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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

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

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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

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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

A comprehensive toxicology screen is of little value in the initial care of the poisoned patient on the contrary, it is time-consuming and expensive Specific quantitative levels of certain drugs may be extremely helpful (Table 38 6), however, especially if specific antidotes or interventions (eg, dialysis) would be indicated based on the results If a toxicology screen is required, urine is the best specimen Many hospitals can perform a quick but limited screen for drugs of abuse (typically these screens include only opiates, amphetamines, and cocaine, and some add benzodiazepines, barbiturates, and tetrahydrocannabinol [marijuana]) There are numerous false-positive and falsenegative results For example, opioids, such as fentanyl, oxycodone, and methadone are usually not detected by routine opiate screening

A plain film of the abdomen may reveal radiopaque iron tablets, drug-filled condoms, or other toxic material Studies suggest that few tablets are predictably visible (eg, ferrous sulfate, sodium chloride, calcium carbonate, and potassium chloride) Thus, the x-ray is useful only if positive

Goldfrank LR (editor): Goldfrank s Toxicologic Emergencies, 9th ed McGraw-Hill, 2006 Hovda KE et al Anion and osmolal gaps in the diagnosis of methanol poisoning: clinical study in 28 patients Intensive Care Med 2004 Sep;30(9):1842 6 [PMID: 15241587] Khajuria A et al Osmolality revisited deriving and validating the best formula for calculated osmolality Clin Biochem 2005 Jun;38(6):514 9 [PMID: 15885229] Olson KR (editor): Poisoning and Drug Overdose, 5th ed McGraw-Hill, 2006

Some drugs or toxins may have profound and irreversible toxicity unless rapid and specific management is provided outside of routine supportive care For these agents, laboratory testing may provide the serum level or other evidence required for administering a specific antidote or arranging for hemodialysis

Secondary hyperglycemia has been associated with various disorders of insulin target tissues (liver, muscle, and adipose tissue) (Table 27 6) Other secondary causes of carbohydrate intolerance include endocrine disorders often specific endocrine tumors associated with excess production of growth hormone, glucocorticoids, catecholamines, glucagon, or somatostatin In the first four situations, peripheral responsiveness to insulin is impaired With excess of glucocorticoids, catecholamines, or glucagon, increased hepatic output of glucose is a contributory factor; in the case of catecholamines,