Pediatric Electrolyte Emergencies: Recognition and Management in the Emergency Department (Pharmacology CME)

Table of Contents

 

About This Issue

Electrolyte emergencies may present with a wide variety of findings. Early recognition and treatment of electrolyte abnormalities decreases both morbidity and mortality. This issue summarizes the causes of derangements in pathophysiology for sodium, potassium, calcium, magnesium, and phosphorus, and provides recommendations for evidence-based assessment and management of pediatric electrolyte emergencies. In this issue, you will learn:

The most common and most life-threatening electrolyte derangements

Common etiologies for electrolyte abnormalities

Key aspects to ask about while taking the history

Physical examination findings that may indicate a particular electrolyte abnormality

Recommended laboratory testes to obtain when differentiating electrolyte derangements

Electrocardiogram changes that are associated with specific electrolyte abnormalities

A weight-based approach to correcting electrolyte emergencies, including important formulas for electrolyte corrections in pediatric patients and recommendations for electrolyte repletion based on severity

1. About This Issue
2. Abstract
3. Case Presentations
4. Introduction
5. Critical Appraisal of the Literature
6. Etiology and Pathophysiology
7. Differential Diagnosis
8. Prehospital Care
9. Emergency Department Evaluation
   1. History
   2. Physical Examination
      1. Sodium Abnormalities
         • Hyponatremia
         • Hypernatremia
      2. Potassium Abnormalities
         • Hypokalemia
         • Hyperkalemia
      3. Calcium Abnormalities
         • Hypocalcemia
         • Hypercalcemia
      4. Magnesium Abnormalities
         • Hypomagnesemia
      5. Phosphorus Abnormalities
         • Hypophosphatemia
10. Diagnostic Studies
    1. Laboratory Studies
    2. Electrolyte-Specific Studies
       1. Sodium Abnormalities
       2. Potassium Abnormalities
       3. Calcium Abnormalities
       4. Magnesium and Phosphorus Abnormalities
11. Treatment
    1. Sodium Abnormalities
       1. Hyponatremia
       2. Hypernatremia
    2. Potassium Abnormalities
       1. Hypokalemia
       2. Hyperkalemia
    3. Calcium Abnormalities
       1. Hypocalcemia
       2. Hypercalcemia
    4. Magnesium Abnormalities
       1. Hypomagnesemia
    5. Phosphorus Abnormalities
       1. Hypophosphatemia
12. Special Populations
    1. Neonates
13. Controversies and Cutting Edge
14. Disposition
15. Summary
16. Time- and Cost-Effective Strategies
17. Risk Management Pitfalls to Avoid for Patients With Electrolyte Emergencies
18. 5 Things That Will Change Your Practice
19. Case Conclusions
20. Tables and Figures
21. References

Abstract

Early recognition and treatment of electrolyte abnormalities protect the patient from derangements in the renal, myocardiac, and central nervous systems. Correction of electrolyte derangements decreases both morbidity and mortality. This issue reviews sodium, potassium, calcium, magnesium, and phosphorus abnormalities and provides a systematic approach to the evaluation and management of the ill child with an electrolyte emergency.

Case Presentations

A 3-day-old girl is brought in by her father, with concern for shaking episodes...

• The infant was born full-term and has been fed formula at home. The father has been mixing the formula himself and is unsure whether his measurements have been exact. The infant began vomiting today and is more lethargic, with intermittent jerking episodes.
• The girl's vital signs are: temperature, 37°C; heart rate, 200 beats/min; blood pressure, 60/30 mm Hg; respiratory rate, 30 breaths/min; and oxygen saturation, 100% on room air. The child has a sunken anterior fontanelle.
• What workup should you initiate at this time?

A 5-year-old girl is brought into the emergency fast track for concern for abnormal urination...

