Electrolyte Imbalance Complete Guide

Understanding Electrolytes

Electrolytes are minerals in the blood and body fluids that carry an electrical charge. They are essential for numerous physiological processes including nerve function, muscle contraction, hydration, and acid-base balance. This comprehensive guide explores electrolyte functions, the causes and consequences of electrolyte imbalance, and strategies for maintaining optimal electrolyte health.

The major electrolytes include sodium, potassium, calcium, magnesium, chloride, phosphate, and bicarbonate. Each has specific functions and regulatory mechanisms. The kidneys play a central role in maintaining electrolyte balance by adjusting excretion based on intake and physiological needs.

Electrolyte imbalances range from mild and asymptomatic to severe and life-threatening. They can result from various causes including kidney disease, hormonal disorders, medications, gastrointestinal losses, and excessive sweating. Recognition of symptoms and appropriate laboratory testing are essential for diagnosis and treatment.

Functions of Major Electrolytes

Sodium

Sodium is the primary extracellular cation and the major determinant of extracellular fluid volume. It is essential for nerve impulse transmission, muscle contraction, and cellular function. Serum sodium concentration is tightly regulated between 135-145 mEq/L.

Sodium imbalances significantly affect cellular function. Hypernatremia (high sodium) causes cellular dehydration. Hyponatremia (low sodium) causes cellular swelling. Both conditions can be serious and require careful management.

Potassium

Potassium is the primary intracellular cation. It is essential for maintaining resting membrane potential, nerve function, and muscle contraction, particularly cardiac muscle. Serum potassium is normally maintained between 3.5-5.0 mEq/L.

Potassium has profound effects on cardiac function. Both hyperkalemia (high potassium) and hypokalemia (low potassium) can cause life-threatening cardiac arrhythmias. Even modest deviations from normal require attention.

Calcium

Calcium serves structural, signaling, and functional roles in the body. It is essential for bone health, muscle contraction, nerve transmission, blood clotting, and cellular signaling. Serum calcium is normally maintained between 8.5-10.5 mg/dL.

Calcium regulation involves vitamin D, parathyroid hormone, and the kidneys. Disorders of calcium can affect multiple organ systems including bones, kidneys, muscles, and the nervous system.

Magnesium

Magnesium is a cofactor for over 300 enzymatic reactions. It is involved in energy production, protein synthesis, muscle and nerve function, blood glucose control, and blood pressure regulation. Serum magnesium is normally maintained between 1.7-2.2 mg/dL.

Magnesium deficiency is common and often underdiagnosed. It can cause muscle cramps, cardiac arrhythmias, and neurological symptoms. Magnesium status is important for overall electrolyte balance.

Chloride and Bicarbonate

Chloride is the primary extracellular anion and follows sodium in fluid shifts. It is involved in acid-base balance through its relationship with bicarbonate. Bicarbonate is the primary extracellular buffer, maintaining acid-base balance within a narrow range.

Acid-base disorders often involve chloride and bicarbonate disturbances. The kidneys regulate bicarbonate reabsorption and chloride handling. Understanding acid-base physiology helps interpret electrolyte patterns.

Causes of Electrolyte Imbalance

Fluid-Related Causes

Dehydration

Dehydration occurs when fluid losses exceed intake. Causes include inadequate fluid intake, excessive sweating, vomiting, diarrhea, and diuretic medications. Dehydration concentrates electrolytes, potentially causing hypernatremia and other imbalances.

Isotonic dehydration (equal loss of water and sodium) maintains normal serum sodium but reduces extracellular fluid volume. Hypertonic dehydration (more water than sodium lost) causes hypernatremia. The type and severity of dehydration determine electrolyte impacts.

Overhydration

Excessive fluid intake or impaired water excretion can cause overhydration and dilutional electrolyte abnormalities. This is particularly important for sodium, as excessive water intake can cause hyponatremia.

Syndrome of inappropriate antidiuretic hormone (SIADH) causes water retention and hyponatremia. Heart failure and kidney disease can impair water excretion. Careful attention to fluid balance is important in these conditions.

Gastrointestinal Causes

Vomiting

Vomiting causes loss of gastric acid (hydrochloric acid), resulting in metabolic alkalosis. The kidneys compensate by increasing bicarbonate excretion, which can lead to decreased serum chloride. Sodium and potassium losses may also occur with persistent vomiting.

