---

⚡ ELECTROLYTE & GLUCOSE EMERGENCIES — Complete Clinical Reference

(Textbook-Based: Harrison's, Rosen's Emergency Medicine, Tintinalli's, Washington Manual)

---

🔴 1. HYPERKALEMIA (K⁺ > 5.5 mEq/L)

Normal Value

• K⁺ = 3.5–5.0 mEq/L → >5.5 = Hyperkalemia

Causes / Etiology (Yaad karne ka trick: "DAVID")

⚡ ECG Changes — Progressive Sequence (MOST IMPORTANT!)

K⁺ Level       ECG Finding
─────────────────────────────────────────────────────
5.5–6.5        Peaked/Tall T waves (tent-shaped, narrow base)
6.5–7.5        PR prolongation, P wave flattening/disappearance
7.0–8.0        QRS widening (>0.12 sec)
>8.0           Sine wave pattern → VF → Asystole

Tip: ECG mein PQRST changes = P flat→ QRS wide→ T tall → Sine wave → Death

🔬 Investigations

• Serum K⁺ (confirm; repeat if suspicious pseudohyperkalemia)
• 12-lead ECG (STAT)
• BMP/RFT: Urea, Creatinine, Glucose, HCO₃
• ABG (acidosis evaluation)
• Urine K⁺, Urine Na⁺, Urine osmolality
• Aldosterone + Renin levels (if adrenal cause suspected)
• CBC (to rule out high WBC/RBC causing pseudohyperkalemia)

Differential Diagnosis

• Pseudohyperkalemia (hemolysis, thrombocytosis, leukocytosis)
• Addison's disease / Adrenal crisis
• Rhabdomyolysis
• Tumor Lysis Syndrome
• Type IV RTA (Hyporeninemic hypoaldosteronism)

🏥 Treatment (3 Steps — Harrison's + Rosen's)

Step 1: MEMBRANE STABILIZATION (Cardiac Protection — FIRST!)

⚠️ Do NOT give if Digoxin toxicity → causes "Stone Heart" (Ca⁺⁺ + Digoxin = fatal arrhythmia)

Step 2: SHIFT K⁺ INTO CELLS (Temporizing)

Step 3: REMOVE K⁺ FROM BODY

ICU Management

• Continuous cardiac monitoring (telemetry)
• IV access, stop all K⁺ supplements/KCl drips
• Stop ACEi/ARB/K-sparing diuretics
• Treat underlying cause (acidosis, AKI)
• Repeat K⁺ every 1–2 hrs during acute treatment

OPD Prescription (Chronic Hyperkalemia)

1. Low potassium diet (avoid banana, orange, potato, coconut water)
2. Tab Furosemide 20–40 mg OD (if HTN/fluid overload)
3. Review/stop ACEi, ARB, Spironolactone if K⁺ >5.5
4. Tab Patiromer 8.4 g OD (if on ACEi for CKD/HF)
5. Regular follow-up: RFT + Serum electrolytes q4–6 weeks

---

🔵 2. HYPOKALEMIA (K⁺ < 3.5 mEq/L)

Causes (Trick: "GODIVA")

⚡ ECG Changes

K⁺ Level    ECG Finding
──────────────────────────────────────────────
<3.5        Flattening of T waves
<3.0        U wave appears (most characteristic!)
<2.5        ST depression, T-U fusion
<2.0        Widened QRS, VT/VF risk

U wave = hallmark of Hypokalemia (seen best in V2–V3) Diff from Long QT: In hypokalemia, QU interval prolonged, not true QTc

🔬 Investigations

• Serum K⁺, Mg²⁺ (hypomagnesemia causes refractory hypokalemia)
• ABG (alkalosis suggests GI/diuretic cause)
• Urine K⁺:Creatinine ratio (>13 = renal loss; <13 = GI loss)
• Aldosterone, Renin, Cortisol (if hypertensive hypokalemia)
• 12-lead ECG

Differential Diagnosis

• Primary hyperaldosteronism (Conn's syndrome) — HTN + hypokalemia
• Cushing's syndrome
• Bartter's syndrome (normotensive + renal K wasting)
• Gitelman's syndrome
• Hypokalemic periodic paralysis (familial or thyrotoxic)
• Refeeding syndrome

