okay this is uh Anatomy 1352 Ross College it's Unit Nine part two of it welcome back so we left off after discussing the kidneys and how they maintain fluid balance within the body let's go back and look at the fluids themselves how they're interacting with through the system and also back towards the kidney so body fluids is a big ISS you to maintain remember fluid alone water makes up more than half the body it's pretty wide range there adult males down towards 55% newborns up towards 80% of the body so we've got constant movement of water with diffusion osmosis between different places different quote and quotes compartments filtration reabsorption going on at the kidneys a lot of fluid moving overall so what fluid are we actually talking about fluid first we divide into either inside or outside a cell intra in t a means inside so intracellular fluid all the fluid inside your body cells yeah two-thirds of the total fluid extracellular extra outside extracellular fluid outside the cells the remaining third of the fluid that concludes fluid in tissues fluid in between the cells in the tissues fluid in the vessels and many other smaller compartments looking at the breakdown of the extracellular 34s of that is interstitial fluid iner between interstitial fluid between the cells a lot of that is the fluid in connective tissues then you have the remaining qualifies as intravascular in inside the vessels that's about quarter of it all most of the intravascular is blood plasma you look and see other places too the lymphatic system considerably smaller than the blood plasma volume cerebros spinal fluid joint cavity synovial fluid liquid in the eyes the lymph fluid within the ears Cirrus fluid peritoneum pericardial plural spaces very small amount of fluid there but nonetheless fluid now thinking about in and out of the body fluid intake fluid loss so on average people are taking in a little over two lers of fluid a day on average some days it's substantially higher some less there's also a small amount of water 200 Ms 6 ounces coffee cup not a Starbucks jumbo coffee cup but a normal household coffee cup of water is made through metabolic processes so this is dehydration synthesis this is cellular respiration oxygen electrons hydrogen ions turned into water that is that water you see that metabolic water is reasonably fixed that's about how much you get per day for average siiz person then you have your outgoing fluid let's go from bottom up here fecal matter about 100 Ms of fluid daily you're not changing that okay some days it's a little more some days it's a little less depending on volume of the feces but when you average it out about a 100 Ms a day inhale exhale air coming in is drier than what's the body conditions you're humidifying the air as you bring it in and as you exhale you lose some of that water around 300 Ms a day again on average and then evaporation at the skin you lose over a half a liter a day even when you're not noticeably sweating so these three here are pretty fixed volumes that add up to about a liter that's outgoing no matter what now I don't care if you know the exact volumes I want you to know what the water loss is that's most important so then the remainder of what goes out goes out through the kidneys so if we took in about two and a half liters as you see from above we lost one liter skin lungs and fecal then we've got about a liter and a half going out through the kidneys again now remember the bottom three don't change they may go up but they're not going to be going down so you know evaporation you're sweating a whole lot clearly that goes up a lot we're just talking restful conditions here so if you decrease your water intake which of these factors changes water out through the kidneys and if you dramatically increase or decrease your water intake if you drop to only a liter a day of fluid in what's going out to the kidneys is going to be very minimal and that's going to make maintaining body conditions more difficult it's also going to create much more concentrated urine so now discussing fluid there's a lot of feedback going on and it all base around dehydration so we don't physically sense dehydration what we're sensing are the changes seen in the body with dehydration so and we'll get to those there in a bit now for some people dehydration is a slower process however when you look at elderly and infants dehydration can progress much quicker unfortunately the sense of thirst doesn't always keep up with the rates of dehy rates of water loss and it is possible to become seriously dehydrated before you're even developing a sense of thirst and as anybody knows working with elderly patients you see confused mental status when dehydrated how many of them already have memory issues um varying degrees of even if it's minimal dementia throw on some dehydration you just make the whole situation worse and as we commonly know with elderly patients who have difficulty moving difficulty getting to the bathroom fighting dehydration is a daily battle sadly um how pronounced is this if you're not aware of this if you work with it you know it but those of you who don't work with older patients it's very noticeable especially when someone you're very familiar with patient you've