Loss of gastric contents stimulates aldosterone release, promoting potassium excretion. This can cause hypokalemia. Chloride depletion maintains the alkalosis despite potassium replacement if chloride is not also replaced.

Diarrhea

Diarrhea causes loss of intestinal fluid, which is rich in bicarbonate and potassium. This can cause metabolic acidosis (from bicarbonate loss) and hypokalemia. The acidosis may cause a shift of potassium out of cells, masking the severity of total body potassium depletion.

Cholera and other secretory diarrheas cause particularly severe bicarbonate and potassium losses. Chronic diarrhea can lead to significant malnutrition and electrolyte depletion.

Malabsorption

Malabsorption syndromes can cause electrolyte imbalances through impaired nutrient absorption. Celiac disease, inflammatory bowel disease, and short bowel syndrome may all affect electrolyte status.

Fat malabsorption particularly affects fat-soluble vitamins and may affect calcium and magnesium. Protein-losing enteropathy can cause hypoalbuminemia affecting calcium binding.

Renal Causes

Kidney Disease

Kidney disease disrupts electrolyte regulation. Acute kidney injury can cause rapid and severe electrolyte imbalances. Chronic kidney disease progressively impairs electrolyte excretion, leading to hyperkalemia, hyperphosphatemia, and hypocalcemia.

The stage of kidney disease determines the pattern of electrolyte abnormalities. Early disease may have minimal effects. End-stage renal disease requires dialysis to maintain electrolyte balance.

Diuretic Use

Diuretic medications affect electrolyte excretion. Loop diuretics (furosemide, bumetanide) cause sodium, potassium, chloride, and magnesium loss. Thiazide diuretics cause sodium and potassium loss but less magnesium loss. Potassium-sparing diuretics (spironolactone, amiloride) cause potassium retention.

Monitoring electrolytes is essential when starting or adjusting diuretic therapy. Replacement of lost electrolytes may be necessary. Interactions with other medications and conditions affect electrolyte outcomes.

Endocrine Causes

Adrenal Disorders

The adrenal glands produce aldosterone, which regulates sodium and potassium balance. Addison’s disease (adrenal insufficiency) causes aldosterone deficiency, leading to sodium loss, potassium retention, and hyponatremia. Hyperaldosteronism (excess aldosterone) causes sodium retention and potassium wasting.

Cortisol deficiency in adrenal insufficiency affects cortisol-dependent systems and can cause hyponatremia. Salt-wasting in adrenal crisis can be life-threatening.

Thyroid Disorders

Thyroid hormone affects sodium balance through effects on renal function and ADH secretion. Hypothyroidism can cause hyponatremia, particularly in severe cases. Hyperthyroidism may cause mild hypercalcemia.

Calcium metabolism is also affected by thyroid status. Hyperthyroidism can cause increased bone turnover and hypercalcemia. Thyroidectomy can affect parathyroid function and calcium balance.

Other Causes

Medications

Many medications affect electrolyte balance. ACE inhibitors and ARBs affect potassium excretion. NSAIDs affect sodium and potassium handling. Proton pump inhibitors can cause hypomagnesemia. Chemotherapy agents cause various electrolyte disturbances.

Reviewing medication lists is important when evaluating electrolyte abnormalities. Adjusting or replacing offending medications may resolve imbalances. Coordination between prescribers is important.

Excessive Sweating

Profuse sweating causes loss of sodium, chloride, and smaller amounts of potassium. Sweat sodium concentration is typically lower than plasma but significant losses occur with prolonged heavy exercise in heat.

Heat-related sweating can cause hyponatremia if water replacement exceeds sodium replacement. Sports drinks with electrolytes are recommended for prolonged intense exercise. Recognizing and replacing sweat losses prevents imbalances.

Types of Electrolyte Imbalances

Sodium Imbalances

Hyponatremia (Low Sodium)

Hyponatremia is defined as serum sodium less than 135 mEq/L. It results from too much water relative to sodium or sodium loss exceeding water loss. Causes include SIADH, heart failure, liver disease, kidney failure, diuretics, and excessive water intake.

Symptoms of hyponatremia relate to cellular swelling, particularly in the brain. Mild hyponatremia causes headache, nausea, and fatigue. Severe hyponatremia (below 120 mEq/L) causes confusion, seizures, and coma. The rate of development affects symptom severity.

