Priority 1A – Airway Threats (intervene in seconds)

• Direct airway compromise
  • Laryngospasm → severe hypocalcemia (Ca2+ < 7 mg/dL) or severe hypomagnesemia (Mg2+ < 1 mEq/L)
• Tongue / pharyngeal edema – massive fluid shifts; angioedema after rapid electrolyte correction
• Loss of protective reflexes
  • Severe hyponatremia (Na < 115 mEq/L) → seizures → aspiration risk
  • Hypernatremia (> 160 mEq/L) → coma → cannot protect airway
  • Severe hypercalcemia (> 14 mg/dL) → obtundation
• Key bedside signs: stridor, gurgling, absent gag, secretion pooling, snoring in an unresponsive patient

Priority 1B – Breathing Failure (intervene within minutes)

• Respiratory‑muscle weakness / paralysis
  • Severe hypokalemia (K < 2.5 mEq/L) – diaphragm weakness, ascending paralysis
  • Severe hyperkalemia (K > 7.0 mEq/L) – respiratory muscle paralysis
  • Severe hypophosphatemia (PO₄ < 1 mg/dL) – ventilator‑weaning failure
  • Severe hypomagnesemia (Mg < 1 mEq/L) – muscle weakness, bronchospasm
• Fluid‑related breathing issues
  • Pulmonary edema – crackles, pink frothy sputum, orthopnea / PND (often dilutional hyponatremia)
  • Pleural effusions – ↓ breath sounds, dull percussion (severe overload)
• Critical thresholds: RR < 8 or > 30, shallow or paradoxical pattern, accessory muscle use, SpO₂ < 90 %, can’t speak full sentences

Priority 1C – Circulation Collapse (intervene within minutes)

• Dysrhythmias by electrolyte
  • Hyperkalemia > 5.5 mEq/L: peaked T → no P + wide QRS → sine‑wave / V‑fib
  • Hypokalemia < 3.5 mEq/L: U waves, flat T → PVCs/V‑tach → torsades (< 2.5 mEq/L)
  • Hypocalcemia < 8.5 mg/dL: prolonged QT, torsades risk, ↓ contractility → CHF
  • Hypomagnesemia < 1.5 mEq/L: torsades, refractory V‑tach/V‑fib; worsens digoxin toxicity
• Fluid‑volume emergencies
  • Hypovolemic shock – tachycardia, hypotension, dry mucosa, often hypernatremia
  • Fluid overload / CHF – S₃, JVD, pulmonary crackles, dilutional hyponatremia

Priority 2 – Neurological Disability (intervene in 30–60 min)

• Hyponatremia
  • 130–134 mEq/L: HA, nausea
  • 125–129 mEq/L: confusion, weakness
  • 120–124 mEq/L: somnolence
  • < 120 mEq/L: seizures, coma (acute changes are most dangerous)
• Hypernatremia
  • 146–149 mEq/L: irritability
  • 150–159 mEq/L: lethargy → obtundation
  • > 160 mEq/L: seizures, coma
• Hypocalcemia – Chvostek, Trousseau, perioral numbness, tetany, seizures (post‑thyroid)
• Other neuro triggers – hypermagnesemia (DTR loss → paralysis); hypophosphatemia (confusion); hypercalcemia (confusion → psychosis → coma)

Priority 3 – Moderate Symptoms (intervene in 2–4 hrs)

• Gastro‑intestinal – N/V (any imbalance), diarrhea (K⁺·Mg⁺⁺ loss), constipation (Ca⁺⁺ excess, K⁺ loss), cramping
• Musculoskeletal – cramps (Na⁺/Ca⁺⁺/Mg⁺⁺), non‑respiratory weakness, bone pain (hypercalcemia), rhabdo risk (severe hypophos)
• Fluid balance – moderate edema, > 2 kg/day weight gain, ↓ urine output, skin tenting

Priority 4 – Stable / Monitoring (intervene in 8–12 hrs)

• Fatigue, mild weakness
• Irritability, mild nausea, anorexia
• Mild, oriented confusion
• Stable vital signs

Critical Assessment Pearls (quick reference)

• Hypovolemia clues: orthostatic Δ HR > 20 or SBP ↓ > 20, urine SG > 1.030, BUN:Cr > 20 : 1, ↑ Hct
• Hypervolemia clues: daily weight gain, peripheral edema, crackles, JVD, BUN:Cr < 10 : 1
• Red‑flag combinations: ↓ LOC + weight gain (severe hyponatremia); weakness + constipation + confusion (hypercalcemia); post‑thyroid tingling (hypocalcemia); diuretic use + dysrhythmia (hypo‑K/Mg)