had for weeks months years sometimes and it can be very noticeable I remember when my dad was still alive and in that last two or so years of life movement was very very difficult for him a lot of pain and Joints um and he was chronically dehydrated because he did did not want to get up and move to the bathroom depending on how dehydrated he was I could tell within 5 minutes in a conversation with him he was clearly more confused when significantly dehydrated so it's a factor that's easy to pick up by paying attention and knowing your patients so what does lead to dehydration and sensing of it well you can see three basic conditions caused by dehydration number one decreased production of saliva leading to dry mouth and a dry throat you get increased osmolarity in the blood so you lose the water but keep the salts so the OS osmotic concentration Rises um your body is able to sense osmolarity through osmo receptors not going to ask you that um but you can sense that concentrations at the hypothalamus and then increased volume because again you're losing water decreased pressure how are these all sensed well dry mouth and osmolarity are picked up directly by the hypothalamus decreased blood pressure we pick up and detect at the kidney renin is produced clearly we know that one jux the juxa glomular cells won't ask a juxa glomular but renin is produced renin we already know leads to angot tensin 2o hypothalamus does detect monitor however you want to phrase it it's aware of the levels of angiotensin too so increasing Angiotensin 2 plus the dry mouth increased osmolarity they all stimulate thirst Center in hypothalamus which finally leads to an increased sense of thirst you feel thirsty you drink more water you increase the water negative feedback we start fixing the problems that started the situation to begin with so this is how fluid balance and intake goes now where's the main sensing regulation Center here hypothalamus patients with a damaged hypothalamus commonly due to tumor on hypothalamus or possibly due to cranial surgery patients with damage here may not have a functioning or normally at least normally functioning sense of thirst and those individuals have to be monitored much more carefully I had an uncle who had this condition following a small hypothalmic tumor and his wife had to prompt him multiple times a day drink water to keep his sense of hydration hydration up because he had no sense of thirst whatsoever now this is normal functionality but what else can dramatically impact this very heavy sweating um diarrhea lot of water loss there for both of them actually vomiting a lot of water loss again in the case of these three conditions you may become critically dehydrated even before you sense thirst and when these three situations heavy sweating diarrhea vomiting it's very very important to get fluids in unfortunately with gastrointestinal Di diarhea vomiting you may require medical intervention for administration of water in other words IV fluids so all right more questions again we'll leave them for discussion in class if you want to ask or cover them there so back to our hormones for regulating fluid balance one of the ways is of course regulating or the main way regulating your ions and remember water goes wherever your solutes go water follows sodium also chloride but wherever sodium goes pretty much chloride is going too so to maintain water we're maintaining these ions many of the times so in order to maintain the sodium which is the dominant extracellular um ion we use three hormones our Angiotensin aldosterone and& as we already know so Angiotensin aldosterone reabsorption of sodium plus chloride and also water through osmosis in general that goes up during dehydration the reverse to get rid of water decrease blood volume Atri atrial naturetic peptide drives excretion of sodium plus chloride and water volume goes down pressure goes down so those are three really biggies when it comes to dealing with the ions now yes aldosterone also affects potassium there are other ions into play with calcium um phosphate chloride but working around sodium and chloride follows it that is the major effect because is the dominant positively charged or cation in the um extracellular fluid so looking here again we've talked about all three I'm not going to go over this image we'll leave it paused here for a minute you can go through it as you wish it's just a repeat of things we've already done you know you've got stretching of the heart in the case of increased sodium uptake because we start here with increased sodium the changes you see down to volume increase stretching the heart is up but with increased volume you're shutting down the Raa system so renin goes down and tensin goes down aldosterone goes down and the associated changes and then what happens Downstream once those hormones have changed a& up the other ones down and you can follow what we already know and have covered multiple times for uh atral nettic peptide all right now there are times when you have water issues but plenty of ions and that's when anti-diuretic becomes the dominant hormone remember antidiuretic it's causing you to not get rid of water but instead keep or retain water now this one functions at a different