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a day and we'll get started. So hi, guys. Money for you. But one of the co founders of the six PM Siris and, um, acute Medical Trust grade doctor in the Southwest. And I'm going to be covering electrolyte abnormalities. Thesis in part. The first part was mostly focused on sodium and today recovering. Yeah. See, um, calcium and a little bit of magnesium. So as usual, if you haven't really done so, please drawing our social media pages. It's how we can keep you up today about the latest Siris That's running What weapons were running on a day to day basis. And we occasionally post questions on there to console that you're learning on. If you haven't really done so, please also make a metal account. It's how we where were post all of our events. We post all of our, um, sort of content as well as our slides and, oh, uh, lecture recordings as well on a Z. Usual. Quick. Thank you did. And the you have have sponsored us. Without the MD, we wouldn't been able to get the six PM Siris off the ground Once you finish medical school. When you start working as a foundation doctor, every going to need some sort of medical legal legal advice, indemnity insurance or some other forms support which the end you can provide. So if you're interested in joining, the QR code is in the bottom, right? And if you drawing, you can pick between the free pocket prescriber book, a set of flash cards for revision, which I've got and I've used previously on the Foundation Program Handbook as well for more information on that. Okay, Without further ado, we're gonna get started. So question number one a 62 year old lady presents a 62 year lady presents to her GP with uncontrolled hypertension. 160 over 100 only takes the center problem. Not a pain. She's been started on another medication. A week later, a renal function is checked. What is the mechanism with this newly started medication? That's cool. Okay, White interesting spread of answers. Think I've covered this before? Okay, well, it's sort of majority onset and KCC inhibition. So that would mean that you've opted for for Rousseff being added in which is the incorrect answer. So the correct answer is NCC inhibition or at the distal convoluted feeble because you prescribed a fires I genetic for her hypertension. And let's talk a little bit about fires like directed. So just very quickly about a centimeter so eight and him it is typically increase potassium. So when you look at this lady's sort of bloods when we go back, she's got normal renal function. So that suggests the ACE inhibitor is not causing any issues, so there's no reason to get. There's no reason to sort of change the ace inhibitor along. Keep her on it. Some of you opted for a RB, but that would usually be of patients are intolerant of a some hip. It is or, you know, having issues with coughing because 18 of disconjugal because by taking breo so there's no reason to give an angiotensin receptor blocker at this point. And that's have a little look on NCCN. A vision hasn't mentioned NK CC inhibition, which were the majority of opted for, is a feruzzi minus. She's not overloaded, so we're not concerned about heart failure. Edo that this moment of time so I wouldn't be adding wrong to a loop diuretic, But I can see that you were looking to see that she's globally know electrolytes, which rules might can do. But five. Identix can also do that. So if you're under anti hypertensive UK guidelines, so as a probably previously mentioned lots of times before initially, if the less than 55 years old you pick an ace inhibitor or if they can't tolerate or or the coughing with or whatever it is, you can start him on the ARB. The one cardiac arrest, as we always mention always get asked about, is if someone has Type two diabetes, you up for an ACE inhibitor because it helps protect the kidneys in terms of reducing protein urea. Now calcium channel blockers are sort of we can use initially for anybody over 55 years old or after a Caribbean. And then the second line, which is what she was on, was an ace inhibitor on a calcium channel blocker. So because of BP still uncontrolled, you would opt for the next thing, which would be a fireside heretic, which caused her low electrolytes. If that makes sense, the answer would have been NCCN Hib Ishan very quickly because of confidence to death already in multiple violations we've got the nephron. Where? Genetics Acting Westwood of some anti hypertensive act. So you got the cream areas. Approximate convoluted shoe where the majority of sort of absorption of different things take place, such as bicarbonate, sugars, sodium. Lots of things get absorbed there. Then you've got the loop of handling descending and a sending in the ascending loop of handy's wind. Five. These sodium, potassium crawl right code transporters, which is simple, it is, is where new genetics fact, but is no indication for a loop diuretic in this lady because they're only issues hypertension, so she wouldn't have been prescribed the loop diuretic in terms of the dust or convoluted she billed. That's the final place where sort of sodium regulation takes place. So that's where you can find in actuals that you mentioned before, which are upregulated by old Austro on part of the running all the strong and do tens and system where passengers sparing diuretic act or be in different methods, depending on which one you pick and then five by genetics. Part of the anti hypertensive guidance in the UK Act on sodium chloride cold transporters within the distal convoluted issue, which is why they can cause low electrolytes to cause low sodium because they inhibit the absorption of sodium through this channel on because of sort of increased sodium. Being sense would ended this store convinced she go up again. It's these in actuals that will try and hold on to more sodium that's being excreted because of this direct IQ. And in return you'll release potassium, which is why I am cause low potassium and low sodium. Which is what happened. This lady As a result of fires I genetic. So a question number two a 24 year old is five days POSTOP for Prandin Proctor colectomy for severe crone's Her eye. The ostomy is producing high. I put, which is usually about 1.2 to 1.5 liters in a day is a lot for relying the ostomy you notice she is hyperkalemic, but with adequate intravenous replacement. It does not improve. What are the blood test? Do you want to request? Okay. The majority of us correctly still correct answers, magnesium, the clue and living yet being that this is sort of a refractory kind of hypokinesia me that's not responding to treatment, which makes you think if the magnesium is normal, which we'll talk about? Why so in Hyperkalemic? If someone's hyperkalemic, it's It's always worth checking the magnesium, particularly going to be doing the surgical job where they're going to be starved. They're gonna have diarrhea, vomiting or nausea or