World Journal of Emergency Medicine, 2013, 4(2): 113-116 doi: 10.5847/wjem.j.issn.1920-8642.2013.02.005

Original Articles

General characteristics of patients with electrolyte imbalance admitted to emergency department

Arif Kadri Balcı, Ozlem Koksal, Ataman Kose,, Erol Armagan, Fatma Ozdemir, Taylan Inal, Nuran Oner

Faculty of Medicine, Department of Emergency Medicine, Uludag University, Bursa, Turkey

Corresponding authors: Ataman Kose,

Received: 2012-12-20   Accepted: 2013-03-29   Online: 2013-06-15


BACKGROUND: Fluid and electrolyte balance is a key concept to understand for maintaining homeostasis, and for a successful treatment of many metabolic disorders. There are various regulating mechanisms for the equilibrium of electrolytes in organisms. Disorders of these mechanisms result in electrolyte imbalances that may be life-threatening clinical conditions. In this study we defined the electrolyte imbalance characteristics of patients admitted to our emergency department.
METHODS: This study was conducted in the Emergency Department (ED) of Uludag University Faculty of Medicine, and included 996 patients over 18 years of age. All patients had electrolyte imbalance, with various etiologies other than traumatic origin. Demographic and clinical parameters were collected after obtaining informed consent from the patients. The ethical committee of the university approved this study.
RESULTS: The mean age of the patients was 59.28±16.79, and 55% of the patients were male. The common symptoms of the patients were dyspnea (14.7%), fever (13.7%), and systemic deterioration (11.9%); but the most and least frequent electrolyte imbalances were hyponatremia and hypermagnesemia, respectively. Most frequent findings in physical examination were confusion (14%), edema (10%) and rales (9%); and most frequent pathological findings in ECG were tachycardia in 24%, and atrial fibrillation in 7% of the patients. Most frequent comorbidity was malignancy (39%). Most frequent diagnoses in the patients were sepsis (11%), pneumonia (9%), and acute renal failure (7%).
CONCLUSIONS: Electrolyte imbalances are of particular importance in the treatment of ED patients. Therefore, ED physicians must be acknowledged of their fluid-electrolyte balance dynamics and general characteristics.

Keywords: Emergency department; Electrolyte imbalance; Patient characteristics

PDF (265KB) Metadata Metrics Related articles Export EndNote| Ris| Bibtex  Favorite

Cite this article

Arif Kadri Balcı, Ozlem Koksal, Ataman Kose, Erol Armagan, Fatma Ozdemir, Taylan Inal, Nuran Oner. General characteristics of patients with electrolyte imbalance admitted to emergency department. World Journal of Emergency Medicine, 2013, 4(2): 113-116 doi:10.5847/wjem.j.issn.1920-8642.2013.02.005


Fluid and electrolyte balance is one of the key issues in maintaining homeostasis in the body, and it also palys important roles in protecting cellular function, tissue perfusion and acid-base balance. Fluid and electrolyte balance must also be maintained for the management of many clinical conditions. Electrolyte imbalances are common findings in many diseases.[1,2] Imbalances in every electrolyte must be considered in a combined and associated fashion, and examinations must aim to clarify the clinical scenario for an effective and successful treatment. Most of important and prevailing electrolyte imbalances are hypo- and hyper-states of sodium, potassium, calcium, and magnesium.

The kidney is a principally responsible organ for retention and excretion of electrolytes and fluid in healthy individuals.[3] But, other mechanisms like hormonal interactions of antidiuretic hormone, aldosterone, and parathyroid hormone, and other factors such as physiological stress also play important roles in regulating fluid and electrolyte balance in the organism. Studies about the clinical prevalence of electrolyte imbalances often report that these disorders are frequently seen in elderly and critically ill patients, and occur in the progression of diseases such as diabetes mellitus, acute or chronic renal failures, severe cardiovascular events like myocardial infarctions, etc.[4,5,6] To summarize, disturbances in electrolyte balances are mathematically measurable biochemical parameters in the bloodstream that determines the clinical manifestations of interactions between metabolic events such as sepsis,[7] hormones,[8] vascular events,[9] medications,[10] hydration deficiencies,[11] and renal physiology.

In this study we evaluated the general characteristics of patients admitted to our emergency department (ED), and diagnosed as having electrolyte imbalance. Literature data generally focused on imbalances of specific electrolytes, and the majority of the studies recruited patients of a specific disease or risk group. To our knowledge, only three studies focused on electrolyte imbalances in emergency department patients, and two of them conducted with elderly patients.[12,13,14] According to our search in PubMed database, our study will be the second study that investigates the generic electrolyte disturbances in ED admissions, and we think that it will contribute to the literature data by providing valuable information for the ED physicians.


