Immediate Questions

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A. What do physical exam findings say about patient's hydration status? Vital sign changes (tachycardia) coupled with mental status exam and weight loss indicate severe dehydration in this infant due to hypovolemia from repeated emesis. Immediate attention is required.

B. What do electrolyte findings indicate? Electrolyte findings for this infant include Na+ of 131 mEq/L, K+ of 2.1 mEq/L, Cl- of 88 mEq/L, and bicarbonate (HCO3) of 30 mEq/L. This patient has hypochloremic, hypokalemic metabolic alkalosis caused by loss of gastric fluid (primarily H+ and Cl- ions). Because of the gastric outlet obstruction, there is no contribution to the ongoing fluid losses by pancreatic, intestinal, or biliary fluid. To compensate for Cl- losses, there is concomitant urinary Na+ and HCO3 loss. If this condition persists, extracellular volume deficits will continue and renal compensation will occur, with urinary excretion of K+ and H+ in efforts to preserve Na+ and subsequently maintain extracellular volume.

C. What are initial concerns in immediate management of this patient? Although emesis may ultimately require surgical intervention, hydration and electrolyte status are the primary concerns in initial management. Replacing fluid losses through adequate hydration and correction of electrolyte alterations should be the first steps in resuscitation of this infant. If fluid status is not addressed, infant may progress to a state of hypovolemic shock or symptomatic hypokalemia.

III. Differential Diagnosis. Confirm alkalosis (defined as pH > 7.44) and determine whether primary etiology is respiratory (decrease in Pco2) or metabolic (increase in HCO3).

A. Respiratory Alkalosis. Caused by a primary decrease in Pco2 and seen in patients with hyperventilation (anxiety, fever, high altitude, salicylates, mechanical ventilation, sepsis, pneumonic processes, CNS disorders, hyperthyroidism) and urea cycle disorders.

B. Metabolic Alkalosis. Caused by elevation in serum HCO3, which can be caused by a net loss of H+, gain of HCO3, or loss of extracellular fluid volume. A useful classification is based on urine Cl-levels.

1. Saline responsive. Involves urine Cl- levels < 10 mEq/L, which indicates renal reabsorption of Cl- has occurred and patient will respond to saline replacement. Examples include vomiting (eg, pyloric stenosis), nasogastric (NG) suctioning, cystic fibrosis, congenital Cl--wasting diarrhea, posthypercapnia, and Cl--deficient formula intake.

2. Saline resistant. Involves urine Cl- levels > 20 mEq/L. Examples include diuretic therapy, Bartter syndrome, Gitelman syndrome, hypokalemia, milk-alkali syndrome, excess miner-alocorticoid production or ingestion (Cushing syndrome, hyper-aldosteronism, adrenogenital syndrome, steroids, licorice, chewing tobacco).

IV. Database. History of presenting symptoms and medications provides the most useful information. Remember that alkalosis is not a primary disorder; usually it is secondary to an underlying disease process that must be identified and treated to correct the acid-base disturbance.

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Do Not Panic

Do Not Panic

This guide Don't Panic has tips and additional information on what you should do when you are experiencing an anxiety or panic attack. With so much going on in the world today with taking care of your family, working full time, dealing with office politics and other things, you could experience a serious meltdown. All of these things could at one point cause you to stress out and snap.

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