FLUIDS & ELECTROLYTES

Adult body: 40L water, 60% body weight 2/3 intracellular 1/3 extracellular ( 0% inter!titial, 20% intra"a!cular# $n%ant: &0' 0% water (lderly: 40')0% water (xtracellular %luid * di"ided into inter!titial + intra"a!cular !ub!tance! that di!!ol"e in other !ub!tance! %or, a solution solute * the !ub!tance di!!ol"ed solvent * !ub!tance in which the !olute i! di!!ol"ed ' u!ually water (uni"er!al !ol"ent# molar solution (-# ' . o% gra,',olecular weight! o% !olute /er liter o% !olution osmolality * concentration o% !olute /er 0g o% water nor,al range 1 2&)'22) ,3!,/0g o% water osmolarity * concentration o% !olute /er L o% !olution * !ince 10g11L, + water i! the !ol"ent o% the hu,an body, o!,olarity + o!,olality are u!ed interchangeably electrolyte ' any o% "ariou! ion!, !uch a! !odiu,, /ota!!iu,, or chloride, re4uired by cell! to regulate the electric charge and %low o% water ,olecule! acro!! the cell ,e,brane5 Ions * electrically charged /article! Hydrostatic ressure '/u!he! %luid out o% "e!!el! into ti!!ue !/ace6 higher to lower /re!!ure * due to water "olu,e in "e!!el!6 greater in arterial end * !welling: "arico!e "ein!, %luid o"erload, 0idney %ailure + 789 Osmotic ressure '/ull! %luid into "e!!el!6 %ro, wea0er concentration to !tronger concentration ' %ro, /la!,a /rotein!6 greater in "enou! end ' !welling: li"er /roble,!, ne/hrotic !yndro,e !ctive trans ort * u!e o% energy to ,o"e ion! acro!! a !e,i/er,eable ,e,brane again!t a concentration, che,ical or electrical gradient Di""usion * /article! in a %luid ,o"e acro!! a !e,i/er,eable ,e,brane %ro, an area o% greater to le!!er concentration !cid # yield! hydrogen ion! ' 87l, carbonic acid, acetic acid ("inegar#, lactic acid $ase * yield! 386 bind! with 8 ion! ' ,agne!iu, + alu,inu, hydroxide (antacid!#, a,,oniu, hydroxide (hou!ehold cleaner#

Fluid $alance Re%ulation Thirst reflex triggered by: 15 decrea!ed !ali"ation + dry ,outh 25 increa!ed o!,otic /re!!ure !ti,ulate! o!,orece/tor! in the hy/othala,u! 35 decrea!ed blood "olu,e acti"ate! the renin/angionten!in /athway, which !i,ulate! the thir!t center in hy/othala,u! Renin-Angiotensin 15 dro/ in blood "olu,e in 0idney! 1 renin relea!ed 25 renin 1 act! on /la!,a /rotein angioten!in (relea!ed by the li"er# to %or, angioten!in $ 35 A7( 1 con"ert! Angioten!in $ to Angioten!in $$ in the lung! 45 Angioten!in $$ 1 "a!ocon!triction + aldo!terone relea!e ADH * /roduced by hy/othala,u!, relea!ed by /o!terior /ituitary when o!,orece/tor or barorece/tor i! triggered in hy/othala,u! Aldosterone * /roduced by adrenal cortex6 /ro,ote! :a + water reab!or/tion Sensi&le & Insensi&le Fluid Loss ;en!ible: urine, "o,iting, !uctioned !ecretion! $n!en!ible: lung! (400,l/day# ;0in (400,l/day e"a/oration, 200,l/day !weat# <$ (100,l/day# I' Fluids Isotonic L= >:;; (052%:;;# :Hypotonic ?)@ ' i!otonic in bag ' dextro!e14uic0ly ,etaboliAed1hy/otonic ?25)@ 054)% :;; 053% :;; 052% :;; ?)0@ ?10@ ?):;; ?)L= 3%:;; !las"a expanders

Hypertonic

Colloids (usually CHONs)

Albu,in >la!,a * %or hy/oalbu,ine,ia, "olu,e'de/leted /atient! ' ha! /rotein, including 79 ($ to $B# ?extran * !ynthetic /oly!accharide, gluco!e !olution ' increa!e concentration o% blood, i,/ro"ing blood "olu,e u/ to 24 hr! ' contraindicated: heart %ailure, /ul,onary ede,a, cardiogenic !hoc0, and renal %ailure 8eta!tarch * li0e ?extran, but longer'acting ' ex/en!i"e ' deri"ed %ro, corn !tarch