place within the nephron we've mentioned it already primary target for ADH is at the collecting ducts in the kidneys proximal convoluted tubule especially the collecting duct and with the channels you see and the ability to reabsorb at the collecting ducts there isn't an ability to reabsorb the ions but you can reabsorb water directly that's why you can able to separate water from your ions here now anti-diuretic hormone does have another name it's called vasopressin that's the oldfashioned name for it but for some of you you might recognize the term vasopressin this is the drug used to treat low levels of anti-diuretic hormone also don't forget ADH posterior pituitary source so when we have vasopressin administered to the patient when patient has increased ADH what do we do retain more water less total urine is produced but the urine that is produced produced is more concentrated so think along those lines all right now there is a condition we call water intoxication and this just is well you think of intoxication you think of alcohol um in that case ethanol intoxication it's simply having too much of it um you can have too much of damn near everything there is literally water intoxication um we even use a term intoxication for bacterial toxins uh viral toxins poisons from nature because they's still toxins so intoxication now water intoxication occurs when you input of water the amount you're drinking exceeds what can go out through the kidneys very healthy kidneys have a maximum of about 15 M milliliters per minute going out that's a very healthy kidney think of an older patient who may have poor renal function and they might be at a third to a quarter of that rate just a few Ms a minute when you have that condition it is possible to reabsorb water or absorb water through the gut faster than the kidneys can get rid of it now for a very healthy person it is more of a challenge to reach water intoxication thankfully um but for patient with poor kidney function sometimes it's quite easy and therefore dangerous so what happens when you have water intoxication first what's going on in the body and then we'll look at the outward effects so first thing is the salts aren't changing but water's coming in faster than you get rid of it that causes the interstitial fluid that causes the intravascular fluid all that extracellular fluids they become more dilute they drop in concentration of the electrolytes simply because you put more water in but did not put in more electrolytes this develops what we call a hypotonic solution low o osmotic factors low electrolytes in the solution run way back to AP1 we can think about that what happens in hypotonic well salts are going to try and move out of the cell water however is moving in the cell to try and get a balance on inside and out and as we know water always moves faster than salts so cells take in water quickly they begin to swell and that disrupts function if those cells swell too much they rupture they they're dead so outward symptoms here first thing is Confusion And as it progresses the danger very dangerous you can get are convulsions coma and it is potentially fatal so how would you counteract this well there's two ways to do it but both of them involve giving more salt to bring the concent conentration of the electrolytes up you can give oral salt which unfortunately takes a little while you would do that in a less severe case of water intoxication if you're at the point of convulsions in coma you're going to give IV salt so how do we do that well you're thinking well isn't a IV solution isotonic yes it is most of the time you can actually get IV Solutions that are hypertonic excess dissolved factors higher salt higher glucose you run that in and then you can slowly bring the extracellular fluid back up to an isotonic condition once that is stabilized cells will slowly return to normal size begin to reverse your conditions hopefully not too much damage has occurred this is a bigger issue in poor function patients although those patients have greater comprehension of this usually older people um older than I say than young teenagers um so they're better Adept at it water intoxication unfortunately does happen in young children you've got that kid Who's playing um Elementary or Middle School sports but they're not real good so what are they doing sitting on the bench not doing a whole lot not sweating a lot you do it in the summer months and you got coaches yelling drink more water drink more water constantly constantly constantly well that's more critical for the people who are sweating a lot that kid who's not sweating as much can actually drink water at a dangerous rate and take too much in resulting in water intoxication so luckily that's not common but you do see it every once in a while those patients usually usually show up at er and that's majority of where you see them so all right the electrolytes are ions electrolytes are anything that turns into an ion when it goes into solution our salts for example so what are our ion functionality um they do affect osmosis and movement of water they're also involved in acid base balance those are very important beyond that some of those ions are very important for your action potential so your