🏥 Treatment

Mild (K⁺ 3.0–3.5): Oral Replacement

• Tab K-Cl (Slow-K) 20 mEq BD–TDS
• Dietary: Banana, orange, potato, coconut water

Moderate–Severe (K⁺ <3.0 or symptomatic):

⚠️ Contraindication: Never give K⁺ in D5W (drives K into cells further); always give in NS

Correct Hypomagnesemia FIRST

• If Mg²⁺ <1.5: give Inj. MgSO4 2 g IV over 20 min
• Hypokalemia resistant to K replacement without correcting Mg²⁺

ICU Management

• Cardiac monitoring mandatory if K⁺ <3.0
• KCl infusion via infusion pump (never free flow!)
• K⁺ target ≥4.0 mEq/L in cardiac patients (heart failure, post-MI)
• Monitor K⁺ every 2–4 hrs during replacement

OPD Prescription

1. Tab Potassium Chloride SR (Slow-K) 20 mEq BD × 5–7 days
2. Tab Spironolactone 25 mg OD (if diuretic-induced hypokalemia)
3. If on diuretics: switch to K-sparing (Spironolactone, Amiloride)
4. Dietary advice: bananas, green vegetables, coconut water
5. Follow-up: Serum K⁺ after 1 week

---

🟠 3. ACUTE HYPERCALCEMIA (Ca²⁺ > 10.5 mg/dL / Ionized Ca >1.3 mM)

Causes (Trick: "MISHAP")

Symptoms — "Bones, Stones, Groans, Psychic Moans"

• Bones: Bone pain, fractures
• Stones: Kidney stones, nephrocalcinosis
• Groans: Nausea, vomiting, constipation, abdominal pain, pancreatitis
• Psychic Moans: Depression, confusion, coma

⚡ ECG Changes

Classic finding:   SHORT QT interval
ST changes:        ST elevation (can mimic MI!)
Severe cases:      Sinus bradycardia, Heart block, VF
Osborn wave:       Rarely seen despite normothermia

🔬 Investigations

• Total serum Ca²⁺ (corrected for albumin: add 0.8 mg/dL per 1 g/dL ↓ albumin)
• Ionized Ca²⁺ (gold standard)
• PTH (high → primary hyperparathyroidism; low → malignancy)
• PTHrP (if PTH low + malignancy suspected)
• 25-OH Vitamin D, 1,25-OH Vitamin D
• Urine Ca²⁺ (24hr), Phosphate
• ALP, LFT, Bone X-rays/DEXA
• ECG, ECG monitoring

Differential Diagnosis

🏥 Treatment (Hypercalcemic Crisis)

Acute/ICU Management:

⚠️ Furosemide — routine use no longer recommended; only after adequate fluid resuscitation

Contraindications

• Do NOT give Thiazides (increase Ca reabsorption)
• Bisphosphonates contraindicated in: Severe renal failure (eGFR <30), Pregnancy
• Calcitonin — tachyphylaxis in 48 hrs; don't rely for chronic use

OPD Prescription

1. Adequate hydration (2–3 L oral fluid/day)
2. Tab Alendronate 70 mg weekly (if hyperparathyroidism/mild hypercalcemia)
3. Avoid: Thiazides, Vit D supplements, Calcium supplements, immobilization
4. Refer: Endocrinology for primary hyperparathyroidism
5. Monitor: Serum Ca²⁺, Creatinine, 24-hr urine Ca every 3 months

---

🟡 4. HYPOCALCEMIA (Ca²⁺ < 8.5 mg/dL / Ionized Ca <1.0 mM)

Causes (Trick: "VIPER")

Additional Causes

• Massive blood transfusion (citrate toxicity)
• Alkalosis (respiratory/metabolic) — ↓ ionized Ca²⁺
• Sepsis, critical illness
• Drugs: Bisphosphonates, Phenytoin, Furosemide, Calcitonin
• Tumor lysis syndrome, Rhabdomyolysis

Symptoms

• Neuromuscular: Paresthesia (perioral, fingertips), Tetany, Carpopedal spasm
• Signs: Chvostek sign (facial nerve tap → facial twitch), Trousseau sign (BP cuff → carpopedal spasm)
• Laryngospasm (emergency!), Seizures
• Cardiac: Prolonged QT → TdP