This study was conducted in the ED of Uludag University Faculty of Medicine, and included 996 patients with electrolyte imbalance. The patients were over 18 years of age and admitted to the ED with complaints other than traumatic in origin.

After admission and clinical examinations, data were collected from the patients with electrolyte imbalance after written informed consent was obtained. Demographic and clinical parameters of the patients included date of birth, complaints, vital signs, electrocardiographic (ECG) findings, physical examination findings, pathologic signs, oncological disease and metastatic state if any, drugs used, diagnosis, serum electrolyte levels, and discharge information from the ED. The local ethical committee of Uludağ University Faculty of Medicine approved this study (17-Jan-2012; Approval No: 2012-2/16).

Statistical analysis

SPSS v16.0 software was used for statistical analyses in this study. Descriptive statistics were presented as frequencies and percentages.


In the 996 patients with electrolyte imbalance, 55% (n=545) were male. The mean age of patients was 59.28 ±16.79 years. The most common symptoms of the patients were dyspnea (14.7%, n=146), fever (13.7%, n=136), and systemic deterioration (11.9%, n=118). Most and least frequent electrolyte imbalances were hyponatremia and hypermagnesemia, respectively. The distribution of electrolyte imbalances in our study population is presented in Table 1.

Table 1   Distribution of electrolyte imbalance

ElectrolytesImbalanceNumber of patients%

Na+: sodium; K+: potassium; Ca++: calcium; Mg++: magnesium.

New window| CSV

Confusion (14%), edema (10%) and rales (9%) were most frequently seen in physical examination. ECG examinations revealed normal sinus rhythm in 62% of the patients, and most frequent pathological findings were tachycardia (24%) and atrial fibrillation (7%). Some patients also had chronic diseases, which were treated with drugs. The most frequent comorbidity was malignancies, which are seen in 39% (n=367) of the patients. Most frequent oncological diagnoses in these patients were lung and hematological malignancies. By physical, clinical and laboratory examinations, sepsis was frequently diagnosed in 11% of the patients, pneumonia in 9%, and acute renal failure in 7%. All patients had at least one comorbid disease. The frequencies of prevalent symptoms, findings of physical examinations, ECG patterns, comorbidities and diagnoses are summarized in Table 2.

Table 2   Most frequent symptoms, findings, ECG patterns, comorbidities and diagnoses of the patients

VariablesNumber of patients%
Systemic deterioration11811.9
Abdominal pain989.8
Angina pectoris383.8
Findings in physical examinations
ECG patterns
Normal sinus rhythm61362
Atrial fibrillation687
Atrioventricular block364
Spiked T121
ST segment change121
Diabetes mellitus20320
Coroner artery disease13013
Chronic renal failure9810
Congestive heart failure808
Chronic obstructive pulmonary disease687
Cerebrovascular disease364
Acute renal failure717
Cerebrovascular disease667
Acute coronary syndrome626
Urinary tract infection566
Gastrointestinal bleeding364

New window| CSV

Electrolyte imbalances according to chronic diseases of the patients are presented in Table 3. According to this table all electrolytes were lower than their normal levels in chronic disease states.

Table 3   Electrolyte imbalances according to chronic diseases

(n=367) %
(n=98) %
(n=80) %
(n=68) %
(n=36) %

Na+: sodium; K+: potassium; Ca++: calcium; Mg++: magnesium; HT: hypertension; DM: diabetes mellitus; CAD: coroner artery disease; CRF: chronic renal failure; CHF: congestive heart failure; COPD: chronic obstructive pulmonary disease; CVD: cerebro-vascular disease.

New window| CSV


Electrolyte gradients are controlled precisely between intra- and extracellular compartments for sustaining the normal physiological functions of the muscles and nerves. The main responsible organ for this regulation is the kidney, but other mechanisms like hormonal activities of antidiuretic hormone, aldosterone and parathyroid hormone are also involved in this process. The disorders of these systems may deteriorate the electrolyte balances and results in emergencies.

Sodium imbalances are particularly important in patients who need intensive care because both hypo- and hypernatremia are associated with increased mortality in these patients regardless of age, gender and diagnoses.[15] Our study center provides tertiary health services in its region as a university based hospital, and particularly deals with clinically advanced diseases and complicated patients. Therefore, we particularly investigated electrolyte imbalances in our patients carefully, with an awareness of clinical importance of this entity. We determined sodium imbalance in 65% of our patients, and 60% of them had hyponatremia. This rate of sodium imbalance was defined in accordance with the literature data.