electrical currents and muscles and nerves that would be your sodium potassium also calcium there for release of neurotransmitters muscle contraction also and then many of them especially the low concentration ones serve as co-actors for enzymes iron in hemoglobin Cobalt in vitamin B12 these are very critical co-actors that you you don't need much of but you very much need a little bit so now electrolytes can either be measured in milligrams per deciliter or they can be measured in Mille equivalents now Milli equivalence is beginning to fall out of favor because of confusion many hospitals are standardizing on only a single unit to help things keep in and balance there Millie equivalence takes into account the charge of something so that's important too and that's giving concentrations of total annion cations in your solution now for something like sodium or chloride where the charge is one it's not as critical but when you get to something like calcium or it's plus two charge the number of Millie equivalents is a very different number than than the milligrams per deciliter so there is where you have a problem someone will be knowing the normal range for Milly equivalents but instead looking at lab results in milligrams per deciliter and it's depending on that different unit it's not the same range and that has led to Medical errors and that is why um hospitals are put to standardize on MGS per decil only so um that's what that is though some more questions you guys can pull these up they're right in your lecture outlines again if you want to cover these during our question and answer session we'll do it you tell me now what do our specific electrolytes for um I'm not going to read these directly to you we're going to hit the highlight here but sodium extracellular fluid we know it's involved in our water balance we know it's involved in signaling Regulators of course aldosterone and gensin now when sodium is out of balance here's where things become very crit very important if you have low sodium it is hypo low nmia na is the natrium sodium emia condition of the blood so hyponatremia literally translates to low blood sodium the opposite is hypernia so high blood sodium you can see the big problem with high blood sodium very rapidly because we see a lot of hypernia in this country we don't see much hyponatremia high blood sodium high volume high pressure hyponatremia is a major contributor to hypertension high blood pressure it also therefore is also contributing to edema in our patients and this is why patients who do have high blood pressure are often on a limited sodium intake diet trying to get that sodium levels down volume down pressure down and that is the ideal way to do it if a blood pressure is not too high and B the patient will actually follow recommendations this is the first attack when you to go after when you deal with hypertension in a patient especially when they're at the prehypertension stage or low end of um stage one hypertension if you get higher up the no amount of diet modification is going to fix the entire problem and then medications must come into play although with those medications you still have to assist with diet so that the diet is not literally fighting against the effects of the medication chloride it's anion of course it's abundant in the extracellular fluid it's part of our balancing and of course um hydrochloric acid chlorides there part of your gastric juices um affectors everything that affects sodium affects chloride also so our aldosterone um Angiotensin 2 ADH also does have a minor effect on chloride too so when you are recovering water you are bringing in a little bit of chloride with it don't focus on that for ADH mostly focus on the water aspect of it potassium now there's very low blood potassium around five milligrams per deciliter but this one's M much more abundant inside of cells remember where it is for your action potentials um it's functioning intracellular the way that sodium is functioning extracellular it's help in regulating pH by regulating ion balances potassium alone has no direct effect on ph its effect is by ratios and proportions of hydrogen ions relative to potassium ions inside outside of a cell don't get caught up on the potassium and pH in fact it's probably better off to just forget about that one detail so uh what else just as important in the action potential for neurons muscles as sodium main regulator is elderone for getting rid of excessive potassium most patients do not have an issue of low pottassium and those that do it almost always can be fixed by a healthier diet greater intake of fruits and veggies one of your veggie or fruits that is really high in pottassium is actually bananas so um conditions you get hyperemia and hypoc calmia remember pottassium is calium K that's where it comes from emia blood hyper hypo low so hyperemia high blood potassium hypokalemia low blood potassium low is less critical high can be very dangerous in fact hyperemia causes ventricular fibrillation and we know that usually when a patient's in ventricular FIB we're looking at coding the patient because they're not pumping blood there have been a few cases in the past it's usually in a hospital settings where people have been killed by