Acid Base Balance

EMT Paramedic Fall 2007

And Now! Acids and Bases Yippy!

Homeostasis

The biological and chemical processes occurring in our bodies depend on a consistent environment.
Homeostasis is our bodys system for maintaining that consistency.

Homeostasis & Acid-Base

Metabolic processes within our bodies function within a very narrow pH range.
Many diseases and environmental influences can greatly impact this delicate range.

Lets First Review

SpO2 = 90-100 (measures saturated hemoglobin through skin) SaO2 = 90-100 (measures saturated hemoglobin in arterial blood)

More review

PaCO2 = 35-45 (dissolved CO2 in blood)

PaO2 = 80-100 for adult and child 40-70 for newborn 60-80 for geriatric (measures dissolved oxygen in blood)

Matilda

Matilda is 87 years old. Her doctor has called and told her to come down because her blood gasses were off in her labs. These are her labs. SpO2 = 68 PaCO2 = 50 PaO2 = 55

Who cares?

You do! Because the more we know about acid-base derangements the better we can treat patients in order to correct the derangements.

Acids and Bases

Acids

A substance that releases H+ Ions when dissolved in water

acid Ketones Carbonic acid

Bases

Also known as alkalis, these are H+ seekers and also dissociate in water. When bases dissolve in water the hydroxyl ion is released (OH-) this little guy actively seeks out and attaches itself to acids floating around in the blood-stream.
Bicarbonate

is most common base. OH- + CO2 = HCO3

Acid-Base Physiology

During energy production, byproducts are released. Two of these main byproducts effect acid-base. Carbon dioxide (CO2) Hydrogen (H+)

Control that Hydrogen

The key to acid-base regulation is controlling hydrogen ion concentrations.

pH

P-what? I thought we were talking about hydrogen. The hydrogen ion concentration outside the cell is typically 4x10-8 mols/L or 0.00000004 equivalents per liter.

That number is to small to work with so we use the pH scale instead.

pH Scale

Potential of Hydrogen
1-14 7

is mid-range 7.35-7.45 is normal for human body.

So are we acidic or alkaloid?

pH and Hydrogen

pH levels are inversely proportional to H+ This means as H+ increases pH decreases and as pH increases, H+ decreases.

Condition

pH

H+

Alkalosis

increases

decreases

Acidosis

decreases

increases

Hmm So?

If we are normally 7.35 to 7.45 and that is considered slightly alkaloid then at what point are we acidotic?
Anything

below 7.35 is acidotic to humans and anything above 7.45 is alkaloid.

0.4

Fatal Values

pH of less than 6.9 and pH of greater than 7.8 are typically not conducive with life.

Picky Picky

The body must maintain a fairly narrow alkaline environment in order for things to go smoothly.
Any imbalances can be very serious.

Back to Matilda

So here are her values from before and now what do you think that means to her pH? SaO2 = 68 PaCO2 = 50 PaO2 = 55 pH= 7.23

How do we keep it all balanced?

Balancing Systems

Buffer System Respiratory System

Buffer System

Fastest acting (nano-seconds) Considered the chemical sponge (too much H+ use a sponge to clean it up. Or, need more give it a squeeze) It can collect hydrogen ions when they are over-abundant and release them when they are scarce.

How does it work?

Basically the cells produce CO2 and H+ during metabolism. The buffer system will change those two through chemical reactions to keep things balanced.
H+ <-> HCO3 <-> - H2CO3 <-> - H2O <-> CO2
Hydrogen Bicarb Carbonic Acid Water Carbon Dioxide

Gosh! Whats that mean?

Easyif the body needs more acid, the buffer system takes water and carbon dioxide and makes carbonic acid (with the help of the enzyme carbonic anhydrase). Then carbonic acid can be split apart to make bicarbonate and hydrogen. This can go both directions

Respiratory System

Second fastest to respond (usually within minutes) Triggered by Chemoreceptors in the vessels.

Example Diabetic keto-acidosis

Breathe!

When the pH gets a little out-o-wack a message is sent to the lungs. It tells them whether to breathe faster and harder or slower and more shallow.

How does that work?

Hydrogen binds with bicarbonate. This makes carbonic acid. Carbonic acid then breaks down into water and carbon dioxide.

In red blood cells carbon dioxide is carried to the lungs and exchanged for oxygen. The majority of CO2 is transported as bicarbonates in the plasma

So in the lungs?

Oxygen has an affinity to hemoglobin and it climbs on board kicking off the CO2 The CO2 and water are displaced and through osmosis and diffusion are blown out with expiration of air.

