Acid-Base Disturbances - ABG - Acidosis and Alkalosis - Introduction!

what's up guys how are you doing as you know i've released my acid base course yesterday on my website medicosisperfictionnatis.com today i'll give you the first video as a free sample so enjoy this course has 30 videos 25 cases notes my perfectionist ultimate notebook and mind map and it's about eight gigabytes of content you get to download it to your computer and keep it for you forever at medicosisperfixnet.com at any point if you have decided to purchase the course use promo code asset base to get a 40 percent discount towards the asset-based course and any other course on my website available for the next 28 students only now let's start the lecture hey it's medical system fictionals where medicine makes perfect sense welcome to a new premium course we'll talk about acid-base disturbances you are in it for a wild ride but if you finish this course you will be happy you did and your future self will thank you let's get into this of course you know from chemistry that a ph of 7 is normal anything below 7 is acidic anything after 7 is basic and this is the most basic facts enough with my dad jokes instead of just memorizing everything why don't you make it simple at the rule of fours what's the normal sodium 140 chloride 104 bicarbonate just 24. ph 7.4 potassium 4 phosphate 4 albumin 4 but this is grams per deciliter not milligram all of the others are melee equivalent per liter and ph does not have a measuring unit if i write this equation like this a equals b over c now of course you know that between a and b there is a direct relationship if b goes up a will go up if b goes down a will go down this is easy between a and c well these are inversely proportional to each other if c goes up a goes down and vice versa how about the relationship between b and c how about the relationship between b and c it's a direct relationship if b goes up c goes up of course as long as a remains constant so a and b direct relationship as long as c remains constant a and c inverse relationship provided that b is is constant and b and c direct provided that a is constant how about this equation right here a plus b equals c now between a and b is inverse relationship let's say that a was two b was three and c was five and you want the c to remain constant now the relation between a and b is of course is going to be inverse if this two becomes 3 this 3 has to become a 2 so that the total is 5. duh similarly between a and c there is direct relationship and b and c are directly proportional to each other how do i remember it well if any two entities are divisible by each other or subtracted from each other it's a direct relationship let me give you an example how about this a equals b over c are b and c divisible by each other of course they are like divisible right now and therefore they are directly proportional to each other okay how about a and c well a and c cannot divide them by each other you can only multiply them a times c like the scissors some criss-cross action so these are only multiplied by each other that's why they are inversely proportional same thing here a and b these are added to each other that's why they are inversely correlated however a and c yes you i can get the c here with a minus so it's going to be a minus c and that's why there's a minus between them they are directly proportional acid-base disturbance first what's an acid well acid has three definitions it's any substance that it yields protons wind dissolves in water example take hcl put it in freaking water what's going to happen to the hcl well h plus and chloride vitus did it give you a proton absolutely yes and that's why hydrochloric acid i here declare you a freaking acid an acid is a proton donor an acid is an electron pair acceptor the first definition is called the arrhenius acid the second definition is this one and the second one is this no one cares and s is something that yields protons so if x in water gave you protons x was an acid okay a proton donor look at this h plus nh3 okay who's gonna donate the proton this one and that's why this one is the acid conversely this one will be the base because it has accepted the proton an electron pair acceptor is an acid same thing here the hydrogen ion will accept a pair of electrons from the nh3 and that's why h here is the acid and h3 is the base easy peasy lemon squeezy imagine that you have a test tube and it has a solution and this solution has some hydrogen ions what's the hydrogen ion concentration well it's the concentration of the hydrogen ions in the test tube of course you know that amount equals volume times concentration and therefore concentration equals amount over volume and that's why the concentration of any electrolyte in your body is always merely equivalent per liter or milligram per deciliter or gram per deciliter it's always an amount over a freaking volume the amount of hydrogen ions in the tube over the volume of whatever fluid is in the test tube the higher the number of protons in the test tube the greater the concentration of hydrogen ions that's true and therefore the more acidic the solution is beautiful and when the solution is more acidic what's going to happen to the ph well the ph is gonna go down the ph is always the opposite of the h what's a base a base