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Com osition o" Fluids ;aline !olution! * water, :a, 7l ?extro!e !olution! * water or !aline, calorie! Lactated =ingerD! * water, :a, 7l, E, 7a, lactate >la!,a ex/ander! * albu,in, dextran, /la!,a /rotein (/la!,anate# ' increa!e! oncotic /re!!ure, /ulling %luid! into circulation >arenteral hy/erali,entation * %luid, electrolyte!, a,ino acid!, calorie! Fluid 'olume De"icit Hypertonic# !o,e diuretic!, ?iabete! in!i/idu!, ?iabete! -ellitu!, in%ection!, %e"er, decrea!ed water inta0e, !alt tablet/!alt water inta0e, watery diarrhea Hypotonic# diuretic!, !alt'wa!ting renal di!ea!e!, Addi!onD! di!ea!e Isotonic# diuretic!, diarrhea, "o,iting, blood lo!!, third'!/acing ;/;: thir!t ?ry !0in, ,ucou! ,e,brane! $ncrea!ed te,/, %lu!hed !0in =a/id, thready /ul!e $ncrea!ed 8ct, !/eci%ic gra"ity, etc5 Late: hy/oten!ion decrea!ed F3 adult * 30,l/hr children * 1'2,l/0g/hr 0id!: de/re!!ed %ontanel! Fluid 'olume E(cess Hypertonic# cau!e ' hy/ertonic $G %luid!, hy/eraldo!teroni!, -ay lead to: 789, ede,a etc Hypotonic# increa!ed water inta0e, ta/ water ene,a!/irrigation!, ;$A?8 Isotonic# renal %ailure, cortico!teroid! ;/; 789'li0e weight gain, ede,a, a!cite! crac0le!, dy!/nea di!tended nec0 "ein! bounding /ul!e con%u!ion, wea0ne!! increa!ed 7G> ?ecrea!ed 8ct, HF: etc Eid!: bulging %ontanel! Old vs) in"ants Hody water + regulation: 3ld * 40')0% ' 0idney! cannon concentrate or dilute urine a! e%%iciently ' di,ini!hed thir!t ,echani!, $n%ant * u/ to 0% (20% i% /re,ature# ' 0idney! i,,ature until age 2 ' larger body !ur%ace area %or !iAe ' higher ,etabolic rate re4uire! ,ore water ;0in turgor: 3ld * u!e !ternu,, %orehead, inner thigh, to/ o% hi/ bone $n%ant * abdo,en, inner thigh!

ELECTROLYTE I*$!L!+CES
SODIU* :a ' ,o!t abundant extracellular cation ' clo!ely a!!ociated with chloride ' in%luenced by diet, aldo!terone 13)'14) ,(4/L 9unction! ' neuro,u!cular, ner"e tran!,i!!ion ' o!,olarity + oncotic /re!!ure i,/ul!e

!ource: table !alt, /roce!!ed %ood!, !,o0ed//re!er"ed ,eat!, corned bee%, ha,, bacon, /ic0le!, 0etchu/, ba0ing /roduct! (ba0ing /owder + !oda#, !hell%i!h, al0a'!etlAer + cough !yru/! Hy onatremia u!ually %ro, hy/er"ole,ia /ull! water into cell! * cerebral ede,a 7au!e diuretic!, !alt'wa!ting renal di!ea!e !uctioning, diarrhea, "o,iting, ta/ water ene,a ;$A?8, Addi!onD! Lithiu, ;/; bounding /ul!e, tachycardia 8y/oI;: (low (7G#, hy/erI;: (high (7G# >ale, dry !0in (low (7G# @eight gain, ede,a (high (7G# 789 ;/; (high (7G# @ea0ne!!, headache, con%u!ion increa!ed $7> ;/; -gt ?iet: high !odiu,, water re!triction ;aline or L= @eigh daily, $+3 Hy ernatremia /ull! water %ro, cell! * cell! !hrin0 thir!t ,echani!, triggered cell! beco,e hy/erexcitable 7au!e 7u!hing!, ?iabete! in!i/idu! ;alt'water drowning =enal %ailure ;/; Iachycardia, hy/erten!ion ?ry, !tic0y ,ucu! ,e,brane! Ihir!t, dry tongue Iwitching, tre,or, hy/erre%lexia $rritability, !eiAure!, co,a 7hloride * ,ay be ele"ated -gt ?iet: low !odiu, ()00,g * 3g/day# @eigh daily, $+3 Loo/ diuretic! (thiaAide! o0# ?e!,o/re!!in acetate (??AG># na!al !/ray $% 9G?, increa!e %luid/water inta0e

