SPECIAL RESUSCITATION SITUATIONS

特殊情況下的復甦術

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致命的電解質異常

40 歲女性Sudden collapse

經心臟電擊術後

40 歲女性12 導程心電圖

40 歲女性 血中鉀離子濃度過高 (K=7.0meq/L)

致命的電解質異常

造成心臟停止或降低急救成效 在檢驗數值出來前即採取急救措施 以高血鉀最易致命

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高血鉀

血鉀 > 5.0 mEq/L

pH 0.1 U

serum K+ 0.3

mEq/L

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高血鉀原因Drugs (K+-sparing diuretics, ACEI, NSAIDs, K

supplements)ESRDMuscle breakdown (rhabdomyolysis)Metabolic acidosisPseudohyperkalemiaHemolysisTumor lysis syndromeDiet (rarely sole cause)Hypoaldosteronism (Addison disease,

hyporeninemia)Type 4 renal tubular acidosisOther: hyperkalemic periodic paralysis

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高血鉀

症狀 : 全身無力 ( 由下肢往上漸進式發生 ) ，呼吸衰竭

心電圖變化 T 波變高 P 波變平 PR 延長 QRS 波變寬

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– S 波變深– idioventricular rhythm– sine waves– VF 、心跳停止

Hyperkalemia

Etiology – renal failure, transcellular shifts, cell death, drugs, pseudohyperkalemia

Manifestations – cardiac, neuromuscular

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高血鉀症的症狀

Hyperkalemia

Treatment Stop potassium ! Get an ECG Hyperkalemia with ECG changes is a

medical emergency

Hyperkalemia Treatment

First phase is emergency treatment to counteract the effects of hyperkalemia IV Calcium

Temporizing treatment to drive the potassium into the cells glucose plus insulin Beta2 agonist

NaHCO3

Therapy directed at actual removal of potassium from the body sodium polystyrene sulfonate (Kayexalate) dialysis

Determine and correct the underlying cause

低血鉀

血鉀 < 3.5 mEq/L 原因

攝取減少 流失過多 ( 腸胃道及腎臟為主 ) 由細胞外移至細胞內

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低血鉀

症狀 : 無力、疲累、麻痺 呼吸困難 便秘、麻痺性腸阻塞 小腿痙攣 肌肉崩解

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低血鉀

心電圖變化 U 波 T 波變平 ST 改變 心律不整 ( 服用 digoxin 者尤

甚 ) PEA or Asystole

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低血鉀症的症狀心率不整 (Arrhythmia) Atrial or ventricular tachyarrhythmia Decreased amplitude of P wave U wave. Conjoined T-U wave: "camel's

hump"

處置減少流失及補充鉀 心律不整或 K+ <2.5 IV K +

最大量 10-20 mEq/h + ECG

心跳停止 (VF/VT):

2 mEq/min 10 mEq /5-10 min

血鉀 1mEq 須補充 150-400 mEq

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高血鈉

血鈉 > 145 mEq/L 症狀 : 口渴、意識不清、無力、躁動、局部神經症狀、抽搐、昏迷

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處置

減少水份流失、補水 低血容 : 補生理食鹽水 缺水量 = 體重 x 0.5 x ( 血鈉 - 140) /140 ♂

體重 x 0.4 x ( 血鈉 - 140) /140 ♀

70 公斤男性，血鈉 160 ，缺水量 ? L

血鈉 0.5-1.0 mEq/h (< 12 / 24 hrs) Daily supply: Water deficit x 10 / ( 血鈉 - 140) Rate: Daily supply/24 + ongoing demand

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低血鈉

血鈉 < 135 mEq/L 症狀 : 急性或 <120 才有症狀噁心、嘔吐、頭痛、躁動、疲累、抽搐、昏迷或死亡

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處置 補鈉排水 SIADH: 限水 ( 50 - 66% ) Na+ deficit= (desired [Na+] - current [Na+])

x 0.5 x body wt (kg) (* 0.5 for men, 0.4 for women.)