Eylea cyst or whatever it is. What it could have. High output whatever, especially in general surgery. Colorectal surgery. Second magnesium because magnesium eyes sort of thing, crooks kind of electrolyte and that if someone's magnesium is low, it's going to be very, very difficult to correct a hypokalemia, which was the case in this patient. And that's because magnesium is involved. Sort of in Reno excretion of potassium If you have a high magnesium that from deuces your renal excretion, if you've got a low magnesium that increases your renal expression of potassium, which means even if you correct it, you're still going to be peeing it out lots. So if someone's my potassium is low, even if before, even if before you start, just just check the magnesium because easy and cheap tied on, and it's not really any sort of big issues are doing, and it's an easy problem to correct Because I've mentioned a low magnesium mix. It very difficult to treat a let's go back makes it very difficult to treat a low potassium. And in terms of passing options, you can replace it orally or intravenously, depending on sort of trust guidelines. So, typically some trust, say, free 0.2 or above free. You can replace or really anything below free or something just 3.2. You would do typically go with IV or if someone's unable to take or medications. For whatever reason. I even reduced absorption because ideas and blockage and know by mouth or they're sort of, whatever reason, they have another safe swallow. Then you would, you know, up for IV, regardless on been terms of IV replacement in terms of typical fluid regimes. So typically you can add 20 minimal potassium chloride, or 40 minutes or so Potassium chloride in a bag. Important thing when you're replacing potassium intravenously outside of outside of a hatred EU or an I C. U setting is that you shouldn't replace it more than 10 minimal per hour because if you go any faster than that, that puts them at risk of sort of going on the opposite end of hyperkalemia and puts them at risk of an arrhythmia. So outside of hate to you or a sort of ice, you setting it shouldn't. Fasting should be replaced faster intravenously faster than the speed of 10 minimal power. And if they've got diarrhea, any or electrolytes can exacerbate diarrhea as well and make things worse because they all act this sort of slight osmotic agents. So if they've got diarrhea and you're thinking that they're they're, it's, it's always gonna make it worse than that. The MTA a V a Z well, in terms of clinical features. So potassium Think of the cardiac electricity mentioned high or low potassiums can cause cardiac arrhythmias, which can range, and very in hypokalemia. What you worry about particular, which I have another one here is a prolonged QT. So where the prolonged QT What you're concerned about is that eventually progress on to poorly more fixed CT, which is also known as two sides. The points on Dreesen. We worry about that because that can progress on to a more serious arrhythmia, such as ventricular fibrillation or VT. So that's why you know it's important to watch our Hyperkalemic is, but and general clinical practice from life seen a hypokalemia tends to be more better tolerated than the hyper Kony. Mia is, but not always depends on the patient's other things. You can possibly seeing the EKG or you waves, which are these sort of small waves that can appear after a T wave in between the pee in the T wave. And they come right after a T wave. And you also get smaller T waves as well, sort of opposite of hyper convenient. And the other concern you can see sometimes is because last time, you know, is just important for muscle movements and sort of contractions and other things. Is is generalized weakness and cramps, and sometimes even in patients in particular in colorectal general surgery. If they've got a really low magnesium, it can actually put them into an idea. So make an IV. It's much worse if they don't already have one. So that's why it's so important to, you know, sort of daily electron monitoring in these patients in particular and in terms of causes. So I sort of split it into free things in terms of how to think about it. so one would be sort of decreased intake. So your potassium is highest in your sort of. So you're interested in that Potassium is a lot higher than your sort of extra signing, or or you know, your your plasma potassium, your blood potassium. However, your blood potassium in terms of levels is strongly reflective of how your total body potassium issue. If you got a low sort of blood potassium, that probably means that your sort of potassium depleting all over across the place and decreased intake and rapidly sort of food intake and rapidly sort of low potassium levels, especially in starve patients. And that's why it's important to monitor electrolytes in these sorts of patients on a daily basis. Other things that can cause that are shifting. You know, the insurance is part of the hypokinesia a guy nice because, of course, is potassium shifting to the interest send in the space. So anybody that's receiving insulin is, you know, diabetics or whatever that can cause a slight, you know, potassium beater. I'd run ergic, so you know, for the same reason that sort of nebulous so be it was part of the hyper convenient guidelines. It can also cause interested in assisting of potassium. So that's something else you need to keep an eye on is well, it's another sort of cause of it, potentially and and the most common thing rainy in terms of what causes hyperkalemia. Just remember grand. That's the way that I used to remember it. So G I losses, which could be from vomiting, diarrhea, fistulas, idea. Ostomies is always what I remember. It could be renal extraction because if you know diuretics for some sort of congenital issues such as barter syndrome, which is a disease of the n K C C channel, the same channel that frusemide axon. So that's just one example. It could be an adrenal issues. So you know Cushing's because quarter so has some slight mineralocorticoid court court effects. And remember, I said anything that causes increased mineralocorticoid scan will cause increased sodium reabsorption and increase potassium excretion on steroids for that same reason, because they're acting, it's quarter so, and they also have mineralocorticoid effects. Most of them do. Cons is just the name of primary hyperaldosteronism I eat adrenal uh, it's a dream, or hyperplasia causing hyperaldosteronism. So that's another thing to consider again. That's just more Austro. Which means more sodium reabsorption and more potassium experience causing havoc, anemia. And for the reason that I mentioned that magnesium regulates potassium renal excretion, a low magnesium is very important to check, and it's easily correctable factor in someone with hypokinesia. Okay, so, uh, apologies policies for that survey, guys eso Next question is the 25 year old gentleman