Open the app
Emergency Medicine Mnemonics

GOLD MARK (better than MUDPILES): Anion Gap Metabolic Acidosis Mnemonic (7,440.12 MRRM)

Mar 5, 2025 · 1 hr 2 min · 60.5 MB
0:00-1:02:59

Streams straight from the publisher. PodNod never proxies or re-hosts episode audio.

Open in PodNod



The GOLD MARK causes are divided into three major pathophysiologic groups based on the source of the acid production:


  1. ​ Alcohols (Toxic Ingestions) → Emergency Toxins
  • ​ Glycols → Ethylene glycol (antifreeze) and propylene glycol
  • ​ Methanol → Windshield washer fluid, homemade alcohol substitutes
  • ​ Why grouped together?
  • ​ Common in suicide attempts, accidental ingestions, or chronic alcoholics.
  • ​ Key labs: Serum osmolality, anion gap, osmolar gap.
  • ​ Imaging: Calcium oxalate crystals on urine microscopy (ethylene glycol).
  • ​ Treatment: Fomepizole or ethanol (blocks alcohol dehydrogenase), hemodialysis in severe cases.


  1. ​ OTCs & Medication-Related Causes → Common but Easily Missed
  • ​ Oxoproline → Chronic acetaminophen (Tylenol) use, often in malnourished patients
  • ​ Aspirin → Salicylates, including bismuth subsalicylate (Pepto-Bismol)
  • ​ Why grouped together?
  • ​ Often overlooked in chronic users or the elderly.
  • ​ Key signs: Tachypnea (respiratory alkalosis), tinnitus (aspirin), altered mental status.
  • ​ Key labs: Salicylate level, ABG (mixed acid-base disorder).
  • ​ Treatment: Alkalinization (sodium bicarb drip), dialysis for severe cases.


  1. ​ Metabolic Causes → Endogenous Acid Production
  • ​ L-lactate → Type A (ischemia), Type B (mitochondrial dysfunction)…L for Loser anaerobic (super winded loser in the race: anaerobic)
  • ​ D-lactate → Short gut syndrome, bacterial overgrowth …GI can think “diet for D”
  • ​ Renal Failure → Uremia, organic acids
  • ​ Ketones → Starvation, alcohol, diabetic ketoacidosis (DKA) think… Keytones are SAD
  • ​ Why grouped together?
  • ​ These involve internal production of acids due to organ dysfunction.
  • ​ Key labs:
  • ​ Lactate level (for sepsis, ischemia).
  • ​ BHB (beta-hydroxybutyrate) for DKA.
  • ​ BUN/Cr for renal failure.
  • ​ Urinalysis (ketones, glucose, uremia markers).
  • ​ Treatment:
  • ​ Fluids, treat underlying cause (DKA → insulin drip, renal failure → dialysis).



Clinically Important Considerations for EM Physicians


In the ED, when a patient has metabolic acidosis with an elevated anion gap, think:

  1. ​ What is the patient’s history?
  • ​ Suicide attempt or confusion? → Alcohols, aspirin
  • ​ Chronic Tylenol use or malnourished? → Oxoproline
  • ​ Sepsis, shock, ischemia? → L-lactate
  • ​ Short gut, diarrhea, recent antibiotics? → D-lactate
  • ​ Known diabetes, alcoholism, or fasting? → Ketones
  • ​ Chronic kidney disease? → Uremia


  1. ​ What tests should I order immediately?
  • ​ ABG/VBG → Confirms metabolic acidosis.
  • ​ Anion gap calculation → Determines if the acidosis is anion gap or non-anion gap.
  • ​ Serum osmolality & osmolar gap → Alcohol toxicity (ethylene glycol, methanol).
  • ​ Lactate level → Sepsis, ischemia, mitochondrial dysfunction.
  • ​ BHB (Beta-hydroxybutyrate) → DKA vs. alcoholic/starvation ketosis.
  • ​ Salicylate level & acetaminophen level → Toxic ingestion screening.
  • ​ CMP (BUN/Cr, glucose, liver enzymes, electrolytes) → Renal failure, DKA, liver dysfunction.


Takeaway: What’s an Emergency?

  • ​ Dialysis Emergencies → Methanol, ethylene glycol, severe aspirin toxicity, uremia.
  • ​ Toxin Emergencies → Alcohols (treat with fomepizole), salicylates (alkalinization & dialysis).
  • ​ Septic Shock / Tissue Hypoxia → Elevated L-lactate = immediate resuscitation with fluids & source control!
  • ​ DKA → Fluids, insulin drip, and monitor for electrolyte shifts (esp. potassium).