A 70 year old man presents to your ED feeling unwell with abdominal pain and vomiting for two days. He has a history of NIDDM, HTN and high Cholesterol. He is immediately triaged to your resuscitation bay, placed on 15 litres oxygen by non rebreather mask and iv access is obtained.
Vitals:
BP = 160/50
PR 115/min
T 37.5 Celsius
RR 40/min
His ABG and blood results are as follows
pH 7.030 (7.36-7.44)
pCO2 30.6 (35-45 mmHg)
pO2 65.8
HCO3 8 (24 +- 2 mmol/l)
Na 119 (137-145 mmol/l)
K 7.3 (3.3 -5 mmol/l)
Cl 87 (99-111 mmol/l)
Glucose 42 (3.4-6 mmol/l)
ketones >7
Lactate 5.4 (<2)
troponin 0.06 (<0.05)
Urea 25.9 (3-7 mmol/l)
Creat 155 (<130 umol/l)
WCC 22.8 (4 -11)
N 21 (4- 7)
Plt 416 (140-400)
Hb 103
CRP 155
Questions:
1. Describe the abnormalities
2. Interpret the findings
3. What are your priorities in management
Unwell elderly patient, significantly tachopnoeic, mild tachycardia and low grade fever. Managed appropriately in a resus staffed area.
Acidaemia
Metabolic acidosis
Expected CO2– 1.5×8+8= 20
Element of respiratory acidosis.
pO2 of 65.8 on 15l high flow oxygen suggesting signifiant hypoxia.
Anion Gap: Na-Cl-HCO3—- 24
High anion gap metabolic acidosis with differentials in this case including DKA, raised lactate, renal failure (uraemia), sepsis and consideration of toxins if relevant
Osmolality 2x Na+urea+glucose= 305.9 Raised osmolality but as per most definitions of HHS osmolality of 320 usually cut off.
Significant hyponatraemia. Corrected Na (accounting for hyperglycaemia)= 129
Hypochloraemia likely secondary to hyponatraemia
Severe hyperkalaemia requiring immediate correction with Calcium gluconate for cardiac stability and insulin to correct the K+. Even accounting for acidaemia still significant hyperkalaemia.
Raised glucose of 42 in patient with background of Diabetes- ?DKA ?HHS.
Ketones>7. Could be related to DKA state vs starvation state
Significant raised lactate with causes including shock/hypoperfusions, DKA, sepsis
Renal failure noted. Needs comparison to old. is patient making urine? Close urine output needs to be observed given unwell patient and renal impairment. Given acidotic state and hyperkalaemia if not producing urine may require haemodialysis. Urea significantly raised more than creatinine. Consideration of other causes such as GI bleed may need to be addressed.
Small trop rise likely to be secondary to current state as opposed to additional cardiac cause but requires cardiac monitoring (also given hyperkaelamia).
Raised WCC/CRP likely due to the underlying infective cause.
In conclusion unwell elderly patient with multiple co morbidities. High anion gap metabolic acidosis. Likely DKA (differential would be HHS with significant dehydration and starvation) driven by underlying infection. Significant hypoxia despite high flow oxygen ?underlying respiratory disease
Priorities of treatment
Resus with fluids with close monitoring of urine output (catheter)
ECG/Cardiac Monitoring
10ml 10% Calcium Gluconate
Insulin infusion to bring hyperglycaemia down with bolus to correct hyperkalaemia.
Bloods/CXR/Urine looking for cause infection
?Broad spectrum antibiotics
Admit to high dependency unit
Close observation of oxygen sats- if failing to respond may require intubation.
High risk arrhythmia.