How do you calculate the A-a gradient?

FiO2 = 21%
PAO2 = 95% - 100%
95/21 or 200/21 = 4 to 5 %
A-a gradient = air from ATM into CIRCULATION
~ V/Q ratio approx. 1
Ex.
FiO2 = 40% / 40%
PaO2 = 160 % / 95%
160%/ 40% = 4 no A-a gradient
95% / 40% = 2.3 theres an A-a gradient
When do you have hypoxia with a NORMAL A-a Gradient?
GBS : V/Q ratio is a function of the INTRAPARENCHYMAL LUNG. Can still be hypoxia.
What is the current acid-base status?
7.20/80/42/32
I.
II.

Acidosis/ Alkalosis ( 7.35 7.45 ) - Acidosis

Are the lungs doing their job?
a. H2O + CO2 <-> H2CO3 + H
b. CO2 lungs 2 substrates that the body can alter; should be blowing
off (hyperventilation)
c. H2CO3 kidneys (PCT/ prevents reabsorption)
III.
Kidney?
a. They should hold on the HCO3
ANS: Respiratory Acidosis
45 year old with abdominal pain T1DM, with wheezing and crackles
VS: 38.3, 112/54, 116, 23
7.05/30/90
Na 132
Cl 102
BUN 63
Gluc 552
K 5.8
HCO 8
Crea 2.3
ANS: Metabolic Acidosis
1. Winters Formula = Estimated PCO2 for MA

PCO2 = ( 1.5 x HCO3 ) + ( 8+/- 2)

PCO2 = (1.5 x 8) + 8 = 20 +/- 2
-

To tell if the lungs are maxed out? Yes

2. Na (Cl + HCO3)
HAGMA:
Methanol
Uremia
Diabetic Ketoacidosis
Prophylene glycol
Isoniazid/ Iron
Lactic Acidosis
Ethanol
Salicylates
NAGMA:
RTA
GIT
132 (8+102) =
27 yo SEIZURE
Na 133
K 4.2
Cl 95
HCO3 18
pH 7.22
Lactic Acid 12.7 on ABG
Next step?
a. Infuse HCO3 IV ( for pH =/< 7.19
b. Begin NS at 200 cc/hour
c. Observation with apt chemistries in 2 hours
d. Dialysis ANS
URGENT DIALYSIS INDICATIONS:
1. Symptomatic/Persistent
a. Hyperkalemia
b. Acidosis
2. Refractory/ Symptomatic
a. Fluid overload
b. Uremia
c. Dialysible Toxins Lactate
23 yo man found with several bottles of rubbing alcohol opened near him
Na 141. K 4.2, Cl 106, HCO3 23, Glucose 127
a. Urine Na

b.
c.
d.
e.

Measure serum osmolarity -- ANSWER

Urine toxicology
Ua for crystals for ethylene glycol
Gastric lavage dont lavage unknown ingestions

ALMOST ALL ALCOHOLS RAISE THE ANION GAP/ OSMOLAR GAP

Raises the osmolar gap, but DOES NOT ALTER ANION GAP
Isopropenol doesnt alter anion gap
This anion gap/ HCO3 is NORMAL
2x (Na + K) + (BUN/2.8) + (Glucose/18)
Case 3
63 yo woman 7.50/45/85/36
What is primary Acid-Base Disorder?
Metabolic Alkalosis
Is there respiratory disorder?
Metabolic alkalosis
*** Estimating PCO2 in metabolic alkalosis
0.8 x HCO3 + 20
0.8 x 36 + 20 = 48.8