is any substance that yields oh when dissolved in water example take naoh for example sodium hydroxide all right put it in water it will give you n a plus and o h minus so you have a cation and an anion did it give you a freaking hydroxyl group the answer is yes that's why it's a base a base is a proton acceptor well i accepted the protons and therefore i'm a base or an electron pair donor i donated my pair to the proton and that's why i'm a base same three doofus is right here what is the hydroxyl ion concentration well again concentration equals amount over volume amount of the hydroxyl ions over the volume of the fluid in the test tube the higher the number of hydroxyl ions in the tube the greater the hydroxyl ion concentration and therefore the more basic the more alkaline the solution is when the concentration of oh is high the poh will be low because the poh like the ph is inversely related to the concentration of the ion a more acidic solution has greater hydrogen ion concentration and a lower ph a less acidic solution will have a lower age and a higher ph conversely a more basic solution will have a greater hydroxyl ion concentration and therefore a lower poh a solution that is very acidic will have a lower ph and a higher poh and let me tell you something ph plus poh of a solution always equal 14. if two entities are added to each other they are inversely correlated as your ph goes up poh goes down as your ph goes down poh goes up the old classic archetypal chemical equation acid plus phase equals salt and water acid base salt water should i use the hydrogen ion concentration a lot well it's complicated because this number is so small look at this look at this would you like to use this in the hospital no one will understand you the reason doctors went to medical school is that they suck at math so let's make it easy for them all right ph is the negative logarithm of h you see this number 10 power negative 7 you just take the 7 and leave the negative and that's your ph the ph is the negative log of h and therefore the relationship between ph and h is inverse as hydrogen ion concentration go up ph is going to go down outside your body what is considered neutral a ph of 7 and what the fluid does that mean it means that the hydrogen ion concentration in that solution is this woke number right here if hydrogen ion concentration goes up ph goes down and vice versa easy peasy the lower the ph the greater the acidity let me give you two solutions first solution has a ph of five the second solution has a ph of 1.5 which one is more acidic the 1.5 it has a higher hydrogen ion concentration what is the neutral ph well the neutral ph is seven okay now why is your normal blood ph especially the arterial ph 7.4 uh why not seven like neutral why is your blood slightly basic let me tell you why because in your body you have an alkaline reserve but there is no such thing as an acidic reserve in your body what do you mean mitochosis i mean inside your body you have tons of bicarbonate making a reserve ready to counteract the acidosis but there is no such thing in your body as an acidic reserve it doesn't exist so if i have more base than acid my ph will be slightly basic but why do i have an alkaline reserve but no acid reserve because normally your metabolism secretes acids you're having acids all the time therefore you should be ready with some bases to counteract the acidosis lest you should die consider metabolism for carbohydrate they give you what carbon dioxide and carbon dioxide once it smells water it's gonna become carbonic acid say it again carbonic acid yes your metabolism creates acids fats metabolism will give you carbon dioxide a freaking acid proteins they will give you carbon dioxide uric acid sulfuric acid phosphoric acid acid acid acid that's why you are more vulnerable to acidosis and that's why you gotta have enough alkaline reserve and therefore your ph should be slightly basic normally speaking do you remember glycolysis which is part of metabolism yeah glucose will give you pyruvate acetyl coa and then the krebs cycle have you noticed that your metabolism secretes tons of carbon dioxide which is an acid by the way and then the electron transport chain the electron transport chain secretes what water so metabolism secretes water your metabolism secretes carbon dioxide and water carbon dioxide and water by a beautiful enzyme called carbonic anhydrase n means no hydro means water no water i will remove the water from here and it will give you something that has no water called carbonic acid and that's why carbon dioxide is a phytic acid because it gives you an acid and then the carbonic acid will dissociate into bicarbonate and protons note that the bicarbonate has co3 and there is co2 inside of it in other words bicarbonate is a form of carrying carbon dioxide in the blood the partial pressure of carbon dioxide in the arterial blood is proportional to the metabolic production over the ventilation rate let's say that my metabolism is going bananas too much metabolism what's gonna happen to the carbon dioxide it's gonna go up and we call this metabolic acidosis because carbon dioxide is a freaking acid because it gives you carbonic acid what if i have hypoventilation i'm not breathing like this i will not be able to get rid of the carbon dioxide from my lungs and