Acid Base Study Guide

for the USMLE Step 1

Rahul Damania, MD
PGY-4 Pediatric Critical Care
Co-Founder HyGuru
USMLE Lecturer & 1-on-1 Tutor
 • Answering USMLE Acid Base Qs
• Go through the pathophysiologic
mechanisms behind:
• Metabolic Acidosis
Contents of •
•
Metabolic Alkalosis
Respiratory Acidosis
Handout • Respiratory Alkalosis
• Synthesize with Davenport Diagram
• Review:
• Renal Tubular Acidosis

Citation: Usmle Step 1 2019: First Aid Usmle

Approach
• Respiratory
3. What is the compensation?
• Kidney?
• Metabolic
• Takes 24 hrs
• Lungs?
• Respiratory
• Immediate effect
Metabolic Acidosis
 • What will the bicarbonate likely be?
Metabolic • Low
• What will the compensation likely be?
Acidosis • Lung à hyperventilation
• Check Winter’s Formula
 • Check the anion gap!
• Normal (8-12) or it can be increased (> 8 – 12)
What is causing • If it is increased…
a Metabolic • “there is something that is being added to the
ECM”
Acidosis? • If it is normal…
• “I am gaining/losing positive & negative ions
equally”
Metabolic Alkalosis
 • What will the bicarbonate likely be?
• High
Metabolic • What will the compensation likely be?
Alkalosis • Lung à Hypoventilation
• 1 mEq/L increase in HCO2 à 0.7 mm Hg
increase in PCO2
 • Mechanisms:
• Too much RAAS à what does
aldosterone do?
What is causing • Na in, and K+ and H+ excreted
• Any volume contracted state à what is
the Metabolic the mechanism?
Alkalosis? • Fires off RAAS
• Vomiting à what is the mechanism?
• Loss of HCl
Respiratory Acidosis
Respiratory Acidosis
• What will the CO2 likely be?
• High
• What will the compensation likely be?
• Kidney à HCO3 reabsorbed

Acute respiratory acidosis, the PaCO2 is In chronic respiratory acidosis, the PaCO2 is
elevated with an accompanying acidemia elevated with a normal or near-normal pH and
(ie, pH < 7.35). an elevated serum bicarbonate levels (ie, >30
mEq/L).
 • Mechanisms:
• “I’m not blowing out my CO2 properly…”
• What would be causes?
• Airway obstruction
• Lung disease
What is causing • Respiratory muscle weakness. What would be
the Respiratory mechanism?
• Weak muscles = poor ventilation
Acidosis? • What change would you need in respiratory
rate in order to have respiratory acidosis?
• Decreased RR à keeping onto CO2
• Opioid
Respiratory Alkalosis
Respiratory • What will the CO2 likely be?
• Low
Alkalosis • What will the compensation likely be?
• Kidney à HCO3 excreted
 • Mechanisms:
• ”I’m blowing off too much CO2”
• Panic attack from studying too much
• What would be causes?
• Hypoxemia à
What is • High altitude
causing the • Pulmonary embolism (V/Q mismatch)
• Tumors in brain à mechanism?
Respiratory • Compression of brain stem respiratory centers
Alkalosis? • What change would you need in respiratory rate in
order to have respiratory alkalosis?
• Increased RR à blowing off CO2
• Salicylates early
Summary
Davenport
diagram
Renal Tubular Acidosis
 • Type 2 RTA mechanism?
• Renal loss of HCO3-. Potassium?
• HypoK
• Type 1 RTA mechanism?
Renal Tubular • Failure to acidify titratable acid and NH4+.
Potassium?
Acidosis • HypoK
• Type 4 RTA mechanism?
• Hypoaldosteronism. Potassium?
• HyperK