
CNS tumors
SIADA syndrome

hypo osmolar
patient volume status 
maganitude of hypo natremia duration 
severity degree

hyper volemic patient

nephrotic cirrhotic

diuretic salt and water restriction

salts water diuretics

diuretics

cause euo volemic

SIADA syndrome
chest granuloma chest tumors cause
CNS
cause

drugs
PP receptors antagonist

Page | 34
 Electrolyte Balance

Liver disease hyper volemic

salts

B2 receptors
collecting duct
channel collecting duct anti diuretic hormone
water
anti diuretic hormone effect B2 receptors receptors
water loss
 water

Heart failure
severe hypo natremia

Hypo volemic patient

rate correction

rapid correction

acute hypo natremia

48

base line 48

base line
48 hypo natremia
acute

symptomatic Hypo natremic

symptomatic

Page | 35
Electrolyte Balance

acute acute
rate

Normal
145 135
120

acute 120
equivalent 2 1 rate of correction

110 120
Upper limit
safe limit
130 125 safe limit

125 110
145

15
equivalent 2 1

15
acute

fluid
15 deficit acute

long standing chornic

equivalent 0.5
equivalent

15
30

chronic acute
chornic

Page | 36
Electrolyte Balance

brain cells shrinkage

quadriplagia ponti brain stem
ponti cells atrophy

quadriplegia
rate

rate
12

24 day

10
Long standing chornic

12 0.5 rate

reports text

10
0.5 0.4 rate

volume equation
equation

equations
total body water serum sodium

equation total body water

Male 60 general
50 female

100

Page | 37
Electrolyte Balance

60 
50 

total body water

total body water

154 0.9
308 1.8
2.7
3

simply

10 deficit
total body water 10
60 40 total body water
total 400

400
150 154 % 0.9

450
150 450

total 450
150 154 0.9

3 150 450
3

24 10
3
10
24

Page | 38
Electrolyte Balance

24 3

2.7

24

rate of correction

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