has taken a heroin overdose and has had a long line on the floor for several hours before paramedics got to him. He's currently stable. Deedee. His Bloods were in table. What is the cause of his hypercholesteremia? And that's pretty cool. A. No surprises there. Majority of you answered correctly. Shameless bunch. That was my fault. I apologize for that Guy's on soda. Correct answer is rhabdomyolysis. So let's talk a little bit about rhabdomyolysis and hyperckemia. So let's start with Hyperkalemic, in fact, so the reason we worry about Hypo is that remember, if you've done sort of some sort of life support training, I don't know. Basic life support, intermediate life support for some of you even have done a a less if your son foundation doctors and there's that is part of the cardiac arrest protocol. You go for your four hundreds in your forties for cause of cardiac arrest. And one of the causes of cardiac arrest is hypokinesia. Hyperkalemia predisposes someone to some serious arrhythmias. May DVT and VF which form part of the cardiac arrest protocol, if that makes sense. So that's why we worry a lot about hyperkalemic. So if you someone's on hypertension, you're gonna be quite aggressive about it and treat it early. Run and make sure that you manage whatever the cause of it is. So in terms of hyperkalemia a Kaiser common causes so things to consider stopping nephrotoxic Someone's got a K I. If they got potassium sparing drugs such as, you know, spironolactone and a panorama which are mineralocorticoid receptor antagonists or amiloride, which is more of an accent Asus inhibition type of drug. Then you want to be stopping those lots of IV fluids if they've got an a k I. And you know if they've got you need to check your guidelines because it depends on it. But if they've got severe hypoglycemia or hyperkalemia weird sort of, the CT changes the unity, giving them either calcium gluconate attempts and 10 mills or calcium chloride, which is mawr concentrated. I'll talk about the kind a minute Fatima, So the reason you get costs in Brooklyn or calcium chloride is because it's Zaccardelli membrane stabilizer. But I'm not sure people actually no know what that means. So when you've got hyperkalemic, I jaw sort of resting. You have the arrest in membrane potential and sort of your action potential for four things happening, if that makes sense. So in hyperkalemia, your your cardiac memory becomes more hyper excitable, and that means there's more likely for action potentials to be going off. And that means you're more predisposed to redness such a CT and fee F. Now what calcium gluconate are costing chloride does is it makes the difference between a resting memory and potentially action potential larger. So makes it more difficult for the cardiac membrane to the excitable, which makes it less likely for someone to have V e T o V f that can potentially been who Hello? Can you hear me, guys? I'm not sure if someone's putting the check. If I've been there, if someone's lost what I've said, Okay, fine. But in certain okay, fine. Um, so where was I? So when you given casting gluconate or calcium chloride, it sort of makes that difference between an action potential and the rest in May memory potential wider again. So it makes it more difficult to make things excitable, which means you're less likely to have VT and VF, and I go on to a cardiac arrest. So that's why it's so important to be giving. That's why it's the first thing, and I became a day. It'll be together either calcium gluconate or some trust use casting chloride. The only difference between custom chronic constant gluconate is Carson chloride contains more calcium for your buck, and you have to get it through a big sort of central sort of not central line. But you have to get for a big peripheral or central line because there's more irritated towards the veins of that makes sense. So that's really the difference between between the two now in terms of what you have to do next. So once you've sort of tried to protect the cardiac membrane from V. T. V. F. You need to try and solve the issue because it'll only lot it's protection only last for so long before you have to give it again. So you give drugs toe interest in for selling any chef, the potassium, so insulin, dextrose and so be it will do it. Remember what I've said? Inches and shift passing from extra, saying It's interesting the space and some people can do the same thing Adrenergic inch in the reason why we give dextrose with insurance because, obviously, incident. Also, uh, make sure sugars go from your you know, intraventricular space with the interest in the space. So that completes that should be utilized, which means you're a risk of hypoglycemia so that that shows is given to sort of try and reduce that risk of getting hypoglycemia. That's way both of those are given Now. All of that is just you've literally taken a box and put it somewhere else. But it's still in the same house, you know, actually gotten rid of the issues. Just you've sort of bought some time. And what the ultimate solution and what will prevent someone from, you know, becoming hyperkalemic against You need to pee like a calcium out. Really? So montri urine up. But they must be peeing the potassium. If they're not peeing the potassium out, the problem is just going to keep happening again. They're probably gonna have a fracture. Hyper continue. And remember, in terms of indications of hemodialysis, one of the things is refractory hypokinesia. So that's why it's so important to be monitoring out. Because if they're peeing, you're going to be fine. If they're not peeing, it's probably heralding something bad. That may happen, in which case are the appropriate four. So the further escalation or, you know, hemodialysis. In that case, you need to speak with the renal team or the ice UTI method makes sense now, in terms of the CD changes, you'll get these tall 10 to tease and flat piece kind of together. One will be that one will be smaller the other way bigger you get these wide QRS complex is. And if attentional e sort of with very severe or high levels, I became, Yeah, I've seen it with someone with a potassium of mine. You get the sign of soda waves, which are again sort of Harold, a bad omen that something's going probably progress into V F E. T. Or cardiac arrest. If we don't manage it. If you see Sinus little waves panic basically and start treating now in terms of sort of causes of hyperkalemic. Uh, I think if it's two ways, it's either related to decreased excretion or sort of sending a sort of shifting or sending the destruction of potassium. So in terms of saline of destruction, remember what I said interested in your potassium is higher than extra saline. Uh, so if you've got destruction of cells, all the contents are gonna be car cleaning these higher months of potassium. So things like Truman Lysis syndrome, rhabdomyolysis says in this case, and even mass blood