Issues:

shock – bleeding (haematemesis), vomiting, sepsis

jaundice – liver failure, cholangitis

Sepsis

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

Causes:

– 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.

Immediate priorities:

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

ICU consult