⚡ ELECTROLYTE EMERGENCIES

COMPREHENSIVE DUAL-LEVEL CARE PROTOCOL

PRIMARY CARE → SECONDARY CARE

📋 For Doctors Only | Not for Public Use

Covers: Hyperkalemia | Hypokalemia | Hyponatremia | Hypernatremia | Hypocalcemia | Hypercalcemia

🔰 SYMBOL LEGEND

Symbol	Meaning
✅	Common / Characteristic / Present
❌	Absent / Not seen / Rare
⚠️	Variable / Sometimes present / Caution

🏥 LEVEL OF CARE OVERVIEW

Procedure/Action	Primary Care	Secondary/Tertiary Care
Clinical recognition	✅	✅
ECG interpretation	✅	✅
IV Calcium gluconate (hyperkalemia)	✅	✅
IV Dextrose-Insulin (hyperkalemia)	✅	✅
IV Potassium replacement	⚠️ (peripheral, slow)	✅ (central line, faster)
IV Calcium replacement	⚠️ (peripheral)	✅
Hypertonic saline (3% NaCl)	⚠️ (if available)	✅
Hemodialysis	❌	✅
Central venous access	❌	✅
ICU monitoring	❌	✅

⏱️ CRITICAL TIME TARGETS

Electrolyte Emergency	Critical Action	Target Time
Severe Hyperkalemia (K⁺ > 6.5 + ECG changes)	IV Calcium gluconate	Immediate (within 2-3 min)
Symptomatic Hyponatremia (seizures)	Hypertonic saline	Immediate
Symptomatic Hypocalcemia (tetany/seizures)	IV Calcium gluconate	Immediate
Severe Hypokalemia with arrhythmia	IV Potassium	Immediate
Severe Hypercalcemia	IV fluids + Bisphosphonate	Within 1-2 hours

📖 NORMAL ELECTROLYTE VALUES

Electrolyte	Normal Range	Critical Low	Critical High
Sodium (Na⁺)	135-145 mEq/L	< 120 mEq/L	> 160 mEq/L
Potassium (K⁺)	3.5-5.0 mEq/L	< 2.5 mEq/L	> 6.5 mEq/L
Calcium (Total)	8.5-10.5 mg/dL	< 7.0 mg/dL	> 14 mg/dL
Calcium (Ionized)	4.5-5.5 mg/dL (1.1-1.4 mmol/L)	< 3.2 mg/dL	> 6.0 mg/dL
Magnesium (Mg²⁺)	1.5-2.5 mg/dL	< 1.0 mg/dL	> 4.0 mg/dL
Phosphate (PO₄³⁻)	2.5-4.5 mg/dL	< 1.0 mg/dL	> 7.0 mg/dL

🔴 SECTION 1: HYPERKALEMIA

⚠️ Most immediately life-threatening electrolyte emergency – can cause fatal arrhythmias within minutes

1️⃣ DEFINITION & CLASSIFICATION

Severity	Potassium Level	Risk
Mild	5.0-5.9 mEq/L	Low
Moderate	6.0-6.4 mEq/L	Moderate
Severe	≥ 6.5 mEq/L	High
With ECG changes	Any level with ECG changes	Critical

📌 ECG changes are more important than absolute K⁺ level

2️⃣ CAUSES OF HYPERKALEMIA

Common Causes (Mnemonic: "MACHINE")

Letter	Cause	Examples
M	Medications	ACE-I, ARBs, K⁺-sparing diuretics, NSAIDs, TMP-SMX, Heparin, Digoxin toxicity
A	Acidosis	Metabolic acidosis (K⁺ shifts out of cells)
C	Cellular destruction	Rhabdomyolysis, Tumor lysis, Hemolysis, Burns, Trauma
H	Hypoaldosteronism	Addison's disease, Type 4 RTA
I	Intake (excessive)	IV K⁺ supplementation, Oral supplements, Salt substitutes
N	Nephrons (kidney failure)	Acute or Chronic Kidney Disease
E	Excretion (reduced)	Renal failure, Obstruction

India-Specific Common Causes

Cause	Notes
CKD (very common)	High burden in India; often undiagnosed
ACE-I / ARB use	Common in HTN/DM patients
Traditional medicines	May contain K⁺
Rhabdomyolysis	Heat stroke, snake bite, infections
Dietary	Coconut water, banana excess in renal patients
Potassium supplements	Over-the-counter availability

Pseudohyperkalemia (False Elevation)

Cause	Mechanism
Hemolyzed sample	Most common; repeat sample
Prolonged tourniquet	Causes local hemolysis
Fist clenching	Releases K⁺ from muscle
Thrombocytosis / Leukocytosis	K⁺ released during clotting
Delayed processing	K⁺ leaks from RBCs

📌 If K⁺ is unexpectedly high without clinical/ECG correlate, repeat the sample before treating

3️⃣ CLINICAL FEATURES

System	Symptoms/Signs
Cardiovascular	Arrhythmias, bradycardia, hypotension, cardiac arrest
Neuromuscular	Weakness, paresthesias, ascending paralysis (mimics GBS)
GI	Nausea, vomiting, diarrhea
Often	Asymptomatic until severe/cardiac events

⚠️ Cardiac manifestations can occur without warning

4️⃣ ECG CHANGES IN HYPERKALEMIA (Progressive)

K⁺ Level (mEq/L)	ECG Changes
5.5-6.5	Tall, peaked T waves ("tenting")
6.5-7.0	Prolonged PR interval
	Flattened or absent P waves
7.0-8.0	Widened QRS complex
	"Sine wave" pattern
> 8.0	Ventricular fibrillation, Asystole

ECG Progression Visual

Normal → Peaked T → ↑PR → Flat P → Wide QRS → Sine Wave → VF/Asystole

K⁺ 5.5 6.0 6.5 7.0 7.5 8.0+

📌 Get ECG in ALL patients with K⁺ > 5.5 – ECG changes guide urgency

5️⃣ HYPERKALEMIA – PRIMARY CARE MANAGEMENT

Immediate Assessment

Action	Details
Confirm true hyperkalemia	Repeat sample if unexpected; check for hemolysis
ECG	Look for changes (peaked T, wide QRS, flat P)
Vitals	HR, BP, rhythm
Symptoms	Weakness, palpitations
Cause	Medications, renal function, diet