transfusions because of sort of some license of blood search and get from quick transfusions because of sort of the rubbing against all the vessel walls. And the physical factors of it can cause an increase in potassium. And it's something to one of her now, in terms of decreased excretion. AKI zvehr economy. I pulled Austrian is, um so you know, that's why you see it in adrenal insufficiency. Remember, adrenal insufficiency affect all layers of the adrenal cortex, including the one including the zonegran, maybe low salt that produces mineralocorticoid or lost urine. Remember what I said about the estrogen? More the strongly call sodium reabsorption potassium excretion. So if you go hyperaldosteronism, you're gonna have more sodium making out in the urine, and you're going to be holding on to more potassium, as you can sometimes see in in patients with Addison New Crisis or adrenal insufficiency. DKA. It's related to the lack of insulin because, remember, insulin, though the way to remember is in changes to pack potassium at the cells. DKA is a state of one volume depletion and no insulin and the production of key tone. So because you have low insulin, you're you're gonna have more potassium. That's sort of extra signing that, and within sort of the vascular space, a sin habits can also increase potassium in that they essentially inhibit all those drawn on potassium, sparing diuretics because they spare potassium. Now someone asked me in terms of wise, not the not the Round A Care isn't incorrect answer, but really sort of. The overall process is rhabdomyolysis stomach, since a guy's correct, but it's a step in the process in that what happens with rhabdomyolysis is that you get, you know, breakdown of muscle cells protein release of myoglobin within the blood myoglobin is nephrotoxic and therefore causes a K. I travel a blockage and because you get the destruction, the cells, you get increased potassium release from sort of a setting of destruction. Point of view, but because it also causes Tribune a blockage within the kidneys and also cause an acre, so naked eye is also correct. But it's only half of the answer, if that makes sense. So that's why it's not the complete correct answer. Fatima is what I want to say. I hope that makes sense from that perspective. So, you know, incorrect with not to complete. My answer is a lot that I'm trying to say. Okay on again, Just that line because we whenever we say cardiac membranes sort of stabilize. Er, this is what it actually means in terms of its ready what I've mentioned. But I'll keep this in the slides. Somebody asked in DKA management is potassium needed only post interviews. So yeah, so one of the things that we do with you don't notice it in your hospital DKA protocols. If you whatever hospital medical school, you have a look at a daycare protocols. One of the things that the regular monitor in terms of blood is regular VBG and regularly monitor the potassium. And if the potassium is below a certain amount, you have to replace it in the fluids that you're giving, which is mostly going to be sort of sailing with potassium added in possibly so ast, part of the sort of sort of the biggest dick a Lexus is avoiding depression status while you're getting lots of fluids. Part of it's also making sure you monitor the potassium correctly and monitor it for our, uh, Denny. I'll come a little bit more on to that towards towards the end, because otherwise it will. It will take a while to cover that. I'll mention a question later, guys. So question number three a 70 or gentleman with longstanding, poorly controlled diabetes comes in for his annual diabetes checkup. He has blood taken and of results or tabled. What is the likely cause of his hypocalcemia? Okay, brilliant. So the majority of you've answered correctly, so the correct answer is diabetic nephropathy, and we'll talk a little bit about sort of the mechanism of calcium and re absorption in terms of it's physiology can always think it's interesting to know. So when someone's got hypocalcemia, you need a picture. You all IV replacement again. It would depend on your I'm not going to give you numbers because very much depends on your hospital. Sort of trust. Guidance what you do. But if they're symptomatic rule of fund if anybody's got symptomatic hypocalcemia, go for IV. And you also need to consider replacing vitamin D if it's low and in CKD patients because they'll have a high phosphate, which I'll talk about a little bit later. You also need to consider giving phosphate binding agents and if they've got a low magnesium, similar to a low potassium, because magnesium is involved in the production of power and release parathyroid hormone thing you to make sure that you replace the magnesium so from someone's got a low calcium. Also, check the magnesium again. Sometimes I think I'll see mucus again. It's a similar thing type game. You can give casting blue Kaneda or calcium chloride. And as I've mentioned, Carson chloride is three times stronger than sort of calcium gluconate. So it has to be given for a large vein. Is it can be irritating now in terms of remembering the symptoms of hypocalcemia what I always used to use during medical schools. The new Monix spasmodic seeing you get muscle spasms, you get periorbital seizure, sort of numbing on the side of the mouth, increased anxiety and increased seizure threshold. The muscle tone is increased. Your ent a shin is could be impaired. Get them a Titus in. But I go for mercy and get Bostick's sort of sign. Talk about a little bit later. You can also get cardiomyopathies in the northern. So remember spasmodic as a sort of new Monica remembering the symptoms of hypocalcemia. Now the way I used to remember the causes was I just had a full list of low things, anything that was hypo kind of cause that so if you got hyper vitamin D, you know, low vitamin D amount that will do it. Hypoalbuminemia can do it hypoparathyroidism for obvious reasons, which will come about Hypo Renal is, um so if someone's got long term seeking your a k I I prop happen is, um so if someone's got long time liver damage that can also do it, we'll talk about while next life hypermagnesemia, and that helps regulate the production and release of parathyroid hormone and hyperphosphatemia. Because forced weight is a sort of the problem with high phosphate is that it's kind of like a key Late in agent for state binds the things on one of the things that it binds to It is free calcium or ionized calcium so high phosphate can actually lower someone's calcium. Even more so hypophosphatemia can do it. Which could be because of CKD, for example, this phosphinates because they pack calcium back into back into bones on and also pseudohypoparathyroidism. So what pseudo hyper parathyroidism means is that the body cells are resistant to the sort of signal from parathyroid hormone resistant, the para fired fired hormone kind of like a nephrogenic diabetes