intentional overdoses of pottassium um there was one instance of a male nurse who was the quote unquote Angel of Death who thought it was for terminally ill and impa patients to encourage them along to where they were ultimately going well without their consent that's murder and that person had been caught giving injections of potassium um the only way they figured it out was by doing the autopsies finding highblood potassium at levels where it clearly was causing viib and cardiac arrest and by tracking back the number of patients involved which was upwards of eight or so there was only one person who had had contact with all eight of them and it was pretty obvious to figure out at that point so it is kind of an interesting thing do be aware of your issues of hyperemia um most patients who have high potassium have a wee bit High not seriously High um you have to get up a good milligram or so above the normal range before you start seeing very dangerous results all right by carbonate this one's involved in CO2 levels and because by carb um because carbonic acid the H2 CO3 does disassociate into bicarbonate and the hydrogen ions the amount of bicarbonate is also an impact on the pH of the blood so get rid of CO2 combine bicarbonate plus acid pH goes up build up CO2 you generate more bicarbonate more acid pH drops and of course the main regulator of bicarbonate is lungs so and there you can have it so bicarbonate does impact um body pH it's actually the weakest of the impactors but it's the one that changes the most so calcium it's the most abundant of your minerals in the body it's even more so than sodium potassium however the vast majority is in your skeleton and teeth so what you see in the body fluids is significantly lower than what's in the than these do see of the sodium potassium so calcium is mostly extracellular we've already mentioned Time and Time and Time Again its roles blood clotting neurotransmitter release muscle function muscle contraction and tone excitability of neurons and muscles very very critical there the main regulator of calcium is parathyroid hormone to a lesser extent calcitonin so and parathyroid hormone we know is Raising blood calcium by causing the kidneys to keep calcium plus breaking down bone and removing calcium from the bone so phosphate that's the counter to calcium in Bones especially phosphate is an anion calcium is a cat the predominant mineral in bone is calcium phosphate the two of them together the bulkier phosphate is is in bone and teeth the rest is out in the body fluids Plus in things like DNA and ATP that's you see phosphate there so now blood levels and fluid levels of phosphate are usually very very stable and phosphate is a more important or stronger buffer for maintaining pH than carbonate however levels are very stable you don't see changes going on like you do with bicarbonate and when we regulate calcium we're generally regulating phosphate so parathyroid hormone also regulates phosphate magnesium is another one about half of it you see in the bone there's magnesium in the bones Magnesium phosphate compared to the calcium it's pretty small it does function in intracellular fluid so inside the cells it can function in place of calcium um occasionally but not as efficiently so it can have a small effect at neuromuscular Junction in place of calcium it is important in heart function myocardial function and it actually can stimulate um low magnesium can stimulate parathyroid hormone to increase calcium to compensate for low magnesium its main function though is enzyme co-actors so there are multiple enzymes in metabolism of both carbs and proteins that do require magnesium so that's what we have it now the kidneys directly Monitor and regulate blood calci or blood magnesium levels and they do that independent of hormones so one of the few not a hormone regulated now we've mentioned pH quite a bit acidbase concentration you know we're trying to keep that appropriate level of acid keep it in our um dynamic equilibrium our changing balance we all know our blood PH range 7.35 to 7.45 now we always mention blood pH because the Simplicity of measuring it but because fluid is constantly moving in and out of the blood whatever blood pH is the rest of the body's pH is almost identical so it may be off by 0.01 0.02 but come on that's not that much it's pretty close so now people when you're doing it and healthy we have three different buffering systems chemical buffers to do it plus the lungs and kidneys that help regulate PH altoe so now what is the issue with ph well in the normal range you function good you begin to drift out of the normal range problems the problems intensify by the distance outside that normal range now we do know the kidneys can get rid of acids acidic urine and one thing you're going to see when patients have kidneys shut down you can pretty much Start a timer when if kidney function does not restart you've got about 48 hours till that individual is dead what kills them is a drop in PH to the point it starts interfering with neural and muscular function and basically neuron stop firing muscles stop Contracting especially really important muscles like you know diaphragm and heart so ultimately there are a number of people where end