Treatment Algorithm by Severity

Scenario	Immediate Action
K⁺ > 6.5 OR any ECG changes	Calcium gluconate FIRST → then shift K⁺ → then remove K⁺
K⁺ 6.0-6.4, no ECG changes	Shift K⁺ (Insulin-Dextrose, Salbutamol) → Remove K⁺
K⁺ 5.5-5.9, asymptomatic	Remove K⁺ (diuretics, dietary restriction); monitor

Step-by-Step Treatment Protocol

Step	Treatment	Purpose	Onset	Duration
1	Calcium Gluconate	Stabilize cardiac membrane	1-3 min	30-60 min
2	Insulin + Dextrose	Shift K⁺ into cells	15-30 min	4-6 hrs
3	Salbutamol (nebulized)	Shift K⁺ into cells	15-30 min	2-4 hrs
4	Sodium Bicarbonate	Shift K⁺ (if acidotic)	30-60 min	2-4 hrs
5	Diuretics / Kayexalate	Remove K⁺ from body	Hours	Hours
6	Dialysis	Remove K⁺ (definitive)	Immediate effect	As long as needed

Detailed Drug Dosing

Step 1: Calcium Gluconate (Cardioprotection)

Parameter	Details
Indication	K⁺ ≥ 6.5 OR any ECG changes
Dose	10 mL of 10% Calcium Gluconate (1 g = 10 mL)
Route	IV slow push over 2-3 min
Onset	1-3 minutes
Duration	30-60 minutes
Repeat	May repeat in 5-10 min if ECG changes persist
Monitoring	ECG during administration

⚠️ If on Digoxin: Give more slowly (over 20-30 min) in D5W – rapid calcium can precipitate digoxin toxicity

Calcium Gluconate vs Calcium Chloride

Preparation	Elemental Calcium	Notes
Calcium Gluconate 10% (preferred)	90 mg per 10 mL	Safer for peripheral IV; less tissue necrosis
Calcium Chloride 10%	270 mg per 10 mL	3× more calcium; use via central line only

Step 2: Insulin + Dextrose (Shift K⁺ into cells)

Parameter	Details
Dose	Regular Insulin 10 units IV + 25 g Dextrose (50 mL of 50% Dextrose)
Route	IV
Onset	15-30 minutes
Duration	4-6 hours
K⁺ reduction	0.5-1.0 mEq/L
Monitoring	Check blood glucose at 30 min, 60 min, 2 hrs (risk of hypoglycemia)

Preparation	How to Give
Regular Insulin 10 units	IV bolus
50% Dextrose 50 mL	IV bolus (can give via peripheral line slowly)
OR 25% Dextrose 100 mL	Safer for peripheral vein

📌 Always give Dextrose WITH Insulin to prevent hypoglycemia

If Blood Glucose Already High (> 250 mg/dL)

Scenario	Dextrose Dose
Glucose > 250 mg/dL	Give Insulin alone (no dextrose)
Glucose 200-250 mg/dL	Give half dextrose (25 mL of 50%)
Glucose < 200 mg/dL	Full dextrose dose

Step 3: Nebulized Salbutamol (Shift K⁺ into cells)

Parameter	Details
Dose	10-20 mg nebulized (4-8 respules of 2.5 mg)
Route	Nebulization
Onset	15-30 minutes
Duration	2-4 hours
K⁺ reduction	0.5-1.0 mEq/L
Caution	Tachycardia; use cautiously in cardiac patients

📌 Synergistic with Insulin-Dextrose – use both for greater effect

Step 4: Sodium Bicarbonate (If Acidotic)

Parameter	Details
Indication	Metabolic acidosis (pH < 7.2, HCO₃ < 15)
Dose	50-100 mEq (50-100 mL of 8.4% NaHCO₃)
Route	IV over 30-60 min
Onset	30-60 minutes
K⁺ reduction	Variable (0.5 mEq/L)
Not effective	In non-acidotic patients

⚠️ Sodium Bicarbonate is NOT first-line; only if acidosis present

Step 5: Remove K⁺ from Body

Diuretics (If Renal Function Adequate)

Drug	Dose	Notes
Furosemide	40-80 mg IV	Promotes K⁺ excretion; only if UOP present

Potassium Binders (Remove K⁺ via GI Tract)

Drug	Dose	Onset	Notes
Sodium Polystyrene Sulfonate (Kayexalate)	15-30 g PO/PR	4-6 hrs	Slow; avoid in ileus
Patiromer	8.4 g PO	7 hrs	Newer; better tolerated
Sodium Zirconium Cyclosilicate	10 g PO	1-2 hrs	Fastest onset

📌 Kayexalate is slow and should NOT be relied upon for acute management; use as adjunct

Dialysis (Definitive Treatment)

Indication for Urgent Dialysis
K⁺ > 6.5 with ECG changes not responding to medical therapy
K⁺ > 7.0 mEq/L
Oliguric/Anuric renal failure
Refractory to medical management
Life-threatening arrhythmias

Hyperkalemia – Primary Care Quick Protocol

If K⁺ ≥ 6.5 OR ECG Changes	Action
Step 1	Calcium Gluconate 10% – 10 mL IV over 2-3 min
Step 2	Insulin 10 U IV + 50% Dextrose 50 mL IV
Step 3	Salbutamol 10-20 mg nebulized
Step 4	IV fluids if not contraindicated
Step 5	TRANSFER for dialysis if K⁺ > 6.5 or not responding

Transfer Indications

Indication
K⁺ > 6.5 mEq/L
ECG changes not resolving
Oliguric/Anuric renal failure
Refractory to initial treatment
Need for dialysis
Concurrent acidosis not correcting

6️⃣ HYPERKALEMIA – SECONDARY CARE MANAGEMENT

Continued Management

Treatment	Details
Continue Insulin-Dextrose	Monitor glucose q1h
Repeat Salbutamol	If still elevated
Dialysis	Definitive treatment; removes 25-50 mEq/hr
Treat underlying cause	CKD, medications, acidosis

Monitoring

Parameter	Frequency
K⁺	Every 1-2 hrs until stable
ECG	Continuous until K⁺ < 6
Blood glucose	Every 30-60 min (post insulin)
Renal function	Daily

Dialysis Modalities

Modality	K⁺ Removal Rate	Notes
Hemodialysis	25-50 mEq/hr	Most rapid; preferred
CRRT	Slower	For hemodynamically unstable patients
Peritoneal Dialysis	Slowest	If HD unavailable

