6/9/2017 Gastro, Fluids and MSK FRCEM Success
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You have scored 20%
You answered 10 correct out of 49 questions.
Your answers are shown below:
Hartmann’s solution may be preferred to sodium chloride 0.9% as it may reduce the risk of:
a) Hypernatraemia
b) Hyponatraemia
c) Fluid overload
d) Hyperchloraemic acidosis
e) Osmotic demyelination syndrome
Something wrong?
Answer
Hartmann’s solution (compound sodium lactate) can be used instead of isotonic sodium chloride solution during or
after surgery, or in the initial management of the injured or wounded; it may reduce the risk of hyperchloraemic
acidosis.
Notes
Solutions of electrolytes are given intravenously to meet normal uid and electrolyte requirements or to replenish
substantial de cits or continuing losses when the patient is nauseated or vomiting and is unable to take adequate
amounts by mouth. When intravenous administration is not possible, uid (as sodium chloride 0.9% or glucose 5%) can
also be given by subcutaneous infusion.
Sodium chloride
Normal saline (sodium chloride 0.9%) contains:
http://frcemsuccess.com/rev/sc56/ 1/107
,6/9/2017 Gastro, Fluids and MSK FRCEM Success
Na+ 150 mmol/L
Cl– 150 mmol/L
Sodium chloride in isotonic solution (0.9%) provides the most important extracellular ions in near physiological
concentrations and is indicated in sodium depletion which can arise from such conditions as gastroenteritis, diabetic
ketoacidosis, ileus, and ascites.
Chronic hyponatraemia arising from inappropriate secretion of antidiuretic hormone should ideally be corrected by
uid restriction. If sodium chloride is required for acute or chronic hyponatraemia, regardless of the cause, the de cit
should be corrected slowly to avoid the risk of osmotic demyelination syndrome and the rise in plasma sodium
concentration should not exceed 10 mmol/L in 24 hours. In severe hyponatraemia, sodium chloride 1.8 % may be used
cautiously.
Hartmann’s solution
Hartmann’s solution (compound sodium lactate) can be used instead of isotonic sodium chloride solution during or
after surgery, or in the initial management of the injured or wounded; it may reduce the risk of hyperchloraemic
acidosis.
Hartmann’s solution contains:
Na+ 131 mmol/L
K+ 5 mmol/L
HCO3– 29 mmol/L
Cl– 111 mmol/L
Ca2+ 2 mmol/L
Glucose
Glucose solutions (5%) are used mainly to replace water de cit. Average water requirements in a healthy adult are 1.5
to 2.5 litres daily and this is needed to balance unavoidable losses of water through the skin and lungs and to provide
suf cient for urinary excretion. Dehydration may occur when these losses are not compensated for by intake e.g. in
coma, or in the elderly. Excessive loss of water without loss of electrolyte is uncommon, occurring in fevers,
hyperthyroidism, diabetes insipidus and hypercalcaemia.
Glucose solutions are also used to correct and prevent hypoglycaemia and to provide a source of energy in those too ill
to be fed adequately by mouth.
Glucose solutions are also given in regimens with calcium and insulin for the emergency management of
hyperkalaemia. They are also given after correction of hyperglycaemia during treatment of diabetic ketoacidosis, when
they must be accompanied by continuing insulin infusion.
Potassium chloride mixtures
Potassium chloride with sodium chloride intravenous infusion is the initial treatment for the correction of severe
hypokalaemia and when suf cient potassium cannot be taken by mouth. Repeated measurement of plasma-potassium
http://frcemsuccess.com/rev/sc56/ 2/107
,6/9/2017 Gastro, Fluids and MSK FRCEM Success
concentration is necessary to avoid the development of hyperkalaemia, particularly in renal impairment. Initial
potassium replacement therapy should not involve glucose infusions, because glucose may cause a further decrease in
the plasma-potassium concentration.