of life is because of the the the actual stopping is because of drop in body pH so pH is critical so what are our three buffers well proteins the carbonic acid by carbonate system and phosphate buffer we've said that what is a buffer something that's either able to bind up they sometimes say sequester or hide they just bind it up either hydrogen ions or or hydroxy so when one of them is in excess one of the buffers is able to absorb it and bring us back to the normal range protein buffers are most abundant in the major one they're able to absorb both hydrogen ions or hydroxy albumin in the blood plasma hemoglobin and red blood cells these are biggies there are also other proteins that play in the extracellular fluid carbonic acid bicarbonate system that we've discussed before um is in balance with carbon dioxide so by maintaining carbon dioxide you maintain right pH by by carbonate levels and hydrogen ion levels now of the three buffers bicarbonate is the weakest one but is the easiest one to adjust minute by minute by lung function and then another very important one is the phosphate buffer it's a very stable amount it's not changing um and it does help just like proteins proteins are a little better at it phosphate buffers mostly are absorbing excess hydrogen ions or releasing them depending what the pH would happen to be so know your three buffers know how that bicarbonate one works review what it was back in respiratory as we discussed it the balance between CO2 carbonic acid and then bicarbonate plus hydrogen ions or acid so now we do deal with um getting outside of ranges here and and right now we're going to do looking at what happens around bicarbonate or carbon dioxide when you exhale carbon dioxide you're removing CO2 in the process bicarbonate is also converted back to CO2 hydrogen ions become get absorbed as you get rid of CO2 blood pH will rise if you keep more CO2 get rid of less let it build up it'll shift to more bicarbonate and drop in PH so if we increase breathing ventilation you get rid of more CO2 you get R you lose acid blood pH Rises if it rises above 745 we call it alkalosis it is a higher than normal blood pH it is more alkaline than NE than is expected the reverse is true at the other end of things if you de increase ventilation you lose less CO2 more builds up more of it shifts to bicarbonate you release more acid pH drops if it go if it goes below 7.35 now it's considered acidosis yes I know we're still in the alkaline range at this point but the blood is more acidic than it should be therefore acidosis now how do we regulate this breathing and regulate Co to it's all through regulating your rate of respiration we already know CO2 is the major effector of rate of breathing um we have um chemical receptors chemo receptors for CO2 in the aorta and cored arteries and also directly in the medulla oblongata and all the information feeds to the medulla to change your respiratory rate when you're not thinking about it and the changes in respiration will be to correct and return your pH to between our 735 745 range now kidneys also get rid of um hydrogen ions and ammonia um and that is in order to get rid of excess acid from the body excess Al we're always losing some Alkaline through digestive so there's always some acid or almost always some acid to get rid of so uh we want to talk about here we've already mentioned before if hydrogen ions develop too high if pH drops too low it's fatal and this is end of life for some patients especially when it's kidney shut down now because they can get rid of hydrogen ions and ammonia um you can end up with urine that is a thousand times more acidic than the blood so down around pH 4 and A2 instead of up at almost 7 and A2 so you know 7.4 something so that's a significant change now in the rare cases when the patient has excessive bicarbonate they're too alkaline uh kidneys actually can get rid of bicarbonate ions and this would make a slightly alkaline urine pH in the rain of over seven not higher than eight so it is possible you just don't see it a lot now acidosis alkalosis are conditions and you have to think how they affect they both affect the nervous and muscle the most so um when you see acidosis you get depression of the central nervous system slowed nervous activity uh slowed transmission at the synapse disorientation is very common uh patients as it progresses to more acidic they can go towards coma and even death so however going back to your patients who are in mild acidosis and also have unmanaged diabetes malius they're dealing with keto acidosis one of the ways to sense if you know them well enough that their sugar is very high they're going to have a lot of disorientation and confusion so or more than usual let's say alkalosis the reverse end of things so instead of depressing the central nervous now we're causing overe excitability nervousness muscle spasms can occur uh way too many muscle spasms you call it convulsions and that can lead to locking up of respiratory muscles so they won't relax and that's going to cause death by Suffocation uh even worse would be if the heart contracts but won't relax you immediately stop pumping blood again death via the same way not enough oxygen delivered to the tissues so we look