🟡 SECTION 2: HYPOKALEMIA

7️⃣ DEFINITION & CLASSIFICATION

Severity	Potassium Level	Risk
Mild	3.0-3.4 mEq/L	Low
Moderate	2.5-2.9 mEq/L	Moderate
Severe	< 2.5 mEq/L	High

8️⃣ CAUSES OF HYPOKALEMIA

Common Causes

Category	Examples
GI Losses	Vomiting, diarrhea, NG suction, laxative abuse
Renal Losses	Diuretics (thiazides, loop), hyperaldosteronism, RTA
Transcellular Shift	Insulin, β2-agonists, alkalosis, refeeding
Decreased Intake	Malnutrition, alcoholism, anorexia
Medications	Diuretics, amphotericin B, aminoglycosides

India-Specific Common Causes

Cause	Notes
Diarrheal illness	Very common; GI losses
Chronic diuretic use	Common in HTN/HF patients
Malnutrition	Especially in vulnerable populations
Hypokalemic Periodic Paralysis	Seen in thyrotoxicosis (Graves')
RTA	Distal RTA
Primary Aldosteronism	Underdiagnosed

9️⃣ CLINICAL FEATURES

System	Features
Neuromuscular	Weakness (proximal > distal), fatigue, cramps, paralysis, rhabdomyolysis
Cardiovascular	Arrhythmias (PACs, PVCs, AF, VT, VF), hypotension
GI	Constipation, ileus
Renal	Polyuria, metabolic alkalosis
Respiratory	Respiratory muscle weakness

🔟 ECG CHANGES IN HYPOKALEMIA

K⁺ Level	ECG Changes
3.0-3.5	Flattened T waves
2.5-3.0	ST depression, T wave inversion
	U waves (most characteristic)
< 2.5	Prolonged QT interval
	Increased risk of Torsades de Pointes
	AF, VT, VF

U Wave

Prominent U wave (> T wave amplitude) is characteristic of hypokalemia

1️⃣1️⃣ HYPOKALEMIA – PRIMARY CARE MANAGEMENT

Severity-Based Approach

Severity	Route	Treatment
Mild (3.0-3.4)	Oral	Oral K⁺ supplementation + dietary
Moderate (2.5-2.9)	Oral or IV	Oral preferred; IV if symptomatic
Severe (< 2.5) or symptomatic	IV	IV KCl infusion + monitoring
Life-threatening (arrhythmias)	IV	Urgent IV KCl + cardiac monitoring

Oral Potassium Replacement

Preparation	Dose	Notes
Potassium Chloride (KCl) liquid	20-40 mEq PO TID	Take with food (GI irritation)
KCl slow-release tablets	8-20 mEq PO BD-TID
Potassium citrate	20-40 mEq PO TID	Use if concurrent metabolic acidosis

Dietary Sources of Potassium

Food	K⁺ Content (approximate)
Banana (1 medium)	10 mEq
Orange juice (1 cup)	10 mEq
Coconut water (1 cup)	15 mEq
Potato (1 medium)	15 mEq
Spinach (½ cup cooked)	10 mEq
Tomato (1 medium)	8 mEq

IV Potassium Replacement

General Principles

Principle	Details
Concentration	Max 40 mEq/L via peripheral IV
	Max 60 mEq/L via central line
Rate	Max 10-20 mEq/hr via peripheral IV
	Max 40 mEq/hr via central line (with monitoring)
Monitoring	Continuous ECG if giving > 10 mEq/hr
Recheck K⁺	Every 2-4 hrs during replacement

IV KCl Preparation

Preparation	How to Use
KCl 20 mEq in 1 L NS	Run at 100-200 mL/hr (20-40 mEq over 10-20 hrs)
KCl 40 mEq in 1 L NS	Max for peripheral; run at 100 mL/hr
KCl 10 mEq in 100 mL NS	For faster replacement; run over 1 hr (via central preferred)

Replacement Guide (Estimated)

K⁺ Level	Approximate Deficit	Replacement Needed
3.0-3.5	100-200 mEq	40-80 mEq
2.5-3.0	200-400 mEq	80-120 mEq
2.0-2.5	400-600 mEq	120-200 mEq
< 2.0	> 600 mEq	> 200 mEq

📌 For every 0.3 mEq/L drop in serum K⁺ below 3.5, total body K⁺ deficit is ~100 mEq

Correct Concurrent Magnesium Deficiency

Key Point
Hypomagnesemia causes refractory hypokalemia
Check Mg²⁺ in all hypokalemic patients
Correct Mg²⁺ before/with K⁺ replacement

Drug	Dose	Route
Magnesium Sulfate	2-4 g	IV over 1-2 hrs
Magnesium Oxide	400-800 mg	PO daily

Hypokalemia – Primary Care Quick Protocol

Scenario	Action
Mild (K⁺ 3.0-3.4)	Oral KCl 40-60 mEq/day + dietary; recheck in 2-3 days
Moderate (K⁺ 2.5-2.9)	Oral KCl 60-80 mEq/day; consider IV if symptomatic
Severe (K⁺ < 2.5)	IV KCl 20-40 mEq in 1L NS over 2-4 hrs; TRANSFER
With arrhythmias	IV KCl urgently + TRANSFER immediately

Transfer Indications

Indication
K⁺ < 2.5 mEq/L
Symptomatic (weakness, paralysis, arrhythmias)
ECG changes
Need for rapid IV replacement (> 10 mEq/hr)
Concurrent hypomagnesemia not correcting
Refractory to oral replacement

1️⃣2️⃣ HYPOKALEMIA – SECONDARY CARE MANAGEMENT

Severe Hypokalemia Protocol

Step	Action
1	Central line access (if rapid replacement needed)
2	KCl 20-40 mEq IV over 1-2 hrs (with cardiac monitoring)
3	Recheck K⁺ after every 40-60 mEq given
4	Correct hypomagnesemia concurrently
5	Identify and treat underlying cause

Monitoring

Parameter	Frequency
K⁺	Every 2-4 hrs during active replacement
Mg²⁺	Every 6-12 hrs
ECG	Continuous if severe or arrhythmias
Urine output	Hourly

