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