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Abd2009

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emergency medicine

emergency medicine

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    • 1. Disturbance Of Acid-Base Regulation Dr. Matongjun Emergency Department of Tianjin General Hospital
    • 2. ABG
      • pH 7.35 – 7.45
      • P CO2 35 – 45 mmHg
      • P O2 75 – 100 mmHg
      • HCO 3 - 22 – 26 mmol/L
    • 3. Acid-base homeostasis
      • Buffer system
        • Carbonic acid / Bicarbonate
      • Organ regulation
        • Lungs
          • Characteristic: Sensitive, quickly, but tired easily so can not continue long term
        • Kidneys
          • Characteristic: powerful but slower (hours to days)
    • 4.  
    • 5. Henderson-Hasselbalch equation pH=pKa+lg [HCO 3 - ] [H 2 CO 3 ]
    • 6.  
    • 7. Category
      • SABD
        • pH: acidosis, alkalosis
        • Etiology: respiratory, metabolic
      • MABD
        • Two or three SABD are taking place simultaneously
    • 8. Metabolic Acidosis
    • 9. Definition
      • HCO 3 - ↓ , H + ↑
        • pH   HCO 3 -  * compensation process P CO 2  *
    • 10. manifestation
      • Kussmaul’s respiration
      • Nausea , vomiting and abdominal pain
      • Tachycardia, cardiac output decrease and hypotension
      • Headache, weakness, lethargy and confusion, the level of consciousness is depressed, the deep tendon reflex decrease.
      • Alter plasma potassium and Calcium concentration
    • 11. Category
      • Increased anion gap and normal anion gap
      • Anion Gap
        • [Na + ] - ( [Cl - ] + [HCO 3 - ] )
        • Normal range 8~16 mmol/L
        • unmeasured anions, consist of proteins (primarily albumin), sulfates, phosphates, and organic acids
    • 12. Anion Gap All anions and cations in Serum TOTAL 151 TOTAL 151 Sulfates 1 Phosphates 2 Magnesium 1.5 Organic acids 5 Potassium 4.5 Proteins 15 Calcium 5 Bicarbonate 24 Sodium 140 Chloride 104 CATIONS ANIONS
    • 13. Category
      • Increased AG
        • HCO 3 - decreases and replaced by other anions
      • Normal AG (hyperchloremic)
        • HCO 3 - decreases and replaced by Cl -
    • 14. Elevated AG Metabolic Acidosis Lactic acidosis L Unmeasured osmoles , Ethylene glycol, Aldehydes , Paraldehydes U Alcoholic lactic acidosis A Methanol ingestion M Starvation ketosis S Salicylate intoxication S Uremia U Diabetic ketoacidosis K Etiology
    • 15.
      • increased serum chloride concentrations
      • generally due to gastrointestinal or renal bicarbonate wasting
      • Ingestion of chloride salts or chloride-containing anion exchange resins
      Normal AG Metabolic Acidosis
    • 16. Treatment
      • Remove the Cause
      • alkali therapy
        • Benefit: decrease the risk of cardiovascular compromise
        • Risk: 5%NaHCO 3 is hyperosmotic, hypernatremia, hypercapnia, cerebrospinal fluid acidosis, and overshoot alkalosis
        • Indication: renal failure; arterial blood pH below 7.20 or HCO 3 - concentration below 10 mmol/L
        • Goal: Maintain the blood pH > 7.20 and plasma HCO 3 - concentration > 10 mmol/L
    • 17. Metabolic Alkalosis
    • 18. definition
      • plasma HCO 3 - concentration >27 mmol  L
      • arterial blood pH>7.40
      • Compensation
        • PaCO 2 ↑
    • 19. Etiology
      • loss of acid from GI tract or urine, loss fluid with a chloride HCO 3 - concentration ratio that is higher than plasma
        • loss of gastric contents, Vomiting or nasogastric suctioning.