Treatment depends on the cause and severity. Fluid restriction is first-line for many causes. Hypertonic saline is used for severe symptomatic hyponatremia. Correcting too quickly can cause osmotic demyelination syndrome, so gradual correction is important.

Hypernatremia (High Sodium)

Hypernatremia is defined as serum sodium greater than 145 mEq/L. It results from water loss exceeding sodium loss or excessive sodium intake. Causes include diabetes insipidus, excessive sweating, vomiting, diarrhea, and hypertonic fluid administration.

Symptoms of hypernatremia relate to cellular dehydration. Thirst is the primary defense against hypernatremia. Confusion, lethargy, and neuromuscular irritability occur as sodium rises. Seizures and coma occur with severe hypernatremia.

Treatment involves replacing water deficit with hypotonic fluids. The rate of correction must be carefully controlled to prevent cerebral edema. Addressing the underlying cause is essential for prevention.

Potassium Imbalances

Hypokalemia (Low Potassium)

Hypokalemia is defined as serum potassium less than 3.5 mEq/L. Causes include diuretic use, vomiting, diarrhea, hyperaldosteronism, and certain medications. Intracellular shift of potassium can also cause low serum potassium despite normal total body potassium.

Symptoms of hypokalemia include muscle weakness, cramps, fatigue, and cardiac arrhythmias. Severe hypokalemia can cause paralysis and life-threatening arrhythmias. ECG changes including ST depression and U waves may occur.

Treatment involves potassium replacement and addressing the underlying cause. Oral potassium is preferred for mild to moderate deficiency. Intravenous potassium is used for severe deficiency but must be given carefully to avoid phlebitis and cardiac effects.

Hyperkalemia (High Potassium)

Hyperkalemia is defined as serum potassium greater than 5.0 mEq/L. Causes include kidney failure, medications (ACE inhibitors, potassium-sparing diuretics), tissue breakdown, and acidosis. Spurious hyperkalemia from hemolysis or fist clenching must be ruled out.

Symptoms are often minimal until severe hyperkalemia develops. Muscle weakness, paresthesias, and palpitations may occur. Cardiac effects are the primary concern, including bradycardia, heart blocks, and ventricular fibrillation.

Treatment includes stabilizing the cardiac membrane with calcium, shifting potassium into cells with insulin and glucose, and removing potassium from the body with diuretics, binders, or dialysis. Severe hyperkalemia requires emergency treatment.

Calcium Imbalances

Hypocalcemia (Low Calcium)

Hypocalcemia is defined as serum calcium less than 8.5 mg/dL. Causes include hypoparathyroidism, vitamin D deficiency, kidney disease, magnesium deficiency, and acute pancreatitis. The ionized fraction is most physiologically important.

Symptoms of hypocalcemia include neuromuscular irritability (tetany, paresthesias, seizures), cardiac effects (prolonged QT, heart failure), and cataract formation. Chvostek’s sign (facial twitch with cheek tap) and Trousseau’s sign (carpal spasm with BP cuff inflation) suggest hypocalcemia.

Treatment involves calcium and vitamin D replacement. Acute severe hypocalcemia requires IV calcium. Chronic management involves oral calcium and activated vitamin D. Magnesium repletion is needed when hypomagnesemia is present.

Hypercalcemia (High Calcium)

Hypercalcemia is defined as serum calcium greater than 10.5 mg/dL. Causes include hyperparathyroidism, malignancy, granulomatous diseases, and thiazide diuretics. The most common causes are hyperparathyroidism and cancer.

Symptoms include “bones, stones, groans, and psychiatric overtones”: bone pain, kidney stones, abdominal pain, and neuropsychiatric symptoms. Cardiac effects include shortened QT interval. Severe hypercalcemia causes lethargy and coma.

Treatment involves hydration, loop diuretics to increase calcium excretion, bisphosphonates for malignancy-associated hypercalcemia, and treatment of underlying causes. Denosumab and calcitonin provide additional options.

Magnesium Imbalances

Hypomagnesemia (Low Magnesium)

Hypomagnesemia is defined as serum magnesium less than 1.7 mg/dL. Causes include diarrhea, alcoholism, diuretics, proton pump inhibitors, and diabetes. Hypomagnesemia often coexists with hypokalemia and hypocalcemia.