1. Fournier Gangrene ( Diabetic foot of your PENIS / MIXED INFECTION): Culture

ENTEROCOCCI
2. Mollarets Meningitis HSV/ Multiple Infections
a. TX: Acyclovir
3. Which of the following is most likely to have staphylococcus saprophyticus?
a. Cathetered patient
b. Young healthy, sexually active women: ANSWER
c. Diabetes
Staphylococcus 31 species, 30 coagulase (-), 1 coagulase (+)
staphylococcus aureus coagulase allows s. aureus melts into tissues!!
4. For uncomplicated cystitis, which of these is not a good drug
COVERS E.COLI
a. Nitrofurantoin, 1st line safe in pregnancy
b. TMP/SMZ safe in pregnancy, -- can cause kernicterus
c. Fosfomycin safe
d. Erythromycin
5. Which of the following is NOT an accurate method of dx?
a. Urine nucleic amplification test for urethritis in men
i. Most accurate; standard
b. Self administered swab for cervitis in women
i. Good; dont need a doctor; for STDs
c. Gram stain of urethral discharge in men
i. Advantage: dx of chlamydia instantly, gram (+) diplococcic

TREATMENT: ceftriaxone + azithromycin

No more cefexime
d. Blood chlamdyia testing for PID in women
6. Which of the following is the most sensitive test of CSF for neurosyphilis?
a. > FTA 99%
b. Blood = VLDRL most sensitive test
There is no such thing as CHRONIC LYME DISEASE stop antibiotics
TOXIC SHOCK SYNDROME
- Toxin out of staphylococcus
- SKIN, LIVER, KIDNEY, BRAIN SHOCK
- Tx: Clindamycicn (Preents the production of toxin) + Vancomycin (MRSA)
- TOXIN:
o Tampon
o Nasal Packing
o Sutures in Wounds
o NOT BY DIAPERS
TSST just the skin
Which of the following is the 1st line indication for AMPHOTERICIN?
- MUCORMYCOSIS and CRYPTOCOCCUS
Pulmonary Aspergillosis Voriconazole
HOT
-

TUB
PSEUDOMONAS
Malignant otitis externa
Endocarditis in IV drug user
Hot Tub Foliculitis
Ecthyma gangrenosum

ERTAPENEM doesnt COVER PSEUDOMONAS

CMV lungs = Cancer
HIV true pathogen or bronchoalveolar lavage
Nocardia LUNGS and BRAIN
Tx: Minocycline, sulfa drug
BK = Borrowed Kidney similar to Parvo Virus
- No treatment
Camping in CONNECTICITY
(+) facial palsy, clusters of vesicular eruptions over his external auditory canal?
RAMSAY HUNT SYNDROME varicella infection; herpes zoster
Ehrlicha INCREASED LFTS, DEC WBC, DEC PLATELETS
Babesia = hemolysis; ixodes tick
IXODES TICK

1. Lyme
2. Ehrlicha
3. Babesia
Whats the treatment?
Babesa Azithromycin + Atovaquone
Varicella Valacyclovir, Acyclovir, Famcyclovir
Lyme Disease (+) facial palsy Doxycycline lyme of the face is not CNS
CNS / Cardiac === IV CEFTRIAXONE
DX wth splenectomy for ITP gets scratched by a pet dog? The ff day he us
hypotensive
CAPNOCYTOPHAGIA DOG BITE
Eikenella human
Pasteurella Cat
HIV px with INCREASED AST/ALT
CT: Liver with cystic spaces filled with blood (Peliosis hepatis)
Nodular lesions in extremities: BIOPSY: SILVER STAINS/WARYHIN STARRY Positive
looks like finger
Dx: Bacillary angiomatosis BARTONELLA SPP
TX: Doxycycline/ raise T cell level
Bartonella Quintana / TRENCH FEVER serologic diagnosis
ANTHRAX/ BLACK as COAL
Treatment DOXYCYCLINE/ CIPROFLOXACIN
Pentamidine leishmaniasis, PCP, Killing Pancrease DM
Amphotericin decrease RENAL TA, distal RTA, Dec K and RTA
Hepatosplenic candidiasis
REVERSE ISOLATION NEVER HELPS
HANDWASHING!
Stenotrophomonas Maltophilia
- Gram negative rod cured with SULFA DRUG TMP/SMZ