insipidus, where the kidneys are sort of resistant at the genetic a woman pseudohypoparathyroidism. It's a similar process where all the organs of resistant, in fact, that parathyroid hormone, which means you won't be reabsorbing as much calcium from, say, your GI track and your arm or renal excretion of calcium from your from your kidneys. So that's why it's called the Cedar Hyper Para Fire isn't because you've got a normal high parathyroid a month, but the organs are reacting to it in the way that it should kind of like hyperpara fire. It isn't so. A little bit of a drinker to be all like are drawings and diagrams. At least I do in terms of explaining things. So vitamin D very, very important for sort of calcium metabolism as well. It's also phosphate with have is, um, Reabsorption. So vitamin D is sort of a free step metabolism in that there's sort of an activated vitamin D that comes either from food, which is known as sort of ago color cholecalciferol, which is vitamin D free. There's another version called Ergo Culp Cocoa Nickel Ergocalciferal. It comes from plants, which is vitamin D, too, but that is in the strongest vitamin D three years. So you're buying supplements or tablets for vitamin replacement. Make sure that it says vitamin D free on the on the supplement side of it of things. So when it's in your skin, you have UVB radiation acts on it, and that causes high dropped her drops in a shin of it gets brought to the liver. When I saw you the first step of Hydroxylation takes place where a vitamin D free becomes 25 hydroxyvitamin d free. Then it goes from the liver on to the kidneys, where it becomes 1 25 dihydroxy. That's when the free, which is also known as calcitriol and that's activated vitamin D. And that's the vitamin D that has all the physiological effects from re absorb reabsorb in calcium from your from your gut or increasing production from casting from you Got and decreasing renal excretion. If that makes sense on be sort of a zoo mentioned parathyroid hormone when it's released, cause it has similar functions. The vitamin D think of powerful hormone alongside with the practically does all the same things that vitamin D does, so it causes increase the absorption of calcium from your got to increase. Your intravenous calcium causes decreased venous excretion again to increase your intravenous constant, and it causes increased bone breakdown where sort of calcium and phosphorus stores hydroxy appetite within the bone, and if you get increased bone breakdown that causes increased intravenous calcium again. So if you've got a low power fired hormone, as with hypoparathyroidism, that means you get decreased re absorption from calcium from the garden and decrease really increased reno excretion, causing low calcium and similar with vitamin D. If you've got a low vitamin D amount, exactly the same processes asparagus fired hormone, you'll get decreased, gotten the absorption of calcium and increased renal excretions. The vitamin D and perform for gum practically have the same synergistic function alongside each other. So that's the way to remember the function of both. Now a little bit about calcium, because people get confused when I talk about the different types of calcium's. And I did a swell back in medical school cause I didn't quite understand, because when you look at someone's blood stairs things like calcium adjusted calcium. And then there's ionized calcium, which you see on the on the blood gas, and you just wonder what it is. So this is sort of a breakdown of how calcium is sort of traveling intravascularly within your blood. So 50% of your calcium in a normal patient is free, and that's also known as iron eyes, calcium and where you would have come across there is blood gases or what measure ionized calcium. And why is important? Distinguish is that it's that because the ionized calcium is what's important in terms of physiological function. Calcium that's bound to other things can enter cells that can do anything freely free calcium can enter cells and cause sort of these other things that you've got a low iron iced calcium that's a low, physiologically active calcium. And that's what causes the symptoms of sort of hypocalcemia. If that makes sense rather than the rest of it now 40% of calcium bound albumin. Because albums obviously transport protein and lots of thing about the calcium, that's what albumin is important, and that's one right hypoalbuminemia you can get in the calcium. But, um, that's about the calcium isn't physiologically active. It's not physiologically important in that if you've got a low calcium because of less being about album, but you're a nice is normal. In theory, you shouldn't have the physiological effects of Hypocalcemia because the, uh, the album and Bob Car seat isn't important. It's the free calcium of the ionized calcium that's important, and 10% of calcium is bound to you. Other things such as phosphates and you know, uh, just other things in general citrate and just other thing, small small amount of respond to other things on just I won't mention of portions, because otherwise we'll get a bit complex. But what can affect some sort of calcium levels is the serum albumin level, as I mentioned, but more related to that. Our calcium bounty albumin. So again about I a nice and adjust calcium so busy, logically active calcium is free online I calcium, and that's measured on the blood gas, and that's why I tend to like. But gas is passed any better. That's what's used in intensive care because they have our lines when it can measure serial blood gases and look at ionized calcium over over a period of time because easy to do in intensive care. Now, I just said calcium is what was used on the ward's because it's easier to do because it could be added on to the daily bloods of gold top, which the sort of the blood vial that we used to practically just everything except for blood count, is used as a surrogate marker for your sort of physiologic physiological calcium in that if you've got a low adjusted calcium, it's likely that you'll have a no I nice calcium was used as indirect markers, but it's not a direct measure of it, and that's what I don't tend to like it. But it's the easy thing, and it's what's used in the warden's what's more practical do. So question number four, and then we'll have a small break to try and also some more questions. So a 45 year old lady has had a total fire addicting you for for Nick in a fiery cancer following surgery, you and the left to ask to review her and the night she feeding on. Well, you know that as a BP is being taken, her rest flexes and her fingers a stand kind of like this. This is the best thing is the best acting I can do for you guys. And she has had blood test. What sign has been elicited? Let's bring the okay, the majority, he answered correctly. So the correct answer is true. So psych and some of you went for more stacks, which is another sign