🔵 SECTION 3: HYPONATREMIA

1️⃣3️⃣ DEFINITION & CLASSIFICATION

By Severity

Severity	Sodium Level
Mild	130-134 mEq/L
Moderate	125-129 mEq/L
Severe	< 125 mEq/L
Critical	< 120 mEq/L

By Onset

Type	Onset	Risk
Acute	< 48 hrs	High risk of cerebral edema; can correct faster
Chronic	> 48 hrs	Risk of osmotic demyelination if corrected too fast
Unknown	Unknown	Assume chronic; correct slowly

By Volume Status

Type	Volume Status	Causes
Hypovolemic	↓ TBW, ↓↓ Na⁺	Diarrhea, vomiting, diuretics, burns
Euvolemic	Normal TBW	SIADH, hypothyroid, adrenal insufficiency
Hypervolemic	↑↑ TBW, ↑ Na⁺	Heart failure, cirrhosis, nephrotic syndrome

1️⃣4️⃣ CAUSES OF HYPONATREMIA

By Volume Status

Hypovolemic	Euvolemic	Hypervolemic
Vomiting	SIADH	Heart failure
Diarrhea	Hypothyroidism	Cirrhosis
Diuretics	Adrenal insufficiency	Nephrotic syndrome
Burns	Polydipsia	Renal failure
Third-spacing	Medications

SIADH Causes (Common)

Category	Examples
CNS	Stroke, trauma, meningitis, SAH
Pulmonary	Pneumonia, TB, lung cancer
Malignancy	Small cell lung cancer, pancreatic cancer
Drugs	SSRIs, Carbamazepine, Oxcarbazepine, Vincristine, Cyclophosphamide, NSAIDs
Post-operative	Pain, nausea, hypovolemia

India-Specific Common Causes

Cause	Notes
Diarrheal illness	Common; hypovolemic hyponatremia
TB meningitis	SIADH
Pulmonary TB	SIADH
Medications	SSRIs, Carbamazepine
Excessive water intake with exercise	Exercise-associated hyponatremia
Cerebral malaria / Encephalitis	SIADH

1️⃣5️⃣ CLINICAL FEATURES

Na⁺ Level (mEq/L)	Symptoms
130-135	Usually asymptomatic
125-130	Nausea, malaise, headache
120-125	Vomiting, confusion, drowsiness
115-120	Seizures, obtundation
< 115	Coma, respiratory arrest, death

Severity of Symptoms

Category	Features
Mild	Nausea, headache, fatigue
Moderate	Confusion, vomiting, drowsiness
Severe	Seizures, coma, respiratory arrest

📌 Rate of fall is more important than absolute level – acute drops cause more symptoms

1️⃣6️⃣ HYPONATREMIA – PRIMARY CARE MANAGEMENT

Assessment

Step	Action
1	Confirm true hyponatremia (rule out pseudohyponatremia)
2	Assess volume status (hypo, eu, hypervolemic)
3	Assess symptom severity
4	Estimate acuity (acute vs chronic)

Pseudohyponatremia

Table 3021
Cause	Mechanism	Action
Hyperglycemia	Dilutional	Correct for glucose
Hyperlipidemia	Lab artifact	Use direct ion-selective electrode
Hyperproteinemia	Lab artifact	Use direct ion-selective electrode

Corrected Sodium (for Hyperglycemia)

Corrected Na⁺ = Measured Na⁺ + [1.6 × (Glucose - 100) / 100]

Measured Na⁺	Glucose	Corrected Na⁺
130	500	130 + (1.6 × 4) = 136.4
125	800	125 + (1.6 × 7) = 136.2

Treatment Based on Symptoms & Acuity

Scenario	Treatment	Rate of Correction
Severe symptoms (seizures, coma)	Hypertonic saline (3% NaCl)	1-2 mEq/L/hr for 2-3 hrs
Moderate symptoms	3% NaCl or NS (based on volume)	Max 10-12 mEq/L in 24 hrs
Mild/Asymptomatic	Treat underlying cause	Max 8 mEq/L in 24 hrs
Chronic (> 48 hrs)	Slow correction	Max 8 mEq/L in 24 hrs

Hypertonic Saline (3% NaCl) Protocol

When to Use

Indication
Severe symptomatic hyponatremia (seizures, coma, severe confusion)
Na⁺ < 120 mEq/L with neurological symptoms

Preparation

Preparation	How to Make
3% NaCl (if available)	Use directly
If not available:	Add 60 mL of 23.4% NaCl to 440 mL NS = 3% NaCl
Or:	Add 30 mL of 23.4% NaCl to 500 mL NS ≈ 2.4% NaCl

Dosing

Parameter	Details
Bolus for seizures	100 mL of 3% NaCl IV over 10 min
	May repeat ×2 if symptoms persist
Infusion	0.5-2 mL/kg/hr
Target rise	1-2 mEq/L/hr for first 2-3 hrs
Max correction	10-12 mEq/L in first 24 hrs
	8 mEq/L in 24 hrs if chronic

Example Calculation

Weight	3% NaCl at 1 mL/kg/hr	Expected Na⁺ rise
70 kg	70 mL/hr	~1 mEq/L per hour

📌 Recheck Na⁺ every 2-4 hrs during correction

Treatment Based on Volume Status

Volume Status	Assessment	Treatment
Hypovolemic	Dry mucosa, ↓ skin turgor, ↓ JVP, tachycardia	Normal Saline (0.9% NaCl)
Euvolemic	No signs of volume excess or deficit	Fluid restriction (1-1.5 L/day); treat cause
Hypervolemic	Edema, ↑ JVP, ascites	Fluid restriction + Diuretics; treat underlying

Hypovolemic Hyponatremia – NS Treatment

Calculation	Details
Start with	NS at 100-150 mL/hr
Monitor	Na⁺ every 4-6 hrs
Expect	Na⁺ will rise as volume is repleted

Primary Care Summary – Hyponatremia

Scenario	Action
Severe symptoms (seizures/coma)	3% NaCl 100 mL bolus × 2-3; TRANSFER immediately
Moderate symptoms	If hypovolemic: NS; If euvolemic: fluid restrict; TRANSFER
Mild/Asymptomatic	Treat underlying cause; monitor; transfer if worsening

Transfer Indications

Indication
Na⁺ < 125 mEq/L
Any neurological symptoms
Need for 3% NaCl
Unknown etiology
Not responding to initial treatment
Need for close monitoring

