Chem Path Flashcards
Normal pH range
7.35 - 7.45
Normal PCO2
4.7 - 6kPa
Normal Bicarbonate
22 - 30 mmol/L
Normal PO2
10 - 13 kPa
Blood gas results in Metabolic Acidosis
pH
HCO3
CO2
pH LOW
HCO3 LOW
CO2 normal or LOW in compensation
Causes of Metabolic Acidosis (4)
- DKA - increased H+ production
- Renal tubular - decreased H+ excretion
- Intestinal fistula - decreased HCO3
- Lactate build up
Blood gas results in Respiratory Acidosis
pH
HCO3
CO2
pH LOW
HCO3 normal or HIGH in compensation
CO2 HIGH
Causes of Respiratory Acidosis (4)
- Impaired gas exchange e.g. pneumonia, COPD
- Poor perfusion
- Decreased ventilation e.g. head injury
Blood gas results in Metabolic Alkalosis
pH
HCO3
CO2
pH HIGH
HCO3 HIGH
CO2 normal/High
Causes of Metabolic Alkalosis (3)
- D&V
- Pyloric stenosis - babies vomit up all their stomach acid
- hypokalaemia
Blood gas results in Respiratory Alkalosis
pH
HCO3
CO2
pH HIGH
HCO3 normal/LOW
CO2 LOW
Causes of Respiratory Alkalosis (2)
- Mechanical ventilation
2. Hyperventilating/Panic attack - blow off all your CO2
Why look at the PO2?
Gives an indication of lung function, and tissue oxygenation
What's the problem? pH 6. 90 (7.35-7.45) H+ 126 nmol/l (35-46) pCO2 3.0 kPa (4.7-6.0) pO2 24.0 kPa (10.0-13.3) Bicarbonate 6 mmol/l (22-30)
Metabolic Acidosis with partial respiratory compensation
What's the problem? pH 7. 55 (7.35-7.45) H+ 28 nmol/l (35-46) pCO2 8.2 kPa (4.7-6.0) pO2 10.0 kPa (10.0-13.3) Bicarbonate 51 mmol/l (22-30)
Metabolic Alkalosis with partial respiratory compensation
What's the problem? pH 7. 55 (7.35-7.45) H+ 28 nmol/l (35-46) pCO2 3.0 kPa (4.7-6.0) pO2 14.4 kPa (10.0-13.3) Bicarbonate 20 mmol/l (22-30)
Respiratory Alkalosis
What’s the problem?
72 year old man
Long history of chronic obstructive airways disease
On diuretics for cardiac failure
Potassium 2.6 mmol/l (3.5-5.5)
pH 7. 41 (7.35-7.45) H+ 39 nmol/l (35-46) pCO2 10.4 kPa (4.7-6.0) pO2 7.8 kPa (10.0-13.3) Bicarbonate 47 mmol/l (22-30)
Which?
Normal
Metabolic Acidosis
Respiratory Acidosis
Metabolic Alkalosis
Respiratory Alkalosis
Mixed metabolic acidosis and respiratory acidosis
Mixed metabolic alkalosis and respiratory alkalosis
Mixed metabolic alkalosis and respiratory acidosis
Mixed metabolic acidosis and respiratory alkalosis
Mixed metabolic alkalosis and respiratory acidosis
A young woman was admitted to hospital 8 hours after she had taken an overdose of aspirin. Arterial blood: pH 7. 46 (7.35-7.45) H+ 35 nmol/l (35-46) pCO2 2.0 kPa (4.7-6.0) pO2 17.8 kPa (10.0-13.3) Bicarbonate 10 mmol/l (22-30)
Normal
Metabolic Acidosis
Respiratory Acidosis
Metabolic Alkalosis
Respiratory Alkalosis
Mixed metabolic acidosis and respiratory acidosis
Mixed metabolic alkalosis and respiratory alkalosis
Mixed metabolic alkalosis and respiratory acidosis
Mixed metabolic acidosis and respiratory alkalosis
Mixed metabolic acidosis and respiratory alkalosis
Arterial blood: pH 6. 93 (7.35-7.45) H+ 116 nmol/l (35-46) pCO2 9.7 kPa (4.7-6.0) pO2 65.8 kPa (10.0-13.3) Bicarbonate 15 mmol/l (22-30)
Normal
Metabolic Acidosis
Respiratory Acidosis
Metabolic Alkalosis
Respiratory Alkalosis
Mixed metabolic acidosis and respiratory acidosis
Mixed metabolic alkalosis and respiratory alkalosis
Mixed metabolic alkalosis and respiratory acidosis
Mixed metabolic acidosis and respiratory alkalosis
Mixed metabolic alkalosis and respiratory acidosis
How to calculate the anion gap?