of hypocalcemia. But it's not this one in particular, so I took a little bit about true so signs. So Fosamax is when you have tapping of the facial know, particularly over the sort of perote, it sort of parotid gland psoriasis like grand roughly around here. When you talk it, you get this sort of sideways movement of your mouth, which causes the sort of twitching sort of this perioral twitching. And that's for sex time, which is a sign of hypocalcemia. That's not the one that's been a listed here. True, So sign now. Eso Typically, what happens is you have it sort of. The the waiting list is you have a BP cuff. You leave it on for 2 to 3 minutes, which causes sort of this sort of temporary sort of ischemia. It's not really skinny. Temporarily reduce blood flow. And if the sort of nerves are hyper excitable, which which is what happens? Intrusive sign. You'll get that sort of sort of typical wrist flexion and finger extension that's called truce of somebody's typically 2 to 3 minutes of cover inflation, which you can imagine it's it's very uncomfortable to do on somebody I don't like it when someone's been fainting. A cough for about one minute on my arm blended in 2 to 3 minutes, but if you want to do on somebody. Just let him know because there's no it's not comfortable. Slight elicit. Now I've been ski Sinus is related to the upper motor neuron lesions, and that's when you sort of scratch the end of the feet. Or keep it very simple. Scratch the feet and the courses up going planters and normally partition going down or neutral Karnik Sinus sign of manages. Um, so it's bending of the hip and knee and then extending of the EKG, which is basically to do with sort of a rejected rigidity of the sort of inflamed meninges is what is causing pain and discomfort. Do do do so quick. Question. Which side is more specific and sensitive for hypocalcemia is a lost X Or is it true? So sign she had to pick one and I buy it. Which one would you go? It so majority kind of offered for Bostick sign. But if we're talking about which sign is more specific and sensitive, it's actually true. So science to truces line is more sensitive. Specifically, Hypercar see me in in Boston access because Last X can also be seen in hypermagnesemia on metabolic Calculosis and that it also causes a lot of sort of nerve hyper excitability. Okay, last question. And then I'll start answering lots of questions that people can have from I concede from the chat. So a 42 year old African being lady presents to a GP with painful Nigel's on their shins. She requests you across the chest. X ray shows abnormal changes. Her bloods indicate hypercalcemia. What is the most likely diagnosis? Okay, that majority answered correctly, which is nicely the question towards the end. So the correct answer is sarcoidosis. So liberal happen calcemia, and then we'll talk about so so so in terms of the mansion principles high because, senior, it's very simple. It's fluids, foods, foods for its fluid and what's caused it. So you try and and sort of the flu that you would not force. Typically, savings, he tried to say in line is stabilize the blood as much as you can. And that would just basically binding the calcium out and reduce the effects of the hyper calcemia and then other things to consider. Save someone's got sort of metastatic bone disease or other things are disphosphanates and also calcitonin, which I've seen very rarely used. I haven't seen cost only being used, but I have seen this foreskin. It's being used in the acute sight things, things like alendronate and other things with a single dose. Medications on it again. You treat the underlying cause depending on what the cause is between to find out what's actually caused it. So when you combine the symptoms are sure many of you would have come across this and heard of this before. Renal stones, pissing Thrones, painful bones, abdominal moans, listless grounds and psychiatric overtones. So calcium conform. If it's high months of calcium that conformed increased, we sort of renal stone information into your attire. Colic because lots of different, like there's There's different types of stone in the made of different types of things, but cast in forms of background for a lot of thumb pissing thrown so calcium accessible, small tick agents so you'll get increased sort of diuresis and peeing, so you'll be peeing a lot. We get polyuria with a painful bones, depending on the course, or say if they're sort of parathyroidism or medicine or sort of osteo netiquette metastases that break down bone or parathyroid hormone that also breaks down the bone because the bone is spinning and become instruction. We could get pain from the bones. Calcium, as I've mentioned. So the way to remember is calcium is the great stabilizer and that you have more than that. It will stabilize everything. So not just one. Stabilize your cardiac. Remember who also stabilize your gut and stop it for a moving so it can lead to constipation. That's the way that I remember, but also because it causes dehydration as well. So it's kind of like a It's kind of like a to to sort of way that it hit. It makes you constipated. This is going to make a general tight, and it connects somewhat confused. Any just commit somewhat confused and delirious in general, anyways, for all the reasons above which connect anybody confused in various, especially if you're elderly now in terms of causes. So I don't quite a list, of course, is we to remember, but sort of hyper parathyroidism is something to obviously remember, because if you got increased PT eight, remember that breaks down more of your bone. Your increased got reabsorption of calcium. You get decreased. We know creation overall interest in increasing the IV calcium. We can talk a little bit about the types of primary tertiary secondary tertiary, but I'm going to be covering that a parrot firewood teacher. I don't want to go too much into that malignancy. So especially if you've got sort of bone metastases that are osteolytic and break down the bone that can increase your calcium amount multiple myeloma, and that you can get these plasma Cytomel again. Sort of these bone kind of lesions again that will sort of ink increase the amount of calcium that's running around the bloodstream. Vitamin D toxicity for obvious reasons. And the vitamin D has the same function parathyroid hormone and that, you know, increased bone breakdown, increasing IV calcium increased got reabsorption and decreased renal excretion milk arclight syndrome, which I won't be covering today. But you know, it is very this rare sort of drunk related syndrome, which causes metabolic alkalosis, AKI and hypocalcemia sarcoidosis, which is to be in yet that we've covered severe fire. Looks toxicosis on a swell is that there's pseudo hyper parathyroidism well, which is quite a mouthful again, which is more related to the sensitivity of your of your calcium channels to power fire at home. So