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@eb 7o/y, >age 2 o% & >re/ared by: <igi <o

,OT!SSIU* E* ,o!t abundant intracellular cation ' exchange! with 8 ion! to ,aintain acid' ba!e balance ' al0alo!i! 1 hy/oE6 acido!i! 1 hy/erE ' a%%ected by in!ulin le"el! 35)') ,(4/L 9unction! ' ,u!cular (e!/ heart# contraction ' neuro,u!cular contraction, including !,ooth ,u!cle! ' /art o% !odiu,'/ota!!iu, /u,/ !ource: dried %ruit! (/rune!#, %ruit! (banana, cantalou/e, gra/e%ruit, orange, a/ricot!, a"ocado#, "egetable! (!/inach, broccoli, green bean!# nut!, ,il0, ,eat, co%%ee + cola, !alt !ub!titute! =?A: 40'60 ,(4/day Hy o-alemia >oor ,u!cle contraction 7au!e Al0alo!i! Ioo ,uch in!ulin 7u!hingD! @ater intoxication (diabete! in!i/idu!# ?iuretic! (loo/ + thiaAide# 7ortico!teroid! ?igoxin ?iarrhea, :+G ;/; arrhyth,ia @ea0, thready /ul!e (7<: ;I de/re!!ion5 9lattened I wa"e, F wa"e, >G7!

Hy er-alemia $ncrea!e! cell excitability, ,ay di!charge inde/endently without !ti,ulu! 7au!e =a/id E in%u!ion, exce!!i"e inta0e =enal %ailure Addi!onD! 3"eru!e o% E'!/aring diuretic! -etabolic acido!i! $n!ulin de%iciency -a!!i"e cell da,age (burn!, tu,or ly!i! !yndro,e, blood cell he,oly!i!# Hlood tran!%u!ion! ;/; Arrhyth,ia ;low cardiac rate (7<: narrow//ea0ed I wa"e, widened K=;, /rolonged >= inter"al, %lattered > wa"e, G %ib

Iwitching (early# or /araly!i! (late# <$ hy/er,otility, diarrhea -gt $n!ulin L gluco!e ?iuretic! (loo/, thiaAide!# * no E'!/aring (xchange re!in! ;odiu, /oly!terene !ul%onate (Eayexalate#' exchange! :a with E in the <$ ;orbitol &0% oral or rectal 7a gluconate * antagoniAe! e%%ect o% E on ,yocardiu, to decrea!e irritability6 doe! not /ro,ote E excretion dialy!i! ?iet: low /ota!!iu,, no !alt !ub!titute!

8y/ore%lexia -u!cle wea0ne!!, /are!the!ia! Leg cra,/! 9atigue, lethargy, co,a 8y/oacti"e bowel !ound!, /aralytic ileu! -gt $G: no ,ore than 1,(4/10 ,l ' ne"er gi"e $GII ' ,a0e !ure /atient ha! "oided 3ral: 0aliu, durule (gi"e with ,eal!# ?iet: high /ota!!iu, -onitor drug le"el! o% cardiac glyco!ide! >rotect %ro, inJury

C!LCIU*

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@eb 7o/y, >age 3 o% & >re/ared by: <igi <o