Normal range?
(Na+ + K+) - (Cl- + HCO3)
14 - 18mmol/L
Causes of raised anion gap metabolic acidosis?
a) Endogenous (3)
b) Exogenous (MUD PILES)
a) DKA
Lactic acidosis
Starvation
b)
Methanol
Uraemia
Drugs
Paracetamol Insecticides Lithium Ethanol Salicylates (aspirin)
How to measure Osmolality?
2(Na + K) + urea + glucose
How to measure the osmolar gap?
Measure Osmolality - Calculated Osmolarity
What’s the normal osmolar gap?
What could cause an increased osmolar gap?
extra solute present in the plasma e.g. ethanol, methanol
What is Osmolality? Units?
Measured total number of particles present in a solution mmol/kg
What is Osmolarity? Units?
Calculated total number of particles present in a solution mmol/L
Normal range for serum osmolality?
275 - 295 mmol/kg
Normal range for sodium?
135 - 145 mmol/L
Pathogenesis of HYPOnatraemia?
increased extracellular water, dilutionary effect
Level of severe HYPOnatraemia?
Signs of HYPOnatraemia? (4)
- nausea and vomiting
- confusion
- seizures
- coma
In true HYPOnatraemia will the osmolality be high or low?
LOW
Clinical features of HYPOvolaemia? (7)
- low BP
- tachycardia
- postural hypotension
- reduced skin turgor
- dry mucous membranes
- confusion/drowsiness
- reduced urine output
Clinical signs of HYPERvolaemia? (3)
- raised JVP
- bibasal crackles
- peripheral oedema
Classification of hyponatraemia (3)
- HYPERvolaemic
- EUvolaemic
- HYPOvolaemic
Causes of HYPERvolaemic HYPOnatraemia? (3)
- Heart failure
- Cirrhosis
- NephrOtic syndrome
Causes of HYPOvolaemic HYPOnatraemia? (3)
- D&V
- diuretics
- salt losing nephropathy
Causes of SIADH? (4)
- CNS - trauma, inflammation, abscess
- Lung - pneumonia, abscess, small cell lung Ca
- Malignancies - lymphoma, Ewing’s sarcoma, lung, GI, GU
- Drugs - SSRI, TCA, PPI, opiates, amitriptyline
Diagnostic test for SIADH?
Short SynACTHen test
How would you treat a HYPOvolaemic HYPOnatraemic patient?
Replace with 0.9% N.Saline
How would you treat a HYPERvolaemic HYPOnatraemic patient?
Fluid restrict and treat underlying cause
What must you NOT do when correcting sodium?
why?
Serum Na must NOT be corrected > 12 mmol/L in the first 24 hours
Risk of osmotic demyelination (central pontine myelionlysis)
What are the effects of central pontine myelionlysis?
- quadriplegia
- pseudobulbar palsy
- seizures
- coma
- death
Drugs used to treat SIADH? (2)
- Vaptans
2. Demeclocyline
What are the two main stimuli for ADH secretion?
a. Reduced bld volume & reduced serum osmolality
b. Increased bld volume & increased serum osmolality
c. Increased bld volume & reduced serum osmolality
d. Reduced bld volume & increased serum osmolality
d. Reduced bld volume &; increased serum osmolality
Causes of hyponatraemia post-surgery? (2)
- dilutionary due to over hydration with hypotonic IV fluids
- transient increase in ADH due to stress of surgery
Clinically HYPERnatraemic?
> 145mmol/L
Causes of HYPOvolaemic HYPERnatraemia?
- GI
- Skin
- Renal
GI - vomiting, diarrhoea
Skin - excessive sweating, burns
Renal - loop diuretics, osmotic diuresis
Causes of EUvolaemic HYPERnatraemia?
- resp
- skin
- renal
- resp - tachypnoea
- skin - excessive sweating, fever
- renal - DI
Causes of HYPERvolaemic HYPERnatraemia? (2)
- Hypertonic saline
2. Conn’s syndrome - mineralocorticoid syndrome
Signs of HYPERnatraemia? (6)
- lethargy
- thirst
- irritability
- confusion
- coma
- fits
What investigations would you order in a patient with suspected diabetes insipidus?
a. Serum glucose (exclude diabetes mellitus)
b. Serum potassium (exclude hypokalaemia)
c. Serum calcium (exclude hypercalcaemia)
d. Plasma & urine osmolality
e. Water deprivation test
e. Water deprivation test
Symptoms of DI? (2)
polyuria
polydipsia
Types of DI?
- Cranial - lack of ADH
2. Nephrogenic - insensitivity to ADH
Causes of cranial DI? (3)
- head trauma
- tumour
- surgery
How does cranial DI respond to desmopressin?
ability to concentrate urine
What is Psychogenic Primary Polydipsia?