⚡ ECG Changes

Classic finding:   PROLONGED QT interval (ST segment lengthening)
Can mimic:         Acute MI (J-point elevation, absent ST segment)
Severe:            TdP (Torsades de Pointes) → VF

Opposite of Hypercalcemia: Long QT vs. Short QT

🔬 Investigations

• Total Ca²⁺ (corrected) + Ionized Ca²⁺ (gold standard)
• Magnesium, Phosphate
• PTH (low → hypoparathyroidism; high → pseudohypoparathyroidism / VitD def)
• 25-OH Vitamin D, ALP
• ABG (alkalosis → ↓ ionized Ca²⁺)
• ECG, QTc interval

🏥 Treatment

Acute/Symptomatic (Tetany, Seizure, Laryngospasm):

Subacute/Chronic:

• Tab Calcium Carbonate 1–2 g elemental Ca/day in divided doses
• Cap Calcitriol (1,25 VitD) 0.25–0.5 mcg BD (especially hypoparathyroidism)
• Tab Cholecalciferol (VitD3) 60,000 IU weekly × 8 weeks (if VitD deficient)

Correct Hypomagnesemia FIRST (if coexisting):

• Inj MgSO4 2 g IV over 20 min

ICU Management

• Continuous ECG monitoring (watch QTc)
• IV Ca gluconate infusion via peripheral or central line
• Target: total Ca²⁺ >7.5 mg/dL, symptoms resolved
• Avoid hyperventilation (worsens alkalosis → drops ionized Ca²⁺)

Contraindications

• Ca Chloride peripherally — causes severe tissue necrosis
• Rapid IV Ca²⁺ bolus in digoxin patients — fatal arrhythmias

OPD Prescription

1. Tab Calcium Carbonate 500 mg BD (with meals)
2. Cap Calcitriol 0.25 mcg BD (if hypoparathyroidism)
3. Tab Cholecalciferol 60,000 IU weekly × 8 wks, then monthly maintenance
4. Avoid: Furosemide (promotes Ca excretion)
5. Monitor: Ca²⁺, PO4, PTH, VitD levels q3 months

---

🟢 5. HYPOGLYCEMIA (Blood Glucose < 70 mg/dL)

Causes

Symptoms — "Two levels"

• Adrenergic (mild, BG 50–70): Sweating, Tremor, Palpitations, Anxiety, Hunger
• Neuroglycopenic (severe, BG <50): Confusion, Seizure, Coma, Focal deficits

⚠️ Unawareness: In ICU/anesthesia, adrenergic symptoms masked — only neuroglycopenic features seen

Whipple's Triad

1. Symptoms of hypoglycemia
2. Low plasma glucose at time of symptoms
3. Relief of symptoms with glucose correction

🔬 Investigations

• Bedside glucose (STAT), then lab glucose to confirm
• Insulin level (high in insulinoma or factitious)
• C-peptide (high in insulinoma; low in exogenous insulin use)
• Proinsulin
• Sulfonylurea screen (urine)
• Cortisol, GH (hypopituitarism)
• LFT (liver failure)

🏥 Treatment

Conscious Patient:

• 15–20 g fast-acting carbs orally: 4–6 glucose tablets / 150 mL OJ / 3 tsp sugar
• Recheck in 15 min; repeat if still <70 ("15–15 rule")
• Follow with complex carb snack

Unconscious/IV Access:

Refractory / Sulfonylurea-induced:

• Octreotide 50–100 mcg SC q6–12h (blocks insulin secretion)
• Diazoxide 3–8 mg/kg/day oral (for insulinoma, not acute)

ICU Management

• Target glucose 140–180 mg/dL (surgical ICU) / 140–200 mg/dL (medical)
• Bedside glucose q1–2h during insulin infusion
• Protocol: If BG <70 → Stop insulin infusion → Give D50W → Recheck in 15 min
• If BG <40 or patient symptomatic → D50W 50 mL IV STAT

OPD Prescription

1. Educate patient on "15-15 rule"
2. If sulfonylurea-induced: switch to DPP-4i or SGLT2i
3. Reduce insulin dose if recurrent nocturnal hypoglycemia
4. Snack before bedtime (if on evening insulin)
5. Glucagon emergency kit prescription for home