1️⃣7️⃣ HYPONATREMIA – SECONDARY CARE MANAGEMENT

Monitoring Protocol

Parameter	Frequency
Na⁺	Every 2-4 hrs during active correction
Urine Na⁺, Urine Osmolality	At presentation; guide diagnosis
Volume status	Continuous
Neurological status	Continuous

Osmotic Demyelination Syndrome (ODS) Prevention

Risk Factor for ODS
Chronic hyponatremia (> 48 hrs)
Na⁺ < 105 mEq/L
Hypokalemia
Malnutrition
Alcoholism
Liver disease

Prevention Strategy
Correct Na⁺ by max 8 mEq/L in 24 hrs in chronic hyponatremia
Max 10-12 mEq/L in 24 hrs in acute
If overcorrected: Give D5W or Desmopressin to lower Na⁺ back

If Overcorrection Occurs

Action
Stop hypertonic saline
Give D5W to lower Na⁺ back
Desmopressin (DDAVP) 2-4 mcg IV to prevent further rise
Target: Lower Na⁺ back to safe correction limit

Specific Treatment by Cause

Cause	Treatment
SIADH	Fluid restriction; Tolvaptan (15-30 mg PO if available); Salt tablets
Adrenal insufficiency	Hydrocortisone 100 mg IV q8h
Hypothyroidism	Levothyroxine
Heart failure	Fluid restriction; Diuretics; GDMT
Cirrhosis	Fluid restriction; Avoid NSAIDs
Diuretic-induced	Stop diuretic; Volume replacement

🟣 SECTION 4: HYPERNATREMIA

1️⃣8️⃣ DEFINITION & CLASSIFICATION

Severity	Sodium Level
Mild	146-150 mEq/L
Moderate	151-159 mEq/L
Severe	≥ 160 mEq/L

📌 Hypernatremia almost always indicates water deficit (not salt excess)

1️⃣9️⃣ CAUSES OF HYPERNATREMIA

Category	Causes
Decreased water intake	Altered mental status, no access to water, elderly, infants
Increased water loss	Diabetes insipidus, osmotic diuresis (DKA, HHS), diarrhea, sweating, burns
Increased Na⁺ intake	Hypertonic saline, NaHCO₃, Salt poisoning (rare)

India-Specific Common Causes

Cause	Notes
Elderly with limited access to water	Common
Heat stroke	Summer months
Diarrheal illness	Especially in children
DKA/HHS	Osmotic diuresis
Altered mental status	Unable to drink

2️⃣0️⃣ CLINICAL FEATURES

System	Features
Neurological	Lethargy, irritability, confusion, seizures, coma
Other	Thirst (if conscious), dry mucous membranes, oliguria

Severity of Symptoms

Na⁺ Level	Features
146-155	Thirst, lethargy
156-165	Confusion, muscle twitching
> 165	Seizures, coma, intracranial hemorrhage

2️⃣1️⃣ HYPERNATREMIA – MANAGEMENT

Water Deficit Calculation

Water Deficit (L) = TBW × [(Measured Na⁺ / 140) - 1]

TBW = Weight (kg) × 0.6 (men) or × 0.5 (women/elderly)

Example (70 kg male, Na⁺ = 160)
TBW = 70 × 0.6 = 42 L
Deficit = 42 × [(160/140) - 1] = 42 × 0.14 = 6 L

Rate of Correction

Type	Correction Rate	Max in 24 hrs
Acute (< 24 hrs)	1 mEq/L/hr	Can be faster
Chronic (> 48 hrs)	0.5 mEq/L/hr	Max 10-12 mEq/L
Unknown	Assume chronic	Max 10 mEq/L

⚠️ Rapid correction of chronic hypernatremia can cause cerebral edema

Fluid Selection

Fluid	When to Use
D5W	Pure water deficit (DI, inadequate intake)
0.45% NaCl	Volume depletion + water deficit
0.9% NaCl	Severe hypovolemia/shock (initially); then switch

Treatment Protocol

Step	Action
1	If hypovolemic/shock: NS bolus first to restore circulation
2	Calculate water deficit
3	Replace deficit over 48-72 hrs
4	Give 50% of deficit in first 24 hrs
5	Use D5W or 0.45% NaCl
6	Add ongoing losses (urine, insensible)
7	Monitor Na⁺ every 4-6 hrs

Infusion Rate Calculation

To lower Na⁺ by 1 mEq/L, need ~3-4 mL/kg of free water

Example (70 kg, Na⁺ 160 → target 150 in 24 hrs)
Need to lower by 10 mEq/L
Free water needed ≈ 70 × 3.5 × 10 = 2450 mL (approximately)
Plus ongoing losses
Give as D5W or 0.45% NaCl over 24 hrs

Monitoring

Parameter	Frequency
Na⁺	Every 4-6 hrs during correction
Volume status	Continuous
Urine output	Hourly
Neurological status	Continuous

Primary Care Summary – Hypernatremia

Scenario	Action
Hypovolemic + Hypernatremia	NS initially until hemodynamically stable → then D5W or 0.45% NaCl
Euvolemic (DI, inadequate intake)	D5W or 0.45% NaCl; correct slowly
Severe (Na⁺ ≥ 160)	TRANSFER for close monitoring

🟤 SECTION 5: HYPOCALCEMIA

2️⃣2️⃣ DEFINITION & CLASSIFICATION

Parameter	Normal	Low
Total Calcium	8.5-10.5 mg/dL	< 8.5 mg/dL
Ionized Calcium	4.5-5.5 mg/dL (1.1-1.4 mmol/L)	< 4.5 mg/dL
Severe (Symptomatic)		Ionized Ca < 3.2 mg/dL

Corrected Calcium (for Albumin)

Corrected Ca = Measured Ca + 0.8 × (4 - Albumin)

Example	Measured Ca 7.5, Albumin 2.5
Corrected	7.5 + 0.8 × (4 - 2.5) = 7.5 + 1.2 = 8.7 mg/dL (normal)

📌 Always correct for albumin; or use ionized calcium

2️⃣3️⃣ CAUSES OF HYPOCALCEMIA

Category	Causes
PTH Deficiency	Post-thyroidectomy/parathyroidectomy, Autoimmune
PTH Resistance	Pseudohypoparathyroidism
Vitamin D Deficiency	Dietary, Malabsorption, Liver/Kidney disease
Hyperphosphatemia	CKD, Rhabdomyolysis, Tumor lysis
Chelation	Citrate (blood transfusion), EDTA
Drugs	Bisphosphonates, Denosumab, Foscarnet, Cinacalcet
Other	Acute pancreatitis, Sepsis, Hungry bone syndrome