7a * cation, ,o!t abundant in entire body ' 22% in bone, teeth ' o% the 1%, hal% bound to /rotein (u!ually albu,in#, hal% ioniAed (acti"e %or,# ' 05 g/dL 7a %or e"ery 1 g/dL albu,in increa!e or decrea!e ' a%%ected by >I8, 7alcitonin, albu,in, Gita,in ? (calcitriol# ' 1000'1200,g/day %or adult!6 1)00 %or elderly, /regnant, lactating 45)')5) ,(4/L 5)'105) ,g/dL * total 9unction! ' !0eletal + cardiac contraction ' !0eletal + dental growth/den!ity ' clotting (79 $G# * i,/ortant in con"erting /rothro,bin to thro,bin ;ource!: ,il0, yogurt, chee!e, !ardine!, broccoli, to%u, green lea%y "egetable! Hy ocalcemia 7au!e 8y/o/arathyroidi!, (idio/athic or /o!t!urgical# Al0alo!i! (7a bind! to albu,in# 7ortico!teroid! (antagoniAe Git ?# 8y/er/ho!/hate,ia Git ? de%iciency =enal %ailure ("it ? de%iciency# ?ecrea!ed cardiac contractility Arrhyth,ia (7<: /rolonged KI inter"al, lengthened ;I !eg,ent Irou!!eauD! !ign (in%late H> cu%% 20,, abo"e !y!tole %or 3 ,in 1 car/o/edal !/a!,# 7h"o!te0D! !ign (ta/ %acial ner"e anterior to the ear 1 i/!ilateral ,u!cle twitching# Ietany 8y/erre%lexia, !eiAure! Laryngeal !/a!,!/!tridor ?iarrhea, hy/eracti"e bowel !ound! Hleeding =elated electrolyte i,balance!: 8y/o,agne!e,ia, hy/o0ale,ia, hy/er/ho!/hate,ia -gt 7alciu, gluconate 10% $G 7alciu, chloride 10% $G ' both u!ually gi"en by ?r, "ery !lowly6 "enou! irritant6 cardiac /rob! 3ral: calciu, citrate, lactate, carbonate6 Git ? !u//le,ent! ?iet: high calciu, watch out %or tetany, !eiAure!, laryngo!/a!,, re!/ + cardiac arre!t !eiAure /recaution!

' 7au!e

u!ually %ro, bone re!or/tion 8y/er/arathyroidi!, (eg adeno,a# -eta!tatic cancer (bone re!or/tion a! tu,orD! ecto/ic >I8 e%%ect# * eg5 -ulti/le ,yelo,a IhiaAide diuretic! (/otentiate >I8 e%%ect# $,,obility -il0'al0ali !yndro,e (too ,uch ,il0 or antacid! in aeg! with /e/tic ulcer# Arrhyth,ia (7<: !hortened KI inter"al, decrea!ed ;I !eg,ent 8y/ore%lexia, lethargy, co,a 7on!ti/ation, decrea!ed bowel !ound! Eidney !tone! Hone %racture! %ro, re!or/tion $% /arathyroid tu,or 1 !urgery ?iet: low 7a, !to/ ta0ing 7a 7arbonate antacid!, increa!e %luid! $G %lu!hing (u!ually :a7l# Loo/ diuretic! 7ortico!teroid! Hi/ho!/honate!, li0e etidronate (7alcitonin# + alendronate (9o!a,ax# >lica,ycin (-ithracin# * inhibit! bone re!or/tion 7alcitonin * $- or intrana!al ?ialy!i! (!e"ere ca!e# @atch out %or digitali! toxicity >re"ent %racture!, handle gently

;/;

-gt

;/;

Hy ercalcemia
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*!.+ESIU*
@eb 7o/y, >age 4 o% & >re/ared by: <igi <o

-g * 2nd ,o!t abundant intracellular cation ' )0% %ound in bone, 4)% i! intracellular ' co,/ete! with 7a + > ab!or/tion in the <$M ' inhibit! >I8 15)'25) ,(4/L 9unction!: ' i,/ortant in ,aintaining intracellular acti"ity ' a%%ect! ,u!cle contraction, + e!/ecially relaxation ' ,aintain! nor,al heart rhyth, ' /ro,ote! "a!odilation o% /eri/heral arteriole! !ource!: green lea%y "egetable!, nut!, legu,e!, !ea%ood, whole grain!, banana!, orange!, cocoa, chocolate Hy oma%nesemia 7au!e 7hronic alcoholi!, (,o!t co,,on# $n%la,,atory bowel di!ea!e, !,all bowel re!ection, <$ cancer, chronic /ancreatiti! (/oor ab!or/tion# Iwitching, tre,or!, hy/eracti"e re%lexe! >G7!, tachycardia N Li0e hy/ocalce,ia, hy/o0ale,ia >otentiate! digitali! toxicity -agne!iu, !ul%ate $G, $- (,a0e !ure renal %unction i! o0# * ,ay cau!e %lu!hing 3ral: -agne!iu, oxide 300,g/day, -g'containing antacid! (;( diarrhea# ?iet: high ,agne!iu, Hy erma%nesemia 7au!e -agne!iu, treat,ent %or /re'ecla,/!ia =enal %ailure (xce!!i"e u!e o% -g antacid!/laxati"e! 8y/ore%lexia 8y/oten!ion, bradycardia, arrhyth,ia 9lu!hing ;o,nolence, wea0ne!!, lethargy, co,a ?ecrea!ed == + re!/iratory /araly!i! Nli0e hy/ercalce,ia -gt ?iuretic! ;to/ -g'containing antacid! + ene,a! $G %luid! rehydration 7alciu, gluconate * (antidote, antagoniAe! cardiac + re!/iratory e%%ect! o% -g#

