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Important diagnostic variables in the physical examination include blood pressure, pulse rate, temperature, pupil size, sweating, and the presence or absence of peristaltic activity Poisonings with many drugs fit into one of four common syndromes

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The osmolar gap is defined and calculation of the gap is described in Table 38 5 It is increased in the presence of large quantities of low-molecular-weight substances, most commonly ethanol Common poisons associated with increased osmolar gap are acetone, ethanol, ethylene glycol, isopropyl alcohol, methanol, and propylene glycol Note: Severe alcoholic ketoacidosis and diabetic ketoacidosis can also cause an elevated osmolar gap resulting from the

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

Console.WriteLine("Before starting: \n value of myInt: {0} \n value of myFloat: {1}", myInt, myFloat);

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)

What are the values of myInt and myFloat at the breakpoint 2. Step into the Multiply( ) method, up to the call to Divide( ). What are the values of theInt and theFloat at this point 3. Stop debugging, run the program again, and when it reaches the breakpoint in Run( ), set a watch on myInt. Step through the methods. When does the value of myInt change 4. Set another breakpoint in Add( ) at this line:

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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Figure 3.10 The Contents pane provides access to project file, libraries, and resources such as images.

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

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

theInt = theInt + theInt;

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

Run the program. How many calls are in the call stack when the program reaches this breakpoint Exercise 9-2. The program in this exercise is similar to the first, but it has a logic error. Type this program into Visual Studio, or download it from this book s website:

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

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