India-Specific Common Causes

Cause	Notes
Post-thyroidectomy	Common surgical complication
Vitamin D deficiency	Very prevalent in India
CKD	Secondary hyperparathyroidism with hypocalcemia
Malnutrition	Low calcium intake
Malabsorption	Celiac disease, tropical sprue

2️⃣4️⃣ CLINICAL FEATURES

Symptoms & Signs

System	Features
Neuromuscular	Paresthesias (perioral, fingers, toes), muscle cramps, tetany, seizures
Cardiac	Prolonged QT, arrhythmias, heart failure
Respiratory	Laryngospasm, bronchospasm
Psychiatric	Anxiety, irritability, psychosis
Chronic	Cataracts, dental abnormalities, basal ganglia calcification

Classic Signs

Sign	Description	How to Elicit
Chvostek's sign	Facial muscle twitch	Tap facial nerve anterior to ear
Trousseau's sign	Carpal spasm	Inflate BP cuff above systolic × 3 min

ECG Changes

Finding
Prolonged QT interval
ST segment changes
T wave changes
Risk of Torsades de Pointes

2️⃣5️⃣ HYPOCALCEMIA – MANAGEMENT

Severity Assessment

Severity	Features	Treatment
Mild (Ca 7.5-8.5, asymptomatic)	No symptoms	Oral calcium + Vitamin D
Moderate (Ca 7-7.5 or mild symptoms)	Paresthesias, mild cramps	Oral or IV calcium
Severe (Ca < 7 or symptomatic)	Tetany, seizures, laryngospasm, prolonged QT	IV Calcium Gluconate

IV Calcium Replacement (Severe/Symptomatic)

Acute Treatment

Drug	Dose	Route	Rate
Calcium Gluconate 10%	1-2 g (10-20 mL)	IV	Over 10-20 min
	= 90-180 mg elemental calcium

📌 Calcium Gluconate is preferred over Calcium Chloride for peripheral IV (less tissue necrosis)

Maintenance Infusion (If Ongoing Need)

Preparation	Details
Add 6-8 ampoules (60-80 mL) of 10% Calcium Gluconate to 1 L D5W	= 0.5-0.8 mg/mL elemental calcium
Infuse at	50-100 mL/hr
Target	Ionized Ca > 4.0 mg/dL

Calcium Gluconate Preparation

10% Calcium Gluconate	Contains
10 mL ampoule	1 g = 90 mg elemental calcium
20 mL ampoule	2 g = 180 mg elemental calcium

Concurrent Magnesium Replacement

Key Point
Hypomagnesemia causes refractory hypocalcemia
Check Mg²⁺ in all hypocalcemic patients
Correct Mg²⁺ before/with Ca²⁺ replacement

Drug	Dose
Magnesium Sulfate 50%	2-4 g IV over 30-60 min

Oral Calcium Replacement (Mild/Maintenance)

Preparation	Elemental Ca	Dose
Calcium Carbonate	40%	500-1500 mg elemental Ca/day (in divided doses)
Calcium Citrate	21%	Better absorbed; use if achlorhydria

Vitamin D Replacement

Preparation	Dose	Notes
Cholecalciferol (D3)	1000-4000 IU/day	For chronic deficiency
Calcitriol	0.25-1 mcg/day	For CKD or hypoparathyroidism
Alfacalcidol	0.25-1 mcg/day	Alternative to Calcitriol

Monitoring

Parameter	Frequency
Ionized Ca or total Ca	Every 4-6 hrs during IV replacement
Mg²⁺	Every 6-12 hrs
ECG	Continuous if severe or QT prolonged
Phosphate	Daily

Caution in Hyperphosphatemia

If Phosphate > 6 mg/dL
Correct phosphate first (dietary restriction, phosphate binders)
IV calcium can precipitate with phosphate → soft tissue/vascular calcification
Use lower calcium doses; correct phosphate urgently

Primary Care Summary – Hypocalcemia

Scenario	Action
Severe symptoms (tetany, seizures, laryngospasm)	Calcium Gluconate 10% 10-20 mL IV over 10-20 min; TRANSFER
Mild symptoms	Oral calcium 1-2 g/day + Vitamin D; monitor
Post-thyroidectomy	Check Ca q6-12h; IV calcium if symptomatic; TRANSFER if severe

🟠 SECTION 6: HYPERCALCEMIA

2️⃣6️⃣ DEFINITION & CLASSIFICATION

Severity	Calcium Level	Risk
Mild	10.5-12 mg/dL	Low
Moderate	12-14 mg/dL	Moderate
Severe (Hypercalcemic Crisis)	> 14 mg/dL	High

2️⃣7️⃣ CAUSES OF HYPERCALCEMIA

Common Causes (90%)

Cause	Mechanism
Primary Hyperparathyroidism	Excessive PTH
Malignancy	PTHrP, osteolytic metastases, calcitriol production

Other Causes

Category	Causes
Vitamin D	Excess supplementation, Granulomatous diseases (Sarcoidosis, TB)
Drugs	Thiazides, Lithium, Vitamin A toxicity
Endocrine	Thyrotoxicosis, Adrenal insufficiency
Immobilization	Prolonged bed rest
Other	Milk-alkali syndrome, Familial hypocalciuric hypercalcemia

India-Specific Considerations

Cause	Notes
Malignancy	Common; especially lung, breast, myeloma
Primary hyperparathyroidism	Underdiagnosed
Granulomatous disease	TB (common in India), Sarcoidosis
Vitamin D toxicity	Over-supplementation (increasingly common)

2️⃣8️⃣ CLINICAL FEATURES

Mnemonic: "Bones, Stones, Groans, and Psychiatric Moans"

Category	Features
Bones	Bone pain, fractures, osteoporosis
Stones	Kidney stones, nephrocalcinosis
Groans (GI)	Constipation, nausea, vomiting, pancreatitis
Psychiatric Moans	Confusion, depression, psychosis, coma
Other	Polyuria, polydipsia, weakness, shortened QT, arrhythmias

