Four Rs of fluids

Resuscitation	Rehydration	Rectification	Regular (Maintenance)
Situation
Shock Decreased blood pressure Increased lactic acid Decreased urine output	Hypovolemia +/- electrolyte abnormalities "Pre-shock" (downtrends in blood pressure or urine output, increasing tachycardia) Diabetic ketoacidosis Rhabdomyolysis Post-obstructive diuresis Hypovolemic acute prerenal failure Pancreatitis	Electrolyte abnormalities +/- hypovolemia Hypovolemic hyponatremia Hypernatremia Hypokalemia Hyperchloremic acidosis	NPO
Choice of fluids
NS LR Albumin Hespan (but numerous contraindications)	Typically composition is directed by published guidelines (as in DKA) or fluids can be formulated by the considerations for maintenance fluids given in the column furthest to the right. Remember that 40 mEq of potassium in a peripheral line has a maximal infusion rate of 125 mL/hr	Hypovolemic hyponatremia 0.9% saline ("NS", 154 mEq Na/L) 3% saline (513 mEq Na/L) Hypernatremia 0.45% saline ("1/2 NS", 77 mEq Na/L) D5 (0 mEq Na/L) Hypokalemia Given normal renal function, assume 20 mEq of potassium increases serum potassium 0.25 mEq/L Hyperchloremic acidosis Assuming mild hyponatremia or normal sodium consider 150 mEq NaHCO3 in 1000 mL of D5 or free water (1)	Based on electrolytes, specifically: sodium, potassium, chloride, bicarbonate, and glucose (and occasionally phosphate) as well as blood pressure. If they are hypertensive consider hypotonic (1/2 NS) rather than isotonic (NS, LR) solutions even if they are mildly hyponatremic. If Na is within normal limits < 140 use NS, > 140 use 1/2 NS If K is within normal limits < 4 add 20 mEq KCl If hypoglycemic or marginally hyperglycemic use the D5 variant of the 1/2 NS or NS chosen above
Rate
20 mL/kg of crystalloid (NS or LR) over 15-20 minutes (thus a pressure bag is needed)	100-1000 mL/hr titrated to whatever volume deficit you are correcting	Hypovolemic hyponatremia The initial rate to correct by 10 mEq/L in 24 hours with NS is by rough calculation 1.35 x wgt [kg] for the rate in mL/hr. If using 3% saline multiply by 0.3 (2) Titrate the rate to serial BMP, if life threatening hyponatremia (e.g. seizures) correction may be more rapid for the first few hours but still < 10-12 mEq/L over 24 hours Hypernatremia The initial rate to correct by 10 mEq/L in 24 hours with D5 is by rough calculation 1.35 x wgt [kg] for the rate in mL/hr. If using 0.45% saline multiply by 2. Titrate the rate to serial BMP, such that the rate of correction < 10-12 mEq/L over 24 hours Hypokalemia Maximal correction via peripheral line is 40 mEq/L in 500 mL NS over four hours or 125 mL/hr Hyperchloremic acidosis As per "rehydration" rates	40-20-10 "rule" (for patients with normal electrolyte hemostatic mechanisms) 40 mL/hr for the first 10 kg 20 mL/hr for the second 10 kg 10 mL/hr for each additional 10 kg
How do you know it's working
Blood pressure increases Lactic acid decreases Urine output increases	Blood pressure, heart rate, and urine output improve ("preshock") Anion gap decreases (diabetic ketoacidosis) CK and renal function improve (rhabdomyolysis) Replace 50% of urine output per hour (post-obstructive diuresis) Urine output increases and renal function improves (hypovolemic acute prerenal failure) Amylase and lipase improve (pancreatitis)	Hypovolemic hyponatremia Sodium corrects by < 2 mEq/L every 4 hours, thus check BMP or I-STAT every 2-4 hours and titrate rate and composition of fluids appropriately Hypernatremia Sodium corrects by < 2 mEq/L every 4 hours, thus check BMP or I-STAT every 2-4 hours and titrate rate and composition of fluids appropriately Hypokalemia Electrolyte correction monitoring at most Q8H Hyperchloremic acidosis Electrolyte correction monitoring at most Q8H	The patient remains hemodynamically stable without electrolyte abnormalities or worsening renal function

1. Assuming NaHCO3 comes in a stock solution of 1 mEq/mL, then [C] = solute osmolarity / solution volume

   = solute osmolarity / (solute volume + solvent volume)

   = 150 mEq / (0.150 L + 1 L) = 130 mEq NaHCO3/L

   In 850 mL of solvent, then [C] = 150 / 1000 = 150 mEq Na HCO3/L

2. Assuming total body water [L] = 0.5 x wgt [kg] (acutally TBW fraction varies between 0.45 and 0.6 depending on gender and age). We want to change the current plasma sodium by 10 mEq/L/24 hours (i.e. the maximum safe change in serum sodium that will not precipitate central pontine myelinolysis) and recall that the concentration of sodium in 0.9% saline or NS is 154 mEq/L, then:

   infusion rate = 0.5 x wgt [kg] x 10 / 154 (L x mEq/L/24 hr) / (mEq/L)

   = 5 x 1000 x wgt [kg] / (154 x 24) mL/hr

   = 1.35 x wgt [kg] mL/hr for NS

   If we are using 3% saline, multiply by 0.9/3 (0.9% / 3%) or 0.3

   In the case of hypernatremia, we know that 1/2 NS is half the concentration of NS, such that if we did a similar infusion rate calculation the denominator would be half what is above, or simply multiplying by 2.

Encephalopathy in a nutshell

Although not the definitive, all encompassing, reasons for encephalopathy/delirium/altered mental status, this short list certainly covers many of the most prevalent causes.

Etiology	Physical Exam	Bedside Diagnostic Tests	History	STAT Diagnostic Tests
"Bugs" Infection	Temperature SpO2 Meningeal signs Lines (vascular, GI, GU)		Headache Aspiration Productive cough Vomiting / Diarrhea Urinary changes	CXR UA and urine c/s Blood c/s Sputum c/s C. difficile toxin
"Drugs" Side effects of and withdrawal from drugs		Naloxone trial	MAR (narcotics, corticosteroids, CNS agents) Review home medications Alcohol/substance abuse
"Lytes" Electrolyte abnormalities particularly hypo- and hyperosmolar states		I-STAT	Ins/Outs	BMP Serum osmolarity
"Plights" Inadequate pain control	Pain scale Abdominal examination	Bladder scan
"Beating" Cardiac arrhythmia and ischemia	Heart rate Blood pressure Jugular venous pulsation Heart murmurs and additional sounds	Telemetry I-STAT Troponin		EKG Cardiac markers BNP
"Bleeding" Acute blood loss	Scleral pallor Rectal exam	Fecal occult blood test I-STAT (ABG also has an H&H)	Recent surgery Anticoagulation	CBC
"Gases" Hypoxemia or hypercarbia Acidosis or alkalosis	Respiratory rate SpO2	ABG	History of hypercarbia Previous ABG
"Glucose" Hypo- and hyperglycemia		Accu-check I-STAT	Diabetes mellitus Insulin or oral antihyperglycemic medications
"Gourd" Intracranial pathology (i.e. stroke, mass effect, traumatic brain injury) Seizure	Neurological examination		Documentation of seizure-like activity without formal history of seizure Trauma History of dementia or seizure	CT head without contrast