The second most frequent imbalanced electrolyte was calcium in our patients. Calcium has many functions in intracellular enzymatic pathways, and also plays a role in cellular damage and cell death.[16] We determined hypo- and hypercalcemia in 51% and 4% of our patients, respectively. Confusion was the most frequent finding in physical examinations, and this supposed to be a result of hypocalcemia in our patients. Other frequent findings in physical examinations of our patients were tetany and Chvostek-Trousseau signs, which may be associated with calcium balance disorders. We think that most of calcium imbalances were related to oncological diseases in our patients. The malignancy rate was as high as 39%, and the prevailing diagnoses were cancers of the lung and gastrointestinal system (23% each). The high rates of oncological diagnoses resulted in high frequencies of calcium balance disorders.

One of the main effects of high calcium levels is on the cardiovascular system and electrical transmission pathways of the heart. Therefore, we determined shortened corrected QT intervals and the first degree of atrioventricular block in ECG examinations. Compared these ECG findings according to the higher and lower levels of calcium, we found that hypocalcemic patients had more tachycardia, bradicardia and atrial fibrillation, and hypercalcemic patients had more atrioventricular blocks, spiked T waves and ST segment changes. The rates of these differences between the imbalance groups were statistically significant.

The third most frequent imbalance was in the level of potassium. We found the incidence of hypo- and hyperkalemia was 15% and 8% respectively in our patients. By checking physical examination findings, we found that hypokalemia was characterized by confusion, paresis, and aphasia. Although the clinical signs and symptoms cannot be attributed to a single disorder of electrolyte imbalances, it is meaningful to determine the physical aspects of hemodynamic changes of electrolyte levels in bloodstream. Hyperkalemia is a rare condition, but we found it in 8% of our patients. Williams et al[17] reported that potassium secretion from thrombocytes and leukocytes in severe thrombocytosis and leukocytosis may cause pseudo-hyperkalemia. We determined that the first three of most frequent diagnoses were sepsis, infections, and renal failure, and concluded that these clinical conditions, particularly renal failure, might have caused hyperkalemia in our patients. Statistical analyses showed that patients with hyperkalemia, but not with normo- or hypokalemia, had spiked T waves in ECG examinations. It is known that spiked T waves are specific to hyperkalemia, but not all of our patients with hyperkalemia had spiked T waves. We concluded that the interactions in multiple electrolytes had effect on ECG findings in these patients.

The least frequent electrolyte imbalances were hypo- and hypermagnesemia, which were determined in 5% and 1% of our patients, respectively. Hypomagnesemia is known to have a high prevalence rate, but its diagnosis may be intrigued by some factors. First, it has nonspecific manifestations, and frequently overlooked. Second, magnesium level is not examined “routinely” in blood test.[18] Third, patients may be hypomagnesemic, even with a normal serum magnesium level. And finally, magnesium deficiencies are generally masked by other electrolyte deficiencies.

In conclusion, our patients were diagnosed with various oncological diseases (40%). These malignancies expose a major risk for electrolyte imbalances. Therefore, we were aware of electrolyte imbalances in patients admitted to the ED, particularly in those with underlying oncological diseases. Hence our frequencies may not truly reflect the actual prevalence of each electrolyte's imbalance in the general population.

As we cannot assume that patients have single electrolyte imbalances, we conclude that clinical symptoms and findings are reflections of multiple interactions of electrolytes and regulatory systems in the organism. Therefore, ED physicians must be acknowledged of fluid-electrolyte balance dynamics because of the high incidence rate of clinical entities.

Funding: None.

Ethical approval: The local ethical committee of Uludag University Faculty of Medicine approved this study (17-Jan-2012; Approval No: 2012-2/16).

Conflicts of interest: There are no competing interests involving this study.

Contributors: Balcı AK proposed the study and wrote the paper. All authors contributed to the design and interpretation of the study and to further drafts. All authors read and approved the final version of the manuscript.


Lee CT, Guo HR, Chen JB.

Hyponatremia in the emergency department

Am J Emerg Med 2000; 18:264-268.