therefore carbon dioxide is going to go up and this is called respiratory acidosis because carbon dioxide is an acid conversely what if i'm not metabolizing anything my metabolic rate is low what's going to happen to my carbon dioxide it's going to decrease and this is called metabolic alkalosis the absence of the acid is an alkalosis but what if i am hyperventilating too much ventilation you're washing out your carbon dioxide you're getting rid of the carbon dioxide what's going to have the carbon dioxide in the blood it's going to go down and this is called respiratory alkalosis this is called the golden equation carbon dioxide plus water carbonic anhydrase carbonic acid and then will give you protons and bicarbonate to make it simple we'll just use the reactants and the products and now let's talk about the lucital yields principle let me ask you a question if a goes up what's gonna happen as long as this is a reversible reaction well if a goes up i'm gonna shift to the right yeah of course in order to achieve equilibrium and when you shift to the right c is gonna go up and d is going to go up whether you like it or not what if a decreased well if a decrease the opposite will happen c will go down and d will go down in order to achieve equilibrium now let me ask you a different question if c goes up what's going to happen to d well if c goes up this will lead to disequilibrium therefore d will have to go down to achieve equilibrium one more time now let's answer the same questions what if the protons went up what's going to happen to bicarbonate well bicarbonate will have to go down to achieve equilibrium absolutely and that's why the protons and bicarbonates are always opposites so you're saying that when i gain an acid i will lose a base thank you captain obvious what's gonna happen if carbon dioxide goes up well if carbon dioxide goes up shift to the right protons will go up and bicarbonate will go up whether i like it or not conversely when carbon dioxide goes down protons will go down and bicarbonate will go down let's go back here carbon dioxide went up what's happened to the protons they went up oh and what do you call this acidosis baby because these are acids these are protons when they go up it's acidosis if carbon dioxide goes down oh protons will go down it's an alkalosis why do you say that carbon dioxide is an acid because carbon dioxide will eventually meet water there is water all over your body it's like two thirds of your body is water so eventually carbon dioxide will meet water one day and when they meet each other we give you what carbonic acid say it again carbonic acid yes carbon dioxide is an acid okay awesome there is an enzyme here called carbonic anhydrase i love the name of the enzyme carbonic yeah that's a carbon anhydrase means to remove the water and hydro no water i will remove the water from this medium and i will make carbonic acid that's lovely water is gone because i have an hydrated the medium this beautiful carbonic acid can dissociate into the proton which is the ultimate acid and bicarbonate which is the ultimate base okay carbon dioxide is your lungs job if you find a patient with increased carbon dioxide or decreased carbon dioxide blame his respiratory system from the brain stem in the medulla all the way down to the diaphragm there's a problem in this system okay what if the patient has a problem with bicarbonate blame the kidney blame the metabolism and that's why we have two types of acidosis respiratory acidosis blame the lungs and metabolic acidosis blame the kidney and everyone else same thing with alkalosis we have respiratory alkalosis blame the lungs and metabolic alkalosis it's the kidneys fault and this is called the golden equation there is a silver equation coming up remember glycolysis when you have no oxygen yeah it produces lactic acid yup again metabolism secretes what acids and that's why you are ready with an alkaline reserve and that's why normally your ph should be slightly basic 7.4 remember the rule of fours here is the story freaking morning glory metabolism secretes acids where does metabolism take place cytosol and or mitochondria both of them are in the icf intercellular fluid and that's why the icf is more acidic than the acf physiologically speaking the ecf contains an alkaline reserve ready to buffer and counteract and cancel the acidosis and that's why your blood ph is slightly alkaline at 7.4 we do not have an acid reserve that would have been stupid pause the video bring a piece of paper and write the golden equation three times please and don't forget there is a carbonic anhydrase here what is the main function of your respiratory system oh it's to get oxygen in shut up doofus doofus your main function of the lung is to get the carbon dioxide out it is way way way way way more important than to get the oxygen in i don't believe you let me explain carbon dioxide is an acid because carbon dioxide plus water equals carbonic acid and life is only possible within a narrow range of change in ph too much carbon dioxide you can die from acidosis too little carbon dioxide you can die from alkalosis this is serious the oxygen is important but it's not that serious case in point let's say that your oxygen saturation dropped from 99 percent to 94 percent oh well crimeal river you can survive but let's say your