at respiratory and metabolic caused acidosis or alkalosis and let's talk about them so respiratory alkalosis too much CO2 too much bicarb drop in blood pH the main thing is low rates of breathing so this can be caused by obstructions uh damage to respiratory muscles could be caused by um damage to the medulla those are all possible however the very first two are probably the most likely you're going to counter pulmonary edema so build up a fluid in the lungs why is it building up there damage to the left side of the heart so fluid is backing up into the lungs causing pulmonary edema patient may be breathing in and out but each breath out is removing less CO2 than should be because of the buildup of fluid within the lungs the other condition also lung based then is empyema where you're causing damage and destruction to both the elastic tissue as well as the Alvi you get much lower rates of gas exchange patients with empyema have or usually have chronic respiratory acidosis as long as it's pretty close to the normal range they can deal with it you can cope with it but usually in the end for end of life with empyema patients it's they simply become too acidic and they lead to standard conditions of death by acidosis metabolic acidosis this is when it's not caused by respiratory uh your most common cause of metabolic acidosis is keto acidosis so what symptoms do you see with um metabolic acidosis you can get very severe diarrhea causing it and then the other end is kidney dysfunction diabetic keto acidosis that's the other main cause of it face it look at the number of patients who are diabetic diabetic keto acidosis is definitely the main thing here far as far as cause of metabolic so going on to alkalosis ph2o High respiratory alkalosis this occurs because of couple of things main one here or the primary one is get rid of too much CO2 now what causes that can be multiple cause um but we're going to look at it here so hyperventilation excessive rate of breathing blowing off too much CO2 too much bicarbonate binds with hydrogen ions pH Rises because that bicarbonate is then being converted to carbon dioxide because you don't have enough direct carbon dioxide now altitude sickness at very high altitudes very low oxygen can trigger this because they're breathing too rapidly because they don't have enough oxygen and therefore blow off too much CO2 that is an issue pulmonary disease can cause this stroke can cause this the major cause is temporary rep respiratory alkalosis anxiety and just simple man mechanical hyperventilation so if you think about Grandma's remedy to what happens when you have anxiety breathe in a paper bag what are you doing it's twofold effects as you inhale into that paper bag sorry as you exhale in the paper bag some of the air you exhale is in the paper bag so when you inhale you actually bring back in some of the CO2 the other thing is if you're focused on breathing in that paper bag you know someone keeps telling you breathe in the bag breathe in the bag breathe in the bag you tend to focus on the bag and it helps draw the brain's attention away from whatever's causing the anxiety in the first place so as simple as it seems it's very very effective now don't use a plastic grocery bag because that paper bag some of the air does go in and out through the bag so you still get some oxygen in if you use a plastic bag ain't gonna happen paper bag paper bag don't use a Ziploc bag or grocery bag so and that's that now um metabolic alkalosis this is not very common so it's everything other than respiratory alkalosis causes here are very severe dehydration excessive vomiting you lose ton of acid so you go become alkaline that way or literally overdose on anti acids so excessive intake of anti acids now when we talk excessive intake we mean really excessive intake so you think of that you know 8 to 12 oun bottle of milk of magnesia says take a teaspoon you all know somebody who just takes the bottle and takes a big Swig out of it you know they end up having multiple teaspoons all at once that's not enough to have an effect um for metabolic alkalosis the excessive intake is when when they take big drinks of it repeatedly and they end up going through an entire bottle in a matter of hours now we're at a problem because you're talking about taking 10 or more times the recommended dose to get to that condition so that's a very high intake of that anti acid so because of that you just don't see that much metabolic acid alkalosis the main resp alkalosis you see is literally anxiety hyperventilation um the main metabolic acidosis you see diabetic keto acidosis the main respiratory acidosis is enyma followed secondary pulmonary edema as a side effect of cardiac disease so those are the major ones you see and those are the ones you should be thinking about because that's going to help you counteract the issues in the problem in patients be more proactive head off problems before they get out of control and then we're on to our last questions very straightforward ones here knowing all our conditions and then our four conditions what are they and what are their major causes so not every cause major causes so and that brings to a close unit 9 thank you for playing along the home version of 1352