Symptoms include neuromuscular irritability (tremor, seizures), cardiac arrhythmias (particularly torsades de pointes), and psychiatric symptoms (confusion, depression). Magnesium deficiency is often underdiagnosed.

Treatment involves magnesium replacement, orally or intravenously depending on severity. Concurrent potassium and calcium replacement may be needed. Addressing the underlying cause prevents recurrence.

Hypermagnesemia (High Magnesium)

Hypermagnesemia is rare and usually results from excessive magnesium administration in patients with kidney failure. Symptoms include flushing, hypotension, muscle weakness, and respiratory depression. Cardiac effects include bradycardia and heart block.

Treatment involves stopping magnesium administration and supporting renal excretion. Calcium IV can antagonize magnesium effects. Dialysis is effective for removing magnesium in kidney failure.

Symptoms and Diagnosis

Recognizing Electrolyte Imbalance

Neurological Symptoms

Electrolyte imbalances commonly affect neurological function. Sodium imbalances cause headache, confusion, lethargy, seizures, and coma. Calcium affects neuromuscular excitability, causing paresthesias and tetany. Magnesium deficiency causes tremor and seizures.

Symptom patterns help distinguish different electrolyte abnormalities. The rate of change often matters more than the absolute level. Chronic imbalances may be better tolerated than acute changes.

Cardiac Symptoms

Cardiac effects are among the most serious consequences of electrolyte imbalance. Potassium has the most dramatic cardiac effects, with both high and low potassium causing life-threatening arrhythmias. Calcium and magnesium also affect cardiac conduction.

ECG changes provide important diagnostic information. Hyperkalemia causes peaked T waves, widened QRS, and eventually sine wave pattern. Hypokalemia causes ST depression and U waves. Hypocalcemia prolongs QT interval.

Muscular Symptoms

Muscle symptoms are common in electrolyte disorders. Cramps, weakness, and pain occur with various imbalances. Potassium and magnesium are particularly important for muscle function. Severe hypokalemia can cause rhabdomyolysis.

Tetany from hypocalcemia causes involuntary muscle contractions. Severe hypomagnesemia causes similar symptoms through both direct effects and associated hypocalcemia.

Diagnosis and Testing

Serum Electrolyte Testing

Serum electrolyte testing is the primary method for diagnosing electrolyte imbalances. Basic metabolic panel includes sodium, potassium, chloride, bicarbonate, and often calcium and magnesium. Results should be interpreted in clinical context.

Timing of tests relative to treatments and events matters. Serial measurements help assess trends and response to treatment. Understanding the limitations of single measurements is important.

Advanced Testing

Additional tests may be needed to determine causes of electrolyte imbalance. Urine electrolyte testing helps distinguish causes of hyponatremia and other disorders. Hormonal testing (aldosterone, cortisol, PTH) identifies endocrine causes. Kidney function tests help assess renal contributions.

Imaging studies may be indicated in certain situations. Neck imaging for parathyroid disease, abdominal imaging for adrenal masses, or renal imaging for structural abnormalities may be part of the evaluation.

Treatment Approaches

Replacement Therapies

Oral Rehydration

Oral rehydration solutions provide water and electrolytes for mild to moderate dehydration or losses. Standard solutions contain specific concentrations of sodium, glucose, and other electrolytes that optimize absorption. Sports drinks provide some electrolyte replacement but may be hypertonic.

Oral rehydration is preferred over IV for most cases of mild to moderate dehydration. It is effective, safe, and less expensive than IV therapy. Adequate intake volume is essential for effectiveness.

Intravenous Replacement

IV electrolyte replacement is used for severe imbalances, inability to tolerate oral intake, or conditions requiring rapid correction. IV calcium, potassium, magnesium, and sodium are available in various formulations. Concentrations and infusion rates are carefully controlled to avoid complications.

Potassium should not be given peripherally at high concentrations due to vein irritation risk. Central line administration is needed for concentrated solutions. Cardiac monitoring is often used during IV electrolyte replacement.

Addressing Underlying Causes

Medication Adjustment

When medications cause electrolyte imbalances, adjustment or replacement may be needed. Diuretic regimens may be modified. Potassium-sparing diuretics may be added. Medications affecting calcium or magnesium may be reviewed.

