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Acid Base Balance for EMS

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Acid Base Balance for EMS presentation - appropriate for all levels of EMS personnel; includes interactive components for audience and small group participation and learning; questions? call Porter, …

Acid Base Balance for EMS presentation - appropriate for all levels of EMS personnel; includes interactive components for audience and small group participation and learning; questions? call Porter, Littleton and Parker EMS in Colorado at 303-765-6367 (303-765-6EMS)

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  • 1. Acid-Base Balance for EMS Anne Clouatre, MHS, EMT-P EMS Regional Program Director Centura Health Porter, Littleton and Parker Adventist Hospitals Emergency Medical Services 303-765-6367
  • 2. Objectives
    • Describe pH, acid, base, and buffer.
    • Compare and contrast the three buffer systems.
    • Arrange the normal blood gas values.
    • Differentiate blood gas values for respiratory
    • and metabolic acidosis and alkalosis.
    • Evaluate common conditions that may cause acidosis and/or alkalosis.
    Porter, Littleton and Parker EMS 303-765-6EMS
  • 3. pH
    • What does it mean?
    • pH stands for the p otential for H ydrogen
    Porter, Littleton and Parker EMS 303-765-6EMS
  • 4. pH Scale
    • The pH scale represents the concentration of hydrogen ions (H + ) and hydroxyl ions (OH - ) in fluids.
    Porter, Littleton and Parker EMS 303-765-6EMS
  • 5. pH Scale
    • The scale ranges from 0-14
      • What is the neutral point on this scale?
    • What number is maximum acidity?
    • What number is maximum alkalinity?
    Porter, Littleton and Parker EMS 303-765-6EMS
  • 6. pH Scale
    • Each unit on the scale represents a logarithm: pH = 1
            • log[H+]
      • Therefore, pH = -log[H+]
    Porter, Littleton and Parker EMS 303-765-6EMS
  • 7. Definition of logarithm
    • A logarithm is a mathematical concept that eases the calculation of large numbers. The log of a number is the exponent of the power to which a given base must be raised to equal that number.
      • T he log of 100 is 2 (100=10 2 )
      • T he log of 1,000 is 3 (1,000 = 10 3 )
            • Brady Paramedic Emergency Care, p. 284
    Porter, Littleton and Parker EMS 303-765-6EMS
  • 8. pH Scale
    • What is the pH of a 0.0020 M solution of HCl?
      • Answer:
        • pH = -log[H+]
        • pH = -log (2.0 x 10 -3 )
          • = -(log 2.0 + log 10 -3 )
          • = -[0.30 + (-3)]
          • =-(-2.70)
        • Therefore, pH = 2.70
            • General Chemistry, 4e; pp. 551, A-6
    Porter, Littleton and Parker EMS 303-765-6EMS
  • 9. pH Scale
    • Because of the logarithmic nature of the pH scale, there is a 10-fold difference between each unit on the scale.
      • Therefore, multiply by 10 for every 1 point of increase or decrease on the scale.
        • A pH of 5.0 is 10x as acidic as a pH of 6.0
    Porter, Littleton and Parker EMS 303-765-6EMS
  • 10. pH Scale
    • A pH of 4.0 is how many times as acid as a pH of 6.0?
      • Answer: 100 times (10x10 = 100)
    • A pH of 11.0 is how many times as alkaline as a pH of 7.0?
      • Answer: 10,000 times (10x10x10x10 = 10,000)
    Porter, Littleton and Parker EMS 303-765-6EMS
  • 11. Acids
    • What is an acid?
      • It is neither LSD nor crud on your battery terminals!
      • It is a substance that increases H + ions in water. Increasing acidity is expressed as a number LESS than 7.
    Porter, Littleton and Parker EMS 303-765-6EMS
  • 12. What is a base?
    • a. A substance, which in water, is equal to increasing the concentration of OH - ions
    • b. What you slide into after a good hit in baseball
    • c. A substance that decreases the concentration of H + ions
    • d. Somewhere you can call for medical consultation
    Porter, Littleton and Parker EMS 303-765-6EMS
  • 13. Human Beings
    • Extraordinarily sensitive to pH changes
    • Most material within cells = 6.8
    • Blood plasma = 7.35-7.45
    • Fluids around cells = 7.2-7.3
    • What are the maximum acid and alkaline pH values that are still conducive to (barely) maintaining life?:
      • 6.9 on the acidotic side
      • 7.8 on the alkalotic side
    Porter, Littleton and Parker EMS 303-765-6EMS
  • 14. Let’s draw a pH scale!