• The girl’s mother says at first, she believed it was bedwetting; however, it has been worsening in frequency. She reports the girl has been drinking excessive amounts of water and now has been having voluminous clear urine for the last 2 days. The girl has been sleepy all day and is now no longer interacting or speaking.
• On examination, the girl has dry mucous membranes, is tachycardic, and has a capillary refill time of 3 seconds.
• What conditions should be on the differential? Are there any immediate interventions that should be pursued?

A high school football player presents fatigued and with diffuse pain…

• The boy has just finished his second practice of the day.
• His heart rhythm appears abnormal on telemetry, and he is sweating profusely.
• What could be causing the observed dysrhythmia in this patient?

A 2-year-old with vomiting and diarrhea is brought in by her parents…

• The girl’s parents report they have had similar symptoms as well, having just arrived from overseas.
• On examination, the child appears listless, with tachycardia and sunken eyes, arousable only to vigorous stimulation. There is nonbloody vomitus on the bed and nonbloody diarrhea in the child’s diaper.
• What immediate concerns need to be addressed for this patient? How might you approach the differential diagnosis?

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Risk Management Pitfalls to Avoid for Patients With Electrolyte Emergencies

1. “I was waiting on exact lab results before I acted on the presentation.” Laboratory results may be delayed, resulting in worsening morbidity. If possible, obtain point-of-care testing to confirm suspicion of electrolyte derangement based on history. Nevertheless, if needed, resuscitate patients with basic airway, breathing, and circulatory techniques until further laboratory results guide exact treatment.

2. “I repleted the calcium, but the level did not respond.” It is important to understand that certain electrolytes are intertwined and require concomitant repletion, such as magnesium and calcium, for levels to respond.

6. “My team tried for a peripheral IV for 10 minutes, and the patient went into torsades de pointes.” IO access is a viable option in pediatric patients, and basic electrolyte replacement may be given via IO line. Delay in obtaining IV access may result in worsening morbidity and mortality.

Tables and Figures

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Key References

Following are the most informative references cited in this paper, as determined by the authors.

1. * Rothrock SG, Green SM, McArthur CL, et al. Detection of electrolyte abnormalities in children presenting to the emergency department: a multicenter, prospective analysis. Detection of Electrolyte Abnormalities in Children Observational National Study (DEACONS) investigators. Acad Emerg Med. 1997;4(11):1025-1031. (Prospective; 300 patients) DOI: 10.1111/j.1553-2712.1997.tb03674.x

4. * Friedman A. Fluid and electrolyte therapy: a primer. Pediatr Nephrol. 2010;25(5):843-846. (Review article) DOI: 10.1007/s00467-009-1189-7

8. Kight B. Pediatric fluid management. StatPearls, 2022. Accessed January 1, 2023. (Review article)

13. * Lynch RE, Wood EG. Fluid and electrolyte issues in pediatric critical illness. In: Fuhrman BP, Zimmerman JJ, eds. Pediatric Critical Care. 4th ed. Mosby-Elsevier Saunders; 2011:944-962. (Textbook chapter)

28. * Hoffman RJ, Wang VJ, Scarfone RJ, et al. Fleisher & Ludwig’s 5-Minute Pediatric Emergency Medicine Consult. Lippincott Williams & Wilkins; 2019. (Textbook)

39. Lexi-Comp. Lexi-Drugs: sodium bicarbonate. 2020. Accessed, January 1, 2023. (Review article)

44. ClinicalTrials.gov. An open-label study to assess safety and efficacy of SZC in paediatric patients with hyperkalaemia (PEDZ-K). Accessed on January 1, 2023. (Clinical trial)

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Keywords: electrolyte, electrolyte emergency, electrolyte abnormality, electrolyte derangement, sodium abnormality, hyponatremia, hypernatremia, potassium abnormality, hypokalemia, hyperkalemia, calcium abnormality, hypocalcemia, hypercalcemia, magnesium abnormality, hypomagnesemia, phosphorus abnormality, hypophosphatemia, laboratory testing, point-of-care electrolyte analysis, electrocardiogram, electrolyte correction, electrolyte repletion