3% saline = 513 mEq Na+/L Na+ 0.5 -1/hr (max. 10-12/24h) 補充太快 pontine myelinolysis

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鎂

Na, K, Ca 之移動所必需低血鎂細胞內鉀無法補齊

穩定細胞膜作用 : 可治療心律不整

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高血鎂

血鎂 > 2.2 mEq/L 最常見原因 : 腎衰竭 其它原因 :

攝取過多 內臟破裂仍持續進食

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高血鎂

神經症狀 : 肌無力、麻痺、運動失調、嗜睡、意識混亂

腸胃症狀 : 噁心、嘔吐 心血管症狀 : 血管擴張、緩脈、換氣不足、心肺停止

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高血鎂

心電圖變化 PR 、 QT 延長 QRS 變寬 P 波電位變小 T 波變高 Complete AV block 、 Asystole

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處置 補鈣離子

CaCl2 ( 5 to 10 mEq IV )可避免致命性心律不整

移除血鎂 血液透析 腎及心血管功能正常

IV N /S + furosemide 減少攝取

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低血鎂

血鎂 < 1.3 mEq/L 比高血鎂症常見 吸收減少、流失增加所致 PTH 或某些藥物

(eg, pentamidine, diuretics, alcohol) 補乳婦女 : 高危險

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低血鎂 - 原因

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• GI loss: bowel resection, pancreatitis, diarrhea• Renal disease• Starvation• Drugs: diuretics, pentamidine, gentamicin, digoxin• Alcohol• Hypothermia• Hypercalcemia• Diabetic ketoacidosis• Hyperthyroidism/hypothyroidism• Phosphate deficiency• Burns• Sepsis• Lactation

低血鎂 - 症狀

肌肉震顫、束顫或強直 眼球震顫 意識改變、運動失調、眩暈、抽搐、吞嚥困難

低血鈣、低血鉀

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低血鎂 - 心電圖變化

QT 延長 末段 T 波倒置 Heart blocks

VF

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處置 Severe or symptomatic hypoMg

1 to 2 g IV MgSO4 over 15’ Torsades de pointes

2 g of MgSO4 over 1 - 2’ Seizures

2 g IV MgSO4 over 10’ Calcium gluconate (1 g)

大部分有 hypoCa 腎功能不全者小心補

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鈣 1/2 Ca in the ECF: bound to alb Alkalosis: Ca-alb binding Ca2+

Acidosis Ca2+ serum alb 1 g/dL total serum Ca

0.8 mg/dL (Ca = Serum Ca + 0.8 * (4 - Albumin))

In hypoalb., Ca2+ may be normal Ca antagonizes K and Mg at the cell

mem. Ca regulated by PTH and vit. D

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高血鈣

serum Ca > 10.5 mEq/L or

Ca2+ > 4.8 mg/dL

Primary hyperparathyroidism and

malignancy account for >90%

cases.

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高血鈣 - 症狀

Total serum Ca ≧12 to 15 mg/dL

Neuro. S/S: depression, weakness, fatigue, ,confusion

(at lower levels)

hallucination, disorientation, hypotonicity,

coma (at higher levels)

Renal concentration of urine

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高血鈣 - 症狀 CV S/S: variable

< 15 to 20 : myocardial contractility > 15 to 20 : myocardial depression

Automaticity and ventricular systole is shortened

Arrhythmias ( refractory period ) Digitalis toxicity is worsened Hypertension Many patients with hyperCa develop hypoK

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高血鈣 - 症狀 GI S/S:

dysphagia constipation peptic ulcers pancreatitis

Renal S/S: ability to concentrate urine dehydration diuresis (loss of Na, K, Mg, and P vicious

circle of Ca reabsorption)

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高血鈣 - 心電圖變化 QT 變短 PR and QRS 延長 QRS voltage 變大 T-wave 變平、變寬 Notching of QRS AV block

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處置Symptomatic or >15 mg/dL NS at 300 to 500 mL/h -- 維持尿量 200 to 300 mL/h After adequate rehydration: NS at 100 to 200 mL/h Closely monitor K & Mg Heart F. or Renal I.: hemodialysis Extreme conditions: chelating agents

PO4 50 mmol/8-12 h or EDTA 10 to 50 mg/kg/4 h

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處置 (II)

Lasix (1 mg/kg IV) controversial heart failure: required reuptake of Ca from bone

Reduce bone resorption calcitonin Glucocorticoids (prednisolone

20~40 mg/day)

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低血鈣

serum Ca < 8.5 mEq/L or Ca2+ < 4.2 mg/dL

Causes: toxic shock syndrome abnormalities in Mg tumor lysis syndrome

rapid cell turnover hyperK, hyperP, and hypoCa

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低血鈣 - 症狀Occur when Ca2+ < 2.5 mg/dL Paraesthesia Muscle cramps, carpopedal spasm Stridor Tetany Seizures Hyperreflexia Chvostek and Trousseau signs Cardiac contractility, heart failure

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處置

急性，有症狀 10% Ca gluconate IV 10’

IV drip 0.5 to 2.0 mg/kg/hr in D5W

檢測血鈣 Q4-6H

維持血鈣 7-9 mg/dL

矯正 Mg, K, and pH

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