considered hyper para fired power fired viral is, um your calcium sensitive receptors on your on your parathyroid gland or much more sensitive and upregulated. So even if you've got a normal amount of calcium, it will sort of sense that as a low amount of calcium release more power, fire at home and there by causing, you know, increased interest, increased vascular, it's sort of or calcium. If that makes sense, we can confident a bit again, little bit later on. So sarcoidosis just a bit about it, because I don't want to be covering at me because we're gonna have all the teachers and some point covering this. That's a multi system noncaseating granuloma disease caseating, meaning that when you cut the ground, it almost looks like cheese, which is what you see. The TB typically was commonly affect the lungs, but it can affect any organ system, and you know you can get different types of syndromes with it, so you can get a rough human dose on the dose. Um, which is inflammation of sort of a bunch of fat cells, particularly around the shins, were never there most probable prominent. You can get sort of bilateral hilum and kind of not trust X ray change, which is stage one in terms of checks. Chest X ray changes in regard to sicroidosis. You can also get hypocalcemia, of course. And there's four stages of sort of a chest X ray changes with sarcoidosis, which I will leave in here, and you can have a look into yourself. So before I come in to some of the extras that we're confusing from previous electric slides, I'm just gonna have a look at some of the other questions that were asked and the post up the Lincoln the same time. Not a matter, actually, Bob, it's POSTOP. The you go, There's a link for anybody that one today. Um, I don't actually see any new questions. There is one question that's gonna be a big complex that I come back to towards the end. Okay, fine, let's continue one for a little bit. So what I previously covered and I think I'm confused. A lot of people in my previous sodium talk was about how how blue cortical insufficiency can cause you've anemic hyponatremia. But adrenal insufficiency can cause a hypovolemia hyponatremia, so I'll be our try and covered as best as I can, because I think that confused a lot of people from the previous lecture so already mention. It's in yesterday's lecture, but just again about the adrenal cortex for anything that went there yesterday so that you know grand into free layers from outer to enter the cortex is free layers, and the medulla is the Allegra and the cortex is spent in a further free days, which each release their own substance from out in. So no g f r I was on a glimmer of, you know, so releases mineralocorticoid salt. The particular time releases Group of Quarter quit sugar. On the particular is the most energy pill. A of the cortex releases the a change of sauce around, and the medulla releases catacholamines. Now we Do. You remember, as I mentioned previously is remembers owner G. F R. In that the theory no grand sit above the kidneys, sort of g f R rated primary filtration, and then remember the order of what they released by remember, or do you spend your evening in, which is you have a savory then I've done this ER and then maybe sex if you're lucky. So features of insufficiency just very quickly again, which have covered previously glucocorticoids can cause none specific symptoms of feeling generally unwell and tired hypertension of hypoglycemia. But note how we haven't sent hypovolemia, which is what referring to type of leucopenia. Treat me. Explain that a little bit on the next light. Men around a quarter cords can cause hyponatremia hyperkalemic because of less old Austro means more excretion of sodium and mortar old onto potassium, and wherever sodium goes, water follows. So if you excrete your sodium water is going to follow, and that will cause you to be sort of volume depleted because you're losing fluid with sodium. And that's why it can cause a high privilege and hyponatremia. Um, on the last thing that a primary hyper a certain time MRI, Addison's Conducive Primary adrenal insufficiency hyperpigmentation, because of increased ACTH release, cause an increased melanocyte stimulating factor hormone causing Moorhouse for pigmentation around sun exposed areas such as the palms of the hands. No. So this is this is what I'm trying to get into, how you could corticoid insufficiency on adrenal insufficiency, different terms of what type of hyponatremia and it can cause. So quarters all or Declude, the main group of corticoid that we have. It's suppresses anti genetic hormone release. So if you've got less quarters, all there's less suppression of ADH there for you get increased 88 kind of you get this SIADH essentially and SIADH causes. You've anemic hyponatremia and some people ask is Well, why isn't it with glucocorticoid insufficiency? Then you get hypertension, which could be a sign of hypovolemia. But the hypertension isn't caused because of volume depletion, which is what I probably means hyper meaning less volume, meaning fluid status or for the hypertension is a result of less course along last sympathetic nervous system. Activity around the sympathetic nervous system controls multiple things, including how fast your heart beats, how constructed your blood vessels all form about BP. So it's hypertension not caused by avoiding depletion. If that makes sense. So even though there is hypertension, glucocorticoid insufficiency, it doesn't mean that there's hypovolemia on because quarter saw suppresses 88 your ethical and is less of it. You get more 88 she can get SIADH, which could cause you've anemic hyponatremia. I hope that kind of makes sense whilst in renal insufficiency in deficit, because it also affects mineralocorticoid production, which is that all layers are affected. So you get lost if you would and sodium because of lack of all the steroids, because you get fluid loss to become fluid likely, and that can lead to hypoglycemic hyponatremia because of reduced circulating volume. Does that sort of make sense? Guys? That was quite a mouthful, But hope that explains how you call corticated sufficiency and adrenal insufficiency, which affects all A's and from the mineralocorticoid, their course different hyponatremia is probably not probably stunned into silence, probably stunned into silence again, but it will be on the slides for you to read anyway. So, uh, it doesn't really matter. Um, find our postop the link again and I'll bring it to the next slide where it ends. So that's the last bit of it. And then I'll try and answer any questions that I have. I hope that was useful guys and hope that'll made sense where you can find a quarter for this session. So yesterday's recording and slides for the adrenalectomy posted up today. So being up this evening, and then today's stuff clean electrolytes and the sort of recording will be up tomorrow. So when you complete the feedback