Sodium bicarbonate
Sodium bicarbonate is used to control severe metabolic acidosis (pH < 7.1) particularly that caused by loss of
bicarbonate (as in renal tubular acidosis or from excessive gastrointestinal losses). Mild metabolic acidosis associated
with volume depletion should rst be managed by appropriate uid replacement because acidosis usually resolves as
tissue and renal perfusion are restored.
In more severe metabolic acidosis or when the acidosis remains unresponsive to correction of anoxia or hypovolaemia,
sodium bicarbonate (1.26%) can be infused over 3 – 4 hours with plasma-pH and electrolyte monitoring. In severe
shock, for example in cardiac arrest, metabolic acidosis can develop without sodium or volume depletion; in these
circumstances sodium bicarbonate is best given as a small volume of hypertonic solution, such as 50 mL of 8.4%
solution intravenously.
Albumin
Albumin solutions, prepared from whole blood, contain soluble proteins and electrolytes but no clotting factors, blood
group antibodies, or plasma cholinesterases thus may be given without regard to the recipient’s blood group.
Albumin is usually used after the acute phase of illness to correct a plasma-volume de cit; hypoalbuminaemia itself is
not an appropriate indication and the use of albumin solution in acute plasma or blood loss is wasteful where plasma
substitutes should be used instead.
Concentrated albumin solution (20%) can be used under specialist supervision in patients with an intravascular uid
de cit and oedema because of interstitial uid overload, to restore intravascular plasma volume with less exacerbation
of the salt and water overload than isotonic solutions. Concentrated albumin solution may also be used to obtain a
diuresis in hypoalbuminaemic patients (e.g. in hepatic cirrhosis).
Plasma substitutes
Dextran and gelatin may be used at the outset to expand and maintain blood volume in shock arising from conditions
such as burns or septicaemia; they may also be used as an immediate short-term measure to treat haemorrhage until
blood is available. Dextran and gelatin are rarely needed when shock is due to sodium and water depletion because, in
these circumstances, the shock responds to water and electrolyte repletion.
A patient presents to ED having recently been started on colchicine therapy for acute gout.
Which of the following is the most common side effect that he is likely to complain of:
a) Photosensitivity
b) Diarrhoea
c) Ankle swelling
d) Rash
e) Blurred vision
http://frcemsuccess.com/rev/sc56/ 3/107
, 6/9/2017 Gastro, Fluids and MSK FRCEM Success
Something wrong?
Answer
The most common side effect of colchicine is gastrointestinal upset (nausea, vomiting, diarrhoea and abdominal pain).
Side effects are dose dependent and may be severe enough to limit treatment.
Notes
Gout is a disorder of purine metabolism characterised by a raised uric acid level in the blood (hyperuricaemia) and the
deposition of urate crystals in joints and other tissues, such as soft connective tissues or the urinary tract.
NSAIDs
Acute attacks of gout are usually treated with an NSAID such as diclofenac, indometacin, or naproxen. Treatment
should be started as soon as possible and continued until 48 hours after the attack has resolved. A PPI should be co-
prescribed for gastric protection in people at high risk of gastrointestinal adverse events.
Colchicine
Colchicine is an alternative in patients in whom NSAIDs are contraindicated, not tolerated or ineffective. Although its
use is limited by toxicity at higher doses, it is useful in patients with heart failure or those taking anticoagulants.
The dose is 500 micrograms 2 – 4 times a day until the symptoms are relieved or diarrhoea or vomiting occurs (max 6
mg per course and do not repeat treatment within 3 days).
Colchicine should be avoided in people with blood dyscrasias and bone marrow disease.
Common side effects of colchicine include:
abdominal pain
nausea and vomiting
diarrhoea
Side effects are dose dependent and may be severe enough to limit treatment.
Corticosteroids
Oral or parenteral corticosteroids are an effective alternative in those who cannot tolerate or who are resistant
to NSAIDs and colchicine. Intra-articular injection of a corticosteroid can be used occasionally in acute monoarticular
gout.
Allopurinol
Allopurinol is not effective in treating an acute attack and may prolong it inde nitely if started during the acute
http://frcemsuccess.com/rev/sc56/ 4/107
Dashboard Subscription expires in: 1 Days Extend
You have scored 20%
You answered 10 correct out of 49 questions.