Gee Whiz!

After the CO2 has been blown away in the lungswhat happens? Exactly! The pH increases, bringing the body back to normal.

Renal System

If the lungs and buffers are not able to keep up with the amount of acids, then the kidneys must take action.
It

may take the kidneys hours or days to react to an imbalance.

What do the kidneys do to help?

They regulate pH by expelling excess hydrogen or bicarbonate ions. The kidney tubules are smart. When they expel one ion they will exchange it for another.

Kidneys work OT with COPD

When someone chronically retains CO2 the kidneys become the primary balancing system. Example is the chronic emphysema patient. They rely entirely on the renal system to maintain pH.

More Values

Base Excess BE = +or- 6 Bicarb HCO3 = 22-26mEq/L

Acid-Base Derangements

Respiratory:
Acidosis Alkalosis

Metabolic:
Acidosis Alkalosis

Respiratory Acidosis

Hypoventilation
Retained CO2 pH decreases

Causes:

Trauma, illness, medications.

You guys can treat this!

Causes of Resp. Acidosis

Lungs COPD, Pneumonia, ARDS Airway obst. Mucous plug, atelectasis, FBAO Respiratory depression anesthesia, OD, trauma Inadequate lung expansion skeletal trauma, pneumothorax, ascites

S/S for Resp. Acidosis

H/A (cerebral vasodilation) Tachycardia (hypercapnia) Bradycardia (incr. K+) Cardiac arrhythmias (hyperkalemia) Decr. CNS confusion to coma neuromuscular weakness - hyporeflexia, flaccid paralysis

Tx: for Resp Acidosis

Adequate hydration Bronchodilators OXYGEN

Respiratory alkalosis

Hyperventilation

Pain, anxiety Blows off CO2 pH Increase

O2 or Rebreathe CO2???

Causes of Resp Alkalosis

Anxiety, pain, or hypoxia due to epi release Febrile ASA OD Brain trauma/tumor Septic shock (early)

S/S of Resp. Alkalosis

Dizziness Numbness, tingling in fingers, around mouth Cardiac arrhythmias (decr. K+ and Ca++)

Tx for Resp. Alkalosis

Rebreathe CO2 OXYGEN

Metabolic acidosis

Excessive acid production N/V/D, DM, Rx pH Decreased CO2 Normal

EMS tx is ventilation

Causes of Metabolic Acidosis

Ketoacidosis Lactic acidosis Renal failure Incr. Metabolic rate Poisoning Severe diarrhea

S/S of Metabolic Acidosis

Skin warm, flushed Cardiac arrhythmias (decr. Contractility and inotropic response to catecholamines) Lethargy to coma Decr. Pulse (decr. CO) Decr. BP, dehydration (GI losses)

Tx for Metabolic Acidosis

DKA insulin, fluids Alcoholism-related ketoacidosis glucose and saline Diarrhea correct fluid and electrolyte imbalances Acute renal failure dialysis Lactic acidosis correct hypoxia and hypoperfusion

Tx for Metabolic acidosis, cont.

Admin. Sodium bicarb. IV when pH is <7.2 Potassium replacement when acidosis is corrected, K+ will shift back into cells = hypokalemia Mechanical ventilation; compensatory hyperventilation

Metabolic alkalosis

Infrequent

pH Increased CO2 Normal HCO3 Increased

Diuretics, vomiting Too much IV bicarb

H+ + HCO-3 <----> H2CO3 <---> H20 + CO2

Causes of Metabolic Alkalosis

Persistent vomiting Gastric suctioning Thiazide diuretics Antacid over-use Hyperal, Ringers lactate

S/S of Metabolic Alkalosis

Postural hypotension Muscle weakness due to hypokalemia Severe dizziness, tingling fingers, toes due to decr. calcium

Tx for Metabolic Alkalosis

Fluids and electrolytes

0.45% or 0.9% NS

Cool Web-Sites

http://www.acid-base.com http://www.health.adelaide.edu.au/paedanaes/javaman/respiratory/ab/AcidBase.html

Elderly Edna

Vomiting profusely for 24 hours pH = 7.46 PCO2 = 45 SpO2 = 92

Emphysemic Eddy

Chronically SOB secondary to COPD pH = 7.38 PCO2 = 50 SpO2 = 88

Heroin Holly

Found unconscious in the 7-11 restroom pH = 7.20 PCO2 = 55 SpO2 = 50

Panicky Pat

Freaking out about an acid/base quiz pH = 7.48 PCO2 = 20 SpO2 = 100