        • Diuretics (Cl lost )
        • Hyperaldosteronism (H + and Cl - lost )
      • alkaline drugs ingestion
        • Antacid overuse (HCO 3 - )
        • Blood transfusions (citrate )
    • 20. Diagnosis
      • History
      • Symptoms
        • Irritability and Possible tetany, tingling , facial twitching, muscle tremors
        • volume depletion : weakness, postural dizziness
        • hypokalemia : muscle weakness, paresthesias
      • physical examination
        • respiratory rate
        • BP(hypertension+Hypokalemia+metabolic alkalosis suggest primary mineralocorticoid-induced disease)
    • 21. Treatment
      • stopping the intake of soda bicarbonate
      • Saline-responsive
        • Correct volume deficits
        • potassium supplementation : 4.5-5.5 mmol/L
        • H 2 R antagonists : ranitidine, cimetidine, diminish H + secretion; pump inhibiter, Omeprarole
      • Saline-unresponsive
        • remove the mineralocorticoid source or block with spironolactone
    • 22. Respiratory Acidosis
    • 23. Definition
      • Lungs fail to eliminate CO 2 so PaCO 2 is elevated
      • Compensation
        • HCO 3 - ↑
    • 24. Etiology
      • inhibition of the respiratory center: head trauma, Neurological disorders, anesthesia
      • disorders of respiratory muscle: Chest trauma
      • upper airway obstruction
      • disorders affecting gas exchange across pulmonary capillaries: COPD, pneumonia, acute or chronic respiratory failure , cardiac arrest
    • 25. Signs and Symptoms
      • respiratory distress, dyspnea
      • level of consciousness 
      • If severe, patients may complain of headaches or show signs of increased intracranial pressure
        • due to the vasodilatory properties of C0 2 , increase cerebral blood flow
    • 26. Pathophysiology
      • Acute Compensation
        • l mmol/L increase in HCO 3 - for each 10mmHg in PCO 2
        • The HCO 3 - rarely rises above 30mmol/L
      • Chronic Compensation
        • Over the next 2-3 d
        • the kidneys increase H + secretion leading to an elevation of serum HCO 3 - by 3~4mmol/L for each 10mmHg increase in PaCO 2
    • 27. Treatment
      • improving ventilation
      • HCO 3 - should not be given
      • Oxygen should also be used with care
      • Diet: Low carbohydrate, high fat
    • 28. Respiratory Alkalosis
    • 29. Definition
      • decrease in blood PaCO 2
      • compensatory decrease in HCO 3 - .
    • 30. Causes of Respiratory Alkalosis
      • Increased CNS drive for respiration
        • Anxiety
        • CNS infection/infarction/trauma
        • Drugs - salicylates/nicotine/aminophylline
        • Fever/sepsis - especially Gram-negative sepsis
        • Pregnancy/progesterone
        • Anemia, Pulmonary edema/pneumonia , Pulmonary emboli
        • Carbon monoxide toxicity
        • Reduced inspired 0 2 tension - high altitude
      • Increased mechanical ventilation
    • 31. Signs and Symptoms
      • hyperventilation: rapid, deep respirations
      • perioral and extremity paresthesias, muscle cramps, seizures
      • cardiac arrhythmias
      •  K + ,  Ca +
    • 32. Pathophysiology
      • Acute Compensation
        • extra-and intra-cellular buffering , l~2mmol/L fall in HCO 3 - for every 10mmHg decrease in PaCO 2 The HCO3- rarely goes below 18mmol/L.
      • Chronic Compensation
        • kidneys decrease the secretion of H + , serum HCO 3 - decreases 4~5mmol/L for every 10mmHg decrease in PaCO 2 .