Your answers are shown below:
Hartmann’s solution may be preferred to sodium chloride 0.9% as it may reduce the risk of:
a) Hypernatraemia
b) Hyponatraemia
c) Fluid overload
d) Hyperchloraemic acidosis
e) Osmotic demyelination syndrome
Something wrong?
Answer
Hartmann’s solution (compound sodium lactate) can be used instead of isotonic sodium chloride solution during or
after surgery, or in the initial management of the injured or wounded; it may reduce the risk of hyperchloraemic
acidosis.
Notes
Solutions of electrolytes are given intravenously to meet normal uid and electrolyte requirements or to replenish
substantial de cits or continuing losses when the patient is nauseated or vomiting and is unable to take adequate
amounts by mouth. When intravenous administration is not possible, uid (as sodium chloride 0.9% or glucose 5%) can
also be given by subcutaneous infusion.
Sodium chloride
Normal saline (sodium chloride 0.9%) contains:
http://frcemsuccess.com/rev/sc56/ 1/107
,6/9/2017 Gastro, Fluids and MSK FRCEM Success
Na+ 150 mmol/L
Cl– 150 mmol/L
Sodium chloride in isotonic solution (0.9%) provides the most important extracellular ions in near physiological
concentrations and is indicated in sodium depletion which can arise from such conditions as gastroenteritis, diabetic
ketoacidosis, ileus, and ascites.
Chronic hyponatraemia arising from inappropriate secretion of antidiuretic hormone should ideally be corrected by
uid restriction. If sodium chloride is required for acute or chronic hyponatraemia, regardless of the cause, the de cit
should be corrected slowly to avoid the risk of osmotic demyelination syndrome and the rise in plasma sodium
concentration should not exceed 10 mmol/L in 24 hours. In severe hyponatraemia, sodium chloride 1.8 % may be used
cautiously.
Hartmann’s solution
Hartmann’s solution (compound sodium lactate) can be used instead of isotonic sodium chloride solution during or
after surgery, or in the initial management of the injured or wounded; it may reduce the risk of hyperchloraemic
acidosis.
Hartmann’s solution contains:
Na+ 131 mmol/L
K+ 5 mmol/L
HCO3– 29 mmol/L
Cl– 111 mmol/L
Ca2+ 2 mmol/L
Glucose
Glucose solutions (5%) are used mainly to replace water de cit. Average water requirements in a healthy adult are 1.5
to 2.5 litres daily and this is needed to balance unavoidable losses of water through the skin and lungs and to provide
suf cient for urinary excretion. Dehydration may occur when these losses are not compensated for by intake e.g. in
coma, or in the elderly. Excessive loss of water without loss of electrolyte is uncommon, occurring in fevers,
hyperthyroidism, diabetes insipidus and hypercalcaemia.
Glucose solutions are also used to correct and prevent hypoglycaemia and to provide a source of energy in those too ill
to be fed adequately by mouth.
Glucose solutions are also given in regimens with calcium and insulin for the emergency management of
hyperkalaemia. They are also given after correction of hyperglycaemia during treatment of diabetic ketoacidosis, when
they must be accompanied by continuing insulin infusion.
Potassium chloride mixtures
Potassium chloride with sodium chloride intravenous infusion is the initial treatment for the correction of severe
hypokalaemia and when suf cient potassium cannot be taken by mouth. Repeated measurement of plasma-potassium
http://frcemsuccess.com/rev/sc56/ 2/107
,6/9/2017 Gastro, Fluids and MSK FRCEM Success
concentration is necessary to avoid the development of hyperkalaemia, particularly in renal impairment. Initial
potassium replacement therapy should not involve glucose infusions, because glucose may cause a further decrease in
the plasma-potassium concentration.