    • Need: paper and a writing utensil
    • Activity:
      • 1. Draw the pH scale with a straight, horizontal line. Label it with numbers from 0 to 14
        • 0 on the far left and 14 on the far right
    Porter, Littleton and Parker EMS 303-765-6EMS
  • 15. Add these to your pH scale (There is one for each number.)
    • Oven cleaner
    • Tomatoes
    • Stomach acid
    • Baking soda
    • Black coffee
    • Urine
    • Lemon juice
    • Beer
    • Sea water
    • Household ammonia
    • Bicarbonate of soda
    • Great Salt Lake
    • Hydrochloric acid
    • Distilled water
    • Sodium hydroxide
    Porter, Littleton and Parker EMS 303-765-6EMS
  • 16. Answers…How many do you have correct?
    • pH 0-hydrochloric acid
    • pH 1-stomach acid
    • pH 2-lemon juice
    • pH 3-ice cold beer (also, cola and vinegar)
    • pH 4-tomatoes
    • pH 5-hot, black coffee
    • pH 6-urine (saliva is 6.5)
    • pH 7-distilled water (blood is 7.4)
    • pH 8-sea water
    • pH 9-baking soda
    • pH 10-Great Salt Lake
    • pH 11-household ammonia
    • pH 12-bicarbonate of soda
    • pH 13-oven cleaner
    • pH 14-sodium hydroxide (NaOH) Paramedic Field Care, p. 116
    Porter, Littleton and Parker EMS 303-765-6EMS
  • 17. Buffers
    • “ A substance, especially a salt of the blood, tending to preserve original hydrogen-ion concentration of its solution, upon adding an acid or base.
    • … principal blood buffers include carbonic acid, carbonates, bicarbonates, monobasic and dibasic phosphates, and proteins. Hemoglobin is an important protein buffer.”
            • Taber’s Cyclopedic Medical Dictionary, 18th ed, p. 275
    Porter, Littleton and Parker EMS 303-765-6EMS
  • 18. Buffers and pH Balance
    • pH balance is carefully regulated by three bodily systems:
      • blood chemicals
      • lungs
      • kidneys
    Porter, Littleton and Parker EMS 303-765-6EMS
  • 19. Bicarbonate-Carbonic Acid Buffer
    • This is the first and quickest way of maintaining acid-base balance.
    • This buffer is dependent upon the lung and kidney buffers:
      • Respiratory Renal
      • CO 2 + H 2 O H 2 CO 3 H + + HCO 3 -
      • Carbonic Acid
      • Blood Buffer
    Porter, Littleton and Parker EMS 303-765-6EMS
  • 20. Bicarbonate-Carbonic Acid Buffer
    • Reaction occurs mostly in erythrocytes
      • About 80% of extracellular fluid buffering occurs by way of this buffer system
    • There are 20 parts of HCO 3 - (bicarbonate)
    • to every 1 part of H 2 CO 3 (carbonic acid).
    Porter, Littleton and Parker EMS 303-765-6EMS
  • 21. What do each of these represent?
    • CO 2
    • H 2 O
    • H 2 CO 3
    • H +
    • HCO 3 -
    • O 2
    • Bonus: CO
    • carbon dioxide
    • water
    • carbonic acid
    • hydrogen
    • bicarbonate
    • oxygen
    • carbon monoxide
    Porter, Littleton and Parker EMS 303-765-6EMS
  • 22. Respiratory Buffer System
    • Second fastest; reacts in 1-3 minutes
    • “ Triggered by the action of chemoreceptors in the respiratory centers of the brain stem that detect pH in cerebrospinal fluid” Paramedic Field Care, p. 115
    Porter, Littleton and Parker EMS 303-765-6EMS
  • 23. Respiratory Buffer System
    • Example:
      • Patient with diabetic ketoacidosis (DKA)
      • What type of respirations will this person have and why?
        • Rapid and deep respirations…They indicate that the respiratory system is blowing off CO 2 and H 2 O to rid the body of excess acid by producing a RESPIRATORY ALKALOSIS.
          • This is how the body tries to compensate for the METABOLIC ACIDOSIS brought on by the DKA.