Severity of Symptoms

Ca Level	Symptoms
10.5-12	Usually asymptomatic
12-14	Polyuria, constipation, fatigue
> 14	Confusion, lethargy, arrhythmias
> 16	Coma, cardiac arrest

ECG Changes

Finding
Shortened QT interval
Wide T wave
Bradycardia, heart block
Osborn (J) waves (severe)

2️⃣9️⃣ HYPERCALCEMIA – MANAGEMENT

Severity-Based Approach

Severity	Treatment
Mild (10.5-12, asymptomatic)	Treat underlying cause; encourage hydration
Moderate (12-14)	IV fluids; consider bisphosphonate
Severe (> 14 or symptomatic)	IV fluids + Bisphosphonate + Calcitonin; TRANSFER

Step-by-Step Treatment Protocol

Step	Treatment	Purpose	Onset
1	IV Normal Saline	Volume expansion; promote calciuresis	Immediate
2	Furosemide	Enhance calcium excretion (only after rehydration)	Hours
3	Calcitonin	Rapid Ca lowering	4-6 hrs
4	Bisphosphonate	Sustained Ca lowering	24-72 hrs
5	Steroids (if indicated)	Specific causes	Days
6	Dialysis (if severe/refractory)	Direct Ca removal	Immediate

Step 1: IV Fluid Resuscitation

Parameter	Details
Fluid	Normal Saline 0.9%
Rate	200-500 mL/hr initially
Volume	3-6 L in first 24 hrs
Goal	Urine output 100-150 mL/hr
Caution	Heart failure, CKD – monitor for overload

📌 Patients are often severely dehydrated – aggressive hydration is first priority

Step 2: Furosemide (After Rehydration)

Parameter	Details
Dose	20-40 mg IV
Timing	Only AFTER adequate volume resuscitation
Purpose	Enhance calciuresis
Frequency	Every 6-12 hrs as needed
Monitor	Electrolytes (K⁺, Mg²⁺), volume status

⚠️ Do NOT give Furosemide before hydration – worsens dehydration

Step 3: Calcitonin (Rapid Onset)

Parameter	Details
Dose	4-8 IU/kg
Route	SC or IM
Frequency	Every 6-12 hours
Onset	4-6 hours
Ca reduction	1-2 mg/dL
Duration	Tachyphylaxis in 48-72 hrs (effect wears off)

📌 Calcitonin works fast but effect is short-lived; use as bridge to bisphosphonate

Step 4: Bisphosphonate (Sustained Effect)

Drug	Dose	Route	Onset	Duration
Zoledronic Acid	4 mg	IV over 15 min	24-72 hrs	2-4 weeks
Pamidronate	60-90 mg	IV over 2-4 hrs	24-72 hrs	2-4 weeks

Renal Adjustment	Zoledronic Acid
CrCl 60-89	4 mg
CrCl 50-59	3.5 mg
CrCl 40-49	3.3 mg
CrCl 30-39	3.0 mg
CrCl < 30	Not recommended

📌 Zoledronic Acid is preferred if available (single dose, faster infusion)

Step 5: Steroids (Specific Indications)

Indication	Drug	Dose
Granulomatous disease (Sarcoidosis, TB)	Hydrocortisone or Prednisolone	40-60 mg/day
Vitamin D toxicity
Hematologic malignancy (Myeloma, Lymphoma)

📌 Steroids reduce intestinal calcium absorption and calcitriol production

Step 6: Dialysis (Severe/Refractory)

Indication
Ca > 18 mg/dL
Refractory to medical therapy
Heart failure preventing fluid resuscitation
Severe renal impairment
Life-threatening symptoms

Modality	Details
Hemodialysis	Low-calcium or calcium-free dialysate

Other Treatments

Treatment	Indication
Denosumab	Malignancy-related; if bisphosphonates contraindicated
Cinacalcet	Primary hyperparathyroidism (if surgery not possible)
Phosphate	Generally avoided (risk of calcification); only if phosphate low

Monitoring

Parameter	Frequency
Calcium	Every 4-6 hrs initially
Creatinine	Daily
Electrolytes (K⁺, Mg²⁺, PO₄)	Daily
Volume status	Continuous
Urine output	Hourly

Primary Care Summary – Hypercalcemia

Scenario	Action
Mild (10.5-12), asymptomatic	Encourage oral hydration; investigate cause; monitor
Moderate (12-14)	IV NS 150-200 mL/hr; TRANSFER
Severe (> 14) or symptomatic	IV NS aggressively; Calcitonin if available; TRANSFER urgently

Transfer Indications

Indication
Ca > 14 mg/dL
Symptomatic (confusion, arrhythmias)
Renal impairment
Need for bisphosphonate/dialysis
Unknown cause requiring workup

📌 QUICK REFERENCE CARDS

🔴 HYPERKALEMIA QUICK REFERENCE

text

╔═══════════════════════════════════════════════════════════════════════╗

║ HYPERKALEMIA EMERGENCY ║

╠═══════════════════════════════════════════════════════════════════════╣

║ ║

║ IF K⁺ ≥ 6.5 OR ECG CHANGES OR >7 with or without ECG changes: ║

║ ║

║ ┌─────────────────────────────────────────────────────────────────┐ ║

║ │ STEP 1: STABILIZE HEART │ ║

║ │ → Calcium Gluconate 10% – 10 mL IV over 2-3 min │ ║

║ │ → Repeat in 5-10 min if ECG changes persist │ ║

║ └─────────────────────────────────────────────────────────────────┘ ║

║ ║

║ ┌─────────────────────────────────────────────────────────────────┐ ║

║ │ STEP 2: SHIFT K⁺ INTO CELLS │ ║

║ │ → Regular Insulin 10 U IV + 50% Dextrose 50 mL IV │ ║

║ │ → Salbutamol 10-20 mg nebulized │ ║

║ │ → NaHCO₃ 50-100 mEq IV (only if acidotic) │ ║

║ └─────────────────────────────────────────────────────────────────┘ ║

║ ║

║ ┌─────────────────────────────────────────────────────────────────┐ ║

║ │ STEP 3: REMOVE K⁺ FROM BODY │ ║

║ │ → Furosemide 40-80 mg IV (if urine output present) │ ║

║ │ → Kayexalate 30 g PO/PR (slow; not for acute) │ ║

║ │ → DIALYSIS (definitive – if K⁺ > 6.5 or not responding) │ ║

║ └─────────────────────────────────────────────────────────────────┘ ║

║ ║

║ 🚑 TRANSFER for dialysis if K⁺ > 6.5 or refractory ║

║ ║

╚═══════════════════════════════════════════════════════════════════════╝

🔵 HYPONATREMIA QUICK REFERENCE

Table 3088
Severity	Action
Seizures/Coma	3% NaCl 100 mL bolus over 10 min (repeat ×2 if needed)
Symptomatic	3% NaCl infusion; target rise 1-2 mEq/L/hr
Hypovolemic	Normal Saline
Euvolemic (SIADH)	Fluid restriction
Hypervolemic (HF, Cirrhosis)	Fluid restriction + Diuretics
Chronic (> 48 hrs)	Max correction 8 mEq/L in 24 hrs

