Lactic acidosis

Background

• Most common cause of metabolic acidosis in hospitalized patients

DDX by Type

• Type A
  • Impaired tissue oxygenation
    • Hypovolemia
    • Cardiac failure
    • Sepsis
    • CO poisoning
    • CN poisoning
• Type B
  • No impaired tissue oxygenation
    • Alcoholism
      • Lactate utilization is impaired 2/2:
        • 1. Impaired hepatic gluconeogenesis
        • 2. No NAD+ to convert lactate to pyruvate
    • Sepsis
    • Liver disease
    • Metformin

DDX Complete

1. Any shock state
2. Seizure
3. Dead gut
4. Hepatic failure
5. Malignancy
6. Exercise
7. Use of b‐agonists
8. Toxicologic Causes:
   1. Cyanide
   2. Carbon Monoxide
   3. Metformin
   4. Didanosine
   5. Stavudine
   6. Zidovudine
   7. Linezolid
   8. Strychnine
   9. Emtriva
   10. Rotenone (Fish Poison
   11. NaAzide (Lab Workers)
   12. Apap (if Liver Fx)
   13. Phospine (rodenticide)
   14. NaMonofluoroacetate (Coyote Poison‐ give Etoh as antidote)
   15. Inh (if patient seizes)
   16. Hemlock
   17. Depakote
   18. Hydrogen Sulfide
   19. Nitroprusside (if cyanide toxic)
   20. Ricin & Castor Beans
   21. Propofol
   22. Sympathomimetics (cocaine, methamphetamine)
   23. Jequirty peas (Abrus precatorius)
   24. Prunus Amygdalus plants
   25. Crab tree apple seeds & cassava (yucca)

Source

• Tintinalli
• EMCrit Podcast Acid-Base