            • Paramedic Field Care, p. 115-116
    Porter, Littleton and Parker EMS 303-765-6EMS
  • 24. Renal (Kidneys) Buffer System
    • Slowest; takes hours to days but provides long-term acid-base balance maintenance
    • Kicks in when blood buffers and respiratory buffers are slacking off!
    • Kidneys regulate pH by excreting excess H + or HCO 3 - ions
    Porter, Littleton and Parker EMS 303-765-6EMS
  • 25. Renal (Kidneys) Buffer System
    • What will the kidneys eliminate if the pH of the extracellular fluid is decreasing?
        • H + ions
    • What will the kidneys eliminate if the pH of the extracellular fluid is increasing?
        • HCO 3 - ions
    Porter, Littleton and Parker EMS 303-765-6EMS
  • 26. Normal Arterial Blood Gas Values
    • pH
    • PaO 2
    • PaCO 2
    • HCO 3
    • 7.35 - 7.45
    • 90%-100%
    • 35 - 45
    • 22 - 26 mEq/l
    Porter, Littleton and Parker EMS 303-765-6EMS
  • 27. Normal Arterial Blood Gas Values
    • Normal PaO 2 depends
    • on altitude…therefore, the “full range”
    • of normal PaO 2 is 70%-100%. Paramedic Field Care, p. 117
    Porter, Littleton and Parker EMS 303-765-6EMS
  • 28. Arrange the blood gas values
    • 1. Normal range for pH
    • 2. Normal range for PaO 2
    • 3. Acidotic range for pH
    • 4. Normal range for PaCO 2
    • 5. Alkalotic range for pH
    • 6. Normal range for HCO 3 -
    • 7. Acidotic range for PaCO 2
    • 8. Alkalotic range for PaCO 2
    • 22 - 26 mEq/l
    • 7.35 - 7.45
    • Over 45
    • 70%-100%
    • 35 - 45
    • Below 35
    • Over 7.45
    • Below 7.35
    Porter, Littleton and Parker EMS 303-765-6EMS
  • 29. Respiratory Derangements
    • Respiratory
    • Acidosis_________
      • Caused by retention of CO 2
      • pH is decreased
      • CO 2 level is increased
    • Respiratory Alkalosis________
      • Caused by excessive elimination of CO2
      • pH is increased
      • CO2 level is decreased
    Porter, Littleton and Parker EMS 303-765-6EMS
  • 30. Respiratory Derangements
    • Respiratory
    • Acidosis_________
    • What are some causes for the retained CO 2 ?
    • What is the treatment?
    • Respiratory Alkalosis________
    • What are some causes for the loss of CO 2 ?
    • What is the treatment?
    Porter, Littleton and Parker EMS 303-765-6EMS
  • 31. Metabolic Derangements
    • Metabolic
    • Acidosis_________
      • Caused by production of metabolic acids
      • pH is decreased
      • CO 2 level is normal
    • Metabolic Alkalosis________
      • Caused by excessive diuretics, prolonged emesis, or too much bicarb administration
      • pH is increased
      • CO 2 level is normal
    Porter, Littleton and Parker EMS 303-765-6EMS
  • 32. Metabolic Derangements
    • Metabolic
    • Acidosis_________
    • What are some causes for the production of metabolic acids?
    • What is the treatment?
    • Metabolic Alkalosis________
    • What are some causes for the alkalosis?
    • What is the treatment?
    Porter, Littleton and Parker EMS 303-765-6EMS
  • 33. Respiratory Acidosis
    • What is it?
    • What are the lab values?
    • Numerous causes:
      • Central - narcotic, sedative, alcohol overdose; CNS lesions
      • Neuromuscular - hypokalemia, botulism
      • Thoracic-pulmonary - pneumonia, smoke inhalation, pneumothorax
      • Airway obstruction - foreign body
            • Adapted from Haddad’s Poisoning and Drug Overdose , p. 141
    Porter, Littleton and Parker EMS 303-765-6EMS
  • 34. Respiratory Alkalosis
    • What is it?
    • What are the lab values?
    • Numerous causes:
      • General - anxiety, pain, fever, encephalitis, meningitis sedative
      • Peripheral - hypotension, hypoxemia, CHF, pulmonary embolism
      • Miscellaneous - mechanical ventilation, sepsis, cirrhosis
            • Adapted from Haddad’s Poisoning and Drug Overdose , p. 141
    Porter, Littleton and Parker EMS 303-765-6EMS
  • 35. Metabolic Acidosis
    • What is it?