Coordination between prescribers is important. Pharmacist involvement can help identify problematic combinations. Patient education about medication effects and monitoring supports safe use.

Treating Medical Conditions

Underlying medical conditions causing electrolyte imbalance require treatment. Heart failure management reduces fluid overload and hyponatremia risk. Hyperparathyroidism surgery corrects hypercalcemia. Adrenal insufficiency treatment prevents hyponatremia.

Chronic conditions require ongoing monitoring and management. Patient education about warning signs and preventive strategies supports long-term management.

Prevention and Management

Dietary Considerations

Sodium Intake

Optimal sodium intake balances adequate intake for function against risks of excess. The body requires approximately 500 mg of sodium daily for basic functions. Most dietary guidelines recommend limiting intake to less than 2,300 mg daily.

Processed foods contribute most dietary sodium. Fresh foods prepared at home provide more control. Reading labels helps identify high-sodium products. Individuals with certain medical conditions may need more or less restriction.

Potassium-Rich Foods

Dietary potassium supports healthy potassium balance. Good sources include bananas, oranges, potatoes, spinach, and legumes. A balanced diet typically provides adequate potassium for most people.

Those taking potassium-wasting diuretics may need potassium-rich foods or supplements. However, some conditions (kidney disease, certain medications) require potassium restriction. Individual recommendations depend on clinical context.

Calcium and Magnesium

Calcium and magnesium requirements are best met through diet. Dairy products provide calcium. Leafy green vegetables, nuts, seeds, and whole grains provide magnesium. Fortified foods and supplements fill gaps when dietary intake is insufficient.

Vitamin D is essential for calcium absorption. Magnesium status affects calcium utilization. The relationship between these minerals should be considered in dietary planning.

Special Situations

Athletes and Exercise

Athletes have increased electrolyte needs, particularly for sodium and potassium. Sweat losses vary with intensity, duration, and environmental conditions. Replacing both water and electrolytes prevents imbalances.

Sports drinks provide sodium and carbohydrates that enhance fluid absorption. For long-duration exercise, sodium supplementation beyond sports drinks may be needed. Monitoring sweat rate and weight changes guides fluid and electrolyte replacement.

Elderly Individuals

Older adults are at increased risk for electrolyte imbalances due to reduced thirst sensation, declining kidney function, and multiple medications. Falls and cognitive impairment increase risks of injury from electrolyte-related confusion or weakness.

Regular monitoring of electrolytes is important for those on medications affecting balance. Adequate hydration requires attention. Awareness of warning signs supports early intervention.

Individuals with Chronic Illness

Chronic kidney disease, heart failure, and other conditions require ongoing electrolyte monitoring and management. Dietary restrictions may be needed. Medications affecting electrolytes require regular monitoring. Prompt treatment of imbalances prevents complications.

Coordination of care among specialists ensures comprehensive management. Patient and family education supports adherence to dietary and medication recommendations.

Frequently Asked Questions

Understanding Electrolytes

1. What are the most important electrolytes for daily health? Sodium, potassium, calcium, and magnesium are the most important for daily function. Sodium regulates fluid balance and nerve function. Potassium is essential for heart and muscle function. Calcium supports bones and muscles. Magnesium is a cofactor for hundreds of enzymatic reactions.

2. Can I test my electrolytes at home? Basic home electrolyte testing is limited. Home blood pressure monitors do not assess electrolytes. Some home devices claim to assess hydration status through skin conductance but are not reliable for electrolyte measurement. Laboratory testing is needed for accurate assessment.

3. How do I know if I have an electrolyte imbalance? Mild electrolyte imbalances may cause no symptoms. More severe imbalances cause symptoms including fatigue, muscle cramps, irregular heartbeat, confusion, and weakness. Laboratory testing is the only reliable way to diagnose electrolyte imbalance.

Causes and Prevention

4. What causes electrolyte imbalance in healthy people? Healthy people can develop electrolyte imbalances from excessive sweating, inadequate intake, illness (vomiting, diarrhea), and certain medications. Extreme exercise without electrolyte replacement and excessive water intake can also cause imbalances.