Sodium bicarbonate
Sodium bicarbonate is used to control severe metabolic acidosis (pH < 7.1) particularly that caused by loss of
bicarbonate (as in renal tubular acidosis or from excessive gastrointestinal losses). Mild metabolic acidosis associated
with volume depletion should rst be managed by appropriate uid replacement because acidosis usually resolves as
tissue and renal perfusion are restored.
In more severe metabolic acidosis or when the acidosis remains unresponsive to correction of anoxia or hypovolaemia,
sodium bicarbonate (1.26%) can be infused over 3 – 4 hours with plasma-pH and electrolyte monitoring. In severe
shock, for example in cardiac arrest, metabolic acidosis can develop without sodium or volume depletion; in these
circumstances sodium bicarbonate is best given as a small volume of hypertonic solution, such as 50 mL of 8.4%
solution intravenously.
Albumin
Albumin solutions, prepared from whole blood, contain soluble proteins and electrolytes but no clotting factors, blood
group antibodies, or plasma cholinesterases thus may be given without regard to the recipient’s blood group.
Albumin is usually used after the acute phase of illness to correct a plasma-volume de cit; hypoalbuminaemia itself is
not an appropriate indication and the use of albumin solution in acute plasma or blood loss is wasteful where plasma
substitutes should be used instead.
Concentrated albumin solution (20%) can be used under specialist supervision in patients with an intravascular uid
de cit and oedema because of interstitial uid overload, to restore intravascular plasma volume with less exacerbation
of the salt and water overload than isotonic solutions. Concentrated albumin solution may also be used to obtain a
diuresis in hypoalbuminaemic patients (e.g. in hepatic cirrhosis).
Plasma substitutes
Dextran and gelatin may be used at the outset to expand and maintain blood volume in shock arising from conditions
such as burns or septicaemia; they may also be used as an immediate short-term measure to treat haemorrhage until
blood is available. Dextran and gelatin are rarely needed when shock is due to sodium and water depletion because, in
these circumstances, the shock responds to water and electrolyte repletion.
A patient presents to ED having recently been started on colchicine therapy for acute gout.
Which of the following is the most common side effect that he is likely to complain of:
a) Photosensitivity
b) Diarrhoea
c) Ankle swelling
d) Rash
e) Blurred vision
http://frcemsuccess.com/rev/sc56/ 3/107
, 6/9/2017 Gastro, Fluids and MSK FRCEM Success
Something wrong?
Answer
The most common side effect of colchicine is gastrointestinal upset (nausea, vomiting, diarrhoea and abdominal pain).
Side effects are dose dependent and may be severe enough to limit treatment.
Notes
Gout is a disorder of purine metabolism characterised by a raised uric acid level in the blood (hyperuricaemia) and the
deposition of urate crystals in joints and other tissues, such as soft connective tissues or the urinary tract.
NSAIDs
Acute attacks of gout are usually treated with an NSAID such as diclofenac, indometacin, or naproxen. Treatment
should be started as soon as possible and continued until 48 hours after the attack has resolved. A PPI should be co-
prescribed for gastric protection in people at high risk of gastrointestinal adverse events.
Colchicine
Colchicine is an alternative in patients in whom NSAIDs are contraindicated, not tolerated or ineffective. Although its
use is limited by toxicity at higher doses, it is useful in patients with heart failure or those taking anticoagulants.
The dose is 500 micrograms 2 – 4 times a day until the symptoms are relieved or diarrhoea or vomiting occurs (max 6
mg per course and do not repeat treatment within 3 days).
Colchicine should be avoided in people with blood dyscrasias and bone marrow disease.
Common side effects of colchicine include:
abdominal pain
nausea and vomiting
diarrhoea
Side effects are dose dependent and may be severe enough to limit treatment.
Corticosteroids
Oral or parenteral corticosteroids are an effective alternative in those who cannot tolerate or who are resistant
to NSAIDs and colchicine. Intra-articular injection of a corticosteroid can be used occasionally in acute monoarticular
gout.
Allopurinol
Allopurinol is not effective in treating an acute attack and may prolong it inde nitely if started during the acute
http://frcemsuccess.com/rev/sc56/ 4/107
