Ali Haedar

Department of Emergency Medicine

Saiful Anwar General Hospital
Faculty of Medicine – University of Brawijaya, Indonesia
Special Tips
 Hyperventilation is a diagnosis of exclusion in
tachypnea patients
 Always exclude underlying metabolic acidosis with
Kussmaul breathing, pulmonary embolism, and severe
asthma
 Paper bag rebreathing for hyperventilation is
potentially hazardous ai it can couse significant
hypoxia while raising PCO2 only slightly
Anion Gap
 AG = [Na+} – [HCO3] – [Cl]

 Normal: 3-11 mmol/L

 An elevated AG suggests High Anion Gap Metabolic
Acidosis (HAGMA)
Causes of HAGMA
 S : salicylates, exogenous toxins
(eg metformin, methanol,
toluene, ethylene glycol, iron,
paraldehydes)
 U : Uraemia
 L : Lactate acidosis
 K : ketoacidosis (DKA,
stavation)
 C : Cyanides, carbon monoxide
 A : Alcoholic ketoacidosis
 T : Toluene
 M : Methanol,
methaemoglobinemia
 U : Uraemia
 D : Diabetic Ketocidosis
 P : Paraldehyde
 I : INH, Iron
 L : Lactate acidosis
 E : Ethylene glycol (not ethanol)
 S : Salycilates, solvents
Low Anion Gap
 If AG is very low, consider:
 Hypoalbuminemia
 AG decreases by 2.5 mmol/L for every 1 g/dL decreases
in albumin
 Paraproteinemia
 Hyponatremia
 Mypermagnesemia
 Hypercholestrolemia
 Lab errors
Identify the abnormality for respiratory
failure
Type I: PaO2  60 mmHg (8 kPa)
 A hypoxic pt is often agitated, and sometimes, violent.

Type II: PaCO2  55 mmHg (7 kPa) with/without poor

oxygenation
 A hypercarbic pt is drowsy, so pt may look deceptively ‘comfortable’,
often not tachypneoic.
 Do not treat the high PaCO2 level in pts with chronic compensated
type II respiratory failure (normal pH)

* Consider advance airway management for type I and type II acute respiratory
failure
Look for abnormalities in pH, HCO3,
PCO2, AG for albumin
1. Any abnormalities in any 3, is associated with an acid
base without exception
2. An elevated AG is a marker of HAGMA, even in the
presence of normal pH or HCO3
If pH normal, check for balanced acid
base disorder
1. HCO3<20 PCO2<35 Met Acid + Resp Alka
2. HCO3>24 PCO2>45 Met Alka + Resp Acid
3. HCO3, PCO2 normal AG>11 HAGMA + Met Alka
4. HCO3, PCO2 normal AG normal normal
If pH abnormal, identify the primary
abnormality
 pH < 7.35 and HCO3 < 20 mmol/L : acidosis metabolic

 pH < 7.35 and PCO2 > 45 mmol/L : Acidosis respiratoric

 pH > 7.35 and HCO3 > 24 mmol/L : Alkalosis metabolic

 pH > 7.35 and PCO2 < 35 mmol/L : Alkalosis respiratoric

Identify any secondary abnormalities by
adequacy of compensation
1. Metabolic acidosis: expected PCO2 = (1.5 x HCO3) + 8
mmHg (2)
a. If measured PCO2 is lower than expected, concurrent respiratory
alkalosis
b. If measured PCO2 is higher than expected, concurrent
respiratory acidosis
c. For HAGMA, account for access or missing anions by calculating
the excess anion gap
1) Excess anion gap, AG = AG – 11
2) Add AG to measure HCO3
3) If total = normal HCO3, simple HAGMA
4) If total > normal HCO3, concurrent metabolic acidosis
5) If total < normal HCO3, concurrent NAGMA
2. Metabolic Alkalosis:
expected PCO2 = (0.6 x [HCO3 – 24] = 40 mmHg

a. If measured PCO2 is lower than expected, consider

concurrent respiratory alkalosis
b. If measured PCO2 is higher than expected, consider
concurrent respiratory acidosis
3. Respiratory acidosis or alkalosis
a. Acute
1) HCO3 changes 1 to 2 mmol/L for every change in
PCO2 by 10 mmHg
2) pH changes 0.08 for every change in PCO2 by 10
mmHg
b. Chronic
1) HCO3 changes 4 to 5 mmol/L for every change in
PCO2 by 10 mmHg
2) pH changes 0.03 for every change in PCO2 by 10
mmHg
C. If measured HCO3 is lower than expected, consider
concurrent metabolic acidosis
D. If measured HCO3 is higher than expected, consider
concurrent metabolic alkalosis