> * /ri,ary intracellular anion ' /art o% AI> * energy ' )% bound with 7a in teeth/bone!, !0eletal ,u!cle ' reci/rocal balance with 7a ' ab!or/tion a%%ected by Git ?, regulation a%%ected by >I8 (lower! > le"el# 25)'45) ,g/dL 9unction!: ' bone/teeth %or,ation + !trength ' /ho!/holi/id! (,a0e u/ cell ,e,brane integrity# ' /art o% AI> 8>34 * /ho!/hate * anion ' a%%ect! ,etaboli!,, 7a le"el! !ource!: red + organ ,eat! (brain, li"er, 0idney#, /oultry, %i!h, egg!, ,il0, legu,e!, whole grain!, nut!, carbonated drin0! Hy o /os /atemia 7au!e ?ecrea!ed Git ? ab!or/tion, !unlight ex/o!ure 8y/er/arathyroidi!, (increa!ed >I8# Alu,inu, + -g'containing antacid! (bind ># ;e"ere "o,iting + diarrhea Ane,ia, brui!ing (wea0 blood cell ,e,brane# ;eiAure!, co,a -u!cle wea0ne!!, /are!the!ia! 7on!ti/ation, hy/oacti"e bowel !ound! NLi0e hy/ercalce,ia -gt ;odiu, /ho!/hate or /ota!!iu, /ho!/hate $G (gi"e !lowly, no %a!ter than 10 ,(4/hr# ;odiu, + /ota!!iu, /ho!/hate orally (:eutra'>ho!, E'>ho!# * gi"e with ,eal! to /re"ent ga!tric irritation A"oid >'binding antacid! ?iet: high -g, ,il0 -onitor Joint !ti%%ne!!, arthralgia, %racture!, bleeding

;/;

;/;

-gt

;/;

Hy er /os /atemia 7au!e Acido!i! (> ,o"e! out o% cell# 7ytotoxic agent!/che,othera/y in cancer =enal %ailure 8y/ocalce,ia -a!!i"e HI (> lea0! out o% cell! during !torage o% blood# 8y/erthyroidi!, 7alci%ication o% 0idney, cornea, heart -u!cle !/a!,!, tetany, hy/erre%lexia Nli0e hy/ocalce,ia

;/;

,HOS,HORUS
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-gt

Alu,inu, antacid! a! /ho!/hate binder!: Al carbonate (Ha!alJel#, Al hydroxide (A,/hoJel# 7a carbonate %or hy/ocalce,ia A"oid /ho!/hate laxati"e!/ene,a! $ncrea!e %luid inta0e ?iet: low >, no carbonated drin0!

'

controlled by bu%%er!, lung!, 0idney!

$u""er # /re"ent! ,aJor change! in (79 by relea!ing or acce/ting 8 ion! (uffer "echanis"# %ir!t line (ta0e! !econd!# 15 co,bine with "ery !trong acid! or ba!e! to con"ert the, into wea0er acid! or ba!e! 25 Hicarbonate Hu%%er ;y!te, ' ,o!t i,/ortant ' u!e! 8733 + carbonic acid/82733 ' (20:1# ' clo!ely lin0ed with re!/iratory + renal ,echani!,! 35 >ho!/hate Hu%%er ;y!te, ' ,ore i,/ortant in intracellular %luid!, where concentration i! higher ' !i,ilar to bicarbonate bu%%er !y!te,, only u!e! /ho!/hate 45 >rotein Hu%%er ;y!te, ' he,oglobin, a /rotein bu%%er, /ro,ote! ,o"e,ent o% chloride acro!! =H7 ,e,brane in exchange %or 8733 Respiratory "echanis": 2nd line (ta0e! ,inute!# 15 increa!ed re!/iration! liberate! ,ore 732 1 increa!e /8 25 decrea!ed re!/iration! con!er"e ,ore 732 1 decrea!e /8 carbonic acid (82733# 1 732 L water Renal "echanis": 3rd line (ta0e! hour!'day!# 15 0idney! !ecrete 8 ion! + reab!orb bicarbonate ion! 1 increa!e blood /8 25 0idney! %or, a,,onia that co,bine! with 8 ion! to %or, a,,oniu, ion!, which are excreted in the urine in exchange %or !odiu, ion! Revie01 !cid#$ase Im&alance H * &53)'&54) CO2 * ,ea!ure,ent o% the 732 /re!!ure that i! being exerted on the /la!,a ' 3)'4),,8g ,aO2' a,ount o% /re!!ure exerted by 32 on the /la!,a ' 0'100,,8g SaO2' /ercent o% he,oglobin !aturated with 32 $ase e(cess * a,ount o% 8733 a"ailable in the (79 ' '3 to L3 )teps in interpreting A(* result# 15 inter/ret the /8 25 identi%y i% /ri,ary cau!e i! re!/iratory or ,etabolic 35 deter,ine /re!ence o% co,/en!ation, + i% !o, %ully or /artially