5. Does drinking too much water cause electrolyte problems? Excessive water intake can dilute serum sodium, causing hyponatremia. This is particularly a risk during prolonged endurance events when water is consumed without electrolyte replacement. Balancing fluid and electrolyte intake prevents this problem.

6. Which medications affect electrolytes? Many medications affect electrolytes. Diuretics commonly cause potassium and magnesium loss. ACE inhibitors and ARBs affect potassium. NSAIDs affect sodium and potassium. PPIs can cause hypomagnesemia. Chemotherapy agents cause various disturbances.

Symptoms and Treatment

7. What are the warning signs of electrolyte imbalance? Warning signs include muscle cramps or weakness, irregular heartbeat, fatigue, confusion, headache, nausea, and numbness or tingling. Severe imbalances can cause seizures and unconsciousness. Seek medical attention for concerning symptoms.

8. How are electrolyte imbalances treated? Treatment depends on the type and severity of imbalance. Oral replacement treats mild cases. IV replacement is used for severe imbalances or when oral intake is not possible. Addressing the underlying cause prevents recurrence.

9. Can electrolyte imbalances be fatal? Severe electrolyte imbalances can be fatal. Hyperkalemia and hypokalemia can cause cardiac arrest. Severe hyponatremia can cause cerebral edema and herniation. Hypercalcemia can cause coma. Prompt treatment of severe imbalances is essential.

Daily Management

10. How much water should I drink to prevent electrolyte problems? Fluid needs vary by individual, activity level, and climate. General recommendations are 8 glasses (2 liters) daily, more with exercise or hot weather. During prolonged intense exercise, electrolyte-containing fluids are recommended. Listening to thirst provides guidance.

11. What should I eat to maintain electrolyte balance? A balanced diet including fruits, vegetables, whole grains, lean proteins, and dairy provides electrolytes. Bananas and oranges provide potassium. Leafy greens provide magnesium and calcium. Limiting processed foods reduces excessive sodium intake.

12. Do I need electrolyte supplements? Most people do not need electrolyte supplements if they have a balanced diet and normal organ function. Athletes during prolonged intense exercise, those with certain medical conditions, and individuals on specific medications may benefit from supplementation. Consult healthcare providers before starting supplements.

Special Situations

13. How do I prevent electrolyte problems during exercise? Preventing exercise-related electrolyte problems involves adequate pre-hydration, consuming electrolyte-containing fluids during prolonged exercise, and replacing sodium losses during long-duration events. Monitoring sweat rate and body weight helps guide replacement.

14. Can dehydration cause electrolyte imbalance? Dehydration concentrates electrolytes, potentially causing hypernatremia and other imbalances. With pure water replacement, electrolyte dilution can occur. Appropriate fluid replacement with electrolyte-containing fluids prevents this problem.

15. How do kidney disease patients manage electrolytes? Kidney disease patients require careful dietary potassium, sodium, and phosphorus restriction. Phosphate binders may be prescribed with meals. Dialysis removes accumulated electrolytes. Regular monitoring guides management adjustments.

Service Information

16. How can Healers Clinic help with electrolyte concerns? Healers Clinic in Dubai offers comprehensive evaluation and management of electrolyte disorders. Laboratory testing identifies imbalances and their causes. Medical management addresses underlying conditions. Nutritional consultation provides dietary guidance. Nephrology and endocrinology referrals are available for complex cases.

17. What specialists address electrolyte imbalance? Primary care providers manage common electrolyte imbalances. Nephrologists specialize in kidney-related electrolyte disorders. Endocrinologists address hormonal causes of electrolyte problems. Critical care specialists manage severe imbalances requiring hospitalization.

18. How do I book an appointment for electrolyte testing? Contact Healers Clinic through healers.clinic or call the appointment line. Specify concerns about electrolyte balance for appropriate testing. Fasting may be required for accurate results. Previous laboratory results, if available, should be brought to the appointment.

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Medical Disclaimer

The information provided in this guide is for educational purposes only and is not intended as a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read in this guide.

The content of this guide does not establish a physician-patient relationship between Healers Clinic and any reader. Individual medical advice can only be provided through personal consultation with a qualified healthcare professional.

If you are experiencing a medical emergency, please call emergency services or go to the nearest emergency room immediately.

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This guide was prepared by the Healers Clinic Medical Team and is reviewed regularly for accuracy and completeness. Last updated: January 2026.