🟢 HYPOCALCEMIA QUICK REFERENCE

Table 3089
Severity	Action
Tetany / Seizures / Laryngospasm	Calcium Gluconate 10% – 10-20 mL IV over 10-20 min
Mild/Asymptomatic	Oral Calcium 1-2 g/day + Vitamin D
Always check	Magnesium (correct if low)
Post-thyroidectomy	Monitor Ca q6-12h; IV calcium PRN

🟡 HYPERCALCEMIA QUICK REFERENCE

Table 3090
Severity	Action
Mild (< 12)	Hydration; treat cause
Moderate (12-14)	NS 200-500 mL/hr; consider bisphosphonate
Severe (> 14)	NS aggressively + Calcitonin + Bisphosphonate + TRANSFER
Refractory	Dialysis

💊 DRUG DOSING QUICK REFERENCE

Table 3091
Drug	Dose	Indication
Calcium Gluconate 10%	10-20 mL IV	Hyperkalemia, Hypocalcemia
Insulin + Dextrose	10 U + 50 mL 50% Dextrose	Hyperkalemia
Salbutamol nebulized	10-20 mg	Hyperkalemia
Furosemide	40-80 mg IV	Hyperkalemia, Hypercalcemia
3% NaCl	100-150 mL bolus	Severe hyponatremia
Zoledronic Acid	4 mg IV	Hypercalcemia
Calcitonin	4-8 IU/kg SC/IM	Hypercalcemia
Magnesium Sulfate 50%	2-4 g IV	Hypomagnesemia

⚠️ CRITICAL WARNINGS

Table 3092
⛔ NEVER	✅ ALWAYS
Delay Calcium Gluconate if K⁺ ≥ 6.5 + ECG changes	Get ECG in hyperkalemia
Give Insulin without Dextrose (unless hyperglycemic)	Monitor glucose after Insulin-Dextrose
Correct chronic hyponatremia > 8 mEq/L in 24 hrs	Correct slowly to prevent ODS
Give Furosemide before hydration in hypercalcemia	Rehydrate first, then diuretics
Forget to check Magnesium in refractory hypokalemia/hypocalcemia	Correct Mg²⁺ concurrently
Give rapid IV Calcium in digoxin toxicity	Slow infusion if on Digoxin

🔢 KEY FORMULAS

Table 3093
Calculation	Formula
Corrected Na⁺ (for hyperglycemia)	Measured Na⁺ + [1.6 × (Glucose - 100) / 100]
Corrected Ca²⁺ (for albumin)	Measured Ca + 0.8 × (4 - Albumin)
Water Deficit (Hypernatremia)	TBW × [(Measured Na⁺ / 140) - 1]
TBW	Weight × 0.6 (men) or 0.5 (women/elderly)
K⁺ Deficit (rough estimate)	For each 0.3 mEq/L drop below 3.5 → ~100 mEq deficit

📚 ABBREVIATIONS

Table 3094
Abbreviation	Full Form
Na⁺	Sodium
K⁺	Potassium
Ca²⁺	Calcium
Mg²⁺	Magnesium
PO₄³⁻	Phosphate
HCO₃⁻	Bicarbonate
TBW	Total Body Water
ECG	Electrocardiogram
QT	QT interval on ECG
SIADH	Syndrome of Inappropriate ADH Secretion
ADH	Antidiuretic Hormone
PTH	Parathyroid Hormone
PTHrP	PTH-related Peptide
RTA	Renal Tubular Acidosis
CKD	Chronic Kidney Disease
AKI	Acute Kidney Injury
DKA	Diabetic Ketoacidosis
HHS	Hyperosmolar Hyperglycemic State
DI	Diabetes Insipidus
ODS	Osmotic Demyelination Syndrome
GBS	Guillain-Barré Syndrome
PAC	Premature Atrial Contraction
PVC	Premature Ventricular Contraction
AF	Atrial Fibrillation
VT	Ventricular Tachycardia
VF	Ventricular Fibrillation
NS	Normal Saline
D5W	5% Dextrose in Water
CRRT	Continuous Renal Replacement Therapy
ACE-I	Angiotensin-Converting Enzyme Inhibitor
ARB	Angiotensin Receptor Blocker
TMP-SMX	Trimethoprim-Sulfamethoxazole
SSRI	Selective Serotonin Reuptake Inhibitor
DDAVP	Desmopressin
SC	Subcutaneous
IM	Intramuscular
IV	Intravenous
PO	Per Oral
PR	Per Rectum
UOP	Urine Output
JVP	Jugular Venous Pressure
TB	Tuberculosis
SAH	Subarachnoid Hemorrhage

📖 REFERENCES

Table 3095
Guideline/Source	Year
AHA/ACC Guidelines on Hyperkalemia Management	2023
European Guidelines on Hyponatremia	2014 (Updated 2023)
Kidney Disease Improving Global Outcomes (KDIGO)	Current
UpToDate Clinical Decision Support	Current
API Textbook of Medicine	Latest Edition
Harrison's Principles of Internal Medicine	Latest Edition
Oxford Handbook of Clinical Medicine	Latest Edition

Document Version: 1.0

India-Specific Notes:

CKD is very prevalent – hyperkalemia is common
ACE-I/ARB use widespread – monitor K⁺
Vitamin D deficiency very common – consider in hypocalcemia
TB can cause hypercalcemia (granulomatous) and hyponatremia (SIADH)
Traditional medicines may contain electrolyte-altering substances

Disclaimer: This protocol provides general guidance. Clinical judgment must be exercised. Local protocols and resources may vary.

Nephrology

Emergency Protocols

Electrolyte emergencies

Drug Classifications