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The blood pressure and pulse rate are elevated, though with severe hypertension reflex bradycardia may occur The temperature is often elevated, pupils are dilated, and the skin is sweaty, though mucous membranes are dry Patients are usually agitated, anxious, or frankly psychotic Examples: Amphetamines, cocaine, ephedrine and pseudoephedrine

The osmolar gap ( osm) is determined by subtracting the calculated serum osmolality from the measured serum osmolality



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The blood pressure and pulse rate are decreased and body temperature is low The pupils are small or even pinpoint Peristalsis is usually decreased Patients are usually obtunded or comatose Examples: Barbiturates, benzodiazepines and other sedative hypnotics, GHB, clonidine and related antihypertensives, ethanol, opioids

Glucose BUN Calculated + (mE /L) (mg/dL) (mg/dL) osmolality = 2 [ Na (m q/L)] + ------------------- + ------------------28 18 (osm)

osm = Measured osmolality Calculated osmolality Serum osmolality may be increased by contributions of circulating alcohols and other low-molecular-weight substances Since these substances are not included in the calculated osmolality, there will be a gap proportionate to their serum concentration and inversely proportionate to their molecular weight:





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0 11765 + j 47059 17647 j 70588 05882 + j 23529 05882 + j 23529 15611 j 66290 03846 + j19231 05882 + j 23529 = 03846 + j19231 15611 j 66290 11765 + j 47059 0 11765 + j 47059 05882 + j 23529 11765 + j 47059 29412 j117647

Stimulation of muscarinic receptors causes bradycardia, miosis, sweating, and hyperperistalsis as well as bronchorrhea, wheezing, excessive salivation, and urinary incontinence Nicotinic receptor stimulation may produce initial hypertension and tachycardia as well as fasciculations and muscle weakness Patients are usually agitated and anxious Examples: Carbamates, nicotine, organophosphates (including nerve agents), physostigmine

NOTE A number of different frame types are used in different networks All NICs on the same network must use the same frame type or they will not be able to communicate with other NICs Here s where the MAC address becomes important Figure 2-17 shows a representation of a generic frame Even though a frame is a string of ones and zeroes, we often draw frames as a series of rectangles, each rectangle representing a part of the string of ones and zeroes You will see this type of frame representation used quite often, so you

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Serum concentration = osm x Molecular weight -----------------------------------------(mg/dL) 10

Approximate Corresponding osm (mosm/L) 65 16 16 25

Tachycardia with mild hypertension is common, and the body temperature is often elevated Pupils are widely dilated The skin is flushed, hot, and dry Peristalsis is decreased, and urinary retention is common Patients may have myoclonic jerking or choreoathetoid movements Agitated delirium is frequently seen, and severe hyperthermia may occur

Note: Most laboratories use the freezing point method for calculating osmolality If the vaporization point method is used, alcohols are driven off and their contribution to osmolality is lost Adapted, with permission, from Stone CK, Humphries RL (editors): Current Emergency Diagnosis & Treatment, 5th ed McGraw-Hill, 2004

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Drug or Toxin Acetaminophen Carbon monoxide Treatment Specific antidote (acetylcysteine) based on serum level High carboxyhemoglobin level indicates need for 100% oxygen, consideration of hyperbaric oxygen High level may indicate need for hemodialysis On basis of serum digoxin level and severity of clinical presentation, treatment with Fab antibody fragments (Digibind) may be indicated Low serum level may suggest nonalcoholic cause of coma (eg, trauma, other drugs, other alcohols) Serum ethanol may also be useful in monitoring ethanol therapy for methanol or ethylene glycol poisoning Level may indicate need for chelation with deferoxamine Serum levels can guide decision to institute hemodialysis Acidosis, high levels indicate need for hemodialysis, therapy with ethanol or fomepizole Methemoglobinemia can be treated with methylene blue intravenously High level may indicate need for hemodialysis, alkaline diuresis Immediate hemodialysis or hemoperfusion may be indicated based on serum level Elevated levels may indicate need to consider hemodialysis

Metabolic acidosis associated with an elevated anion gap is usually due to an accumulation of lactic acid or other acids (see 21) Common causes of elevated anion gap in poisoning include carbon monoxide, cyanide, ethylene glycol, medicinal iron, INH, methanol, metformin, ibuprofen and salicylates The osmolar gap should also be checked; combined elevated anion and osmolar gap suggests poisoning by methanol or ethylene glycol, though this may also occur in patients with diabetic ketoacidosis and alcoholic ketoacidosis

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