Talk by Jonathan Ilicki from the annual emergency medicine meeting in Sweden 2017, #SWEETS17. Full talk here: http://scanfoam.org/extreme-acidosis-how-low-can-you-go/

1. HOW LOW CAN YOU GO?
EXTREME ACIDOSISIN CARDIAC ARREST
Jonathan Ilicki MD MSc | Functional Area of Emergency Medicine Solna | Karolinska University Hospital

2. PHYSIOLOGY
PROGNOSIS
LOWER LIMITS
ACIDOSIS

3. 0,00000000
0,00000005
0,00000010
0,00000015
pH 7.1 pH 6.85
[H+]
Park 2015, William 2014, Weil 1986
ABG VBG
Different H+ concentrations in
cardiac arrest
15 x 10-8
5 x 10-8
10 x 10-8
0
≈

4. Dead space?
1mmol
/minBE
METABOLIC RESPIRATORY
(often)
Leadingham 1962, Makino 2005, Spindelboeck 2016, Aufderheide 2004
(always)
(CPP = Coronar Perfusion Pressure)

5. Arrhythmic
Inotropy↓
0
20
40
60
80
100
0 10 20 30
SaO2(%)
pO2 (kPa)
7,4 7,1 6.7
Orchard 1994, Gaskell 1880, Seguchi 1989, Shapiro 1990, Martin 1989, Refsum 1997, Llijitos 2016
pH

6. INCREASE FiO2?

7. SaO2 94-98% ✓

8. 6.3 6.4 6.5 6.6 6.7 6.8 6.9 7.0 7.1 7.2 7.3 7.4
GRAND
MAL
Bozzutto 1988, Orringer 1977, Paz 2014
NON-
ARRESTICU

9. ✓ PHYSIOLOGY
PROGNOSIS
LOWER LIMITS

10. prognosis
Edmonds-Seal 1966, Ganga 2013, Funk 2009, Allyn 2016, Spindelboeck 2016, Farzi 2013
Ph < 7
& witnessed
10% survived
admitted to ICU
ED ICU

11. prognosis
Edmonds-Seal 1966, Ganga 2013, Funk 1998, Allyn 2016, Spindelboeck 2016, Farzi 2013
Ph < 7
& witnessed
10% survived
admitted to ICU
Pre-hospital ED ICU
Early acidosis did NOT predict
hospital admission

12. ✓ PHYSIOLOGY
✓ PROGNOSIS
LOWER LIMITS

13. 6.3 6.4 6.5 6.6 6.7 6.8 6.9 7.0 7.1 7.2 7.3 7.4
35 yr M
Pyloric
obstruction
22 yr F
DKA
21 yr M
Hemorrhagic
shock
65 yr M
SPLENIC BLEED
59 yr M
COCAINE
24 yr M
NEAR-DROWNED
Soler 1974, Warner 2001, Ncomanzi 2014, Spencer 2010, Di Rollo 2012, Smith 2015, Spencer 2009, Opdahl 1996
63 yr M
METFORMIN
LACTic ACIDOSIS
66 yr F
METFORMIN
LACTic ACIDOSIS
CARDIAC ARREST + extreme acidosis

14. PH in arrest:
ABG ≠ VBG
extreme ACIDOSIS:
NEEDS high fiO2
PRE-ARREST Acidosis =
extreme acidosis survivable
1 2
43
Probably
worse
PROGNOSIS
PHIn ed
=