- response to 8 hr fluid deprivation test?
common in mentally ill patients, institutionalised patients
continuous feeling of thirst, will seek fluids from any source possible
able to concentrate urine
Cause of EUvolaemic HYPOnatraemia? (3)
- hypothyroidism
- SIADH
- adrenal insufficiency
Normal range of potassium?
3.5 - 5.5mmol/L
What hormones are involved in potassium homeostasis? (2)
- Aldosterone
2. Angiotensin II
ECG change associated with HYPERkalaemis?
Peaked T waves
Causes of HYPERkalaemia? (7)
- excessive intake
- acidosis
- insulin shortage
- rhabdomyolysis
- Addison’s disease
- reduced GFR - renal/cardiac failure
- drugs
Drugs that can cause HYPERkalaemia? (4)
- ACEi, ARB, NSAIDs, K+ sparring diuretics
Clinical features of HYPOkalaemia? (3)
- muscle weakness
- cardiac arrhythmias
- polyuria/polydipsia
Causes of HYPOkalaemia? (7)
- Hyperaldosterism Conn’s syndrome
- GI loss
- Renal loss
- ostmotic diuresis
- insulin
- beta agonists - salbutamol
- alkalosis
Hyperkalaemia is a side-effect of which of the following drugs?
a. Furosemide
b. Bendroflumethiazide
c. Salbutamol
d. Ramipril
c. Salbutamol
Hypokalaemia is a side-effect of which of the following drugs?
a. Spironolactone
b. Indomethacin
c. Perindopril
d. Furosemide
d. Furosemide
Normal Calcium range
2.2 - 2.6 mmol/L
What happens in response to low calcium? (4)
1. Parathyroids release PTH PTH acts at... 1. Bone - increased calcium resorption 2. Kidney - increases Ca reabsorption - increases PO4 excretion - increases 1a(OH)ase - increases VitD3 3. GI - increases Ca absorption - increases VitD3 absorption
Enzyme required for rate limiting step in activation of 25-hydroxycholecalciferol to 1,25-dihydroxycholecalciferol (VitD3)? Where?
1-alpha-hydroxylase
kidney
Hormones that control Calcium homeostasis?
- PTH
2. Calcitriol
In what condition is 1alpha-hydroxylase secreted in the lung?
Sarcoidosis
Causes an increase in Ca2+
Enzyme required to convert cholecalciferol to 25-hydroxycholecalciferol? Where?
25-hydroxylase
Liver
Where is the majority of calcium within the body?
Skeleton (99%)
What percentage of plasma calcium is bound to albumin?
50%
In sepsis, when albumin is low, what can happen to calcium levels?
low calcium
Effects of Vitamin D3? (3)
- increased calcium absorption from gut
- increased phosphate absorption from gut
- bone remodelling
Vitamin D3 deficiency in children?
Ricket’s
Vitamin D3 deficiency in adults?
Osteomalacia
What happens to Ca/PO4/ALP/PTH in Vit D deficiency?
Low VitD3 Low Ca Low PO4 High PTH High ALP
Clinical features of Osteomalacia? (3)
Pathonogmonic?
- Boen pain
- myalgia
- increased risk of fractures
Looser’s zones
Clinical features of Ricket’s? (4)
- bowing of bones
- widened epiphyses at the wrist
- costochondral swelling
- myopathy
Causes of Osteomalacia? (4)
- renal failure
- lack of sunlight
- chappati’s
- anticonvulsants (sodium valproate) breakdown Vit D3
What is Osteoporosis?
Loss of bone density, associated with age
What happens to Ca/PO4/ALP/PTH in Osteoporosis?
All normal
Clinical features of Osteoporosis? (3)
- increased liklihood of fractures
- Typical NOF
- Typical Colle’s
Diagnosis of Osteoporosis?
Osteopenia?
DEXA scan
T
Risk factors associated with Osteoporosis?
- Age
- Childhood illness, failure to reach peak bone density
- Early menopause
- sedentery lifestyle
- smoking
- alcohol
- low BMI
- endocrine - Cushings, hyperprolactinaemia, thyrotoxicosis
- steroids
Treatment of Osteoporosis?
Bisphosphonates e.g. Alendronate
Symptoms of HYPOcalcaemia? (3)
Signs (2)
- perioral parasthesiae
- carpopedal spasm
- neuromuscular excitability
- Trousseau’s
- Chvostek’s
What is Trousseau’s sign?
flexion of wrist & metacarpal joints and adduction on fingers when BP cuff is applied
due to hypocalcemia
What is Chvostek’s sign?
twitch of facial nerve when masseter at the angle of the jaw is tapped
due to hypocalcemia