DOI:10.1016/s0735-6757(00)90118-9      URL     PMID:10830680      [Cited within: 1]

Hyponatremia is a clinical manifestation of a wide variety of diseases, some of which have high mortality rates. To assess the prevalence, cause, and prognosis of hyponatremia encountered in the emergency department, we conducted a prospective study at a major hospital in southern Taiwan. We included all adult internal medicine patients treated in the emergency department during a 2-month period. Hyponatremia was defined as a serum sodium level below 134 mEq/L, and cases patients were followed till being discharged. Among the 3,784 patients included, 166 case patients were identified. Most (65%) case patients were hypovolemic, and the overall mortality rate was 17.9%. The mortality rate increased as the sodium level decreased, but was not related to gender, age, cause, or serum potassium level. When 21 hyperglycemic patients whose serum sodium levels went beyond 134 mEq/L after the adjustment for blood sugar levels were excluded, the prevalence of true hyponatremia was 3.83%. The most common underlying diseases were those of the gastrointestinal system. It is concluded that hyponatremia is a common condition encountered in the emergency department. The mortality is correlated with the serum sodium level, and adjustment of the level is required in hyperglycemic patients to make a correct diagnosis. Unlike the cases in some other clinical settings, almost all cases of hyponatremia encountered in the emergency department were not iatrogenic and had recognizable underlying diseases. Therefore, more effort is generally required to identify the cause of hyponatremia cases in the emergency department.

Shiber JR, Mattu A.

Serum phosphate abnormalities in the emergency department

J Emerg Med 2002; 23:395-400.

DOI:10.1016/S0736-4679(02)00578-4      URL     [Cited within: 1]

Bockenkamp B, Vyas H.

Understanding and managing acute fluid and electrolyte disturbances

Current Paediatrics 2003; 13:520-528.

DOI:10.1016/j.cupe.2003.08.008      URL     [Cited within: 1]


Fluid and electrolyte balance is important in infants and young children because of their high total body water content and basal metabolic rate. Excessive fluid losses lead to dehydration and hypovolaemia. Inadequate and delayed treatment lead to progressive deterioration in tissue perfusion, vascular collapse and progressive multiple organ failure. However, hasty rehydration may be just as devastating as dehydration in seriously ill paediatric patients with severe electrolyte imbalance. Rapid correction of sodium imbalance can produce cerebral oedema or osmotic demyelination. As a rule, sodium correction of 1–2 mmol/l/h is recommended; rates higher than that may lead to death. Hyperkalaemia is an emergency that requires prompt correction medically or with dialysis. Hypocalcaemia, hypokalaemia and hypophosphataemia are increasingly recognized as critical, especially in septic patients. Fluid and electrolyte disorders should be approached by considering the deficit, the maintenance fluid and continuing losses, and a rate of replacement which will not produce severe neurological deficit.

Ito H, Fujimaki H, Inoue J, Shiraki M.

Disorders of fluid and electrolyte metabolism in elderly diabetics

Nihon Ronen Igakkai Zasshi 1989; 26:233-239.

URL     PMID:2795974      [Cited within: 1]

Goldberg A, Hammerman H, Petcherski S, Zdorovyak A, Yalonetsky S, Kapeliovich M, et al.

Prognostic importance of hyponatremia in acute ST-elevation myocardial infarction

Am J Med 2004; 117:242-248.

[Cited within: 1]

Goldberg A, Hammerman H, Petcherski S, Nassar M, Zdorovyak A, Yalonetsky S, et al.

Hyponatremia and long-term mortality in survivors of acute ST-elevation myocardial infarction

Arch Intern Med 2006; 166:781-786.

[Cited within: 1]

Mahowald JM, Himmelstein DU.

Hypernatremia in the elderly: relation to infection and mortality

J Am Geriatr Soc 1981; 29:177-180.

URL     PMID:7204813      [Cited within: 1]

Sonnenblick M, Algur N.

Hypernatremia in the acutely ill elderly patients: role of impaired arginine-vasopressin secretion

Miner Electrolyte Metab 1993; 19:32-35.

URL     PMID:8345832      [Cited within: 1]

Solini A, Zamboni P, Passaro A, Fellin R, Ferrannini E.

Acute vascular events and electrolytes variations in elderly patients

Horm Metab Res 2006; 38:197-202.