    • What are the lab values?
    • Numerous causes:
      • Renal failure, diabetic ketoacidosis, ibuprofen overdose, antifreeze ingestion (ethylene glycol intoxication)
      • Diarrhea, parenteral alimentation, hydrochloric acid ingestion
            • Adapted from Haddad’s Poisoning and Drug Overdose , p. 122, 133
    Porter, Littleton and Parker EMS 303-765-6EMS
  • 36. Metabolic Alkalosis
    • What is it?
    • What are the lab values?
    • Numerous causes:
      • Sodium chloride-responsive - diuretics, cystic fibrosis
      • Sodium chloride-resistant - licorice ingestion, chewing tobacco
      • Miscellaneous - bicarbonate administration, penicillin, milk-alkali syndrome
            • Adapted from Haddad’s Poisoning and Drug Overdose , p. 138
    Porter, Littleton and Parker EMS 303-765-6EMS
  • 37. What’s the matter?
    • pH: 7.20, PCO 2 : 30, HCO 3 - : 16
    • Respiratory alkalosis, metabolic acidosis
    • POTENTIAL CAUSE? Shock
    • pH: 7.60, PCO 2 : 27, HCO 3 - : 23
    • Respiratory alkalosis
    • POTENTIAL CAUSE? hyperventilation
    Porter, Littleton and Parker EMS 303-765-6EMS
  • 38. What’s the matter?
    • pH: 7.12, PCO 2 : 68, HCO 3 - : 29
    • Respiratory acidosis, metabolic alkalosis
    • POTENTIAL CAUSE? Long-term COPD’er
    • pH: 7.2, PCO 2 : 60, HCO 3 - : 14
    • Respiratory acidosis, metabolic acidosis
    • POTENTIAL CAUSE? Cardiac arrest
    Porter, Littleton and Parker EMS 303-765-6EMS
  • 39. Clinical Features
    • RESPIRATORY
    • ACIDOSIS
    • Altered LOC
    • Tachycardia
    • Cardiac dysrhythmias
    • Diaphoresis
    • Visual disturbances
    • Headache
    • Abnormal breathing
    Porter, Littleton and Parker EMS 303-765-6EMS
  • 40. Clinical Features
    • RESPIRATORY
    • ALKALOSIS
    • Circumoral paresthesia
    • Digital paresthesia
    • Carpopedal spasm
    • Altered LOC
    • Seizures
    • Tetany
    • (All are related to neuromuscular irritability.)
    Porter, Littleton and Parker EMS 303-765-6EMS
  • 41. Clinical Features
    • METABOLIC
    • ACIDOSIS
    • Tachycardia
    • Pulmonary edema
    • Cardiac dysrhythmias
    • Decreased cardiac output
    • Tachypnea
    • Deep breathing
    • Confusion - coma
    Porter, Littleton and Parker EMS 303-765-6EMS
  • 42. Clinical Features
    • METABOLIC
    • ALKALOSIS
    • Neuromuscular irritability
    • Seizures
    • Tetany
    • Delirium
    • Hyperreflexia
    • Cardiac dysrhythmias
    • Headache
    • Abnormal breathing
    Porter, Littleton and Parker EMS 303-765-6EMS
  • 43. Super Mind Tank Scenarios
    • 1. Break into groups of 2-3 people
    • 2. Design a scenario to share with the class. Create it so that you can ask the audience at least 2 questions about your patient.
    • 3. Include the following in your scenario:
        • Patient chief complaint
        • Physical exam findings
        • Vital signs
        • Patient pH, PaCO 2 , and HCO 3 -
    Porter, Littleton and Parker EMS 303-765-6EMS
  • 44. Objectives Assessment
    • Can you describe pH, acid, base, and buffer?
    • Are you able to compare and contrast the three buffer systems?
    • Can you arrange the normal blood gas values?
    • Are you able to differentiate blood gas values for respiratory and metabolic acidosis and alkalosis?
    • Can you evaluate common conditions that
    • may cause acidosis and/or alkalosis?
    Porter, Littleton and Parker EMS 303-765-6EMS
  • 45. THANK YOU Feel free to contact me or the rest of our team if you have any questions or comments: Anne - 303.765.6367 Porter, Littleton and Parker EMS 303-765-6EMS

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