shock – bleeding (haematemesis), vomiting, sepsis
jaundice – liver failure, cholangitis
Requires immediate concurrent resuscitation and investigation
pH 7.10 and HCO3 5 – severe metabolic acidosis
Compensation – Winter’s formula – expected CO2 = 15.5, actual = 15, therefore fully compensated
Anion gap = 35
– lactate, ketones, renal failure
-toxins – no indication here
Delta gap = 1.21, pure HAGMA – likely due to lactate predominantly
Lactate 18 – very high => high mortality, causes shock, sepsis
HB 60 – severe anaemia, secondary to likely haematemesis (liver failure with portal hypertension and oesophageal varices)
WCC 22 – sepsis, vomiting
Glucose 40 – ketones not given, due to uncontrolled/ acute diabetes, ??DKA
Urea 22, Creat 245 – renal failure with predominantly pre renal cause
Na – corrected for high glucose is normal
CL 85 – very low – vomiting
K normal but likely to represent whole body depletion in view of acidosis.
Coagulation profile would be useful
Interpretation – 65 year old man, critically unwell with shock. His presentation is likely to be secondary to haematemesis (portal HTN and oesophageal varices). He has a severe lactataemia with a high mortality.
Resuscitation – massive transfusion protocol may be required.
Attention to airway and breathing – risk of aspiration
Other therapy- ceftriaxone (mortality benefit), PPI, octreotide
Immediate gastroenterology referral (presence in ED if available) for urgent gastroscopy