ph dropped from 7.4 to 6.8 you're what's known as done you're dead there is no patient life is only possible within a narrow range of change in ph so the lung has two main jobs number one to get the carbon dioxide out and then to get the carbon dioxide out and then to get the carbon dioxide up and then to bring in some oxygen in order for the lungs to get the carbon dioxide out or to get the oxygen in they will have to diffuse by simple diffusion and of course simple diffusion is directly proportional to the pressure difference the surface area the temperature the solubility but inversely proportional to the molecular size the thickness of the membrane and the viscosity we have talked about this in my pulmonology playlist on youtube so we already know that it's way more important to get rid of the carbon dioxide than to get the oxygen in however the odds are stacked against co2 why is this right here are two things carbon dioxide and oxygen which one has a high molecular weight well oxygen has just o and o but the co2 has o o and c there is a carbon here so of course this is heavier it has more freaking atoms and there is an inverse relationship between the molecular size and the diffusion so if you are heavier it's harder for you to diffuse the heavier you are the less the diffusion so now what i'm gonna do my carbon dioxide is gonna accumulate in my body i will not be able to exhale it and i will die but wait a second solubility is here to save you if you look at the molecular weight alone oxygen wins because it's lighter so it's easy for it to diffuse but if you look at the solubility or the diffusion coefficient carbon dioxide winds hands down and that's why getting rid of the carbon dioxide is way way way way more important than getting the oxygen in life is only possible within a narrow range of change in p8 your normal ph is about 7.4 you can survive between 7 and 7.7 less than 7 you're dead more than 7.7 you are dead which one is more dangerous and more likely acidosis because your metabolism secretes acids my metabolism secretes acids what kind of acids we have two types of acids volatile acids and non-volatile or fixed acids they are as fixed as a male copulatory organ in the pre-orgasmic phase volatile acids carbon dioxide who will get rid of the volatile acid of course you will breathe them they are volatile you will breathe them out it's the lungs job okay who will eliminate my fixed acids like phosphoric acid sulfuric acid lactic ace uric acid this is the kidney's job let's say that we have a patient with lactic acidosis do you think it's a metabolic acidosis or a respiratory acidosis well lactic acid secretion is the kidneys job if lactic acid is accumulating in my body i will blame it on the kidney and call it metabolic there is a direct correlation between alveolar ventilation and carbon dioxide elimination no kidding if i'm breathing faster i'm washing out my carbon dioxide in other words as the ventilation rate increases the rate of carbon dioxide elimination increases okay what if alveolar ventilation is not working i'm not breathing like this carbon dioxide is not going to be eliminated conversely there is an inverse correlation between alveolar ventilation and the carbon dioxide in your blood what if i'm not breathing i'm not eliminating the carbon dioxide therefore it will accumulate in my blood and if i'm breathing fast alveolar ventilation is increasing and the carbon dioxide in my blood is decreasing some doofuses add the first equation and the second equation and they combine them together this way i don't like it because this implies that there is a direct correlation between carbon dioxide elimination and carbon dioxide partial pressure which is not true so this is not a very sophisticated relationship but some books have it this way who cares doctors suck at meth okay normally which should be more acidic the artery or the vein well this is a this is high school biology stuff okay normally the artery will bring me oxygen and nutrients and the cell would use the oxygen and nutrients and secrete waste products and carbon dioxide say it again waste products and carbon dioxide carbon dioxide is an acid waste products include lactic acid sulfuric acid phosphoric acid uric acid all of these are freaking acids these acids are being dumped onto the veins that's why veins are normally more acidic and therefore they have a lower ph than their arterial counterpart there is more carbon dioxide in the vein because it had just has been dumped by the cell onto the venous side and therefore there is lower bicarbonate in the vein than the artery in other words the vein is more acidic and less basic than its arterial equivalent okay case number one you are a lab scientist and there are four solutions in front of you solution one the hydrogen ion concentration is one times ten power negative seven solution two hydrogen line construction is one times ten power negative eight solution 3 has hydrogen ion concentration of 0.01 and solution 4 has hydrogen ion concentration of 0.0025 please rearrange them from the solution of the lowest ph to the one with the highest ph please pause so let's enter this as you know ph equals what ph is the negative log of h of the hydrogen ion concentration okay so the hydrogen ion concentration the h of the solution is 10 power negative seven