    • 33. Treatment
      • correcting the underlying disorder
        • In ICU, hypoxemia and improper ventilatory settings are the most common cause
        • Rebreathing in a paper bag can help the patient with psychogenic hyperventilation
      • Treatment of the alkalosis is usually not necessary
      • Antianxiety medications, diazepam
    • 34. Diagnosis
      • The proper evaluation of patients with suspected acid-base disorders requires consideration of
      • The clinical picture
      • Blood Gas Results
      • Serum electrolytes
    • 35. Diagnosis
      • metabolic or respiratory
        • determined by the primary change, in HCO 3 - or PCO 2
      • acute or chronic
        • An acute process is measured in minutes to hours
        • a chronic process is measured in days to weeks or longer
      • simple or mixed
        • The primary change of simple disorder is in only one parameter
        • The primary change of mixed disorder is in both
    • 36. ABG
      • The simplest approach to the evaluation of blood gases is to consider pH. Pco 2 and HCO 3 - separately and then combine the information
    • 37. ABG Interpretation
      • Identify whether pH, pCO 2 , and HCO 3 are abnormal
      • pH 7.30
      • pCO2 55
      • HCO3 26
      • Match like disorders
      • pH and pCO 2 are both
      • the two matching values tell what the problem is – Acidosis or Alkalosis
    • 38. ABG Interpretation
      • Determine if abnormality is due to the kidneys (metabolic ) or the lungs (respiratory)
      • pH 7.30
      • pCO2 55
      • HCO3 26
      • Match the like abnormalities
      • Respiratory (lung problem) and Acidosis
      • = Respiratory Acidosis
      • Acid
      • Acid = LUNGS
      • Normal = Kidneys
    • 39. MABD
      • The compensation can be expected. If the compensation is outside the expected range, it is a MABD
      • Two methods to diagnose MABD
        • Method I  A rigorous method which involves calculation of the expected compensations
        • Method II   Look on a nomogram
        • If Pco 2 and HCO 3 - change in opposite direction   consider a MABD
    • 40. Method I
      • Metabolic
        • Acidosis: Expected pCO 2 = 1.5 x [HCO 3 - ] + 8 ± 2
        • Alkalosis: Expected pCO 2 =↑6 mmHg per 10 mEq/L  ↑ in HCO 3 -
    • 41. Method I
      • Respiratory
        • Acidosis
          • Acute Expected  ↑ HCO 3 - = ↑ 1mEq/L for each 10 mm  ↑ PCO 2
          • Chronic: Expected  ↑ HCO 3 - = ↑ 3.5mEq/L for each 10 mmHg  PCO 2
        • Alkalosis
          • Acute Expected ↓ HCO 3 - = ↓ 2mEq/L for each 10 mm Hg  ↓ PCO 2
          • Chronic Expected  ↓ HCO 3 - = ↓ 5 mEq/L for each 10 mmHg ↓ PCO 2
    • 42. Example 1
      • pH=7.08, pCO 2 =14, HCO 3 - =4, Na=140, Cl=104
        • The pH is low indicating the primary disorder is acidosis.
        • The anion gap is 140 - (104 + 4) = 32, thus elevated
        • The pCO 2 is low, the expected compensation
        • The predicted pCO 2 by the above equation is 1.5×4+8 = 14 , This is the observed pCO 2
        • simple increased anion gap metabolic acidosis
      • pH=7.08, pCO2=14, HCO3-=4, Na=140, Cl=124 ?
    • 43. Example 2
      • pH 7.37, pCO 2 =18, HCO 3 - =10, Na=140, Cl=114
      • the pH to be normal
      • The anion gap is 16, thus increased
      • Expected pCO 2 is 1.5×10+8 = 23 (21 at minimum), there must be an element of respiratory alkalosis
      • a combination of increased anion gap metabolic acidosis and a respiratory acidosis
    • 44. Example 3
      • In a patient with severe COPD, and who is diuretics, the pH=7.42, pCO 2 = 65, HCO 3 - =41, Na 143, K 3.1, Cl 88
      • Start with a metabolic alkalosis, why?
      • pCO 2 should be 50.2 mmHg
        • 6 mmHg CO 2 for each 10 mEq/L HCO 3 - , 41-24 = 17; 1.7×6 + 40 = 50.2 mmHg
      • pCO 2 is measured at 65, there is a respiratory acidosis
    • 45.  
    • 46. Thank you

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