DOI:10.1055/s-2006-925224      URL     PMID:16673213      [Cited within: 1]

Alterations in electrolyte balance have been claimed to play a role in the pathophysiology of coronary heart disease; however, the relationship between the electrolyte pattern and other clinical variables immediately after an acute vascular event is unclear. The aim of the present study was to test whether electrolyte and microelement changes characterize the acute phase in patients with different degrees of glucose tolerance admitted to the hospital shortly after an acute cardiovascular or cerebrovascular ischemic event. Two hundred consecutive patients with either myocardial infarction or stroke (SP group), stratified by degree of glucose tolerance, were studied within six hours of admission, and compared against 125 patients admitted for conditions other than acute vascular ischemia (CP). Routine laboratory parameters and serum Na, K, Cl, Mg and Ca concentrations were determined in all patients and compared to those recorded within six months before the admission. Relative to CP and independently of confounding factors including glucose tolerance status, the SP group showed significantly higher plasma glucose and insulin concentrations, higher creatinine and a modified serum electrolyte pattern characterized by significantly lower potassium and magnesium levels and by hypercalcemia and hyperphosphatemia. Irrespective of glucose tolerance, the first hours following an acute vascular event are characterized by marked insulin resistance with a consistent shift in the serum electrolyte pattern. This pattern is the physiological consequence of the attendant compensatory hyperinsulinemia. Its significance for the evolution of ischemic damage remains to be established.

Clark BA, Shannon RP, Rosa RM, Epstein FH.

Increased susceptibility to thiazide-induced hyponatremia in the elderly

J Am Soc Nephrol 1994; 5:1106-1111.

[Cited within: 1]

Miller PD, Krebs RA, Neal BJ, McIntyre DO.

Hypodipsia in geriatric patients

Am J Med 1982; 73:354-356.

URL     PMID:7124762      [Cited within: 1]

Singal BM, Hedges JR, Succop PA.

Efficacy of the stat serum electrolyte panel in the management of older emergency patients

Med Decis Making 1992; 12:52-59.

[Cited within: 1]

Singal BM, Hedges JR, Succop PA.

Prediction of electrolyte abnormalities in elderly emergency patients

Ann Emerg Med 1991; 20:964-968.

DOI:10.1016/s0196-0644(05)82973-7      URL     PMID:1877782      [Cited within: 1]

STUDY OBJECTIVES: To evaluate the operating characteristics of a previously published decision rule (Lowe's criteria) for the ordering of the stat serum electrolyte panel (SEP) and to identify features from the history and physical examination that are predictive for clinically significant electrolyte abnormalities (CSEA) in older emergency patients. DESIGN: A cross-sectional study using a physician questionnaire, record review, and telephone follow-up. SETTING: An urban, university hospital emergency department with approximately 70,000 patient visits a year. TYPE OF PARTICIPANTS: A convenience sample of patients 55 years of age or older who presented for care for any reason were identified by a research associate stationed in the ED. INTERVENTIONS: Physicians managing 1,766 patients were interviewed to determine the presence or absence of 20 dichotomous clinical variables, ten of which constitute Lowe's criteria set. All patients were followed by chart review and/or telephone interview. MEASUREMENTS AND MAIN RESULTS: The determination of clinical significance was made on record review using pre-established guidelines. The SEP was ordered on 800 of the patients on the index visit. The yield of CSEA in this group was 16%. Lowe's criteria operated with a sensitivity of 0.95 (95% confidence intervals, 0.89-0.98) and a specificity of 0.10 (95% confidence intervals, 0.07-0.12) for predicting CSEAs in this population. Logistic regression analysis showed that impaired ability to communicate, acute seizures, vomiting, and prior abnormal electrolytes were independent predictors for CSEA. CONCLUSION: Lowe's criteria showed useful sensitivity but poor specificity in this population. The criteria may be used to encourage selective test ordering by physicians when a low pretest probability for CSEA exists and as part of an algorithm for emergency nurses who order tests to expedite patient care.

Wilson RF, Sibbald WJ.

Fluid and electrolyte problems in the emergency department

JACEP 1976; 5:339-346.

DOI:10.1016/S0361-1124(76)80058-5      URL     [Cited within: 1]

Funk GC, Lindner G, Druml W, Metnitz B, Schwarz C, Bauer P, et al.

Incidence and prognosis of dysnatremias present on ICU admission

Intensive Care Med 2010; 36:304-311.

URL     PMID:19847398      [Cited within: 1]

Bilezikian JP.

Etiologies and therapy of hypercalcemia

Endocrinol Metab Clin North Am 1989; 18:389-414.

URL     PMID:2663480      [Cited within: 1]

Williams ME, Rosa RM, Epstein FH.


Adv Intern Med 1986; 31:265-291.

URL     PMID:3511620      [Cited within: 1]

Whang R, Hampton EM, Whang DD.

Magnesium homeostasis and clinical disorders of magnesium deficiency

Ann Pharmacother 1994; 28:220-226.

URL     PMID:8173141      [Cited within: 1]