Every medical student learns the differential diagnosis for an anion gap metabolic acidosis. The list is particularly crucial for emergency physicians, who often see this finding in sick, undifferentiated patients.
Many people use the mnemonics “MUDPILES CAT” or “GOLDMARK” to help remember this list. An alternative mnemonic, “KULT IMPACT”, provides a practical and organized way of remembering the differential.
“KULT” denotes the most common organic causes:
- Ketones: diabetic ketoacidosis (DKA), alcoholic ketoacidosis, starvation ketoacidosis
- Uremia
- Lactate
- Toxins
“IMPACT” denotes the toxicological causes:
- Iron, Isoniazid
- Metformin
- Phenformin, Paraldehyde
- Aspirin, Acetaminophen, Alcohols (toxic) (remember these together as your tox screen bloodwork)
- Cyanide, Carbon monoxide (remember these together as CN, CO)
- Toluene
Next time you’re faced with an anion gap metabolic acidosis, first think “KULT”, and if the story fits, move on to “IMPACT”!
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Rakesh Gupta
Rakesh is an EM resident at McMaster University. His medical interests include quality improvement, medical education, simulation, and technology in medicine. Outside the hospital, Rakesh enjoys eating delicious food, traveling to exotic locations, and eating delicious food in exotic locations.
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