68 year old man, critically unwell, shocked with severe respiratory failure.

1.

Mixed mild normal anion gap metabolic acidosis and severe respiratory acidosis

Also, likely to have anion gap metabolic acidosis – renal failure and lactic acidosis

?spuriously high HCO3 – attempted compensation for respiratory acidosis

severe hyperkalaemia requiring urgent reduction to prevent arrhythmia, with acute renal failure (??acute on chronic)

Elevated troponin

mild hyponatraemia – corrected is normal

HHS – osmolality > 320, normal anion gap

2.

Severe shock with multiorgan failure

Possible sepsis, NSTEMI, abdominal cause

HHS

Respiratory failure

3. Treat hyperkalaemia

Resuscitate, likely to have a significant fluid deficit

Ventilatory support

Treat cause