---

🔴 6. HYPERGLYCEMIA / DIABETIC EMERGENCIES

Spectrum

DKA Diagnosis — Triad:

1. Hyperglycemia (>250 mg/dL)
2. Ketonemia/ketonuria
3. Metabolic acidosis (pH <7.3, HCO₃ <18, AG >12)

🔬 Investigations

• Blood glucose, Urine ketones, Blood ketones (beta-hydroxybutyrate)
• ABG (pH, HCO₃, pCO₂)
• BMP: K⁺, Na⁺, Cl⁻, HCO₃, BUN, Creatinine
• Anion Gap = Na − (Cl + HCO₃) → normal 8–12
• CBC (leukocytosis in DKA even without infection)
• LFT, Amylase/Lipase
• ECG (hyperkalemia common in DKA!)
• Blood cultures, CXR, Urine C/S (find precipitating cause)
• HbA1c, Calculated serum osmolality

Precipitating Causes — "The 5 I's"

1. Infection (most common — UTI, pneumonia, sepsis)
2. Insulin omission / non-compliance
3. Infarction (MI, stroke)
4. Iatrogenic (steroids, SGLT2i-induced euDKA)
5. Intoxication (alcohol, cocaine)

🏥 DKA ICU Management (Step-by-step)

Fluids:

• 1 L 0.9% NS in first hour (STAT)
• Then 250–500 mL/hr for next 4–6 hrs (based on hemodynamic status)
• Switch to 0.45% NS if corrected Na⁺ normal/high
• Add D5% when glucose <250 mg/dL

Insulin:

• Regular Insulin IV infusion: 0.1 units/kg/hr (no bolus needed if K⁺ >3.5)
• If K⁺ <3.3: Give K⁺ replacement FIRST, then start insulin
• Target: BG fall of 50–75 mg/dL per hour
• When BG <250: Reduce to 0.02–0.05 units/kg/hr

Potassium:

• K⁺ <3.3 → Give 20–40 mEq/hr IV, hold insulin
• K⁺ 3.3–5.5 → Give 20–30 mEq per liter IV fluid
• K⁺ >5.5 → No K supplement, monitor hourly

Bicarbonate:

• Only if pH <6.9 → 100 mEq NaHCO₃ in 400 mL sterile water over 2 hrs
• Not recommended routinely (worsens cerebral acidosis paradoxically)

Resolution Criteria (DKA):

• Glucose <200 mg/dL
• HCO₃ ≥15 mEq/L
• pH >7.3
• Anion Gap <12

Transition to SC Insulin:

• Give SC rapid-acting insulin 1–2 hrs BEFORE stopping IV insulin infusion (overlap!)

Complications During Treatment

HHS Management (Similar but):

• More aggressive fluid resuscitation needed
• Insulin less urgent than fluids initially
• Avoid rapid osmolality correction (risk of cerebral edema)

OPD Prescription (Type 2 DM, Stable)

1. Metformin 500 mg BD (with meals) — first-line
2. Sitagliptin 100 mg OD / Empagliflozin 10 mg OD
3. If HbA1c >9%: Add Insulin (Glargine 0.2 units/kg at bedtime)
4. Dietary counseling: low glycemic diet, carb counting
5. Home glucose monitoring: FBS + PPBS diary
6. Monitor: HbA1c q3 months, RFT, LFT annually

---

📊 ECG Summary Table — Electrolyte Disturbances

---

⚠️ Important Contraindications Summary

---

🔑 Hindi Mnemonics for Quick Recall

---

• Harrison's Principles of Internal Medicine 22E (2025)
• Rosen's Emergency Medicine, 9E
• Tintinalli's Emergency Medicine
• Washington Manual of Medical Therapeutics
• Morgan & Mikhail's Clinical Anesthesiology 7EYeh complete hai! Upar diya gaya reference cover karta hai:

• ECG changes har condition ka sequentially yaad karo
• Contraindications table important hai (Digoxin + Ca, K bolus, Bisphosphonate in renal failure)
• DKA mein insulin se pehle K⁺ check karo — yeh most tested + dangerous step hai
• HHS mein mortality DKA se zyada hoti hai (15–20%)