Electrolyte Imbalance Scenario

What is the patients NEWS score?

You record a low NEWS score so feel you can take your time and do a more thorough assessment. The patient has a past medical history of hypertension and hypercholesterol but otherwise is normally active and well. She has no allergies and medications are Bisoprolol and Atorvastatin. What other questions do you need to ask to complete your SAMPLE acronym for initial medical questioning?

You ask about the patients last oral intake and find out she hasn’t eaten hardly anything for 4-5 days with her vomiting. She has managed to keep herself hydrated however with frequent little sips of water. She explains she feels exhausted to the point it feels like it is an effort to even lift her head. She has slept most of the last three days and doesn’t seem to be improving.  

Because of her diarrhoea and small intake, you query dehydration, what pre-hospital observations/tests may indicate when someone is becoming dehydrated? 

You notice the patients mucous membranes seem wet, skin seems supple and rebounds back quickly, she has mild tachycardia but your unsure if this fits a clinical picture of dehydration. You complete a lying and standing blood pressure and get the results of: 

Lying – 128/82 mmHg 

Standing 1 min – 120/80 mmHg 

Standing 3 min – 117/81 mmHg 

Would you class this as a positive result for orthostatic hypotension? 

You recall you need a drop of 20mmHg systolic or 10mmHg diastolic to class as a postural drop in blood pressure. The patient did not get any dizziness symptoms but just felt absolutely exhausted in completing the task of standing. She states she has been feeling this exhaustion for 1-2 days. It is also accompanied by headaches. You consider the possibility of electrolyte imbalances due to the patient only drinking water whilst experiencing diarrhoea and vomiting. 

What prehospital test could indicate specific electrolyte imbalances? 

You complete your ECG but can’t see any abnormalities, it is normal sinus. However, you are still convinced there is something you are missing. You recall reading an article on isotonic drinks vs plain water in endurance sports and the importance of correct electrolyte replacement which you know the patient has not been doing by drinking water. What electrolyte would you expect to find in larger amounts in sports drinks and is the most common electrolyte found in blood?

What changes usually occur on an ECG with hyponatraemia?

Given the history, length of time unwell, lack of food, and no support available at home, should we refer this patient back to the GP or transport to hospital?

What would be the more appropriate destination for this patient (if local pathways are available)?

What medication could increase the risk of a patient experiencing hyponatraemia?

What medication can be commonly found that may help avoid a patient experiencing hyponatraemia such as in this scenario?

Hyponatraemia is always associated with normovolaemia

A reduction of sodium in blood will cause a….  

(Assuming all other solutes in the blood have maintained the same concentration) 

When extreme hyponatraemia occurs a patient may experience seizures leading to coma and death, why does this occur?

Prompt treatment must be sought for patients with evidence of…