then the ph is just this number seven so this is the first solution second solution the ph is eight how about the third solution well the third solution is 0.01 so this is 10 power negative 2 which is 2. how about solution 4 well if you have a calculator it's about 2.6 but if what if i don't have a calculator well use that organ that you have called the cerebrum as you see this is a lower hydrogen ion concentration than this right and therefore higher ph so it's gonna be higher than two not yet three but let's say between two and three let's arrange them from the lowest ph to the highest ph where's the lowest ph of course solution number three so of course a is out b is out and e is out either c or d and what is the highest ph the highest ph here is eight which is solution two so the answer here is d case number two a nineteen year old female presents with deep rapid gasping breathing abdominal pain she has vomited twice within 30 minutes vital signs are significant for tachycardia tachypnea blood pressure is fine the nurse noted that her breath smells like fruit on physical exam she has dry skin dry mucous membrane dry eyes skin turgot is poor the many mental status exam was 8 out of 30. this is poor i should be 30 out of 30. this is basically if the patient is alert oriented have a good memory can do math etc urine output is increased her blood glucose is 600 milligrams per deciliter her serum sodium concentration is 129. what's the most likely diagnosis please pause what's the name of this deep rapid gasping breathing this is called cosmol's breathing okay and then abdominal pain and she vomited okay but as you see here breath smells like fruit this is acetone oh acetone what is acetone one of the ketone bodies ketone bodies so it could be a key to acidosis yes indeed that's possible especially if she is disoriented like this and when you see glucose of 600 you know that this is diabetic ketoacidosis happens mostly with diabetes type 1 and as you see she's young she's 19. what is the expected ph on abg well it's called divert keto acidosis it has to be an acidic ph what's the normal ph about 7.4 if you are sophisticated from 735 to 745 so it has to be less than 7.35 and the answer here will be e she has acidosis therefore hydrogen ion concentration is high but ph is low now let me lay the foundation for the entire course we have four disorders respiratory acidosis respiratory alkalosis metabolic acidosis metabolic alkalosis what's the problem in respiratory acidosis hypoventilation what's the problem in respiratory alkalosis hyperventilation metabolic acidosis comes in two types hagma enagma high anion gap metabolic acidosis normal and get metabolic acid what's the difference the serum anion gap hegma is usually a toxin most of the time it's an exogenous toxin alcohol like methanol ethylene glycol propylene glycol etc or it could be an endogenous toxin in cases of diabetic ketoacidosis lactic acidosis uremic acidosis then you have the nagma and the enagma is divided into renal and nonrenal based on what based on the urine anion gap not the serum the urine anion gap this will tell you whether the kidney is guilty it's losing the bicarbonate or it's your gut's fault the gut is losing the bicarbonate of course when you lose the base you develop a metabolic acidosis metabolic alkalosis is divided into saline responsive and cellular resistant and it's the same story you either blame your gut or blame your kidney blame them for what for losing the chloride not the bicarbonate losing the chloride in cases of nagma you have lost the bicarbonate and retained the chloride that's why nagma is a hyperchlorimic metabolic acidosis why hyperchloremic because the chloride is kept in your body you lost the bicarbonate but you kept the chloride in your body you have retained the chloride and of course when you lose the base you have an acidosis conversely look at metabolic alkalosis you've lost the chloride and retained the bicarbonate because this is an anion and bicarbonate is an anion and when bicarbonate is retained you get what an alkalosis because bicarbonate is an alkali i hope you like this first lecture this course teaches you about respiratory acidosis respiratory alkalosis metabolic acidosis metabolic alkalosis serum anion gap urine anion gap serum are smaller gaps stool a smaller gap based deficit base excess water deficit these are calculations diabetic ketoacidosis alcoholic ketoacidosis and a comparison between them uraemia which is renal failure as well as renal tubular acidosis by the way uremia will lead to a high anion gap metabolic acidosis but renal tubular acidosis whether it's type 1 type 2 or type 4 will cause a normal anion gap metabolic acidosis learn about the utility of the beta hydroxybutyrate to acetyl acetate ratio this course will help you learn about kidney physiology diuretics pharmacology fanconi syndrome water syndrome gilman syndrome and lydle syndrome and it will help you solve cases of combined or mixed acid-based disturbances such as a patient who presents with hagma plus a metabolic alkalosis plus a respiratory acidosis at the same time in the same patient use discount code acid base at medicosisperfixnetis.com this course will help you be a better clinician and that's it for now we're just scratching the surface the deeper is yet to come i love you