CHLORIDE 7l * extracellular anion, /art o% !alt ' bind! with :a, 8 (al!o E, 7a, etc# ' exchange! with 8733 in the 0idney! (+ in =H7!# 9unction!: ' hel/! regulate H>, !eru, o!,olarity ' /art o% 87l ' acid/ba!e balance (exchange! with 8733# 2)'10 ,(4/L !ource!: !alt, canned %ood, chee!e, ,il0, egg!, crab, oli"e! Hy oc/loremia 7au!e ?iure!i! -etabolic al0alo!i! 8y/onatre,ia, /rolonged ?)@ $G Addi!onD! ;/; ;low, !hallow re!/iration! (,et5 Al0alo!i!# 8y/oten!ion (:a + water lo!!# -gt E7l, :a7l $G E7l or :a7l oral ?iet: high 7l (+ u!ually :a# Hy erc/loremia 7au!e -etabolic acido!i! F!ually noted in hy/er:a, hy/erE ;/; ?ee/, ra/id re!/iration! (,et5 Acido!i!# hy/erE, hy/er:a ;/; $ncrea!ed 7l !weat le"el! in cy!tic

%ibro!i! -gt

?iuretic! 8y/otonic !olution!, ?)@ to re!tore balance ?iet: low 7l (+ u!ually :a# Ireat acido!i!

!cid#$ase $alance *ec/anisms

!CID#$!SE $!L!+CE ,RO$LE*S

Res iratory acidosis ' decrea!ed /8, increa!ed >732 7au!e =e!/iratory de/re!!ion Airway ob!truction (73>?!, etc# $nade4uate che!t ex/an!ion >neu,onia :euro,u!cular di!ea!e! ;/; 8y/o"entilation 8y/oten!ion @ar,, %lu!hed !0in with "a!odilation ?row!ine!!, co,a -gt Low %low 32 7lear re!/iratory tract o% ,ucu! Li4ue%y !ecretion! $% !e"ere: ,echanical "entilation Antibiotic! %or re!/iratory in%ection!, Hronchodilator!, ,uco,y!t Res iratory al-alosis ' increa!ed /8, decrea!ed >732 7au!e 8y/er"entilation %ro, %ear, anxiety, hy/oxe,ia, /ain (xce!!i"e ,echanical "entilation (arly A=?; ;alicylate intoxication ;/; =a/id, !hallow breathing 7he!t tightne!!, /al/itation! ?iAAine!!, lightheadedne!! 7ircu,oral nu,bne!!, tingling Anxiety, tetany, /anic -gt =ebreathe 732 u!ing /a/er bag, cu//ed hand!, rebreather ,a!0 A!!i!t /atient to breathe !lowly >rotect %ro, inJury Anti'anxiety ,edication! a! needed *eta&olic acidosis ' decrea!ed /8, decrea!ed 8733 7au!e ;tar"ation, ,alnutrition diarrhea Eetoacido!i! Irau,a, !hoc0 ;e"ere in%ection, %e"er ;alicylate intoxication 8y/er0ale,ia ;/; ?ee/, ra/id re!/iration! 7old, cla,,y !0in ?row!ine!!, co,a 8y/oten!ion -gt Ireat underlying /roble, ($G + in!ulin in 0etoacido!i!, etc# -onitor electrolyte!, e!/5 E ;odiu, bicarbonate $G

' increa!ed /8, increa!ed 8733 7au!e (xce!!i"e "o,iting Ioo ,uch antacid! hy/o0ale,ia ;/; 8y/o"entilation $rritability, ner"ou!ne!! Ire,or!, tetany ;eiAure! -gt A!!e!! %or hy/oE, hy/o7a (due to 7A binding to albu,in# Ieach /ro/er u!e o% antacid! E !u//le,ent! i% hy/o0ale,ic AcetaAola,ide (?ia,ox# to increa!e renal 8733 excretion L 820

*eta&olic !l-alosis
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