and you could catch up content, it will send you email saying everything's available or you can also followed the metal. Everything's posted on metal guys to make sure you make a metal account. Actually complete the feedback because that's the Get the email on the catcher content. If you follow the event page on Facebook, I posted the Med A link there, and if you click it that, that's also you can get access to a lot of stuff that will be there. But today's today's electoral cording and slide on post Tomorrow was yesterday. Stuff the adrenalectomy recording on slides will be up today, and then somebody asked me. Another question was quite difficult. I'm gonna have a little look and see if I can answer. It was Demi. Let's have a look at it. So then he asked. Potassium and calcium are both positive ions. Don't they both make the cell more positive? Yes and no dummy. So when you get a let's put it this way. So So you all right. But the way that they do is different. So you've got this, remember, you've got the kayak, my sight. And you remember that sort of drawing of the cardiac membrane potential which are drawing a pen, Which sort of looks like this is my pen. It sort of looks like this if I remember my physiology correctly. So this is for a cardiac myocyte action potential. Don't ask me to numb the numbers I've completely forgot with The numbers are. But the point is, you've got this resting memory, potential cardiac. My sight sits and it's not doing anything. And then you've got this action membrane sort of potential way. If it reaches his potential fresh hold, it will cause sort of contraction of the Mahdi. My cardio, uh, sort of self. Now, what happens in Hyperkalemic is that yes, you're right. It is positive. It's a positive ion. And what it does is this resting membrane potential is increased. So instead of sitting here where it is is it sits hair instead. So if I draw this out kind of the same level, but the action memory potential remains the same. So can you see how? Because the resting memory potentials higher because the positive potassium ions in hyperkalemic the difference between the breast in memory, potentially action potentials last, which means it's more. It's more easily. You could make the carding my sight more easily contract more easily excitable, and because it happens much often, it puts you at risk of an arrhythmia. Such a VFFTT. Now calcium is also posted, but it does something a little bit different in that what it does is when you give a call, see gluconate. It doesn't change the resting member and potential that that the potassium is caused have a quick what it does is it increases the action membrane potential. Now, if you ask me how, I don't know. But the point is because it increases the action member in potential. It means the difference between the two is large again, which means the cardiac memory is less excitable. You just like it have E f and VT less likely to go into a cardiac arrest. That's the best that I can answer questions for me if you're if you're still there. I don't know if you're still within the on session, but I hope that sort of makes sense That's the best way that can explain this sort of physiology of potassium and calcium. So does it slightly differently. Um, yeah, I know it is. A lot of the sessions finishes well, just it's it's all get the lecture recording inside. Only be offended. That's why I always posted the feedback early. So no worries and thank you very much for joining the really appreciate it. It's good to see new people around. So I drove us. Do you mind quickly going through calcium correction again, I got a little bit confused relationship. Yeah, we can try and go through that again. So and one of somebody is called C has also posted some health helpful information for me. I was wondering, See if it's still there If you could copy that same thing that you sent me into the chat s so I can talk for it more easily. So let's go back to the calcium slide. So when you say correction um, a J or you referring to treatment of hypocalcemia, are you referring to adjusted? Calcium is what I want to know. Uh uh, Mike ended with confused that I'm going to assume you're talking about albumin. So we'll go there. Thank you. See? Ah. Okay, fine. So it's zero. So sees posted, helpful sort of helpful little sentence, which can also really should also helped was the very behind how adjusted calcium's calculated, but the whole point of how addresses. So you've got a total body and count the total body calc, which is spit into your eye. Nice. Are women bound and your other? So that's what total calcium measures now adjusted calcium measures what your calcium would be, uh, if if you're if your albumin level was normal, so that's particularly relevant in it's particularly relevant in patients with hypoalbuminemia and that if you become hyper abdomen emmick, your calcium levels will naturally be low because albumin axis a storage more medical for the total amount of calcium. But it doesn't necessarily mean you're symptomatic, either because your free or ionized calcium can be normal, which is what determines whether you're symptomatic or not. So the adjusted calcium, but it tells you, is if you're if you're albumin is normal, it will tell you what your total body calcium would be, and by that sort of effect, it would tell you kind of what you level of ionized calcium would be a swell. It's really difficult to explain. Just in one go I just so I'll try and add a few sort of sentences and a slide on it from the the power filed home, because I really can't explain it. And one go ahead because even in my head, I sometimes get a little bit little bit mixed up in baffled. But see sent a little sentence that might be worth reading, but the point is, it isn't easy, but just remember, it is split the album inbound and free calcium and other on If your are Women is low, you're adjusted. Calcium tries to predict what you're told her calcium amount would be if your if your albumin is normal and by in effect indirectly tries and tells you if you're sort of a nice calcium is normal as well, that's the best way I can explain. I'm sorry, I just it's it's it's difficult concept to try and explain, but I'll try and I just sort of another slide and sentence on it. Um, okay, I'll post up the feedback one more time that anybody else have any other questions Okay, bro. Um, I'll take that as a no, thank you very much for joining the guys, you know. Where is it? All pleasure. Pleasure, as always. Um, please join us tomorrow. Same time. Six PM where kitty kitty months will be covering acute medicine. Some of the medical presentations part too. And I hope to see you again on day. I just please complete the feedback on. Make sure to post the adrenal video and slides up today. And today's content electrolytes abnormalities part too. The content will be posted up tomorrow. Thank you very much, guys, and hope to see you soon again. Take a